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Original Article

Post-Keratoplasty Glaucoma in Secondary
Trans-Scleral Fixation of Posterior Chamber
Intra-Ocular Lens Implant

Abdul Hye, Abrar Ahmad Bhatti, Zahid Kamal Siddiqui, Imran Akram Sahaf

Pak J Ophthalmol 2011, Vol. 27 No. 4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
See end of article for
authors affiliations

…..………………………..

Correspondence to:
Abdul Hye
Department of Ophthalmology
Postgraduate Medical Institute
Lahore

Resubmission of paper
August’ 2011

Acceptance for publication
September’ 2011
…..………………………..

Purpose: Purpose of this study was to observe the incidence of post-
keratoplasty glaucoma in secondary scleral fixation of IOL in patients of aphakia
and pseudophakic bullous keratopathy (Group I). These patients were
compared, with clinically matched patients, undergoing penetrating keratoplasty
with posterior chamber IOL in the presence of capsular support (Group II).
Material and Methods: 25 consecutive patients of bullous keratopathy in
aphakic eyes without capsular support or in pseudophakic eyes with AC IOLs
were included in this prospective study. Penetrating keratoplasty was performed
by suturing 0.25 mm larger donor corneal graft with interrupted 10/0 nylon
monofilament sutures, after fixing the IOL to the sclera with 10/0 prolene suture.
The statistical analysis was performed using Fisher’s exact test and chi-square
test 2x2 table. The finding was considered significant at P value < 0.05.
Results: The post-operative visual acuity, in the study population as whole,
ranged from < 0.05 to 0.33 Snellen’s fraction (i.e. hand movement to 6/18
Snellen’s VA). A statistically significant improvement was noted (p-value < 0.05
using Fisher’s exact test and chi-square analysis), when post-operative visual
acuity was compared with pre-operative visual acuity in each group. However,
comparing the study groups, there was no statistically significant difference in
the post-operative visual acuity (p-value> 0.05).
The incidence of post-operative glaucoma was 32% incidence of glaucoma in
group I was 40% (10/25 patients) and in group II was 24% (6/25 patients). The
difference between the two groups in the post-operative incidence of glaucoma
was statistically significant (p value<0.05). Comparing the difference between
pre-operative and post-operative incidence of glaucoma, it was statistically
significant within the group I (p value<0.05) as a whole (p value < 0.05).
Conclusion: While Trans-scleral fixation of posterior chamber intra-ocular lens
has a place in eyes lacking capsular support it does lead to higher frequency of
post-keratoplasty glaucoma.

aised intra-ocular pressure, contributes to loss
of corneal endothelial cells as well as to
progressive optic nerve damage, and is a well

known complication of penetrating keratoplasty. The
incidence of post – keratoplasty glaucoma in aphakic

eyes ranges from 42% to 89%1-2. Corneal edema and
bullous keratopathy in aphakic and pseudophakic
eyes continue to remain the leading indication of
penetrating keratoplasty3-7. In eyes without capsular
support, scleral fixation of posterior chamber IOL is

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preferred because the posterior chamber IOL fixed to
sclera are more physiological, is closer to nodal point
of eye and acts as a barrier against the vitreous
movements. Scleral fixation PC IOLs play a definitive
role in preventing cystoids macular edema and graft
endothelial damage8-12. In addition, the penetrating
keratoplasty procedures combined with closed loop
anterior chamber IOL failed in 60% of the patients in
one study13.

PURPOSE
Purpose of this study was to observe the frequency of
glaucoma (raised IOP) after scleral fixation and scleral
fixation in patients with aphakic and pseudophakic
corneal edema and bullous keratopathy (Group I).
These patients were compared with clinically matched
patients undergoing penetrating keratoplasty with
posterior chamber IOL in the presence of capsular
support (Group II).

MATERIAL AND METHODS
25 consecutive patients of corneal oedema and bullous
keratopathy in aphakic eyes without capsular support
or in pseudophakic eyes with AC IOLs were included
in this prospective study. A complete ophthalmic and
medical history was taken, and ophthalmological
examination, including recording of VA, measuring
IOP with applanation tonometer, and B-scan were
performed (Table 1-2).

In group I, after removal of oedematous corneal
button, adequate anterior vitrectomy was performed
removing the vitreous from the anterior chamber and
from behind the iris. A posterior chamber IOL was
fixed to sclera in an oblique plane, using 10/0 prolene
suture with a small 8.0 mm needle, passed through the
dilated pupil behind the iris emerging in an area of
lamellar scleral flap 1.5 mm from the limbus and tied
under the flap. Penetrating keratoplasty was
completed by suturing 0.25 mm larger donor corneal
graft with interrupted 10/0 nylon monofilament
sutures.

