Phacoemulsification with big-bubble deep anterior lamellar keratoplasty: Variant of the triple procedure

The surgical treatment of patients with combined advanced ectasia and cataract present is challenging. The most common approach is a corneal graft followed by cataract surgery at a later date. A second option is simultaneous corneal grafts with cataract extraction and intraocular lens implantation. This triple procedure has several benefits, which include a shorter period of visual disability and less cost to the patient than the 2-stage technique. There have been attempts to combine phacoemulsification and deep anterior lamellar keratoplasty (DALK) to maximize the advantages of both procedures in a single sitting. Some authors suggest a triple procedure in which the big-bubble DALK technique is performed before phacoemulsification; however, they recommend that phacoemulsification be performed with extreme caution to prevent Descemet membrane rupture. We describe a variant of the triple procedure in which phacoemulsification is followed by a corneal graft using the big-bubble DALK technique.