• Users Online: 4839
  • Print this page
  • Email this page

 Table of Contents  
Year : 2018  |  Volume : 56  |  Issue : 4  |  Page : 251-253

Combined penetrating keratoplasty with extraocular needle-guided haptic insertion technique

1 Department of Vitreo-Retina, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Chennai, Tamil Nadu, India
2 Department of Cornea, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Chennai, Tamil Nadu, India
3 Department of Vitreo-Retina, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Puducherry, India
4 Department of Glaucoma, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Puducherry, India

Date of Web Publication19-Feb-2019

Correspondence Address:
Dr. Prabu Baskaran
Department of Vitreo-Retina, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Noombal, Poonamallee High Road, Chennai - 600 077, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_92_18

Rights and Permissions

Scleral fixation of intraocular lens (SFIOL) is a challenge in eyes with opaque corneas. It is preferable to implant the IOL before performing penetrating keratoplasty. Most techniques described so far involve SFIOL following corneal trephination (open sky) which increases the risk of expulsive choroidal hemorrhage. Extraocular needle-guided haptic insertion technique involves extraocular docking of the IOL haptic into a bent 26-gauge needle followed by its exteriorization. Since this crucial step of SFIOL surgery is completely extraocular, this method can be used to safely place an SFIOL in a well-formed globe even before corneal trephination. Use of a silicone stopper over the leading haptic prevents intraocular rebound of the haptic.

Keywords: Extraocular needle-guided haptic insertion technique, keratoplasty, scleral fixation of intraocular lens

How to cite this article:
Baskaran P, Ramakrishnan S, Ganne P, Krishnappa NC, Venkatesh R. Combined penetrating keratoplasty with extraocular needle-guided haptic insertion technique. TNOA J Ophthalmic Sci Res 2018;56:251-3

How to cite this URL:
Baskaran P, Ramakrishnan S, Ganne P, Krishnappa NC, Venkatesh R. Combined penetrating keratoplasty with extraocular needle-guided haptic insertion technique. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2023 Jan 27];56:251-3. Available from: https://www.tnoajosr.com/text.asp?2018/56/4/251/252500

  Introduction Top

Visual rehabilitation of patients with corneal scarring and aphakia involves keratoplasty with intraocular lens (IOL) implantation. The various options for the placement of an IOL include anterior-chamber IOLs, iris-fixated lenses, and scleral fixation of IOL (SFIOL). SFIOL is preferred over other methods owing to a lesser risk of complications such as glaucoma, graft failure, and macular edema.[1] Conventional sutureless SFIOL surgery involves intraocular handing over of haptics from one forceps to another (hand-shake).[2] However, doing hand shake in an opaque cornea will be the biggest challenge owing to the difficulty in visualization of the intraocular maneuvers. The recent extraocular needle-guided haptic insertion (X-NIT) technique described by Baskaran et al.[3] can address this difficulty, especially in scarred corneas. Here, we describe a combined X-NIT with penetrating keratoplasty (PKP) technique.

  Case Report Top

A 67-year-old gentleman presented with diminished vision in the left eye for 10 years following a fire cracker injury. He gave a history of some intraocular surgery done elsewhere 10 years ago. At presentation, his best-corrected visual acuity (BCVA) was 20/20 on the right and hand movements on the left. Anterior-segment examination of the left eye showed extensive stromal scarring with stromal and epithelial edema. There were inferior sectoral aniridia and aphakia. Ultrasonography of the left eye showed a normal posterior segment without any obvious optic nerve head cupping. The patient underwent X-NIT with PKP as described below. There were no intraoperative complications. There was no postoperative hypotony, vitreous hemorrhage, or choroidal detachment. Six months postsurgery, his BCVA was 20/200 with a clear corneal graft and well-centered SFIOL.

Surgical technique

The surgery was performed under peribulbar anesthesia. 25-guage (G) pars plana ports were placed and good anterior vitrectomy was performed. A fornix-based conjunctival peritomy was done superiorly, and a self-sealing sclerocorneal wound of 5.5 mm was made. A toric IOL marker was used to mark the 3 and 9'o clock hour meridians. Limited conjunctival peritomy was done. Two partial-thickness scleral grooves of 4 mm length were fashioned (1.5 mm behind and parallel to the limbus) using a 23G micro-vitreoretinal blade. Both tunnels were created in a counterclockwise direction. A standard 26G needle (1.5 inch) was bent to 60° at the hub. A 2.5 mm × 3 mm silicone stopper was fashioned using the #240 band used for retinal detachment surgery. The bent 26G needle was pierced through the center of this stopper and the needle was passed into the ciliary sulcus 1.5 mm behind the limbus, just at the commencement of the scleral tunnel fashioned at the 3'o clock meridian. Once the needle was visualized within the pupillary margin, it was brought out through sclerocorneal wound with a McPherson's forceps depressing the posterior lip of the sclerocorneal wound. Once the needle tip was extraocular, 3–4 mm of the leading haptic of a three-piece polymethyl methacrylate IOL (Aurolens, Aurolab, India) was threaded into the needle using a McPherson's forceps [Figure 1]a. The 26G needle with the haptic was then withdrawn out of the sclerotomy. The silicone stopper was slid over the entire needle shaft and onto the exteriorized portion of the haptic. The needle was withdrawn leaving the leading haptic with the silicone stopper to prevent slippage and intraocular rebound of the haptic during further steps. A new 26G needle similarly bent was inserted through the sclera at the 9'o clock meridian and the trailing haptic exteriorized [Figure 1]b. The haptics were tucked into the scleral grooves and the IOL centered [Figure 1]c. The sclerocorneal wound was sutured with 10 o nylon. Ports were removed and the conjunctival peritomy was sutured with 7 o vicryl. The host cornea was measured, marked, and trephined, and the donor button was sutured to the host rim as is done in a routine PKP surgery [Figure 1]d. [Video 1] shows the technique described.
Figure 1: (a) Photograph showing a bent 26-gauge needle with a silicone stopper being brought out of the corneoscleral wound. The leading haptic is threaded into the needle. (b) A second 26-gauge needle is being used to exteriorize the trailing haptic at the opposite meridian. (c) The haptics of the intraocular lens being tucked into the preformed scleral grooves. (d) Photograph showing a corneal graft with a well-centered intraocular lens

