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New surgical technique with a sky web to combat expulsion during open sky penetrating keratoplasty

Poster Details

First Author: A.Jayarathna SRI LANKA

Co Author(s):    B. Supul   P. Kumara   C. Thilakarathna   M. Pasqual   B. Amarasinghe        

Abstract Details


To perform penetrating keratoplasty (PKP) safely, using a sky web consisting of silk sutures (four sagittal with or without two horizontal) to prevent the anterior movement of anterior segment structures during open sky, with minimizing the risk of expulsion in 12 cases of ulcers and full thickness scars, in which impending expulsion was noted with anterior bowing of iris and anterior movement of crystalline lens or intraocular lens during open sky procedure of penetrating keratoplasty, irrespective of all the effort taken maximally to reduce per operative intraocular pressure.


From 30th May to 30th November in National Eye Hospital of Sri Lanka.


First sky web suture was put across the anterior chamber (AC) from 8’o clock to 10’o clock (in case of left eye) entering through the limbus, right at initial dissection of 25 % of the recipient cornea. Same suture continued as 2nd, 3rd and 4th turns across the AC lateral to the previous suture at each turn, at completions of 50%, 75% and 100% of recipient corneal dissection respectively. Central pupil was banked by the middle sutures. Future four cardinal suture sites were undisturbed. Guard sutures of sky web were removed sequentially after putting cardinal sutures. PKP was completed.


None of the 12 patients had an expulsion, only a little choroidal effusion noted if at all in post-operative Brightness scans (B scans). Cornea was considerably clear at one month of follow up in 10 patients without iatrogenic iris or lenticular damage. One patient out of the 10 had a considerably clear central cornea with a scar of a healing recurrent ulcer at the donor-recipient junction. Two patients had primary graft failure.


Sky web is a safe manoeuvre to combat expulsion during open sky procedure of penetrating keratoplasty, setting limits to the anterior movement of irido-lenticular diaphragm. Prior to donor graft suturing, sufficient time was earned to dissect the infectious hypopyon adhered to the iris as well as at the angle and visco-formation of angle with a stable background irido-lenticular diaphragm behind the sky web. This is extremely important in patients who’s IOP is high but couldn't be measured due to irregular cornea and in patients who are unfit for general anaesthesia, hence undergoing PKP under retro-bulbar anaesthesia.

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