Quintuple Procedure for Ocular Surface Reconstruction and Visual Rehabilitation

Area of Science:

• Ophthalmology
• Regenerative Medicine
• Surgical Innovation

Background:

• Limbal stem cell deficiency (LSCD) and corneal scarring impair ocular surface integrity and vision.
• Cataracts further compromise visual function in patients with compromised corneas.
• Staged surgical approaches for these complex conditions can be challenging due to patient compliance and follow-up limitations.

Purpose of the Study:

• To describe a combined quintuple surgical procedure for simultaneous ocular surface and visual rehabilitation.
• To present this combined approach as an alternative to staged surgical management.
• To highlight the intraoperative use of diamond ophthalmic burr (DOB) and optical coherence tomography (OCT) for optimizing the anterior lamellar keratoplasty (ALK) graft-host interface.

Main Methods:

• The quintuple procedure involves modified ALK, cataract extraction, intraocular lens implantation, simple limbal epithelial transplantation, and temporal tarsorrhaphy.
• Intraoperative OCT and DOB were utilized to guide stromal bed creation during ALK.
• The procedure was successfully performed on a patient with LSCD and corneal scarring secondary to a chemical burn.

Main Results:

• Postoperative visual acuity improved significantly from light perception to 20/30 with scleral contact lens use.
• The cornea remained clear and compact with a stable ocular surface at 16 months.
• The temporal tarsorrhaphy was removed at 3 months following complete corneal epithelialization.

Conclusions:

• The quintuple procedure effectively achieves visual and ocular surface rehabilitation, particularly when staged approaches are not feasible.
• Intraoperative OCT provided real-time visualization for precise stromal bed dissection.
• The DOB facilitated the creation of a smooth stromal surface, crucial for an optimal graft-host interface.