TECHNIQUE

Femtosecond-assisted keratoplasty with fibrin

glue–assisted sutureless posterior chamber lens
implantation: New triple procedure
Gaurav Prakash, MD, Soosan Jacob, MS, DNB, FRCS, Dhivya Ashok Kumar, MD,
Smita Narsimhan, FERC, Athiya Agarwal, MD, DO, Amar Agarwal, MS, FRCS, FRCOphth

We report a surgical technique for managing bullous keratopathy secondary to anterior chamber
intraocular lens (AC IOL). The technique comprises femtosecond laser–assisted penetrating kera-
toplasty and AC IOL exchange with fibrin glue–assisted sutureless posterior chamber intraocular
lens (PC IOL) implantation (‘‘glued IOL’’). This new triple procedure combines the unique benefits
of the femtosecond laser and the glued IOL, leading to stable wound configuration, decreased open-
sky time, and less pseudophacodonesis, and there is less risk for the suture-related complications
of transscleral suture fixation.
J Cataract Refract Surg 2009; 35:973–979 Q 2009 ASCRS and ESCRS

Pseudophakic bullous keratopathy (PBK) with an
anterior chamber intraocular lens (AC IOL) is a leading
indication for full-thickness penetrating keratoplasty
(PKP) and IOL exchange.1,2 It presents a unique surgi-
cal challenge because of a previous complicated
surgery, compromised aqueous drainage, unhealthy
wound configuration, and a deficient posterior
capsule. Both the corneal transplantation and the IOL
exchange should be optimized to achieve less ‘‘open-
sky’’ time, easier intraoperative procedures, faster
wound healing, and maximum provision and postop-
erative preservation of the donor endothelial cells.
A paradigm shift has occurred in keratoplasty with
the use of the femtosecond laser for sculpting the do-
nor and host corneas. The top-hat configuration has
Submitted: October 1, 2008.
Final revision submitted: November 30, 2008.
Accepted: December 2, 2008.
From Dr Agarwal Eye Hospital and Eye Research Centre, Chennai,
India.
Amar Agarwal is a consultant to Abott Medical Optics (formerly
Advanced Medical Optics), Irvine, California, USA. No other author
has a financial or proprietary interest in any material or method
mentioned.
Corresponding author: Amar Agarwal, MS, FRCS, FRCOphth, Pro-
fessor and Head, Dr Agarwal Eye Hospital and Eye Research Centre,
19, Cathedral Road, Chennai- 600 086, India. E-mail: dragarwal@
vsnl.com.
resulted in a more stable wound configuration, faster
healing, and more endothelial cells (compared with
those in a standard manual procedure with a compara-
ble epithelial side diameter).3–8
In contrast, current techniques for IOL exchange
during keratoplasty, especially in cases with a deficient
posterior capsule, are less than satisfactory. Trans-
sclerally sutured IOLs have been used in this situa-
tion.9–10 Unfortunately, this technique is associated
with a longer learning curve, prolonged intraoperative
manipulation, postoperative pseudophacodonesis,
and chances of postoperative decentration due to su-
ture degradation or knot slippage.10–17
We have successfully performed fibrin glue–assis-
ted sutureless posterior chamber IOL (PC IOL) im-
plantation in eyes with deficient posterior capsule
support.18 It involves trans-scleral exteriorization
and intrascleral tuck of both the haptics under diamet-
rically opposite scleral flaps, which are then apposed
with scleral glue. This sutureless technique can be per-
formed with routinely available poly(methyl methac-
rylate) (PMMA) PC IOLs and has a short learning
curve. In an ongoing trial, we have achieved satisfac-
tory surgical time and safety, rehabilitation duration,
and postoperative results in more than 100 eyes with
postsurgical aphakia or dislocated IOLs (unpublished
data). There have been no cases of dislocation.
We describe a new triple procedure: femtosecond la-
ser–assisted PKP, AC IOL explantation, and fibrin
glue–assisted sutureless IOL implantation in the pos-
terior chamber for the management of PBK with an

