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Triple procedure for pseudophakic bullous keratopathy in complicated cataract surgery: Glued IOL with single-pass four-throw pupilloplasty with pre-Descemet’s endothelial keratoplasty

Narang, Priya MS; Agarwal, Amar MS, FRCS, FRCOphth*

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Journal of Cataract & Refractive Surgery: April 2019 - Volume 45 - Issue 4 - p 398-403
doi: 10.1016/j.jcrs.2018.11.036
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Pseudophakic bullous keratopathy (PBK) is a known clinical entity that follows a traumatic cataract procedure with accompanied loss of corneal endothelial cells. PBK is often associated with complicated surgical maneuvers with posterior capsular rupture and decentered intraocular lenses (IOLs). IOL explantation or refixation is often required along with an endothelial keratoplasty procedure to replenish the endothelium count. For these specific cases, it is necessary to perform a pupilloplasty procedure to maintain an effective air tamponade in the anterior chamber (AC) because it helps to push the donor lenticule against the recipient bed in an already vitrectomized eye with a deep AC. Herein we describe the triple procedure of fibrin glue–assisted intrascleral haptic fixation of an IOL (glued IOL)1 with single-pass four-throw (SFT)2 pupilloplasty and pre-Descemet’s endothelial keratoplasty (PDEK)3 for enhancing the probable visual potential after a complicated cataract surgery and associated PBK.

Surgical technique

The procedure conformed to the Declaration of Helsinki, informed consent was taken from the patients, and institutional review board approval was obtained. All the surgeries were performed under peribulbar anesthesia with 4 mL lidocaine hydrochloride (Xylocaine 2%) and 2 mL bupivacaine hydrochloride 0.5% (Sensorcaine) under monitored care.

The surgical techniques of glued IOL, SFT, and PDEK have been previously described in the peer literature individually. The foremost technique that was performed for the triple procedure was secondary IOL fixation with glued IOL. The initial step comprised of explantation of the previous IOL if it was decentered or malpositioned, and then a scleral tunnel was made to facilitate the procedure. To mention in brief, fluid infusion was introduced inside the eye with either an anterior chamber maintainer (ACM) or with a trocar ACM. The infusion site was chosen in the quadrant opposite to the surgeon’s seating position to facilitate hand movement and provide enough surgical space for further surgical interventions. Two partial thickness scleral flaps were made 180 degrees opposite to each other and fluid infusion was introduced inside the eye. The sclerotomy incisions were made 1.0 mm away from the limbus beneath the scleral flaps and then a vitrectomy was performed with a 23-gauge vitrectomy probe from the sclerotomy site. A 3-piece foldable IOL was introduced and the tip of the leading haptic was held with end-opening forceps, and then the tip was pulled and externalized followed by the trailing haptic that was externalized with the handshake technique.4 In cases with decentered 3-piece IOLs, the handshake technique was performed until the tip of the haptic was visualized and then the haptic was pulled and externalized from the respective sclerotomy sites. The haptics were tucked and buried into the scleral pockets created with a 26-gauge needle. In addition, if the decentered IOL was a 3-piece IOL, then the same IOL was refixated with the glued IOL technique (Figure 1).

Figure 1
Figure 1:
Surgical steps of the triple procedure. A: A case of pseudophakic bullous keratopathy with scarred cornea. B: A trocar anterior chamber maintainer is placed in position and two partial thickness scleral flaps are made 180 degrees opposite to each other. C: The fibrotic-scarred tissue on the endothelial side is cut and removed. This enhances the intraoperative visualization. D: A subluxated 3-piece intraocular lens is visualized. Limited anterior vitrectomy is performed. E: The handshake technique is performed for trailing haptic externalization. F: Both haptics are externalized.

Following this, the SFT technique was performed, which involves performing a pupilloplasty procedure wherein a 10-0 polypropylene suture attached to the long-arm needle was passed through the proximal and distal portion of the iris to be apposed (Figure 2). A 26-gauge needle was passed through the opposite side and the 10-0 needle was threaded into the barrel of the 26-gauge needle. The 26-gauge needle was then withdrawn, a Sinskey hook was passed through the paracentesis incision, and the loop of suture was withdrawn. The suture end was passed through the loop four times and both the suture ends were pulled. This slides the loop inside the eye and apposes the iris tissue, and then the suture ends were cut with microscissors. The SFT procedure was again performed in the other half quadrant so that an optimum size of pupil was achieved that would be sufficient to provide an effective air tamponade and prevent the escape of air into the vitreous cavity.