In group II, after removal of edematous corneal
button, extra capsular cataract extraction was
performed and posterior chamber IOL was implanted
either in the capsular bag or in the sulcus. Penetrating
keratoplasty was completed by suturing 0.25 mm
larger donor corneal button in a fashion similar to the
group I.

Post-operatively, a combination of Tobramycin
and Dexamethasone eye drops was prescribed, to be

used 2 hourly for 2 weeks and 4 hourly for 2 months.
Topical and oral anti-glaucoma medicines were added
when required.

All patients were followed for at least six months,
and the post-operative visual acuity and IOP were
recorded and compared with pre-operative findings,
not only within the group, but also with each other.
The post-keratoplasty glaucoma was defined as IOP
more than 21 mm Hg, when associated with non-
inflammatory corneal graft edema and/or optic nerve
damage. The characteristic visual field changes and
the glaucomatous optic neuropathy may not be
evident due to corneal edema and visual distortion
related to higher astigmatism. The statistical analysis
was performed using Fisher’s exact test and chi-square
test 2x2 table. The finding was considered significant
at P value < 0.05.

RESULTS
Group I: Twenty five eyes of 24 patients of aphakic or
pseudophakic bullous keratopathy were studied. One
patient had sequential bilateral surgery. The male
patients were more than the females with a ratio of 3:1.
Average age of patients was 45.4 years, with a range of
9 years to 68 years.

Group II: Twenty five eyes of 25 clinically
matched patients undergoing penetrating keratoplasty
with posterior chamber IOL in the presence of
capsular support were included. The male patients
were more than the females with a ratio of 2:1.
Average age of patients was 58.8 years, with a range of
23 years to 86 years. Both groups of patients were
studied and compared primarily in respect of pre-
operative and post-operative visual acuity and
incidence of post-operative glaucoma. The
comparison, between the groups, was performed
using Fisher’s exact test and chi-square analysis. A
finding was considered significance at P value< 0.05.

The improvement in the visual acuity: The pre-
operative visual acuity in both the groups ranged from
perception of light to finger counting at one meter
distance. Comparing the study groups, there was no
significant difference in the pre-operative visual acuity
(p-value> 0.05).

The post-operative visual acuity, in the study
population as a whole, ranged from < 0.05 to 0.33
Snellen’s fraction (i.e. hand movement to 6/18
Snellen’s VA). Comparing the study groups, there was
no significant difference in the post-operative visual
acuity (p-value> 0.05 (Table 3). However the

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Table 1: (Group I)

No ID Age/Sex Eye Visual Acuity
Pre-op Post-op

IOP mmHg
Pre-op Post-op

Remarks

1 RAR 57/M R.E FC 6/12c 12 16 No Glaucoma

2 MK 58/M L.E FC 6/18c 21* 32* Uncontrolled glaucoma
Required Trab. MMC

3 MP 26/M L.E HM 6/18 22* 21* Controlled with topical R

4 AI 25/M L.E HM 6/18 20 39* Uncontrolled glaucoma
Required Trab. MMC

5 MA 31/M L.E FC 6/18c 12 16 No Glaucoma

6 HA 68/M R.E HM 6/36 13 14 No Glaucoma

7 SM 57/M R.E HM 6/60 15 15 No Glaucoma

8 JB 56/F L.E PL 3/60 18 23 No Glaucoma

9 PA 35/M R.E FC 6/12c 23* 21* Controlled with topical R

10 BB 35/F R.E HM 6/36 10 09 No Glaucoma

11 FK 23/M L.E HM 6/18 18 23* Controlled with topical R
Ret.Det. 6 Month Post-op.

12 MR 46/M L.E FC 6/12c 15 17 No Glaucoma

13 H 32/M R.E HM 6/18 17 27* Uncontrolled glaucoma
Required Trab. MMC

14 RB 57/F L.E PL 3/60 24* 14* Controlled with topical R

15 BB 35/F L.E HM 6/60 14 16 No Glaucoma

16 SM 56/M L.E HM 6/36 24 14* Controlled with topical R

17 MS 64/M L.E HM 6/36 14 12 No Glaucoma

18 UF 32/M L.E FC 6/60 23* 28* Uncontrolled glaucoma
Required Trab. MMC

19 NI 09/M R.E PL 6/60 12 13 Ret.Det. 2 Month Post-op.

20 BB 57/F R.E HM 6/36 15 14 No Glaucoma

21 RB 62/F L.E FC 6/18 18* 20* Controlled with topical R

22 Q 52/M R.E FC 6/18 12 13 No Glaucoma

23 IA 42/M L.E FC 6/36 20 21 No glaucoma

24 NS 55/M L.E HM 6/36 15 14 No Glaucoma

25 KD 65/M R.E HM 6/36 15 14 No Glaucoma

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Table 2: (Group II)