Q 2009 ASCRS and ESCRS 0886-3350/09/$dsee front matter 973

Published by Elsevier Inc. doi:10.1016/j.jcrs.2008.12.049
974 TECHNIQUE: NEW TRIPLE PROCEDURE
AC IOL. The unique benefits of femtosecond laser and
a ‘‘glued IOL’’ could be adjunctive and provide en-
hanced results in cases having PKP and IOL exchange.
SURGICAL TECHNIQUE
Femtosecond-Assisted Donor And Host Preparation
The initial part of the surgery is done at the femto-
second laser facility. Donor buttons are prepared
from whole globes. After the suction ring is applied
and adequate vacuum and centration are achieved,
a top-hat configuration is created using a 60 kHz fem-
tosecond laser (IntraLase FS [IntraLase Corp.]) (Fig-
ure 1, top right, bottom left). For the host cut, the
patient is given topical anesthesia. After the suction
ring is applied and adequate vacuum and centration
are achieved, a top-hat configuration is created. The
donor cornea and patient are then moved to the kera-
toplasty operating room.
Combined Keratoplasty and IOL Exchange
with Modification for the Glued IOL
The rest of the surgery is performed under peribulbar
anesthesia. A limited peritomy is done in the inferotem-
poral and superonasal areas 180 degrees apart, and
a 3.0 mm  3.0 mm area is marked on the sclera. Two
partial-thickness limbal-based scleral flaps of 3.0 mm
are created. Two straight sclerotomies, one slightly infe-
rior to the other, are made with an 18-gauge needle
1.5 mm from the limbus under the existing scleral flaps
(Figure 1, bottom right). The top hat is inspected for
J CATARACT REFRACT SURG - VOL 35, JUNE 2009
Figure 1. Top left: Preoperative photo-
graph showing PBK with an AC IOL
in situ. Top right: Femtosecond laser–
created top-hat configuration. Bottom
left: Femtosecond–assisted top-hat con-
figuration showing the predictable and
uniform wound formation. Bottom
right: Inferior straight sclerotomy
made with an 18-gauge needle 1.5 mm
from the limbus under the existing
scleral flaps. Note the diametrically
opposite scleral flaps.
completeness. After the host button is removed, the
AC IOL is explanted (Figure 2, bottom left). Limited
open-sky anterior vitrectomy is then performed.
A posterior chamber 6.5 mm IOL is held with
a McPherson forceps at the pupillary plane with one
hand. An end-gripping 25-gauge microcapsulorhexis
forceps (MicroSurgical Technology) is passed through
the inferior sclerotomy with the other hand. The tip of
the leading haptic is grasped with the microcapsulo-
rhexis forceps and pulled through the inferior scleroto-
my following the haptic curve (Figure 2, bottom right).
The haptic is then externalized under the inferior scleral
flap (Figure 3, top left). The trailing haptic is also external-
ized through the superior sclerotomy under the scleral
flap (Figure 3, top right). After both haptics have been ex-
ternalized, the graft is placed and cardinal sutures are
applied (Figure 3, bottom left). With a 22-gauge needle,
a scleral tunnel is created along the curve of the external-
ized haptic at the edge of the scleral bed of the flap (Fig-
ure 3, bottom right). The haptic is tucked into this tunnel
(Figure 4, top left; higher magnification, Figure 4, top
right). A similar tunnel is created in the complimentary
area on the other side, and tucking is performed. Fibrin
glue (Tisseel, Baxter) is reconstituted from a pack con-
taining freeze-dried human fibrinogen, freeze-dried
human thrombin, and aprotinin solution. The reconsti-
tuted fibrin glue is injected through the cannula of the
double syringe delivery system under the superior and
inferior scleral flaps (Figure 4, bottom left). Local pressure
is applied to the flaps for 30 seconds to allow polypep-
tide formation. The same glue is applied in the area
 TECHNIQUE: NEW TRIPLE PROCEDURE
between the sutures at the entire graft–host junction
(Figure 4, bottom right). The conjunctiva is also apposed
with the glue.
Postoperatively, gatifloxacin eyedrops are pre-
scribed 4 times a day, prednisolone acetate 6 times
a day, homatropine sulfate 3 times a day, and preser-
vative-free tear substitutes 6 times a day.
J CATARACT REFRACT SURG - VOL 35, JUNE 2009
975
Figure 2. Top left: Augmentation of the
top-hat configuration in areas that had
poor laser penetration because of over-
lying opacity. Top right: Posterior uncut
tissue dissected with a Vannas scissors.
Bottom left: Explantation of the AC IOL
after removal of the host button. Bottom
right: Leading haptic grasped with the
microcapsulorhexis forceps for being
pulled through the inferior sclerotomy
following the haptic curve.
Results
The triple procedure was performed in 3 patients
with PBK with AC IOL (Table 1). The mean age of
the patients at presentation was 46 years. The preoper-
ative best corrected visual acuity (BCVA) was light
perception, counting fingers, and counting fingers.
Top-hat configuration was sculpted, with the donor
Figure 3. Top left: Leading haptic exter-
nalized completely under the inferior
scleral flap. Top right: The trailing hap-
tic externalized through the superior
sclerotomy under the scleral flap. Bot-
tom left: The graft button placed and
cardinal sutures applied. Bottom right:
Scleral tunnel created along the curve
of the externalized haptic in the super-
onasal area at the edge of the scleral
bed of the flap.
976 TECHNIQUE: NEW TRIPLE PROCEDURE

