Consider the triple corneal procedure in corneal disease/cataract cases

Dr. Hannush, attending surgeon, Cornea Service, Wills Eye Hospital, and assistant professor of ophthalmology, Jefferson Medical College, Philadelphia, described his approach to performing this procedure.

"The corneal triple procedure, which includes either penetrating keratoplasty or Descemet's stripping with endothelial keratoplasty (DSEK), cataract extraction, and IOL implantation, is indicated in the presence of visually significant corneal disease and cataract. With this procedure, the plan is to replace the cornea, wholly or partially, and remove the cataract," he said.

"The biggest advantage, however, is that only one procedure is being performed for this patient," he emphasized.

Until recently, the biggest disadvantage associated with combined procedures was the unpredictability of the refractive error, Dr. Hannush noted.

A retrospective review

Dr. Hannush conducted a retrospective review of more than 1,100 grafts performed over an 18-year period and identified 174 triple procedures. His evaluation of the procedures determined that if the cornea has sufficient clarity, the surgeon should first consider removing the cataract by performing a classic cataract surgery procedure, through either a limbal or a scleral tunnel incision. The foldable implant is inserted, followed by corneal transplantation.

"The advantage here is that once the pupil is constricted over the implant, the surgeon has decidedly more control of the eye and decreased concern about posterior pressure," he said. Dr. Hannush also added that he likes to place a couple of sutures in the incisions, regardless of the type of incision made.

In cases where the cornea is more opacified and there is no clear view of the cataract, the only option for the surgeon is an open-sky technique, Dr. Hannush explained.

He described a patient whose eye was 20 mm in axial length and had a shallow anterior chamber and a history of laser iridotomy for angle closure. The problem in an eye such as this is that the rhexis is not controlled and there can be vitreous prolapse, he said.

"It is nice to be able to decompress the eye with either a 20- or 25-gauge cutter, the advantage being that the rhexis is well controlled with no concern about posterior pressure after about 0.1 to 0.2 ml of vitreous has been removed from the vitreous cavity," he said. This technique allows the rhexis to be performed with one hand without having to stabilize the lens with another instrument.