Sr. N ID Age/Sex Eye Visual Acuity
Pre-op Post-op

IOP mmHg
Pre-op Post-op

Remarks

1 AG M/55 L.E HM 6/36 21 17* Post-op. Glaucoma-
Controlled with topical R

2 JD M/86 R.E FC 6/24 18 16* Post-op. Glaucoma-
Controlled with topical R

3 AR F/60 L.E 1/60 6/12 14 13 No Glaucoma

4 MRA M/70 R.E FC 6/18 14 15 No Glaucoma

5 M F/65 L.E 1/60 6/24 20 17 No Glaucoma

6 AR F/60 R.E 1/60 6/18 16 17 No Glaucoma

7 BD M/65 R.E HM 6/36 12 13 No Glaucoma

8 MI F/60 L.E HM 6/24 14 16 No Glaucoma

9 HA M/56 R.E PL 6/24 15 15 No Glaucoma

10 MU M/65 R.E PL HM 12 11 No Glaucoma

11 MS M/65 R.E CF 6/36 15 17 No Glaucoma

12 MNB M/27 R.E 5/60 6/36 10 11 No Glaucoma

13 RG M/53 L.E 3/60 6/36 12 11 No Glaucoma

14 RT F/25 R.E 2/60 6/24 12 12 No Glaucoma

15 GS M/80 L.E CF 6/36 15* 16* Pre-and Post-op. Glaucoma-
Controlled with topical R

16 KZ M/57 L.E 4/60 6/6p 12 13 No Glaucoma

17 MA M/58 L.E HM 6/18 13 13 No Glaucoma

18 M F/50 L.E FC 6/12 12 13 No Glaucoma

19 RB 62/F R.E FC 6/18 16* 20* Pre-and Post-op. Glaucoma-
Controlled with topical R

20 MTB 66/M L.E 1/60 6/9 14* 16* Pre-and Post-op. Glaucoma-
Controlled with topical R

21 KY 70/M L.E 1/60 6/9 13 12 No Glaucoma

22 SN 23/F L.E PL 6/9 23* 14* Pre-and Post-op. Glaucoma-
Controlled with topical R

23 MA 55/M L.E FC 6/24 14 15 No Glaucoma

24 HB 72/F R.E HM 6/18 12 13 No Glaucoma

25 RSA 47/M L.E FC 6/24 13 12 No Glaucoma

*IOP with topical anti-glaucoma therapy.

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improvement in the visual acuity in each study group,
was statistically significant (p-value< 0.05), when post-
operative visual acuity compared with pre-operative
visual acuity.

The incidence of post-keratoplasty glaucoma:
(Table 4).

Table 3: Post-operative visual acuity

Visual Acuity
Snellen’s Chart/
Snellen’s fraction

Group I
(N=25) (%)

Group II
(N=25) (%)

Total
(N=50) (%)

From 6/18 to 6/6 11/25 11/25 22/50

From 6/18 to 6/60 12/25 13/25 25/50

Less than 6/60 02/25 01/25 03/50

Table 4: Incidence of pre and post-operative elevated
IOP

Group

Incidence
Pre-operative Post-operative
Patients n (%) Patients n (%)

PKP with scleral fixation
of IOL (Group I N=25)

6/25 (24) 10/25 (40)

PKP with ECCE with
IOL in the bag /sulcus
(Group II N=25)

4/25 (16) 6/25 (24)

Total 10/50 (20) 16/50 (32)

The pre-operative frequency of glaucoma in group

I, was 24% (i.e.6/25 patients) and in group II, was 16%
(i.e.4/25 patients), the total frequency of glaucoma
being 20%. The difference between the two groups in
the pre-operative incidence of glaucoma was not
statistically significant (p value>0.05).

