Double-flanged knotless technique for iris prosthesis and IOL implantation associated with keratoplasty

Introduction: Anterior segment reconstruction and penetrating keratoplasty combined with iris prosthesis (IP) and intraocular lens (IOL) scleral fixation require prolonged open-sky surgery and complex suturing. Herein we present a novel double-flanged knotless surgical technique that minimizes the open sky duration and facilitates the fixation of the IP and IOL complex to the sclera.Methods: After corneal trephination and removal, a temporary keratoprosthesis is fixated. Three 5.0 polypropylene suture segments are introduced in the anterior chamber transconjunctivally and then externalized through keratoprosthesis. Each suture is threaded through the eyelets of the IP and then flanged. The temporary keratoprosthesis is removed, and the IP and IOL complex is positioned in the sulcus. A donor cornea button is sutured in place and the IP is centred on the optical axis by adjusting the polypropylene sutures. Finally, the suture ends are shortened, flanged, and buried under the conjunctiva.Results: Surgery was performed on three eyes of three patients. No intraoperative complications occurred, while cystoid macular edema and ocular hypertension occurred in two patients during the follow-up period. The best corrected visual acuity was 6/20, 8/20, and 13/20. So far the IPs remained stable in the three eyes with a maximum follow-up of 18 months.Conclusion: This novel technique of penetrating keratoplasty combined with an intraocular lens (IOL) and iris prosthesis implantation makes it possible to reduce open sky surgery time, avoid complex suturing, and ensure optimal IOL visual axis alignment by adjusting suture tension.