COMBINED CATARACT EXTRACTION & CORNEAL TRANSPLANTATION Nikolaos G. Ziakas 1 st Eye Clinic Aristotle University of Thessaloniki
DECISION MAKING Simultaneous presence of optically significant corneal disorder and cataract
Assessment of the cataract Impaired visualization of the cataract (use of 10% glycerin drops) Reduced cataract assessment landmarks (fundus details, red reflex) Is vision impaired because of the cornea, the cataract or both? Useful clue: status of the lens in the fellow eye History of inflammation or trauma (unilateral cataract acceleration) Pupillary dilation is mandatory Guard against extraction of a minimally brunescent, but optically clear lens.
Assessment of the cornea Assessment of corneal opacities visualisation of the iris and lens Surface irregularity corneal topography diagnostic hard contact lens refraction
Assessment of the cornea Clinical dilemma dense corneal guttae Without endothelial decompensation cataract extraction alone? Frank discussion with the patient (increased chance of endothelial decompensation post-surgery) In the case of inevitable endothelial decompensation combined surgery
Evaluation of corneal endothelial function HISTORY Morning blur Glare complaints Symptoms of variable contrast sensitivity impairment PHYSIOLOGIC FUNCTION Corneal thickness (pachymetry) Fluorophotometry MORPHOLOGIC EVALUATION Specular microscopy Confocal microscopy
TECHNIQUES FOR CATARACT REMOVAL Phacoemulsification through a scleral tunnel limbal wound Closed chamber technique Requires separate wound Impaired visualization for phaco (especially of the posterior capsule)
OPEN-SKY TECHNIQUE Manual retraction of the iris (stretching, iris hooks) Anterior capsulotomy (ideally continuous curvilinear capsulorhexis) Capsulotomy 7mm or larger (to deliver the entire nucleus)
OPEN-SKY TECHNIQUE Hydrodissection in continuous capsulorhexis (facilitates later cotrical clean up) In absence of hydrodissection, rocking the nucleus with an impaled sharp instrument will loosen it With the help of a microsurgical loop, the nucleus is delivered Control of posterior pressure (pressure on the center of the nucleus during capsulorhexis) Vitreous pressure causes extension of the capsulotomy tear towards the equator
OPEN-SKY TECHNIQUE Residual epinucleus and cortex are aspirated Use of manual irrigationaspiration system (appositioning of the posterior and anterior capsules because of positive pressure) Full removal of cortex PC IOL placement (in the bag or sulcus fixation)
VIDEO
COMPLICATIONS Positive pressure most common cause lid & drape pressure through lid speculum -repositioning of lid speculum -vitreous aspiration (extremely delicate cutdown) in extreme cases Vitreous loss vitrectomy (removal of all vitreous with minimal vitreous traction)
COMPLICATIONS Suprachoroidal Hemorrhage and effusion -positive pressure on an intact posterior capsule -rupture of the pc and zonules with vitreous loss -alteration in the red reflex -elevated retina may be visualized through the operating micr. The anesthesiologist should be instructed to use a paralytic agent to avoid straining against the endotracheal tube of a lightly anesthesized patient
COMPLICATIONS Intraocular lens implantation after vitreous loss in lost ability of residual posterior capsule to support PC IOL AC IOL Iris-sutured PC IOL Iris supported IOL (Artisan) Scleral suture-fixed PC IOL
TRIPLE PROCEDURE When deciding, keep in mind that Cataract may progress more rapidly after keratoplasty Topical steroids after PK can hasten cataract development Postkeratoplasty cataract surgery may traumatize the grafted endothelium
SIMULTANEOUS VS SEQUENTIAL PROCEDURE Final VA (simultaneous = sequential) 5-year graft survival (simulateneous = sequential) Rapid visual recovery (simultaneous) Fewer procedures (simultaneous) Green M, Chow A, Apel A.Outcomes of combined penetrating keratoplasty and cataract extraction compared with penetrating keratoplasty alone. Clin Experiment Ophthalmol. 2007 May-Jun;35(4):324-9. Nguyen DQ, Mumford LL, Jones MN, Armitage WJ, Cook SD, Kaye SB, Tole DM.The visual and refractive outcomes of combined and sequential penetrating keratoplasty, cataract extraction, and intraocular lens insertion. Eye (Lond). 2009 Jun;23(6):1295-301. Epub 2008 Oct 3.
DALK or DSAEK combined with phacoemulsification Deep lamellar keratoplasty combined with cataract surgery. Muraine MC, Collet A, Brasseur G. Arch Ophthalmol. 2002 Jun;120(6):812-5. DSAEK combined with phacoemulsification and IOL implantation suggests that it provides rapid visual rehabilitation with predictable refractive outcomes. Covert DJ, Koenig SB. Ophthalmology. 2007 Jul;114(7):1272-7. New triple procedure: Descemet's stripping and automated endothelial keratoplasty combined with phacoemulsification and intraocular lens implantation. DSAEK combined with phaco and IOL implantation in patients with coexisting Fuchs endothelial dystrophy and cataract improved best spectacle-corrected visual acuity without progressive timedependent complications. Yoo SH, Kymionis GD, Deobhakta AA, Ide T, Manns F, Culbertson WW, O'Brien TP, Alfonso EC. Arch Ophthalmol. 2008 Aug;126(8):1052-5. One-year results and anterior segment optical coherence tomography findings of descemet stripping automated endothelial keratoplasty combined with phacoemulsification.
DALK or DSAEK combined with phacoemulsification DSAEK with cataract surgery allows rapid visual recovery and allows appropriate IOL selection. Terry MA, Shamie N, Chen ES, Phillips PM, Shah AK, Hoar KL, Friend DJ. Ophthalmology. 2009 Apr;116(4):631-9.Endothelial keratoplasty for Fuchs' dystrophy with cataract: complications and clinical results with the new triple procedure. Simultaneous DALK and phaco in coexisting corneal and lenticular pathology with encouraging outcomes Panda A, Sethi HS, Jain M, Nindra Krishna S, Gupta AK. J Cataract Refract Surg. 2011 Jan;37(1):122-6 Deep anterior lamellar keratoplasty with phacoemulsification. DSAEK combined with phaco or lens exchange is safe and effective for corneal endothelial dysfunction with lens disorders Hong J, Hao YS, Ma ZZ, Peng RM, Qu HQ. Zhonghua Yan Ke Za Zhi. 2011 Jan;47(1):11-6 The effect of descemet-stripping automated endothelial keratoplasty combined with phacoemulsification cataract surgery or lens exchange
PHACO-DSAEK
Summary If endothelium functional: only phaco If corneal decompensation: good view: phaco-dsaek poor view: PK & open sky cataract & IOL