Pars plana vitrectomy combined with penetrating keratoplasty  and transscleral-sutured intraocular lens implantation in complex eyes: a case series

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Methods In this prospective, consecutive interventional case series, patients who underwent PKP combined with PPV and IOL implantation from July 2014 to March 2018 at Yokohama Minami Kyosai Hospital were enrolled. The postoperative best corrected visual acuity (BCVA) (converted to logarithm of the minimal angle of resolution [logMAR] units), intraocular pressure (IOP, mmHg), endothelial cell density (ECD, cells/mm 2 ), graft survival, complications, astigmatism, and spherical equivalent (dioptres [D]) were evaluated. Results This study included 11 eyes of 11 patients (three females and eight males; mean age, 61.8 ± 13.9 years) with an injury (n = 6) or bullous keratopathy (n = 5). The BCVA significantly improved from 1.50 ± 0.66 logMAR preoperatively to 0.78 ± 0.59 logMAR (p < 0.001) postoperatively. The baseline ECD significantly decreased from 2396 ± 238 cells/mm 2 preoperatively to 1132 ± 323 cells/mm 2 (p < 0.001) postoperatively. Despite two rejection episodes, graft survival rates were 100%. The mean follow-up period was 38.0 ± 20.5 months. Two patients required combined glaucoma surgery, and three patients underwent subsequent glaucoma surgery. Postoperative astigmatism and spherical equivalent were 3.9 ± 3.2 D and 0.29 ± 2.18 D, respectively. Conclusion The combination of PKP, PPV, and IOL-suture implantation could be a safe and effective approach for eyes requiring anterior segment surgery; however, these eyes are associated with a higher incidence of glaucoma surgery. Ophthalmology penetrating keratoplasty pars plana vitrectomy intraocular lens implantation transscleral-sutured intraocular lens Figures Figure 1 Background Corneal transplantation has been the most common type of organ transplantation over the last century.[1, 2] Despite the increasing number of lamellar surgeries such as deep anterior lamellar keratoplasty (DALK), endothelial keratoplasty (EK), Descemet’s stripping automated endothelial keratoplasty (DSAEK), and Descemet’s membrane endothelial keratoplasty, approximately 40% of all keratoplasties performed are penetrating keratoplasties (PKPs).[3, 4] There are downsides to PKP, such as suture-related problems (higher astigmatism or infection), transplant rejection, glaucoma (steroid-dependent), and rupture due to injury.[3] Despite these problems,[5-7] PKP could drastically improve the sight of patients with severe corneal disease or damage.[8] Simple stromal opacity and corneal oedema caused by endothelial dysfunction could be treated with DALK and EK, respectively.[9, 10] However, most cases that require PKP are complex, and patients can have a history of corneal injury or infection. These cases may require multiple procedures such as a vitrectomy for vitreous problems including vitreous prolapse, vitreous haemorrhage, or retinal detachment; iris reconstruction for an iris defect or angle closure; intraocular lens (IOL) implantation for aphakia; or glaucoma surgery for progressive glaucoma.[8, 11-16] In these situations, simultaneous surgeries could be beneficial to the patient. For example, a full vitrectomy could prevent retinal detachment, and iris reconstruction and IOL implantation could be performed for visual recovery. In cases of extremely high intraocular pressure (IOP) that are resistant to drug therapy, a combined glaucoma surgery might be essential to prevent the progression of glaucoma.[17-22] Herein, this case series investigates the surgical technique and clinical course of PKP combined with pars plana vitrectomy (PPV) and transscleral-sutured intraocular lens implantation (IOL-suture). To the best of our knowledge, this is the first study to investigate this approach and report the good outcomes of simultaneous complex ocular surgeries. Methods Study Design This prospective study was approved by the institutional Review Board (approval no. YKH_26_05_12) and adhered to the tenets of the Declaration of Helsinki. The study procedures followed all institutional guidelines, and all patients provided informed consent. Patients requiring PKP combined with PPV and IOL-sutures from July 2014 to March 2017 were enrolled. Surgical Technique All surgeries were performed under general anaesthesia. All of the surgical steps are shown in Figure 1. The surgical design was determined prior to the surgical steps. Firstly, two scleral tunnels were created after resecting the conjunctiva. A scleral ring for combined surgery (Nishida scleral ring, Inami, Tokyo, Japan) was sutured to the sclera with 6-0 silk (Mani, Tochigi, Japan), and 10-0 polypropylene sutures were fixed to the loop of the IOL (CZ70BD ® , Alcon, Fort Worth, TX ) on both sides using the cow-hitch technique.[23] PPV was performed using a 25-gauge (Constellation; Alcon, Fort Worth, TX) and a wide-viewing system (Resight 500; Carl Zeiss Meditec, Jena, Germany) in closed system (not open-sky) prior to trephination by retina specialists. Even in patients with a history of vitrectomy, the residual vitreous was checked and removed completely by shaving the vitreous base. We performed a complete PPV, stopped the infusion, and reduced the IOP prior to trephination to prevent vitreous prolapse or suprachoroidal haemorrhage. The host cornea was cut using a trephine (Katena, Denville, USA) at 7.5 mm. The donor graft was prepared using a donor punch (Katena, Denville, USA) at either 7.75 mm or 8.0 mm. Using the open-sky PPV technique, the 10-0 polypropylene needles pierced the scleral flap 2.0 mm from the limbus. The donor graft was sutured using 10-0 nylon (Mani, Tochigi, Japan). The appropriate amount of cohesive ophthalmic viscosurgical devices (OPELEAD ® HV [0.85] 1%) was used during the procedure. Postoperative Care Postoperative medications included 1.5% levofloxacin (Cravit) for 2 weeks, 0.1% betamethasone sodium phosphate (Sanbetasone; Santen) for 3 months, and 2% rebamipide ophthalmic solution (Mucosta; Otsuka, Japan, Tokyo) for 3 months, starting at 4 times per day and tapered thereafter. If necessary, glaucoma agents were applied. Patients and Examinations Besides the standard examination using slit-lamp microscopy, the following main outcomes were evaluated both preoperatively and postoperatively in all eyes: best spectacle-corrected visual acuity (BCVA) converted to logarithm of the minimal angle of resolution (logMAR) units, intraocular pressure (IOP, mmHg), and endothelial cell density (ECD, cells/mm 2 ). Graft survival, complications, astigmatism, and the spherical equivalent were also evaluated (measured in dioptres [D]). The main outcome results for all the included cases are shown in Table 1. Table 1 . Patient Characteristics Case OD/OS Aetiology Type of surgery Previous surgeries Additional surgery Pre VA Post VA 1 OD Bullous keratopathy PKP+re-PPV +IOL-suture+GDD Trabeculectomy (failed), PEA+PPV+Silicon oil No CF 20/2000 2 OD Ocular trauma PKP+re-PPV +IOL-suture PEA+PPV GDD 20/29 20/23 3 OS Ocular trauma (perforation) PKP+re-PPV +IOL-suture PEA+PPV+Corneal suture No 20/400 20/250 4 OS Ocular trauma (perforation) PKP+PPV +IOL-suture PEA+Corneal suture No 20/2000 20/220 5 OS Bullous keratopathy PKP+re-PPV +IOL-suture+GDD PEA+PPV+Silicon oil, Silicon oil removal No 20/2000 20/250 6 OS Bullous keratopathy PKP+PPV +IOL-suture ECCE, PKP (twice) No 20/100 20/29 7 OS Ocular trauma PKP+PPV +IOL-suture PKP Trabeclectomy 20/400 20/100 8 OS Bullous keratopathy PKP+re-PPV +IOL-suture PEA+PPV+Corneal suture, PKP GDD 20/2000 20/50 9 OD Bullous keratopathy PKP+PPV +IOL-suture PKP+ECCE No 20/600 20/130 10 OS Ocular trauma PKP+PPV +IOL-suture PEA+PPV +Silicon oil injection +Corneal suture, Silicon oil removal No 20/2000 20/50 11 OS Ocular trauma PKP+PPV +IOL-suture PEA+Corneal suture No 20/600 20/130 All patients underwent pars plana vitrectomy with penetrating keratoplasty and transscleral-sutured intraocular lens implantation. OD, right eye; OS, left eye; Pre, preoperative; VA, best corrected visual acuity; Post, postoperative; PKP, penetrating keratoplasty; PPV, pars plana vitrectomy; IOL-suture, transscleral-sutured posterior chamber intraocular lens implantation; GDD, glaucoma drainage device; PEA, phacoemulsification and aspiration; ECCE, extracapsular cataract extraction; CF, counting fingers. Statistical Analyses Statistical analyses were performed using JMP Pro software version 14.0.0 (SAS Institute, Cary, NC, USA). Statistical significance was defined as p < 0.05. All average values are described as mean ± standard deviation. For the statistical analyses, BCVA was converted to logMAR units. Regarding poor visual acuity, the logMAR values were translated to light perception, logMAR = 2.8; perception of hand motions, logMAR = 2.3; and counting fingers, logMAR = 2.0 [24]. The