Figure 4. Top left: The superior haptic

tucked into the superonasal tunnel.
Top right: The tucking shown at higher
magnification. Bottom left: Reconsti-
tuted fibrin glue injected through the
cannula of the double syringe delivery
system under the inferior scleral flap.
Bottom right: The glue applied at the
graft–host junction.

graft oversized by 0.2 mm in all 3 cases. The femtosec- The immediate postoperative course was unevent-
ond laser parameters for the donor and lenticule prep- ful, and the BCVA had improved to counting fingers,
aration are shown in Table 2. 6/12, 6/9, respectively, at the 1-month follow-up. The

Table 1. Characteristics of the 3 patients.

Characteristic Patient 1 Patient 2 Patient 3

Age, y/sex 75/ F 25/M 35/M

Diagnosis PBK with AC IOL PBK with AC IOL PBK with AC IOL
Systemic problems None None None
Ocular problems None Conjunctival scarring None
with narrow palpebral
aperture (secondary to
viral illness)
Preop
BCVA LP CF CF
Corneal thickness (mm) 648 622 630
Applanation IOP (mm Hg) 24 16 18
AL on A-scan (mm) 22.6 24.3 23.2
Explanted IOL AC IOL AC IOL AC IOL
Postop
BCVA (4 mo) CF 6/12 6/9
Applanation IOP (mm Hg) 18 12 14
Implanted IOL PC IOL (6.5 mm optic, PC IOL (6.5 mm optic, PC IOL (6.5 mm optic,
13.5 mm overall diameter) 13.5 mm overall diameter) 13.5 mm overall diameter)
Implanted IOL power (D) C22.5 C18.0 C21.0
Intraop and postop complications None Preexisting fornix scarring; None
required canthotomy
for suction ring placement

AC IOL Z anterior chamber intraocular lens; BCVA Z best corrected visual acuity; CF Z counting fingers; LP Z light perception; PC IOL Z posterior chamber
intraocular lens; PBK with AC IOL Z pseudophakic bullous keratopathy with AC IOL

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 TECHNIQUE: NEW TRIPLE PROCEDURE 977

Table 2. Femtosecond laser parameters for the 3 donors and recipients.