Figure 2
Figure 2:
Surgical steps of the triple procedure. A: A 10-0 suture on a long-arm needle is passed through the paracentesis incision and the proximal part of the iris tissue to be apposed is held. The needle is passed through it. B: A 26-gauge needle is passed through the paracentesis incision from the opposite side. C: The 10-0 needle is threaded into the barrel of a 26-gauge needle and the needle is withdrawn. A Sinskey hook is passed through the AC and the loop is withdrawn from the AC. The suture end is passed through the loop four times, and both the suture ends are pulled. Then, the knot slides inside the AC. D: Single-pass four-throw is performed and the iris defects are closed (AC = anterior chamber).

The PDEK procedure involves preparing a donor graft by creating a type 1 bubble with a 5 mL air-filled syringe attached to a 30-gauge needle.5,6 The bubble was stained with trypan blue and the graft was cut with corneoscleral scissors all around the periphery of the bubble (Figure 3, A). The graft was harvested and kept aside in the Optisol storage medium (Chiron Ophthalmics, Inc.). Then, the fluid infusion was stopped and air was injected inside the AC from the ACM. Descemetorhexis was performed with a reverse Sinskey hook (Figure 3, B) and the donor graft was then loaded onto the cartridge of a foldable IOL (originally described by Price et al.7) and injected inside the AC (Figure 3, C). The graft was then unfolded using air-fluid mechanics. Air was instilled into the AC that consequently pushed the donor graft against the recipient bed (Figure 3, D and Video 1 [available at]).

Figure 3
Figure 3:
Surgical steps of the triple procedure. A: A type 1 bubble is created and the edge of the bubble is ruptured with a side-port blade. B: A reverse Sinskey hook is introduced and the Descemetorhexis is performed. C: The graft is loaded onto the cartridge of the foldable intraocular lens and injected inside the anterior chamber. D: The graft is unrolled and air is injected beneath the graft to adhere it to the host bed.

The scleral tunnel was secured with a 10-0 nylon suture, and fibrin glue was applied beneath the scleral flaps to seal the sclerotomy site. All the conjunctival peritomy wounds were subsequently sealed with fibrin glue. Postoperatively, the patient was made to lay flat for most of the day.


The data were analyzed using Stata Statistical Software (version 14.0, StataCorp LLC). The descriptive statistics means ± SD and 95% confidence intervals were used to describe the data. A paired t test was used to compare the preoperative and postoperative follow-up data. For statistical analysis, the difference between the donor endothelial cell count and the postoperative cell count was considered to be the total endothelial cell loss for the specific postoperative period that was taken into consideration. The ratio of the endothelial cell loss to the donor cell count when expressed in percentage was considered to be the percent of cell loss. The preoperative endothelial cell density (ECD) of the donor tissue was recorded using an eye bank specular microscope (donor Keratoanalyzer EKA-10, Konan Medical, Inc.) and the postoperative ECD was recorded using noncontact specular microscopy (EM-3000, Tomey Corp.).

The surgical technique was performed in 25 cases and all the cases had a minimum follow-up of 12 months (range 12 to 24 months). The mean donor age was 35.1 ± 10.4 years (range 20 to 55 years) and the mean graft size was 7.6 ± 0.9 mm (range 6.5 mm to 9.0 mm). The refixation of a preexisting 3-piece IOL was performed with the glued IOL method in 9 cases, whereas IOL explantation followed by implantation of a new 3-piece IOL and its fixation with glued IOL was performed in the remaining 16 cases. There was a significant improvement in visual acuity in all the cases. The mean preoperative and postoperative corrected distance visual acuity at 6 months follow-up was 1.51 ± 0.76 logarithm of the minimum angle of resolution (logMAR) and 0.53 ± 0.53 logMAR, respectively (P = .002). There was a significant fall in intraocular pressure (IOP) in the postoperative period. The mean postoperative specular endothelial count was 2207 ± 59.6 cells/mm2 (range 2519 to 1891 cells/mm2) and the mean percentage of ECD loss in the donor graft at the 6-month follow-up was 31.9 ± 5.93%. Partial graft detachment was noticed in two cases on the first postoperative day and rebubbling was performed. There was no incidence of primary graft failure.