Mann-Whitney U test was used to compare the preoperative and postoperative outcomes (BCVA, IOP, astigmatism). Results Patient Characteristics Three female and eight male patients, with an average age of 61.8 ± 13.9 years, took part in this study. The corneal aetiology was either injury (n = 6) or bullous keratopathy (n = 5). The average follow-up period was 38.0 ± 20.5 months (Table 1). Clinical Course (Visual Recovery and Endothelial Cell Density) The BCVA (converted to logMAR units) significantly improved from 1.50 ± 0.66 logMAR preoperatively to 0.78 ± 0.59 logMAR (p < 0.001) postoperatively. The baseline ECD (ECD of the donor tissue) significantly decreased from 2396 ± 238 cells/mm 2 preoperatively, to 1132 ± 323 cells/mm 2 (p < 0.001) postoperatively. Figure 1 shows the graft survival for this case series. Postoperative astigmatism and spherical equivalent were 3.9 ± 3.2 D and 0.29 ± 2.18 D, respectively. Complications The baseline IOP was 15.8 ± 12.9 mmHg preoperatively. Five cases required glaucoma surgery either simultaneously or postoperatively. Two patients had an IOP over 40 mmHg and required combined glaucoma surgery. Three patients had an increased IOP that was resistant to anti-glaucomatous agents and underwent subsequent glaucoma surgery (two patients had pars plana glaucoma drainage devices implanted, and one had filtrating surgery). The postoperative IOP was stable (12.7 ± 3.6 mmHg). One patient developed an epiretinal membrane and required membrane removal. Two eyes showed reversible graft rejection, and there was no graft failure. Discussion The current study shows our technique for a pars plana approach, such as PPV, combined with PKP. All procedures were performed without complications. Under a wide-viewing system, PPV could be completed without the use of an artificial cornea. Any residual vitreous base following PPV could be removed with the shaving technique. Without treatment these patients with complex needs may have gone blind, but following the combined surgery, the visual function of the patients significantly improved, and the mid-term survival rates were excellent. There were no cases of retinal detachment following surgery. Despite the improvement in corneal transparency and visual recovery, the requirement for additional glaucoma surgeries was relatively high. Patients may have a better quality of life if IOL implantation and PKP are performed simultaneously. There are three suggestions regarding the importance and the efficacy of the posterior approach during PKP: First, the prevention of retinal detachment (including proliferative vitreous retinopathy) is very important. It seems appropriate that retina specialists perform PPV in combination with PKP to avoid the risk of retinal detachment following an incomplete vitrectomy such as an anterior vitrectomy in the posterior capsule rupture, or IOL-suture. If there is a complication in the posterior segment during PPV, such as a retinal break, it can be rapidly addressed. [25] Second, the posterior approach in simple cases could be performed without difficulty. Since our case series did not include severe corneal opacity, all procedures could be performed with a wide-viewing system (without any artificial corneas such as Eckardt temporary keratoprosthesis) in closed system prior to trephination (not open-sky vitrectomy). Performing the vitrectomy via closed system PPV rather than open-sky vitrectomy allowed us to reduce the time of open-sky status, an advantage of our procedure. The use of PPV with a temporary keratoprosthesis has been reported. Yokogawa et al. published a report on the combined treatment of PKP or DSAEK using an artificial cornea.[8, 15, 16] In our experience, we had no trouble performing a simple PPV, including the creation of a posterior vitreous detachment and shaving of the peripheral vitreous body. Third, the incidence of globe collapse could be reduced by the use of posterior infusion. Using this approach, the globe could be well-maintained without sudden collapses. The results of this study show that the combined procedure of PKP, PPV, and IOL-suture could be a safe and effective approach for patients requiring anterior segment surgery. Despite the increasing number of scleral fixations,[26] in the present study the preferred method was an IOL-suture. There were limitations to this study, such as the relatively small number of participants, differing aetiologies, and different treatment protocols. First, the lack of long-term follow-up is the most important limitation. Despite suture breakage after IOL suture being one of the major late complications (especially when using 10-0 polypropylene),[27] our follow-up period was relatively short. Second, our procedure was performed with the help of retina specialists. Although the PPV portion was performed by retina specialists with very good results, it is impossible to compare our method to anterior vitrectomy alone or PPV performed by anterior segment surgeons. Thirdly, postoperative glaucoma developed in 5 cases requiring glaucoma surgery. Two cases required an Ahmed valve, one needed a Baerveldt implant, and one case needed filtrating surgery (trabeculectomy) after PKP. One case was treated with a simultaneous glaucoma implant, (Baerveldt) PKP, PPV, and IOL-suture surgery. According to past reports, the combined surgery of PKP and Ahmed valve implantation had a negative impact on graft survival. However, in the present study, the glaucoma shunt tubes were placed into the pars plana, because tube implantation to the pars plana has been shown to result in better corneal graft survival rates and reduce complications compared with implantation into the anterior chamber.[28-32] Since the type of glaucoma surgery was selected according to either the patient’s condition or the glaucoma surgeon’s preference, only one case was treated by trabeculectomy. In the future, long-term studies regarding the correlation between glaucoma surgery and keratoplasty will be necessary for further development. Conclusion In conclusion, the current study advocates the importance and efficacy of the posterior approach combined with PKP for anterior segment surgeons. List Of Abbreviations PPV, pars plana vitrectomy; PKP, penetrating keratoplasty; IOL, intraocular lens; IOL-suture, transscleral-sutured intraocular lens implantation; DALK, deep anterior lamellar keratoplasty; EK, endothelial keratoplasty; DSAEK, Descemet’s stripping automated endothelial keratoplasty DSAEK; BCVA, best corrected visual acuity; logMAR, logarithm of the minimum angle of resolution; ECD, endothelial cell density; IOP, intraocular pressure Declarations Ethics approval and consent to participate: This prospective study was approved by the institutional Review Board (approval no. YKH_26_05_12) of Yokohama Minami Kyosai Hospital and adhered to the tenets of the Declaration of Helsinki. The study procedures followed all institutional guidelines, and all patients provided written informed consent for participation. Consent for publication: Not applicable. Availability of data and Materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Funding: This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Competing interests: The authors declare that they have no competing interests. Authors' contributions: T.H.: writing, review and editing; Y.Y.: review and editing, investigation; T.S.: data curation, and editing; T.K., Y.K., and Y.I.: investigation; K.Y.: project administration, supervision, and validation; All authors critically checked the manuscript and approved the submission. Acknowledgements: The authors thank Dr. Y Ando for critical comments concerning this study. References Zirm EK. Eine erfolgreiche totale keratoplastik (A successful total keratoplasty). Arch Fr Ophthalmol. 1906;64:580-83. Coster DJ, Williams KA. 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Corneal graft survival and intraocular pressure control after penetrating keratoplasty and glaucoma drainage device implantation. Ophthalmology . 2001;108:1978-85. doi:10.1016/s0161-6420(01)00803-x Witmer MT, Tiedeman JS, Olsakovsky LA, Conaway MR, Prum BE. Long-term intraocular pressure control and corneal graft survival in eyes with a pars plana Baerveldt implant and corneal transplant. J Glaucoma. 