Parameter Donor 1 Recipient 1 Donor 2 Recipient 2 Donor 3 Recipient 3

Lamellar cut
Depth (mm) 275 275 275 275 275 275
Outer diameter (mm) 7.8 7.6 8.8 8.6 8.4 8.2
Inner diameter (mm) 6.1 5.9 7.1 6.9 6.7 6.5
Lamellar energy (mJ) 1.40 1.40 1.40 1.40 1.40 1.40
Tangential spot separation (mJ) 5 5 5 5 5 5
Radial spot separation (mJ) 5 5 5 5 5 5
Anterior side cut
Posterior depth (mm) 305 305 305 305 305 305
Anterior diameter (mm) 6.2 6.0 7.2 7.0 6.4 6.2
Anterior energy (mJ) 1.45 1.45 1.45 1.45 1.45 1.45
Anterior side-cut angle 90 90 90 90 90 90
Anterior side-cut spot separation (mm) 2 2 2 2 2 2
Anterior side-cut layer separation (mm) 2 2 2 2 2 2
Posterior side cut
Anterior depth (mm) 245 245 245 245 245 245
Posterior diameter (mm) 7.7 7.5 8.7 8.5 8.7 8.5
Posterior energy (mJ) 1.45 1.45 1.45 1.45 1.45 1.45
Posterior depth (mm) 1200 500 1200 500 1200 500
Posterior side-cut angle 90 90 90 90 90 90
Posterior side-cut spot separation (mm) 2 2 2 2 2 2
Posterior side-cut layer separation (mm) 2 2 2 2 2 2

first case had prexisting advanced glaucoma with tra-
beculotomy; the BCVA did not improve much after the
procedure. At the 4-month follow-up, all 3 patients
maintained the 1-month BCVA. There were no
episodes of keratoplasty-related problems (infection,
rejection, dehiscence) or IOL-related problems (vitre-
ous incarceration, endophthalmitis, subluxation,
haptic extrusion).
DISCUSSION
In PKP cases, all attempts should be made to minimize
endothelial cell loss in the intraoperative and postop-
erative periods. To provide the maximum number of
endothelial cells to the host, there may be a tendency
toward larger grafts in conventional keratoplasty for
bullous keratopathy. However, this is associated
with an increased epithelial cell load, which is proba-
bly associated with a higher risk for graft rejection.19,20
Since a top-hat configuration is larger at the inner end,
it provides a greater number of endothelial cells for the
same number of epithelial cells. In addition, with the
top-hat configuration, smaller outer sizes can be pre-
pared and the graft–host junction can be farther from
the limbus centripetally, reducing chances of neovas-
cularization. These 2 unique advantages of the top-
hat configuration may enhance graft survival by
reducing chances of graft rejection and promoting en-
dothelial survival.
We noted an incomplete cut in one case (patient 2),
which was completed by manual dissection. However,
the partial cuts created by the femtosecond laser acted
as a template for lamellar separation. In future, with
increased penetration and better laser mechanics, the
more challenging scarred cornea might also be suc-
cessfully sculpted.
Intraocular lens exchange is arguably the more chal-
lenging step in this surgery. The safety and long-term
efficacy of a transsclerally sutured PC IOL are less than
satisfactory.12–14 The transsclerally sutured IOL is as-
sociated with a steep learning curve and requires spe-
cial steps that an anterior segment surgeon may not
use routinely. In a previous study,12 ultrasound biomi-
croscopy showed that transscleral suturing of an IOL
had problems related to accurate suturing at the ciliary
sulcus. In addition, there are issues with IOL iris con-
tact, pigment dispersion, high aqueous flare, and vitre-
ous incarceration.
In PKP, the conventional wisdom is to reduce the
‘‘open-sky’’ duration to as short a time as possible as
there is an associated risk for expulsive hemorrhage
or choroidal effusion. The tamponade effect of a se-
curely fixated IOL can be helpful in the duration be-
tween completion of host dissection and suturing of
the donor button (the open-sky period). Transscleral
suture fixation requires adjustment of the sutures
and knots to maintain the IOL in position, leading to