There was no incidence of IOL decentration or dislocation observed in the postoperative period. Hyphema was noticed in two eyes on the first postoperative day that resolved with medical management. No incidence of glaucoma, vitritis, or vitreous hemorrhage was reported during the entire follow-up period. Anterior segment optical coherence tomography showed good graft apposition in all the eyes in the follow-up, and there was marked improvement in the central corneal thickness and corneal clarity in the postoperative period (Figure 4).

Figure 4
Figure 4:
Preoperative images of cases (A, C, E, G, and I) and postoperative images of the same cases (B, D, F, H, and J).


PBK might develop as a sequel to complicated cataract surgery that is characterized by irreversible corneal edema and an eventual corneal decompensation. Placement of an AC IOL might be associated with progressive endothelial cell loss along with decompensation,8–11 and a decentered or a malpositioned posterior chamber IOL incites adequate inflammatory reaction to damage the corneal dexterity. Performing a thorough vitrectomy and securing an IOL fixation with the glued IOL method helps to relieve the inflammatory source attributable to a malpositioned IOL.

The triple procedure allows appropriate IOL placement with replenishment of endothelial cells with the PDEK procedure and an effective air tamponade with SFT pupilloplasty that prevents graft dislocation and its eventual slippage into the vitreous cavity (Figure 5). The complicated cases are often associated with raised IOP because of inflammation and the development of peripheral anterior synechia. SFT has been demonstrated to break the peripheral anterior synechia from the AC angle because of the mechanical pull after a surgical pupilloplasty (Figure 6).12,13 In addition, SFT pupilloplasty has also been demonstrated to allow adequate pupil dilation for fundus examination in the postoperative period.14 SFT pupilloplasty involves a single pass through the AC and does not involve a second pass. Hence, there is no knot formation and the helical structure that is created because of the intertwining of the four-throws has a self-retaining and a self-locking mechanism. The suture line with SFT essentially lies parallel to the iris tissue, and there is a negligible chance for the knot to rub against the donor corneal graft tissue while it is being unfolded inside the AC.15 The authors have previously described the triple procedure with a modified Siepser slipknot technique as the chosen method of pupilloplasty with a fewer number of cases.16,17 However with the documented advantages of the SFT procedure, the current series encompasses SFT pupilloplasty as the preferred method. A comparison of clinical results with varied preferred modes of performing pupilloplasty would add value to the study; however, it was not performed for the current series because of the limitation of cases and data from the previous study. To prevent pupillary block, inferior iridotomy should be performed. However, it was not performed in our case series because all the cases had iris tissue involvement with the presence of an iris defect either in the periphery or mid-periphery area that served as an iridotomy opening.

Figure 5
Figure 5:
Animated illustration showing the role of pupilloplasty for achieving effective air tamponade. A: Air being injected inside the anterior chamber. B: Air seeps back into the vitreous cavity from the area of pupillary and iris defect. C: Air being injected after pupilloplasty. D: Effective air tamponade is achieved.
Figure 6
Figure 6:
Animated illustration describing the role of pupilloplasty. A: Because of a persistent dilated pupil, the iris tissue falls back and blocks the trabecular pathway. B: Pupilloplasty pulls the iris tissue into the center and relieves the mechanical blockage. C: Both the suture ends are pulled, which mechanically pulls the iris centrally. D: Both suture ends are cut with microscissors.

Performing a PDEK procedure has an added advantage of pre-Descemet membrane layer attached to the Descemet membrane–endothelium complex that prevents the graft from curling excessively and helps to unroll it intraoperatively as compared with the Descemet membrane endothelial keratoplasty graft.3,18 Another selective documented advantage with PDEK is the use of younger donor grafts, which most likely involves transferring grafts with a higher endothelial cell count.18

Numerous studies have explained the role of combined techniques for performing varied forms of endothelial keratoplasty with the glued IOL technique.19–22 Selective to our technique, all cases were performed with SFT that probably translates into less intraoperative inflammation because of the involvement of a single pass through the AC. Moreover, with PDEK, no loss of donor tissue was encountered that could be explained because of the stronger adhesions between the pre-Descemet membrane layer and the Descemet membrane in eyes with younger donor tissue. This prevented the formation of type 2 bubbles5,6 during the donor graft preparation and eventually averted the conversion from PDEK to a Descemet membrane endothelial keratoplasty procedure. Altaan et al.6 demonstrated that the ECD loss during PDEK graft preparation was not significant. Hence, the authors contemplate that the reported ECD loss in this study was attributable to surgical maneuver. The authors preferred to use an ACM or a trocar ACM23 because the air and fluid infusion could be easily performed through either of them, depending on the requirements of the surgical step.