2010;19:124-31. doi:10.1097/IJG.0b013e3181a98cc1 Cite Share Download PDF Status: Published Journal Publication published 14 Sep, 2020 Read the published version in BMC Ophthalmology → Version 3 posted Editorial decision: Accept 08 Sep, 2020 Editor assigned by journal 07 Sep, 2020 Submission checks completed at journal 06 Sep, 2020 Editor invited by journal 06 Sep, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-37812","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":2174040,"identity":"8892a412-aa92-4ff0-9a93-1a84494dcb36","order_by":0,"name":"Takahiko Hayashi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYFACNhDBLAciDzwgRgMPVIsxWEsCKVoSG0AUUVrs2Y8lfrpRYZ0+P+zwQ6AtdnK6DYRs4Uk7LJ1zJj134+00A6CWZGOzAwQdlt4gndt2OHfj7ASQlgOJ2whq4X/e/Dv33+F0w9npH4jUIpF2TDq34XCCvHQOsbbceJZmnXMs3XCDdE7BgQQDIvzC3p9mfDunxlpefnb65g8fKuzkCGqBAwOwSgNilYOAfAMpqkfBKBgFo2BEAQDr40TLAPcAeAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-8704-680X","institution":"Yokohama Minami Kyosai Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Takahiko","middleName":"","lastName":"Hayashi","suffix":""},{"id":2174041,"identity":"a05aaf0e-2618-45e6-9350-e2dbce04854b","order_by":1,"name":"Yasutsugu Ida","email":"","orcid":"","institution":"Yokohama Minami Kyosai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yasutsugu","middleName":"","lastName":"Ida","suffix":""},{"id":2174042,"identity":"d77d7099-a450-4fda-b2f8-ddb89650052b","order_by":2,"name":"Toshiki Shimizu","email":"","orcid":"","institution":"Yokohama Shiritsu Daigaku","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Toshiki","middleName":"","lastName":"Shimizu","suffix":""},{"id":2174043,"identity":"660cc1c8-2a2f-4ac5-86b1-c0993cfccc72","order_by":3,"name":"Tsubasa Kuroki","email":"","orcid":"","institution":"Yokohama Minami Kyosai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tsubasa","middleName":"","lastName":"Kuroki","suffix":""},{"id":2174044,"identity":"9aaaaa7c-75ac-4f00-aa60-0bc2dd478d8f","order_by":4,"name":"Yuji Kobashigawa","email":"","orcid":"","institution":"Yokohama Minami Kyosai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuji","middleName":"","lastName":"Kobashigawa","suffix":""},{"id":2174045,"identity":"264b5f73-79e9-4d1c-8cde-d972dce63f86","order_by":5,"name":"Yasuhito Iijima","email":"","orcid":"","institution":"Sofukai Oppama Ekimae Eyeclinic","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yasuhito","middleName":"","lastName":"Iijima","suffix":""},{"id":2174046,"identity":"fa6cb31b-cf98-4d2b-87bf-b54075cdf19c","order_by":6,"name":"Kentaro Yuda","email":"","orcid":"","institution":"Kikuna Yuda Eye Clinic","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kentaro","middleName":"","lastName":"Yuda","suffix":""}],"badges":[],"createdAt":"2020-06-24 18:26:01","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-37812/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-37812/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-020-01639-y","type":"published","date":"2020-09-14T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2363927,"identity":"09a79c45-c4f4-4d6c-9ff9-b2bfd73e89a9","added_by":"auto","created_at":"2020-09-11 15:36:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":265305,"visible":true,"origin":"","legend":"Design of combined penetrating keratoplasty (PKP), pars plana vitrectomy (PPV), and intraocular lens (IOL)-suture surgery\n(A) The surgical design should be determined prior to surgery including where to place the scleral ring and whether to create two scleral flaps or three-ports. After determination of the surgical design, two scleral pockets for the intraocular lens (IOL) suturing are created at the surgeons’ preference. \n(B) A scleral ring (Nishida ring, Inami) is sutured to the sclera with 6-0 silk. \n(C) Two 10-0 polypropylene sutures (PC-9) are fixated to the top of the IOL loop (CZ, Alcon) before the next procedure.\n(D) Three-ports are created using a 25-gauge trocar (Alcon), and the infusion canula was set.\n(E) Using the wide-viewing system, core vitrectomy and peripheral vitrectomy is performed.\n(F), (G) Using a trephine and Katzin Scissors, the host cornea is removed. \n(H) In the open-sky technique (partial dissection), the IOL is sutured to the two scleral flaps 1.5 mm from the limbus.\n(I) The IOL is placed at the back of the iris and is centred.\n(J) The donor graft is sutured using 10-0 nylon.\n","description":"","filename":"OnlineFig.1.Png","url":"https://assets-eu.researchsquare.com/files/rs-37812/v3/OnlineFig.1.Png"},{"id":13591613,"identity":"db9ca948-01d3-472f-b405-a512dd1aba6d","added_by":"auto","created_at":"2021-09-17 05:09:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1079166,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-37812/v3/6d45cb7c-a1bd-4bf4-bbff-e27f7739bf84.pdf"}],"financialInterests":"","formattedTitle":"Pars plana vitrectomy combined with penetrating keratoplasty and transscleral-sutured intraocular lens implantation in complex eyes: a case series","fulltext":[{"header":"Background","content":"\u003cp\u003eCorneal transplantation has been the most common type of organ transplantation over the last century.[1, 2] Despite the increasing number of lamellar surgeries such as deep anterior lamellar keratoplasty (DALK), endothelial keratoplasty (EK), Descemet\u0026rsquo;s stripping automated endothelial keratoplasty (DSAEK), and Descemet\u0026rsquo;s membrane endothelial keratoplasty, approximately 40% of all keratoplasties performed are penetrating keratoplasties (PKPs).[3, 4]\u003c/p\u003e\n\u003cp\u003eThere are downsides to PKP, such as suture-related problems (higher astigmatism or infection), transplant rejection, glaucoma (steroid-dependent), and rupture due to injury.[3] Despite these problems,[5-7] PKP could drastically improve the sight of patients with severe corneal disease or damage.[8]\u003c/p\u003e\n\u003cp\u003eSimple stromal opacity and corneal oedema caused by endothelial dysfunction could be treated with DALK and EK, respectively.[9, 10] However, most cases that require PKP are complex, and patients can have a history of corneal injury or infection. These cases may require multiple procedures such as a vitrectomy for vitreous problems including vitreous prolapse, vitreous haemorrhage, or retinal detachment; iris reconstruction for an iris defect or angle closure; intraocular lens (IOL) implantation for aphakia; or glaucoma surgery for progressive glaucoma.[8, 11-16] In these situations, simultaneous surgeries could be beneficial to the patient. For example, a full vitrectomy could prevent retinal detachment, and iris reconstruction and IOL implantation could be performed for visual recovery. In cases of extremely high intraocular pressure (IOP) that are resistant to drug therapy, a combined glaucoma surgery might be essential to prevent the progression of glaucoma.[17-22]\u003c/p\u003e\n\u003cp\u003eHerein, this case series investigates the surgical technique and clinical course of PKP combined with pars plana vitrectomy (PPV) and transscleral-sutured intraocular lens implantation (IOL-suture). To the best of our knowledge, this is the first study to investigate this approach and report the good outcomes of simultaneous complex ocular surgeries.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective study was approved by the institutional Review Board (approval no. YKH_26_05_12) and adhered to the tenets of the Declaration of Helsinki. The study procedures followed all institutional guidelines, and all patients provided informed consent. Patients requiring PKP combined with PPV and IOL-sutures from July 2014 to March 2017 were enrolled.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed under general anaesthesia. All of the surgical steps are shown in Figure 1. The surgical design was determined prior to the surgical steps. Firstly, two scleral tunnels were created after resecting the conjunctiva. A scleral ring for combined surgery (Nishida scleral ring, Inami, Tokyo, Japan) was sutured to the sclera with 6-0 silk (Mani, Tochigi, Japan), and 10-0 polypropylene sutures were fixed to the loop of the IOL (CZ70BD\u003csup\u003e\u0026reg;\u003c/sup\u003e, Alcon, Fort Worth, TX ) on both sides using the cow-hitch technique.[23] PPV was performed using a 25-gauge (Constellation; Alcon, Fort Worth, TX) and a wide-viewing system (Resight 500; Carl Zeiss Meditec, Jena, Germany) in closed system (not open-sky) prior to trephination by retina specialists. Even in patients with a history of vitrectomy, the residual vitreous was checked and removed completely by shaving the vitreous base. We performed a complete PPV, stopped the infusion, and reduced the IOP prior to trephination to prevent vitreous prolapse or suprachoroidal haemorrhage. The host cornea was cut using a trephine (Katena, Denville, USA) at 7.5 mm. The donor graft was prepared using a donor punch (Katena, Denville, USA) at either 7.75 mm or 8.0 mm. Using the open-sky PPV technique, the 10-0 polypropylene needles pierced the scleral flap 2.0 mm from the limbus. The donor graft was sutured using 10-0 nylon (Mani, Tochigi, Japan). The appropriate amount of cohesive ophthalmic viscosurgical devices (OPELEAD\u003csup\u003e\u0026reg;\u003c/sup\u003e HV [0.85] 1%) was used during the procedure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative medications included 1.5% levofloxacin (Cravit) for 2 weeks, 0.1% betamethasone sodium phosphate (Sanbetasone; Santen) for 3 months, and 2% rebamipide ophthalmic solution (Mucosta; Otsuka, Japan, Tokyo) for 3 months, starting at 4 times per day and tapered thereafter. If necessary, glaucoma agents were applied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Examinations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBesides the standard examination using slit-lamp microscopy, the following main outcomes were evaluated both preoperatively and postoperatively in all eyes: best spectacle-corrected visual acuity (BCVA) converted to logarithm of the minimal angle of resolution (logMAR) units, intraocular pressure (IOP, mmHg), and endothelial cell density (ECD, cells/mm\u003csup\u003e2\u003c/sup\u003e). Graft survival, complications, astigmatism, and the spherical equivalent were also evaluated (measured in dioptres [D]). The main outcome results for all the included cases are shown in Table 1.