Novel Corneal Piggyback Technique for Consecutive Intraocular Lens Implantation and Penetrating Keratoplasty Surgery

CASE REPORT

Yukihiro Matsumoto, MD,* Murat Dogru, MD,*† Jun Shimazaki, MD,† and Kazuo Tsubota, MD*

plasty (DMEK)5 have become more popular for corneal Purpose: “ ” To report a novel piggyback penetrating keratoplasty transplants in corneal endothelial disorders. The most technique performed in a patient with severe keratoconus. commonly performed endothelial keratoplasty techniques Methods: A 43-year-old man underwent cataract surgery and have been superior to standard PKP in safety, risk of graft a new “piggyback” penetrating keratoplasty (PKP) technique in his rejection, and visual outcome. Except for mild bullous right eye, as he suffered from severe keratoconus and mature cataract keratopathy, corneal diseases that can be effectively treated due to severe atopic dermatitis. Under general anesthesia, phacoe- by DSAEK and DMEK are limited. Moreover, other mulsification and aspiration (PEA), intraocular lens (IOL) implan- techniques in partial keratoplasty such as lamellar keratoplasty tation, and “piggyback” PKP while avoiding open-sky surgery was (LKP) and deep anterior lamellar keratoplasty (DALK) are performed to prevent serious complications including IOL and useful in the treatment of corneal stromal disorders. At vitreous prolapse. This PKP technique had been completed as present, PKP technique is still needed for surgical treatment of a totally closed surgery. corneal stromal and endothelial disorders. We performed a novel “piggyback” PKP technique Results: One year after “piggyback” PKP and cataract surgery, the safely and successfully as a totally closed surgery in a patient grafted cornea remained clear and IOL was also well positioned. with severe keratoconus. The advantages and disadvantages Best-corrected visual acuity improved from hand motions to 30/100. of this new procedure are described and discussed. Conclusions: A novel “piggyback” PKP technique was successfully performed in a patient with severe keratoconus. The new CASE REPORT “piggyback” corneal transplantation technique may become an indispensable tool for transplant surgeons who want to improve The patient was a 43-year-old man who complained of decreased vision in the right eye for several months. Although the surgical safety and predictability. patient had severe atopic dermatitis, he had not undergone any Key Words: piggyback technique, corneal transplantation, intraoc- surgery for treatment of the ocular disease. Initial ophthalmologic ular lens implantation examination of the right eye revealed a best-corrected visual acuity (BCVA) of hand motions, a severely conical and thinned cornea with (Cornea 2015;34:713–716) a ruptured Descemet membrane, stromal opacity, and a mature cataract with slit-lamp biomicroscopy (Figs. 1A, B). There were no remarkable findings in the retina with ophthalmic B-scan ultrasound mong corneal transplantation procedures, penetrating examination. Specular microscopy revealed an endothelial cell Akeratoplasty (PKP) has been performed for more than density of 1179 cells per square millimeter. Corneal topography 100 years1,2 and enjoys a confidence level of stability. (TMS-2N; Tomey Co, Ltd, Aichi, Japan) could not measure the corneal surface curvature due to a very steep and irregular corneal Recently, new techniques in endothelial keratoplasty such as contour. With the diagnosis of severe keratoconus and mature Descemet stripping automated endothelial keratoplasty cataract, surgical treatment involving PKP and cataract surgery 3,4 (DSAEK) and Descemet membrane endothelial kerato- was planned under general anesthesia. The procedure started with cataract surgery under general anesthesia. Initially, we performed a continuous curvilinear capsu- Received for publication December 2, 2014; revision received January 20, lorhexis, a 2.75-mm corneal incision, phacoemulsification and 2015; accepted January 23, 2015. Published online ahead of print April 7, aspiration (PEA) (Fig. 2A), intraocular lens (IOL) implantation 2015. (Fig. 2B), irrigation, attained miosis by injection of acetylcholine, From the *Department of Ophthalmology, Keio University School of and finally injected 1.0% hyaluronate viscoelastic material into the Medicine, Tokyo, Japan; and †Department of Ophthalmology, Ichikawa anterior chamber for the consequent PKP procedure. We then General Hospital, Tokyo Dental College, Chiba, Japan. performed a trephination of the recipient’s cornea with the Hess- fl The authors have no funding or con icts of interest to disclose. burg–Barron corneal vacuum trephine (diameter 7.5 mm) and Katzin Presented at the American Society of Cataract and Refractive Surgery (ASCRS) Annual Meeting, April 19–23, 2013, San Francisco, CA. scissors (Fig. 2C). Halfway through the trephination, the IOL Reprints: Murat Dogru, MD, Department of Ophthalmology, Keio University showed a tendency of displacement of the IOL optic moving forward School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, through the pupil with the haptics in the capsular bag despite deep Japan (e-mail: [email protected]). anesthesia. We thought that we could not continue with the corneal Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. trephination, and placed two 10-0 monofilament nylon sutures at

Cornea Volume 34, Number 6, June 2015 www.corneajrnl.com | 713

FIGURE 1. Ophthalmic examina- tions before and after surgery. Slit- lamp biomicroscopic examination reveals the corneal stromal opacity with ruptured Descemet membrane and mature cataract (A). Note the severely conical and thinned cornea due to keratoconus at the initial examination (B). Note the clear donor cornea with mild Descemet membrane folds and well-positioned intraocular lens and iris 3 months after surgery (C, D). The corneal endothelial cell density was 952 cells per square millimeter measured by the specular microscopy (E), and the corneal astigmatism was 3.37 diopters measured by the corneal topography 1 year after surgery (F).