The post-operative incidence of glaucoma in
group I, was 40% (i.e.10/25 patients) and in group II,
was 24% (i.e.6/25 patients), the total incidence of post-
operative glaucoma being 32%. There difference
between the two groups in the post-operative
incidence of glaucoma was statistically significant (p
value<0.05). Comparing the difference between pre-
operative and post-operative incidence of glaucoma, it

was statistically significant within the group I (p
value<0.05), and as a whole (p value<0.05), but not
within the group II (p value>0.05).

DISCUSSION
Raised intra-ocular pressure contributes to loss of
corneal endothelial cells as well as to progressive optic
nerve damage and is a well known complication of
penetrating keratoplasty. The incidence of post-
keratoplasty glaucoma in aphakic eyes ranges from
42% to 89%1-2. The other risk factors for post-
keratoplasty glaucoma are pre-existing glaucoma,
previous graft, and incorrect surgical technique of
keratoplasty. In this study pre-existing glaucoma
(6/25 patients, 24%) in group I, contributed to the
incidence of glaucoma. These patients had pre-
operative AC IOL related gross angle distortion which
causes secondary glaucoma and also increases the
severity of bullous keratopathy. Post-operatively 4
additional patients developed glaucoma, in addition
to the existing cases. Many investigators reported
increased frequency of post-operative glaucoma after
intra-capsular cataract extraction or after extracapsular
cataract extraction with loss of posterior capsular
support. Zimmerman and co-workers14 postulated that
the absence of crystalline lens and the zonules results
in loss of support of the trabecular meshwork,
resulting in raised IOP. The increased number of post-
operative glaucoma, in patients undergoing
vitrectomy and scleral fixation of IOL may be due the
loss of support of trabecular meshwork, in addition to
the factors related to the surgical procedure of
keratoplasty like tight sutures, smaller or equal size of
donor cornea etc.

Johnson et al15 and Heidmann et al16, in two
separate series of patients undergoing combined
penetrating keratoplasty with trans-scleral fixation of
IOL for pseudophakic bullous keratopathy, reported a
post-operative visual acuity of 20/40 or greater in 27%
and 31% of eyes, with 11 to 13 months follow up,
respectively. Clear grafts were noted in 89% to 93% of
cases. Cystoid macular edema was seen in 31% and
36% of cases, which adversely affect the visual
outcome.

Table 5: Incidence of post-keratoplasty elevated IOP: comparison with the reported studies

Richard C.
Troutman and

others

Lyle WA and
Jin JC

T L Vander Shaft
and others

Holland EJ and
others

Present study

Incidence 34% 39% 46% 56% 40%

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Troutman and co-workers17 reported 34% (15 out
of 44 patients) incidence of post operative glaucoma in
a series of patients undergoing combined penetrating
keratoplasty with trans-scleral fixation IOL. These
required anti-glaucoma medications except two, who
required filtration procedures.

Lyle and Jin18 reported 39% incidence of post
operative glaucoma in patients undergoing combined
penetrating keratoplasty with IOL exchange for
pseudophakic bullous keratopathy.

Similarly Shaft and co-workers19 reported 46%
incidence of post operative glaucoma in patients
undergoing combined penetrating keratoplasty with
exchange of original intra-ocular lens with a tripod
posterior chamber IOL sutured to the iris for
pseudophakic bullous keratopathy.

Holland et al20 reported 30% (20 out of 66 patients)
incidence of new onset of post operative glaucoma in
patients undergoing combined penetrating
keratoplasty with trans-scleral fixation IOL for
pseudophakic bullous keratopathy, while 39 out of 105
patients had pre-op glaucoma. So the total incidence of
post operative glaucoma reported in this study was
56% (59 out of 105 patients).

In the present study, the incidence of post-
keratoplasty glaucoma is comparable with reported
studies (Table 5). The variable incidence of post-
operative glaucoma in the above mentioned reported
studies and the present study as well, may be due to
the fact that pre-operative factors responsible for the
glaucoma may vary in different studies22. Per
operative factors like varying surgical techniques by
different surgeons or in-accurate surgical technique,
like relatively smaller or equal size of donor
cornealbutton23 may also have played a role as well as
post-operative factors, like inflammatory sequelae,
suturing technique, and drug induced elevation of IOP
may be responsible23.

CONCLUSION
Trans-scleral fixation of posterior chamber intra-ocular
lens is suitable in cases lacking capsular support
specially when combined with penetrating
keratoplasty. In this study the frequency of the post-
keratoplasty glaucoma in bullous keratoplathy is
significantly higher in those patients who had
undergone scleral fixation of IOL.