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"line-height: 200%; font-family: Helvetica; font-size: 13px;\"\u003eTable 1\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e. Patient Characteristics\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cdiv align=\"center\" style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:150%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003ctable style=\"width: 86%;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eCase\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border:solid windowtext 1.0pt;border-left: none;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOD/OS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border:solid windowtext 1.0pt;border-left: none;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eAetiology\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border:solid windowtext 1.0pt;border-left: none;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eType of surgery\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border:solid windowtext 1.0pt;border-left: none;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePrevious surgeries\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border:solid windowtext 1.0pt;border-left: none;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eAdditional surgery\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border:solid windowtext 1.0pt;border-left: none;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePre\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eVA\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border:solid windowtext 1.0pt;border-left: none;padding:0in 5.4pt 0in 5.4pt;height:44.9pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePost\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eVA\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e1\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eBullous keratopathy\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+re-PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture+GDD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eTrabeculectomy (failed),\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+PPV+Silicon oil\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eCF\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/2000\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOcular trauma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+re-PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eGDD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/29\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/23\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOcular trauma (perforation)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+re-PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+PPV+Corneal suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/400\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/250\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e4\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOcular trauma (perforation)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+Corneal suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/2000\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/220\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eBullous keratopathy\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+re-PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture+GDD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+PPV+Silicon oil,\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSilicon oil removal\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/2000\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/250\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e6\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eBullous keratopathy\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eECCE, PKP (twice)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/100\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/29\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e7\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOcular trauma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eTrabeclectomy\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/400\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/100\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e8\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eBullous keratopathy\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+re-PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+PPV+Corneal suture, PKP\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eGDD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/2000\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/50\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e9\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eBullous keratopathy\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+ECCE\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/600\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/130\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e10\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOcular trauma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+Silicon oil injection\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+Corneal suture,\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eSilicon oil removal\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/2000\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/50\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:8.64%;border:solid windowtext 1.0pt;border-top: none;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e11\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:8.72%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOS\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.96%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eOcular trauma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:13.52%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePKP+PPV\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e+IOL-suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:21.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003ePEA+Corneal suture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:15.0%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003eNo\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.26%;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size: 13px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/600\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:9.9%;border-top:none;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.15pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-family: Helvetica; font-size: 13px;\"\u003e\u003cspan style=\"line-height: 200%;\"\u003e20/130\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"line-height: 200%; font-family: Helvetica; font-size: 13px;\"\u003eAll patients underwent pars plana vitrectomy with penetrating keratoplasty and transscleral-sutured intraocular lens implantation.\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:6.0pt;margin-left:0in;line-height:200%;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"line-height: 200%; font-family: Helvetica; font-size: 13px;\"\u003eOD, right eye; OS, left eye; Pre, preoperative; VA, best corrected visual acuity; Post, postoperative; PKP, penetrating keratoplasty; PPV, pars plana vitrectomy; IOL-suture, transscleral-sutured posterior chamber intraocular lens\u003csub\u003e\u0026nbsp;\u003c/sub\u003eimplantation; GDD, glaucoma drainage device; PEA, phacoemulsification and aspiration; ECCE, extracapsular cataract extraction; CF, counting fingers.\u003c/span\u003e\u003c/p\u003e\u003cbr\u003e\u003cp\u003e\u003cstrong\u003eStatistical Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using JMP Pro software version 14.0.0 (SAS Institute, Cary, NC, USA). Statistical significance was defined as p \u0026lt; 0.05. All average values are described as mean \u0026plusmn; standard deviation. For the statistical analyses, BCVA was converted to logMAR units. Regarding poor visual acuity, the logMAR values were translated to light perception, logMAR = 2.8; perception of hand motions, logMAR = 2.3; and counting fingers, logMAR = 2.0 [24]. The Mann-Whitney U test was used to compare the preoperative and postoperative outcomes (BCVA, IOP, astigmatism).