In our series, all the cases were performed as a single-stage procedure, although the triple procedure can be also performed as a two-stage procedure. The triple procedure was performed in all cases with PBK, although it can also be replicated for cases with aphakic bullous keratopathy. All the cases had a favorable outcome because the triple procedure helps to overcome the complications associated with cataract surgery and paves a way forward for effective management. However, long-term studies with a larger number of cases would validate the results.

What Was Known

  • A procedure of glued intraocular lens (IOL) fixation with endothelial keratoplasty forms an effective management protocol for complicated cases with decentered IOLs and associated pseudophakic bullous keratopathy.

What This Paper Adds

  • A combination technique of glued IOL with a single-pass four-throw (SFT) pupilloplasty and pre-Descemet’s endothelial keratoplasty (PDEK) was an effective procedure to optimize the visual outcome in cases with endothelial dysfunction and inadequate posterior capsule support.
  • Glued IOL should be performed initially because it helps to secure the IOL fixation, followed by SFT pupilloplasty, which imparts stability to the anterior chamber and prevents air diversion into the vitreous cavity, thereby facilitating the PDEK procedure that is eventually performed.


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None of the authors has a financial or proprietary interest in any material or method mentioned.

Supplementary data

Video 1 The video depicts the triple procedure of glued intraocular lens (IOL) with single-pass four-throw (SFT) pupilloplasty and pre-Descemet’s endothelial keratoplasty (PDEK). Corneal epithelial debridement is performed initially to enhance the intraoperative view during the surgery. Fluid infusion is introduced inside the eye and two partial thickness scleral flaps are made 180 degrees opposite to each other, followed by a sclerotomy with a 22.0-gauge needle approximately 1.0 mm behind the limbus and beneath the flaps. Anterior vitrectomy is attempted through the paracentesis incision. A retrocorneal fibrous membrane on the endothelium is stripped off and the adhesions with iris tissue are cut with microscissors and then removed from the anterior chamber (AC). Limited anterior vitrectomy is again performed in the AC, and the haptics of the subluxated IOL are grasped with end-opening forceps and the tip of the haptic is held and externalized from the respective sclerotomy sites with the handshake technique. The haptics are tucked into the scleral pockets created with a 26-gauge needle. SFT pupilloplasty is then performed wherein a 10-0 polypropylene suture attached to the long-arm needle is passed through the proximal and distal iris tissue that is to be apposed. A loop of suture is withdrawn from the AC and the suture end is passed through the loop four times. Both suture ends are pulled and the knot slides inside the eye approximating the iris tissue. The suture ends are cut with microscissors. SFT pupilloplasty is performed again in another quadrant to narrow down the pupil size. A type 1 bubble is created by injecting air from a 5 mL air-filled syringe that is introduced from the rim of the corneoscleral button with the endothelial side up. The 30-gauge needle is introduced up to the mid-periphery and air is injected that forms a type 1 bubble. The edge of the bubble is pierced with a side-port blade, and trypan blue is used to stain the bubble. The graft is obtained by cutting the bubble all around its edge. The graft is then stored and kept aside in the Optisol storage medium (Chiron Ophthalmics, Inc.). Fluid infusion is stopped, and air is infused inside the AC. Descemetorhexis is performed and the host Descemet membrane–endothelium complex is removed. The donor graft is loaded onto the cartridge of a foldable IOL and is injected inside the AC. The graft is unrolled using air and fluidics. Once the entire graft has unrolled, air is injected inside the AC and the donor graft is pushed against the recipient bed. The corneal sutures are passed through the corneal tissue, and all the incisions are closed. Fibrin glue is applied beneath the scleral flaps and all the conjunctival wounds are also sealed.

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