6-o’clock and 9-o’clock positions (Fig. 2D). We then dialed down times per day for 6 months after surgery and have been continued and repositioned the captured IOL. We considered how best to carry since then. One year after surgery, the cornea still remained clear on with PKP while avoiding open-sky surgery and decided to fold despite decreased endothelial cell count (corneal endothelial cell and insert the donor corneal graft (diameter 8.0 mm) into the anterior density, 952 cells/mm2) (Fig. 1E). The IOL was also well positioned. chamber through the 9-o’clock to 12-o’clock incisions (Fig. 2E). We Corneal astigmatism was 3.37 diopters. Surface regularity index could unfurl the donor corneal graft in the anterior chamber by (SRI) was 1.11 and surface asymmetry index (SAI) was 1.89 (Fig. injecting hyaluronate viscoelastic material beneath the donor cornea 1F). Best-corrected Landolt visual acuity was 30/100 postoperatively uneventfully (Fig. 2F). While the upper sutured recipient cornea was at 1 year. in place, we started sewing between the peripheral donor graft and the peripheral recipient cornea (Fig. 2G), placing a total of eight 10-0 nylon interrupted sutures. Following the placement of interrupted DISCUSSION sutures, the recipient’s uppermost cornea was removed, exposing the lower donor corneal graft (Fig. 2H). We could then suture between Corneal transplantation procedures include both con- the donor and recipient corneas continuously, placing a total of ventional PKP and selective keratoplasties such as LKP, twenty-four 10-0 nylon sutures, and removed all the 8 interrupted DALK, DSAEK, and DMEK. PKP is a very effective sutures. Finally, we checked the donor–recipient adaptation (Fig. 2I). transplantation procedure for treating full-thickness corneal Our approach allowed PKP to be completed as a totally closed disorders; however, it has a disadvantage in surgical safety surgery. when associated with an open-sky procedure. Recently, After surgery, the postoperative anterior chamber inﬂamma- several novel techniques in PKP procedures were reported tion and corneal stromal edema decreased gradually with instillation to attain surgical safety, in which the anterior chamber is of 0.1% betamethasone eye drops (Santen Pharmaceutical Co, Ltd, maintained.6–8 In these PKP procedures named “protected Osaka, Japan) 5 times per day. Postoperative medication also ﬂ PKP”, “stabilized PKP”,or“covered cornea technique in included 1.5% levo oxacin eye drops (Santen Pharmaceutical Co, ” Ltd) 5 times per day. Three months after surgery, the grafted cornea PKP, the donor corneal graft was sutured on the trephined remained clear (Figs. 1C, D) and the endothelial cell density recipient cornea, and then the lower recipient cornea was measured using the specular microscope was 1848 cells per square removed through the unsutured segment while maintaining millimeter. Both postoperative topical medications were tapered to 3 the anterior chamber.

FIGURE 2. Triple procedure consisting of PEA and IOL implantation followed “piggyback” PKP. The stages of the procedure were as follows: (A) phacoemulsiﬁcation and aspiration (PEA), (B) intraocular lens (IOL) implantation, and (C–I) following Penetrating keratoplasty (PKP) procedure. C, Trephination of the recipient’s cornea with Katzin scissors. D, Placement of two 10-0 mono- ﬁlament nylon sutures at 6-o’clock and 9-o’clock positions. Note the IOL optic capture through iris. E, Insertion of the folded donor corneal graft into the anterior chamber. F, Unfurling donor corneal graft in the anterior chamber. G, Sewing between the peripheral donor graft and peripheral recipient corneas beneath the overlying recipient cornea. H, Removal of the recipient’s uppermost cornea, exposing the lower donor corneal graft. I, Checking the donor–recipient adaptation, after placement of a total of twenty-four 10-0 nylon sutures.