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree female and eight male patients, with an average age of 61.8 \u0026plusmn; 13.9 years, took part in this study. The corneal aetiology was either injury (n = 6) or bullous keratopathy (n = 5). The average follow-up period was 38.0 \u0026plusmn; 20.5 months (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Course (Visual Recovery and Endothelial Cell Density)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe BCVA (converted to logMAR units) significantly improved from 1.50 \u0026plusmn; 0.66 logMAR preoperatively to 0.78 \u0026plusmn; 0.59 logMAR (p \u0026lt; 0.001) postoperatively. The baseline ECD (ECD of the donor tissue) significantly decreased from 2396 \u0026plusmn; 238 cells/mm\u003csup\u003e2\u003c/sup\u003e preoperatively, to 1132 \u0026plusmn; 323 cells/mm\u003csup\u003e2\u003c/sup\u003e (p \u0026lt; 0.001) postoperatively. Figure 1 shows the graft survival for this case series. Postoperative astigmatism and spherical equivalent were 3.9 \u0026plusmn; 3.2 D and 0.29 \u0026plusmn; 2.18 D, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe baseline IOP was 15.8 \u0026plusmn; 12.9 mmHg preoperatively. Five cases required glaucoma surgery either simultaneously or postoperatively. Two patients had an IOP over 40 mmHg and required combined glaucoma surgery. Three patients had an increased IOP that was resistant to anti-glaucomatous agents and underwent subsequent glaucoma surgery (two patients had pars plana glaucoma drainage devices implanted, and one had filtrating surgery). The postoperative IOP was stable (12.7 \u0026plusmn; 3.6 mmHg). One patient developed an epiretinal membrane and required membrane removal. Two eyes showed reversible graft rejection, and there was no graft failure.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study shows our technique for a pars plana approach, such as PPV, combined with PKP. All procedures were performed without complications. Under a wide-viewing system, PPV could be completed without the use of an artificial cornea. Any residual vitreous base following PPV could be removed with the shaving technique. Without treatment these patients with complex needs may have gone blind, but following the combined surgery, the visual function of the patients significantly improved, and the mid-term survival rates were excellent. There were no cases of retinal detachment following surgery. Despite the improvement in corneal transparency and visual recovery, the requirement for additional glaucoma surgeries was relatively high. Patients may have a better quality of life if IOL implantation and PKP are performed simultaneously.\u003c/p\u003e\n\u003cp\u003eThere are three suggestions regarding the importance and the efficacy of the posterior approach during PKP: First, the prevention of retinal detachment (including proliferative vitreous retinopathy) is very important. It seems appropriate that retina specialists perform PPV in combination with PKP to avoid the risk of retinal detachment following an incomplete vitrectomy such as an anterior vitrectomy in the posterior capsule rupture, or IOL-suture. If there is a complication in the posterior segment during PPV, such as a retinal break, it can be rapidly addressed. [25]\u003c/p\u003e\n\u003cp\u003eSecond, the posterior approach in simple cases could be performed without difficulty. Since our case series did not include severe corneal opacity, all procedures could be performed with a wide-viewing system (without any artificial corneas such as Eckardt temporary keratoprosthesis) in closed system prior to trephination (not open-sky vitrectomy). Performing the vitrectomy via closed system PPV rather than open-sky vitrectomy allowed us to reduce the time of open-sky status, an advantage of our procedure. The use of PPV with a temporary keratoprosthesis has been reported. Yokogawa et al. published a report on the combined treatment of PKP or DSAEK using an artificial cornea.[8, 15, 16] In our experience, we had no trouble performing a simple PPV, including the creation of a posterior vitreous detachment and shaving of the peripheral vitreous body.\u003c/p\u003e\n\u003cp\u003eThird, the incidence of globe collapse could be reduced by the use of posterior infusion. Using this approach, the globe could be well-maintained without sudden collapses.\u003c/p\u003e\n\u003cp\u003eThe results of this study show that the combined procedure of PKP, PPV, and IOL-suture could be a safe and effective approach for patients requiring anterior segment surgery. Despite the increasing number of scleral fixations,[26] in the present study the preferred method was an IOL-suture.\u003c/p\u003e\n\u003cp\u003eThere were limitations to this study, such as the relatively small number of participants, differing aetiologies, and different treatment protocols. First, the lack of long-term follow-up is the most important limitation. Despite suture breakage after IOL suture being one of the major late complications (especially when using 10-0 polypropylene),[27] our follow-up period was relatively short. Second, our procedure was performed with the help of retina specialists. Although the PPV portion was performed by retina specialists with very good results, it is impossible to compare our method to anterior vitrectomy alone or PPV performed by anterior segment surgeons. Thirdly, postoperative glaucoma developed in 5 cases requiring glaucoma surgery. Two cases required an Ahmed valve, one needed a Baerveldt implant, and one case needed filtrating surgery (trabeculectomy) after PKP. One case was treated with a simultaneous glaucoma implant, (Baerveldt) PKP, PPV, and IOL-suture surgery. According to past reports, the combined surgery of PKP and Ahmed valve implantation had a negative impact on graft survival. However, in the present study, the glaucoma shunt tubes were placed into the pars plana, because tube implantation to the pars plana has been shown to result in better corneal graft survival rates and reduce complications compared with implantation into the anterior chamber.[28-32] Since the type of glaucoma surgery was selected according to either the patient\u0026rsquo;s condition or the glaucoma surgeon\u0026rsquo;s preference, only one case was treated by trabeculectomy. In the future, long-term studies regarding the correlation between glaucoma surgery and keratoplasty will be necessary for further development.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the current study advocates the importance and efficacy of the posterior approach combined with PKP for anterior segment surgeons.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003ePPV, pars plana vitrectomy; PKP, penetrating keratoplasty; IOL, intraocular lens; IOL-suture, transscleral-sutured intraocular lens implantation; DALK, deep anterior lamellar keratoplasty; EK, endothelial keratoplasty; DSAEK, Descemet\u0026rsquo;s stripping automated endothelial keratoplasty DSAEK; BCVA, best corrected visual acuity; logMAR, logarithm of the minimum angle of resolution; ECD, endothelial cell density; IOP, intraocular pressure\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate: \u003c/em\u003e\u003c/strong\u003eThis prospective study was approved by the institutional Review Board (approval no. YKH_26_05_12) of Yokohama Minami Kyosai Hospital and adhered to the tenets of the Declaration of Helsinki. The study procedures followed all institutional guidelines, and all patients provided written informed consent for participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication: \u003c/em\u003e\u003c/strong\u003e\u003cem\u003eNot applicable. \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and Materials:\u003c/em\u003e\u003c/strong\u003e The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding: \u003c/em\u003e\u003c/strong\u003eThis research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests: \u003c/em\u003e\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions: \u003c/em\u003e\u003c/strong\u003eT.H.: writing, review and editing; Y.Y.: review and editing, investigation; T.S.: data curation, and editing; T.K., Y.K., and Y.I.: investigation; K.Y.: project administration, supervision, and validation; All authors critically checked the manuscript and approved the submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements: \u003c/em\u003e\u003c/strong\u003eThe authors thank Dr. Y Ando for critical comments concerning this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZirm EK. Eine erfolgreiche totale keratoplastik (A successful total keratoplasty). Arch Fr Ophthalmol. 