Author’s affiliation

Dr. Abdul Hye
Associate Professor
Department of Ophthalmology
Postgraduate Medical Institute
Lahore
Dr. Abrar Ahmad Bhatti
Department of Ophthalmology
Postgraduate Medical Institute
Lahore
Dr. Zahid Kamal Siddiqui
Associate Professor
Department of Ophthalmology
Postgraduate Medical Institute
Lahore
Prof. Imran Akram Sahaf
Professor of Ophthalmology
Department of Ophthalmology
Postgraduate Medical Institute
Lahore

REFERENCE
1. Karesh JW, Nirankari MS: Factors associated with glaucoma

after penetrating keratoplasty. Am J Ophthalmol. 1983; 96: 160.
2. Daily RA. The effects of timolol meleate and acetazolamide on

rate of aqueous formation in normal human subjects. Am J
Ophthalmol. 1982; 93: 232.

3. Arentsen JJ, Morgan B, Green WR: Changing indications for
keratoplasty. Am J Ophthalmol. 1976; 81: 313.

4. Mamilis N. penetrating keratoplasty: clinical indications and
pathological findings. J Catract Refract Surg. 1991; 17: 163.

5. Robin JB. An update of indication of keratoplasty. Arch
Ophthalmol. 1986; 104: 87.

6. Smith RE. Penetrating keratoplasty: changing indications.
Arch Ophthalmol. 1980; 98: 1226.

7. Mamilis N. Changing trends in the indications for penetrating
keratoplasty. Arch Ophthalmol. 1992; 110: 1409.

8. Heidmann DG, Dunn SP: Transclerally sutured intraocular
lenses in penetrating keratoplasty. Am J Ophthalmol. 1992; 113:
619.

9. Soong HK, Meyer RF, Sugar A: Techniques of posterior
chamber lens implantation without capsular support during
penetrating keratoplasty. Refract Corneal Surg. 1989; 5: 249.

10. Soong HK. Implantation of posterior chamber intraocular lens
in the absence of lens capsule in penetrating keratoplasty. Arch
Ophthalmol. 1989; 107: 660.

11. Stark WJ. Posterior chamber intraocular lens implantation in
the absence of capsular support. Arch Ophthalmol. 1989; 107:
1078.

12. Arkin MS, Steinert RF: Sutured posterior chamber intraocular
lenses. In Jakobiec FA, Adamis AP, editors: controversies in
ophthalmology, Vol 34, Boston, 1994, Little, Brown.

13. Speaker MG. Psuedophakic bullous keratopathy: management
of intraocular lens. Ophthalmology. 1988; 95: 1260.

14. Zimmerman T. Transplant size and elevated IOP, Arch
Ophthalmol. 1978; 96: 2231.

186

15. Johnson SM. Results of exchanging anterior chamber lenses
with sulcus fixed posterior chamber IOLs without capsular
support in penetrating keratoplasty. Ophthalmic Surg. 1989;
20: 465.

16. Heidmann DG, Dunn SP. Visual results and complications of
transclerally sutured intraocular lenses in penetrating
keratoplasty. Ophthalmic Surg. 1990; 21: 609.

17. Richard C. Troutman and others: Combined penetrating
keratoplasty and posterior chamber intraocular lens
implantation in the absence of a lens capsule, TB. AM. OPHTH.
SOC. Vol. LXXXVIII. 1990; 326-339.

18. Lyle WA, Jin JC. An analysis of intraocular lens exchange.
Ophthalmic Surg. 1992; 23: 453-8.

19. Schaft TLVD, Rij GV, Renardel JGC, et al. Results of

penetrating keratoplasty for psuedophakic bullous keratopathy
with the exchange of an intraocular lens. Br J Ophthalmology.
1989; 73: 704-8.

20. Holland EJ, Daya SM. Penetrating keratoplasty and transcleral
fixation of posterior chamber lens. Am J Ophthalmol. 1992; 114:
182-7.

21. Bourne WM, Davison MA. The effects of oversize donor
buttons on postoperative IOP and corneal curvature in aphakic
penetrating keratoplasty. Ophthalmology. 1982; 89: 242.

22. Corneal surgery: theory, technique, and tissue/ edited by
Frederick S. Brightbill 3rd ed. chapter 49, page 387,
pathogenesis of post-keratoplasty glaucoma by Catherine
Newton, and Linda L. Burk.