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978 TECHNIQUE: NEW TRIPLE PROCEDURE
a delay in placement of the donor button. It also re-
quires a special IOL with eye haptics and may not be
readily available.
An open-sky procedure is often associated with an-
terior vitrectomy. The resultant hypotony makes su-
ture placement and adjustment difficult. In an open-
sky procedure with a deficient posterior capsule,
there is no tamponade effect and the results can be
disastrous if the patient strains or coughs. The aim
of the surgeon in this scenario should be to reduce
the surgical time. Most of the time consumption in
these cases is in passing the straight needle and ty-
ing and adjusting the sutures. A glued IOL can be
used as a safe and effective alternative. The new
technique has a short learning curve. Most steps, ex-
cept externalization and tucking, are part of routine
anterior segment procedures.18 There is no require-
ment for an extra set of sutures and a straight nee-
dle, which can be difficult to pass in a hypotonous
open globe.
While doing scleral fixation with sutures, the sur-
geon must readjust the knots to maintain the central
position of the IOL. In our procedure, simply manipu-
lating the amount of externalization can cause proper
centration of the IOL. The final tucking of the haptic
provides further stabilization.
A sutured scleral-fixated IOL hangs in the posterior
chamber, with the sutures passing through the haptic
eyes, similar to a hammock, causing dynamic torsional
and anteroposterior oscillation. This pseudophacodo-
nesis may result in progressive endothelial loss. How-
ever, in our technique, rigid haptics are used for
fixation on the scleral side and the stable optic–haptic
J CATARACT REFRACT SURG - VOL 35, JUNE 2009
Figure 5. Diagram showing biomechanical and kinetic
properties of manual keratoplasty with transscleral su-
ture-fixated PC IOL (TSF IOL) (top) and femtosecond-as-
sisted keratoplasty (FAK) with glued IOL (bottom).
Differences between the 2 approaches are indicated by
the points. Point 1, top: Haptic–suture junction in the
TSF IOL, with the IOL hanging like a hammock. Point
1, bottom: Rigid PMMA haptic in glued IOL fixated
with the sclera. Point 2, top: Transverse graft–host junc-
tion. Point 2, bottom: More stable top-hat configuration.
Point 3, top: Size of epithelial side (outer cut) same as
that of endothelial side (inner cut). Point 3, bottom: Size
of epithelial side (outer cut) less than that of endothelial
side (inner cut), leading to greater number of endothelial
cells for smaller epithelial load and placement of sutures
farther from limbus. Point 4, top: Knots in TSF IOL may
degrade and slip. Point 4, bottom: Haptic is securely
tucked and sealed with fibrin glue in glued IOL. Point
5, top: More pseudophacodonesis with TSF IOL. Point
5, bottom: Less pseudophacodonesis with glued IOL.
junction prevents torsional and anteroposterior insta-
bility. Therefore, there is much less pseudophacodone-
sis (Figure 5).
The haptics are covered in the scleral flap and
tucked well inside the scleral pocket. There is an addi-
tional well-apposed layer of conjunctiva over the
sclera. This further reduces the chances of haptic
extrusion.
Femtosecond laser–assisted keratoplasty with top-
hat configuration and a glued IOL provides a unique
solution in cases with bullous keratopathy and AC
IOLs. This is an improvement over the traditional tech-
nique of manual trephination and transscleral suture
fixation of the IOL (Figure 5). The femtosecond laser’s
top-hat configuration provides a greater number of en-
dothelial cells in the donor lenticule and a more stable
wound configuration. Better dynamic stability of the
glued IOL prevents pseudophacodonesis and may re-
duce endothelial cell loss or repositioning surgery.
Combined, these 2 surgical modalities may improve
results. Although our initial results with this technique
are good, larger comparative trials to evaluate the
long-term outcome of the technique with that of man-
ual trephination with a transscleral suture-fixated IOL
will provide more conclusive evidence.
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