1906;64:580-83.\u003c/li\u003e\n\u003cli\u003eCoster DJ, Williams KA. The impact of corneal allograft rejection on the long-term outcome of corneal transplantation. Am J Ophthalmol. 2005;140:1112-22. doi:10.1016/j.ajo.2005.07.024\u003c/li\u003e\n\u003cli\u003eCoster DJ, Lowe MT, Keane MC, Williams KA. Australian Corneal Graft Registry Contributors. A comparison of lamellar and penetrating keratoplasty outcomes: a registry study. Ophthalmology. 2014;121:979-87. DOI:https://doi.org/10.1016/j.ophtha.2013.12.017\u003c/li\u003e\n\u003cli\u003eFlockerzi E, Maier P, B\u0026ouml;hringer D, Reinshagen H, Kruse F, Cursiefen C, et al. Trends in corneal transplantation from 2001 to 2016 in Germany: a report of the DOG-section cornea and its keratoplasty registry. Am J Ophthalmol. 2018;188:91-8. doi:10.1016/j.ajo.2018.01.018\u003c/li\u003e\n\u003cli\u003eStechschulte SU, Azar DT. Complications after penetrating keratoplasty. Int Ophthalmol Clin. 2000;40:27-43. doi:10.1097/00004397-200040010-00005\u003c/li\u003e\n\u003cli\u003eOhguro N, Matsuda M, Shimomura Y, Inoue Y, Tano Y\u003cem\u003e. \u003c/em\u003eEffects of penetrating keratoplasty rejection on the endothelium of the donor cornea and the recipient peripheral cornea. Am J Ophthalmol. 2000;129:468-71. doi:10.1016/s0002-9394(99)00389-x\u003c/li\u003e\n\u003cli\u003eThompson RW Jr, Price MO, Bowers PJ, Price Jr FW. Long-term graft survival after penetrating keratoplasty. Ophthalmology. 2003;110:1396-402. doi:\u003ca href=\"https://doi.org/10.1016/s0161-6420(03)00463-9\"\u003e1016/S0161-6420(03)00463-9\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eYokogawa H, Kobayashi A, Okuda T, Mori N, Masaki T, Sugiyama K\u003cem\u003e.\u003c/em\u003e Combined keratoplasty, pars plana vitrectomy, and flanged intrascleral intraocular lens fixation to restore vision in complex eyes with coexisting anterior and posterior segment problems. Cornea. 2018;37 Suppl 1:S78-85. doi:10.1097/ICO.0000000000001716\u003c/li\u003e\n\u003cli\u003eReinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM\u003cem\u003e. \u003c/em\u003eDeep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the American academy of ophthalmology. Ophthalmology. 2011;118:209-18. doi:10.1016/j.ophtha.2010.11.002\u003c/li\u003e\n\u003cli\u003ePle-Plakon PA, Shtein RM. Trends in corneal transplantation: indications and techniques. Curr Opin Ophthalmol. 2014;25:300-5. doi:10.1097/ICU.0000000000000080\u003c/li\u003e\n\u003cli\u003eWeisbrod DJ, Sit M, Naor J, Slomovic AR. Outcomes of repeat penetratingkeratoplasty and risk factors for graft failure. Cornea. 2003;22:429-34. doi:10.1097/00003226-200307000-00008\u003c/li\u003e\n\u003cli\u003eArundhati A, Jun BZ, Janardhan P, Tan DTH. Iris reconstruction in penetrating keratoplasty--surgical techniques and a case-control study to evaluate effect on graft survival. Am J Ophthalmol. 2008;145:203-9. doi:10.1016/j.ajo.2007.10.006\u003c/li\u003e\n\u003cli\u003eKaradag R, Bayramlar H, Azari AA, Rapuano CJ. Trocar-assisted, sutureless, scleral-fixated intraocular lens implantation combined with penetrating keratoplasty. Cornea\u003cem\u003e. \u003c/em\u003e2016;35:1261-5. doi:10.1097/ICO.0000000000000944\u003c/li\u003e\n\u003cli\u003eLi J, Dong XG. Black diaphragm intraocular lens implantation and penetrating keratoplasty in aphakic eyes with traumatic aniridia. Int J Ophthalmol. 2013;6:183-6. doi:10.3980/j.issn.2222-3959.2013.02.15\u003c/li\u003e\n\u003cli\u003eChen HJ, Wang CG, Dou HL, Feng XF, Feng K, Hu YT, et al. Anatomical outcome of vitreoretinal surgery using temporary keratoprosthesis and replacement of the trephined corneal button for severe open globe injuries: one-year result. J Ophthalmol. 2014;794039. doi:10.1155/2014/794039\u003c/li\u003e\n\u003cli\u003eKhouri AS, Vaccaro A, Zarbin MA, Chu DS. Clinical results with the use of a temporary keratoprosthesis in combined penetrating keratoplasty and vitreoretinal surgery. Eur J Ophthalmol\u003cem\u003e. \u003c/em\u003e2010;20:885-91. doi:10.1177/112067211002000512\u003c/li\u003e\n\u003cli\u003eElhofi A, Helaly HA. Graft survival after penetrating keratoplasty in cases of trabeculectomy versus Ahmed valve implant. J Ophthalmol\u003cem\u003e. \u003c/em\u003e2018;13:9034964. oi:10.1155/2018/9034964\u003c/li\u003e\n\u003cli\u003eAkdemir MO, Acar BT, Kokturk F, Acar S. Clinical outcomes of trabeculectomy Ahmed glaucoma valve implantation in patients with penetrating keratoplasty. Int Ophthalmol\u003cem\u003e. \u003c/em\u003e2016;36:541-6. doi:10.1007/s10792-015-0160-9\u003c/li\u003e\n\u003cli\u003eLee JY, Sung KR, Tchah HW, Yoon YH, Kim JG, Kim MJ, et al. Clinical outcomes after combined Ahmed glaucoma valve implantation and penetrating keratoplasty or pars plana vitrectomy. Korean J Ophthalmol. 2012;26:432-7. doi:10.3341/kjo.2012.26.6.432\u003c/li\u003e\n\u003cli\u003eTai MC, Chen YH, Cheng JH, Liang CM, Chen JT, Chen CL, et al. Early Ahmed glaucoma valve implantation after penetrating keratoplasty leads to betteroutcomes in an Asian population with preexisting glaucoma. PLoS One\u003cem\u003e. \u003c/em\u003e2012;7:e37867. doi:10.1371/journal.pone.0037867\u003c/li\u003e\n\u003cli\u003eAl-Torbak AA. Outcome of combined Ahmed glaucoma valve implant and penetrating keratoplasty in refractory congenital glaucoma with corneal opacity. Cornea\u003cem\u003e. \u003c/em\u003e2004;23:554-9.doi:10.1097/01.ico.0000122704.49054.95\u003c/li\u003e\n\u003cli\u003eAl-Torbak A. Graft survival and glaucoma outcome after simultaneous penetrating keratoplasty and Ahmed glaucoma valve implant. Cornea\u003cem\u003e. \u003c/em\u003e2003;22:194-7. doi:10.1097/00003226-200304000-00002\u003c/li\u003e\n\u003cli\u003eKershner RM. Vertical transscleral sulcus fixation of intraocular lenses in the absence of a posterior capsule. J Cataract Refract Surg. 1992;18:201-2.\u003c/li\u003e\n\u003cli\u003eLange C, Feltgen N, Junker B, Schulze-Bonsel K, Bach M. Resolving the clinical acuity categories \u0026ldquo;hand motion\u0026rdquo; and \u0026ldquo;counting fingers\u0026rdquo; using the Freiburg Visual Acuity Test (FrACT). Graefes Arch Clin Exp Ophthalmol\u003cem\u003e. \u003c/em\u003e2009;247:137-42. doi:10.1007/s00417-008-0926-0\u003c/li\u003e\n\u003cli\u003eNaderi K, Allen F, Dowlut S, Karia N, Chandra A. The risk of rhegmatogenous retinal detachment following anterior vitrectomy during cataract surgery: with versus without pars plana vitrectomy. Graefes Arch Clin Exp Ophthalmol. doi: 10.1007/s00417-020-04843-0.\u003c/li\u003e\n\u003cli\u003eYamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124:1136-42. doi:10.1016/j.ophtha.2017.03.036\u003c/li\u003e\n\u003cli\u003eBausili Portabella MM, Nadal J, Alvarez de Toledo J, Fideliz de la Paz M, Barraquer RI. Long-term outcome of scleral-sutured posterior chamber intraocular lens: a case series. Br J Ophthalmol. 2020;104:712-7. doi: 10.1136/bjophthalmol-2019-314054.\u003c/li\u003e\n\u003cli\u003eParihar JK, Jain VK, Kaushik J, Mishra A. Pars plana-modified versus conventional Ahmed glaucoma valve in patients undergoing penetrating keratoplasty: a prospective comparative randomized study. Curr Eye Res. 2017;42:436-42. doi:10.1080/02713683.2016.1185130\u003c/li\u003e\n\u003cli\u003eRitterband DC, Shapiro D, Trubnik V, Marmor M, Meskin S, Seedor J, et al. Penetrating keratoplasty with pars plana glaucoma drainage devices. Cornea\u003cem\u003e. \u003c/em\u003e2007;26:1060-6. doi:10.1097/ICO.0b013e3181342835\u003c/li\u003e\n\u003cli\u003eAlvarenga LS, Mannis MJ, Brandt JD, Lee WB, Schwab IR, Lim MC. The long-term results of keratoplasty in eyes with a glaucoma drainage device. Am J Ophthalmol\u003cem\u003e. \u003c/em\u003e2004;138:200-5. doi:10.1016/j.ajo.2004.02.058\u003c/li\u003e\n\u003cli\u003eArroyave CP, Scott IU, Fantes FE, Feuer WJ, Murray TG. Corneal graft survival and intraocular pressure control after penetrating keratoplasty and glaucoma drainage device implantation. Ophthalmology\u003cem\u003e. \u003c/em\u003e2001;108:1978-85. doi:10.1016/s0161-6420(01)00803-x\u003c/li\u003e\n\u003cli\u003eWitmer MT, Tiedeman JS, Olsakovsky LA, Conaway MR, Prum BE. Long-term intraocular pressure control and corneal graft survival in eyes with a pars plana Baerveldt implant and corneal transplant. J Glaucoma. 2010;19:124-31. doi:10.1097/IJG.0b013e3181a98cc1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"penetrating keratoplasty, pars plana vitrectomy, intraocular lens implantation, transscleral-sutured intraocular lens","lastPublishedDoi":"10.21203/rs.3.rs-37812/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-37812/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eThe aim\u003cstrong\u003e \u003c/strong\u003eof this study was to evaluate the clinical outcomes of pars plana vitrectomy (PPV) combined with penetrating keratoplasty (PKP) and transscleral-sutured intraocular lens (IOL) implantation (IOL-suture) in complex eyes.