In this report, we present a novel PKP procedure to We did not choose DALK because of the presence of avoid open-sky PKP. In brief, the donor corneal graft was a ruptured Descemet membrane associated with a previous inserted into the anterior chamber beneath the recipient acute corneal hydrops episode. Owing to preoperative risk cornea, followed by removal of the recipient cornea. We factors such as decreased eyelid elasticity resulting from named the new PKP technique as the “piggyback” corneal chronic atopic dermatitis and presence of a very thin recipient transplantation technique, because the upper recipient cornea cornea, we chose to perform the surgery under general and the lower donor corneal graft overlapped during the anesthesia to avoid posterior vitreous pressure-related procedure. Our PKP technique is totally different from the complications. previously reported PKP procedures where the donor corneal The cataract surgery (PEA + IOL implantation) was graft was inserted beneath the recipient cornea. completed uneventfully. However, the IOL ﬁrst showed optic We originally planned a triple procedure consisting of capture in the pupillary area, followed by partial displacement PEA and IOL implantation followed by PKP under general of the IOL optic into the anterior chamber during trephination anesthesia for the treatment of severe keratoconus and mature and excision of the trephined cornea by scissors. Due to the cataract in this patient. The patient could not use hard contact possibility of imminent IOL prolapse, we converted to lenses because of the presence of a severely conical cornea. “piggyback” PKP, which helped in avoiding open-sky PKP.

Attempts to reposition the IOL were unhelpful. We also postoperative astigmatic outcomes. We advocate this pro- thought that “piggyback” PKP had merit in preventing serious cedure in patients who have a risk of IOL and/or vitreous complications including vitreous prolapse and expulsive prolapse during PKP surgery. hemorrhage, because the zonules of Zinn are known to be In summary, we present a novel PKP approach that brittle in severe atopic dermatitis. incorporates a “piggyback” technique while eliminating the It should, however, be noted that the “piggyback” PKP risks of open-sky surgery and prevents serious complications, technique is more complex compared with the standard PKP including vitreous prolapse or expulsive hemorrhage. We technique. Especially, it is most difﬁcult for a surgeon to believe that this new “piggyback” corneal transplantation suture between the lower peripheral donor corneal graft and technique will be an indispensable tool for transplant the peripheral recipient cornea beneath the overlying recipient surgeons seeking to improve the surgical safety and cornea with 10-0 nylon sutures in the piggyback PKP predictability. procedure. We do not advocate this procedure for beginner corneal transplant surgeons. The postoperative donor corneal endothelial cell loss is REFERENCES another problem. In this case, corneal endothelial cell density 1. Payne JW. New directions in eye banking. Trans Am Ophthalmol Soc. 1980;78:983–1026. decreased from 2824 cells per square millimeter (preoperative 2. Polack FM. Keratoplasty and intraocular lenses. Cornea. 1985–1986;4: donor cornea) to 1848 cells per square millimeter (post- 137–147. operative donor cornea after 3 months). Corneal endothelial 3. Price FW Jr, Price MO. Descemet-stripping with endothelial keratoplasty cell density was 952 cells per square millimeter at 1 year after in 50 eyes: a refractive neutral corneal transplant. J Refract Surg. 2005; – surgery. It was reported that the endothelial cell loss was 21:339 345. 4. Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. higher with DSAEK (38%) compared with PKP (20%) 1 year Cornea. 2006;25:886–889. 9 after surgery in a multicenter, prospective clinical trial. The 5. Melles GR, Ong TS, Ververs B, et al. Descemet membrane endothelial “piggyback” PKP procedure resulted in more corneal endo- keratoplasty (DMEK). Cornea. 2006;25:987–990. thelial cell loss (66%) compared with standard PKP and 6. López-Plandolit S, Etxebarria J, Acera A, et al. Protected penetrating keratoplasty: surgical technique and endothelial response [in Spanish]. DSAEK. The problem may be mainly caused by mechanical Arch Soc Esp Oftalmol. 2008;83:231–236. stress to the corneal endothelium. The donor cornea inserted 7. Chen W, Ren Y, Zheng Q, et al. Securing the anterior chamber in by a “taco” fold method may result in an increased corneal penetrating keratoplasty: an innovative surgical technique. Cornea. 2013; endothelial cell loss in DSAEK procedures.10 A longer 32:1291–1295. follow-up for the change of corneal endothelial cell density 8. Arslan OS, Ünal M, Arici C, et al. Novel method to avoid the open-sky condition in penetrating keratoplasty: covered cornea technique. Cornea. is essential. The safety of the procedure, corneal clarity, and 2014;33:994–998. visual acuity results attained at 1 year justify prospective 9. Price MO, Gorovoy M, Benetz BA, et al. Descemet’s stripping randomized clinical trials comparing the standard PKP pro- automated endothelial keratoplasty outcomes compared with penetrating cedure with its “piggyback” cousin. Results from such keratoplasty from the Cornea Donor Study. Ophthalmology. 2010;117: 438–444. clinical trials will pave the way for further studies comparing 10. Mehta JS, Por YM, Por R, et al. Comparison of donor insertion various donor corneal graft insertion methods using forceps techniques for Descemet stripping automated endothelial keratoplasty. or glides in relation to corneal endothelial cell loss and Arch Ophthalmol. 2008;126:1383–1388.