Click here to view

  Discussion Top

Visual rehabilitation in a case of corneal scarring with aphakia can be achieved in many ways. Although the trend is to opt for lamellar corneal surgeries, a PKP will be necessary if there is dense corneal scarring. SFIOL is preferred over other methods of secondary IOL implantation owing to a lesser risk of complications such as glaucoma, graft failure, and macular edema.[1] Sutureless SFIOL surgery avoids suture-related complicationa such as knot breakage and postoperative IOL decenteration.[4] However, visualization of intraocular maneuvers such as intraocular handing over of haptics from one forceps to another (hand-shake) through an opaque cornea is the biggest challenge in such cases.

Sinha et al.[5] have described a method of combining PKP with SFIOL. In this technique, intraocular hand-shake was done open sky since significant corneal opacification precluded intraocular view. Similarly, Karadag et al.[6] have described a trocar-assisted, sutureless SFIOL implantation combined with PKP wherein the IOL is placed open sky and the scleral tunnels are sutured at the end of the surgery. Sethi et al.[7] have used a 26G needle to exteriorize the IOL haptic open sky. However, with open sky scleral fixation, there is an increased risk of vitreous loss and expulsive choroidal hemorrhage.[8] Cervantes[9] has described a novel method of SFIOL implantation in a closed chamber using two needles. However, leaving a sharp needle in the ciliary sulcus while manipulating rest of the IOL may carry the risk of peripheral retinal injury and haptic slippage. This technique involves intraocular threading the IOL haptic through the needle which may not be possible if the cornea is significantly opaque.

Although this procedure can be performed with a good anterior vitrectomy alone, we used the pars plana ports to use an endoilluminator and cause diffuse retroillumination which enhances visualization of the anterior-segment structures.[10]

Although SFIOL can be placed after a PKP is done, the intraocular maneuvers during SFIOL surgery can compromise the donor endothelial health. In this regard, X-NIT technique offers the advantage of a safe SFIOL surgery before cornel trephination in a perfectly formed globe. In this technique, all maneuvers are totally extraocular which makes it suitable and safe in most grades of corneal opacification. This technique has a short learning curve and is safe even in the hands of a novice surgeon.

What was known

  • X-NIT technique is a novel and completely extraocular method of exteriorizing IOL haptics in SFIOL surgery.

What this paper adds

  • X-NIT can be combined with PKP
  • SFIOL surgery can be done before keratoplasty in a completely formed globe even when the cornea is significantly opaque.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Evereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2003;29:301-8.  Back to cited text no. 1
Gabor SG, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007;33:1851-4.  Back to cited text no. 2
Baskaran P, Ganne P, Bhandari S, Ramakrishnan S, Venkatesh R, Gireesh P, et al. Extraocular needle- guided haptic insertion technique of scleral fixation intraocular lens surgeries (X-NIT). Indian J Ophthalmol 2017;65:747-50.  Back to cited text no. 3
[PUBMED]  [Full text]  
Asadi R, Kheirkhah A. Long-term results of scleral fixation of posterior chamber intraocular lenses in children. Ophthalmology 2008;115:67-72.  Back to cited text no. 4
Sinha R, Shekhar H, Sharma N, Tandon R, Titiyal JS, Vajpayee RB, et al. Intrascleral fibrin glue intraocular lens fixation combined with descemet-stripping automated endothelial keratoplasty or penetrating keratoplasty. J Cataract Refract Surg 2012;38:1240-5.  Back to cited text no. 5
Karadag R, Bayramlar H, Azari AA, Rapuano CJ. Trocar-assisted, sutureless, scleral-fixated intraocular lens implantation combined with penetrating keratoplasty. Cornea 2016;35:1261-5.  Back to cited text no. 6
Sethi HS, Naik MP, Gupta VS. 26-G needle-assisted sutureless glueless intrascleral haptic fixation for secondary ciliary sulcus implantation of three-piece polymethylmethacrylate intraocular lens during penetrating keratoplasty. Taiwan J Ophthalmol 2016;6:141-4.  Back to cited text no. 7
[PUBMED]  [Full text]  
Nardi M, Giudice V, Marabotti A, Alfieri E, Rizzo S. Temporary graft for closed-system cataract surgery during corneal triple procedures. J Cataract Refract Surg 2001;27:1172-5.  Back to cited text no. 8
Cervantes LJ. Combined double-needle flanged-haptic intrascleral fixation of an intraocular lens and descemet-stripping endothelial keratoplasty. J Cataract Refract Surg 2017;43:593-6.  Back to cited text no. 9
Shimizu T, Hayashi T, Yuda K, Tsuchiya A, Oyakawa I, Mizuki N, et al. Chandelier illumination for descemet membrane endothelial keratoplasty. Cornea 2017;36:1155-7.  Back to cited text no. 10


  [Figure 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded167    
    Comments [Add]    

Recommend this journal