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eIn this prospective, consecutive interventional case series, patients who underwent PKP combined with PPV and IOL implantation from July 2014 to March 2018 at Yokohama Minami Kyosai Hospital were enrolled. The postoperative best corrected visual acuity (BCVA) (converted to logarithm of the minimal angle of resolution [logMAR] units), intraocular pressure (IOP, mmHg), endothelial cell density (ECD, cells/mm\u003csup\u003e2\u003c/sup\u003e), graft survival, complications, astigmatism, and spherical equivalent (dioptres [D]) were evaluated. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThis study included 11 eyes of 11 patients (three females and eight males; mean age, 61.8 ± 13.9 years) with an injury (n = 6) or bullous keratopathy (n = 5). The BCVA significantly improved from 1.50 ± 0.66 logMAR preoperatively to 0.78 ± 0.59 logMAR (p \u0026lt; 0.001) postoperatively. The baseline ECD significantly decreased from 2396 ± 238 cells/mm\u003csup\u003e2\u003c/sup\u003e preoperatively to 1132 ± 323 cells/mm\u003csup\u003e2\u003c/sup\u003e (p \u0026lt; 0.001) postoperatively. Despite two rejection episodes, graft survival rates were 100%. The mean follow-up period was 38.0 ± 20.5 months. Two patients required combined glaucoma surgery, and three patients underwent subsequent glaucoma surgery. Postoperative astigmatism and spherical equivalent were 3.9 ± 3.2 D and 0.29 ± 2.18 D, respectively.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eThe combination of PKP, PPV, and IOL-suture implantation could be a safe and effective approach for eyes requiring anterior segment surgery; however, these eyes are associated with a higher incidence of glaucoma surgery.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Pars plana vitrectomy combined with penetrating keratoplasty and transscleral-sutured intraocular lens implantation in complex eyes: a case series","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-09-11 15:35:42","doi":"10.21203/rs.3.rs-37812/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-09-08T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-07T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-06T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-06T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-08-12 18:24:34","doi":"10.21203/rs.3.rs-37812/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-09-02T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-08-12T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-12T12:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"editorInvitedReview","content":"","date":"2020-08-12T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nWe congratulate the authors on their manuscript and management of complex patients. Please see my comments below:\n\nLine 79: \"To the best of our knowledge, this is the first report to assess if there is an advantage to performing simultaneous complex ocular surgeries.\" \"Advantage\" compared to what? You need a comparison to say something is better than something else.\n\nLine 101: \"We closed the infusion and reduced IOP just before trephination to prevent vitreous prolapse.\" You have performed a complete PPV, the reason to close the infusion and reduce the IOP prior to trephination is to prevent suprachoroidal hemorrhage.\n\nLine 159: \"The current study shows the advantage of a pars plana approach such as PPV combined with PKP.\" Again, it is not possible to say this without comparing it to something.\n\nLine 171: \"It seems appropriate that retina specialists perform PPV in combination with PKP to avoid the risk of retinal detachment following an incomplete vitrectomy such as an anterior vitrectomy in the posterior capsule rupture, or IOL-suture. If there is a complication in the posterior segment during PPV, such as a retinal break, it can be rapidly addressed. [25] \" This was likely in answer to a previous comment that I made; however, this is not what I was referring to. I was stating you cannot state that a PPV is better by retina or is adequate if performed by an anterior segment surgeon, or that an anterior vitrectomy is not sufficient without comparing them. Moreover, many (most) surgeons do not have access to a retinal colleague with them in the OR. These cases are almost certainly almost always performed by an anterior segment surgeon alone. I do not think it is fair to suggest that these are better done by retina with the data you have. I think you can say that \"in our series, the PPV portion was performed by retina with very good results; however, we are unable to compare this to PPV performed by anterior segment surgeons, nor to anterior vitrectomy alone.\"\n\nLine 179: \"Performing the vitrectomy via closed system PPV rather than open-sky vitrectomy allowed us to reduce the time of open-sky status, an advantage of our procedure.\" - YES, THIS is important.\n\nLine 186: \"Third, the technical difficulty of PKP in the post-vitrectomized eye could be reduced. During surgery, globe rupture could be easily repaired using a posterior infusion. In cases of globe rupture, the eye shape can be repaired, and a suture placed once the situation stabilizes. The suture procedure would then be easier with posterior infusion. \" I am not sure I completely understand or agree with this.\n\nLine 197: \"for a long time. \" Reword.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **i declare i have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorAssigned","content":"","date":"2020-08-07T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-07T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-08-07T12:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-06T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-06T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-06-29 21:05:50","doi":"10.21203/rs.3.rs-37812/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-07-29T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-28T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe manuscript describes the results of a series of patients undergoing complex surgery including PPV, PKP, scleral sutured PCIOL and occasionally a glaucoma drainage implant. The sample size was small (n=11) and very heterogeneous. Six patients had a history of trauma, but the remaining 5 patients had a vague history of bullous keratopathy without description of etiology. The surgical decision process is not well explained. Because the study excluded eyes \"with severe corneal opacity,\" it is surprising why endothelial keratoplasty (DSAEK) was not offered as a better alternative to PKP. The authors also describe using 10-0 polypropylene sutures under scleral flaps to fixate an Alcon CZ70BD, a suture fixation technique that is little used in the post-Yamane and Gore-Tex era. The manuscript does not address the advantages and disadvantages of simultaneous combined surgery versus a staged approach.\nFor the target audience of anterior segment surgeons, a manuscript of this type should offer practical surgical details such as calculating IOL powers in the setting of a PK.\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **No financial disclosures.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-07-18T12:00:00+00:00","index":3,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nFirst just to get this out of the way......I believe that it should be mentioned that using 10-0 prolene to support a CZ70BD in these cases is not adequate given the other choices available. 9-0 prolene, CV-8 Gorte tex, or using 5-0 or 6-0 prolene in a flanged technique as well as Yamane type fixation are alternatives that I think would have a much better chance of lasting. I'm not sure why 10-0 prolene was chosen here but that is a separate matter really from my criticism about the article in general which follow below:\n\n1. It is not clear who needed a pars plana vitrectomy and what the indication for vitrectomy was. Many of these patients have already had previous vitrectomies and some appeared to be simply having silicone oil removed. Were there patients having vitreoretinal pathology addressed at the same time as the PK that specifically required a pars plana approach? So I believe this should be clarified. \n2. There are some statements that are either difficult to understand or incorrect and these are listed below: \n\na.) 95-96 \"Even in the patients that required a vitrectomy, the residual vitreous was checked, and removed completely.\" This statement implies that some patients did not require a vitrectomy. This should be clarified. Perhaps you mean \"even in the patients with prior vitrectomy?\". \n \nb.) 175 \"During surgery, a globe rupture could be easily repaired using a posterior infusion.\" I think most surgeons would be reluctant to blindly place pars plana trocars in a soft rupured globe. It is far safer to firm the eye up with limbal viscoelastic/infusion to facilitate globe reformation with suture repair rather than to go through the pars plana blindly in an eye that is ruptured, soft, and could have choroidal detachments leading to infusion into the suprachoroidal space or trocar damage to retina. \n\nc. ) 177: \"The suture procedure would be easier without a posterior infusion.\" Perhaps you mean to say \"with\" rather than without \n\nd. )in abstract and 41: \"The baseline ECD significantly decreased from 2396 ± 238 cells/mm2 preoperatively, to 1132 ± 323 cells/mm2 135 (p \u003c 136 0.001) postoperatively. Was the baseline cell count in the donor tissue or the patients corneas having PKP? Seems unlikely that this could be the baseline ECD in the patient's corneas because 5 of them had bullous keratopathy. This is unclear.\n\ne.) 174: \"Third, the technical difficulty of PKP in the post-vitrectomized eye could be reduced.\" This comment is not clear ….what specifically is the technical difficulty of doing PKP in a post vitrectomized eye (other than the need to place a Fleringa ring) to stabilize it and how does the author's technique reduce that technical difficulty? The PKP is still being done on a vitrectomized eye. Please clarify. \n\nf.) 5 of these patients had bullous keratopathy.....why no consideration of endothelial keratoplasty instead of repeat PKP? Was there high astigmatism or scarring of the stroma? It would be good to know what the indications were for doing a PKP (or repeat PKP) rather than simply doing EK which can be also be readily combined with scleral fixated IOL and PPV.\n \ng.) Much of the discussion here is disjointed and difficult to follow and this may be because of a translation difficulty. For example the following statement in the article: \"First, the prevention of retinal detachment (including proliferative vitreous retinopathy) is very important. An iris defect, or aphakia with vitreous prolapse, often accompanies complex cases following an injury that requires iris repair and IOL scleral fixation (or suture) combined with PKP\". These seem like disjointed and improperly developed thoughts that do not explain the advantages of your technique. \n\nh. 162-165: \"It seems appropriate for anterior segment surgeons to perform PPV due to the increased risk of retinal detachment following an incomplete vitrectomy such as anterior vitrectomy in posterior capsule rupture, or IOL suture.. If there is a complication in the posterior segment during PPV, such as a retinal break, it can be rapidly responded to.\" This statement is disjointed and not clear. Also were the vitrectomies done here done by the cornea surgeon or was a retina surgeon involved in these procedures? \n\ni. 151 \"Any residual vitreous following PPV could be removed with the shaving technique\" Please elaborate. Are you referring to shaving the vitreous base? \n\n\n\nThere are many advantages of pars plana vitrectomy which are not really explained to the reader and it may be confusing because once you remove the cornea the closed system control is lost and there does not appear to be much advantage anymore. Doing a pars plana vitrectomy however to address vitreoretinal pathology prior to doing a PK is very reasonable and doing it as a combined procedure with retina surgeons as a combined procedure prior to trephination saves the patient a trip to the OR but does create logistic difficulties. I have personally done PPV to deal with vitreous in a closed system and combined with Yamane for example and then immediately trephined and done PKP (or DSAEK) rather than staging and I think that this makes sense. Doing needle passes for Yamane in an open sky means less control when creating those intrascleral tunnels in a soft eye and increases risk of bleeding/choroidal hemorrhage etc, and if there is vitreous adherent to the cornea it is better to amputate that PRIOR to removing the cornea as this will reduce vitreoretinal traction. Clearing vitreous from the anterior chamber prior to placing any instrumentation in the anterior chamber and doing manipulation is a good idea to prevent vitreoretinal traction and thus I think that there are advantages to removing this vitreous if present prior to trephination may be an advantage but this is not discussed at all in this article so many readers may wonder why bother with PPV when an open sky vitrectomy can be done. Also by doing the vitrectomy via closed system PPV rather than open sky you reduce the time that the eye is open which is an advantage which could be mentioned in the discussion but again it is not clear from this article what the indications were for vitrectomy and why this approach is advantageous or better than a staged procedure. \n\n\n\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. 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Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Unable to assess**\n* Are the conclusions drawn adequately supported by the data shown?: **Unable to assess**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **Not relevant to this manuscript**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-12T12:00:00+00:00","index":3,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-11T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-09T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nI would like to congratulate the authors on their manuscript and management of difficult surgical cases. The authors describe a case series of combined PK/PPV/SS-IOL in complex eyes. My comments/suggestions/questions are as follows:\n\nLine 59 - the authors state half of grafts are PK. This is contradictory to the evidence I have seen and my practice where ?80% of grafts are EK. I acknowledge global/regional variation however I would suggest clarifying this.\n\nLine 95 - \"Even in the patients that required a vitrectomy, the residual vitreous was checked, and \u2028removed completely.\" This is confusing, of course if it was needed it was performed. There is a mistake in here somewhere.\n\nLine 98 - \"Using the open-sky PPV technique, the 10-0 polypropylene needles pierced the ...\" Was PPV closed or open sky. From the rest of the paper it appears was CLOSED. I think the authors mean the IOL was placed open sky.\n\nLine 104 - was levofloxacin used for 3 months as well?\n\nLine 162 - \"It seems appropriate for anterior segment surgeons to perform PPV due to the increased risk of retinal detachment following an incomplete vitrectomy such as anterior vitrectomy in posterior capsule rupture, or IOL suture. If there is a complication in the posterior segment during PPV, such as a retinal break, it can be rapidly responded to.\" I would agree that PPV has merits, but you have not proven why an anterior segment surgeon can perform this.\n\nLine 174 - \"Third, the technical difficulty of PKP in the post-vitrectomized eye could be reduced. During surgery, a globe rupture could be easily repaired using a posterior infusion. In cases of globe rupture, the shape of the eye can be repaired, and a suture placed once the situation is stable. The suture procedure would be easier without a posterior infusion.\" This is confusing. The eye is vitrectomized prior to PK in this technique as well, what you are referring to in the first sentence is the INFUSION. The last sentence contradicts the preceding sentences. This needs to be rewritten in a clear manner.\n\nThe authors do not show their method for affixing the suture to the IOL however if they are placing a 10-0 suture (as described) THROUGH the loops (opposed to cow-hitch/girth-hitch) there have been reports of breakage hence the preference of the other techniques. This should be clarified.\n\nThe authors do not address one of the main issues in PPV/PK which is that going from high IOP to low IOP rapidly risks suprachoroidal hemorrhage, arguably the most devastating complication of PK. Many surgeons REDUCE IOP prior to surgery by using mannitol or a Honan balloon so that the eye is soft before going to IOP = 0 during open sky. PPV increases the IOP. Your technique or at least a comment as to the risk (or perhaps lack thereof??) needs to be made.\n\nLastly, although I am interested in this study as I perform many similar surgeries, there is no control group. I believe the authors should include the data on staged procedures (if available in the literature) and compare their data to it. I am well aware of the biases here, including historical bias, etc HOWEVER I would have the authors acknowledge that and report it still.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. 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Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **Unable to assess**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **no financial or competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. 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