This study was approved by the Institutional Review Board of the Dhahran Eye Hospital. All patients underwent sutured scleral-fixated IOL implantation combined with PKP between 2013 and 2018 at the Dhahran Eye Specialist Hospital in the Eastern Province of Saudi Arabia included in the study. After delineating their identities, their health records were reviewed. As this was a retrospective cohort study, the requirement for informed consent for surgery was waived. The Dhahran Eye Specialist Hospital Corneal Transplantation Patient Registry was the primary resource for all preoperative, intraoperative, and postoperative patient information.

Demographic information collected from each patient included age, sex, and eye involvement. Data on history of ocular trauma, prior ocular surgery, and glaucoma were also obtained. Visual acuity was measured using a Snellen chart held at a distance of 6 m, with and without a pinhole occluder. The anterior segment of each eye was evaluated using a slit-lamp. The posterior segment was evaluated using an indirect binocular ophthalmoscope. Intra-and postoperative complications were also documented. The eyes were examined at 1, 3, 6, 12, and 24 months postoperatively and at the last follow-up. Data on the best-corrected visual acuity (BCVA), IOL status, status of the transplanted cornea, intraocular pressure, and other complications and their management were collected. The difference between the BCVA at follow-up and before surgery was defined as success. Improvements better than two lines were considered successful. Patients were graded as “non-blind” if BCVA was better than 20/200. Vision worse than 20/200 with perception of light was graded “blind.” An eye with no perception of light is termed “absolutely blind.”15 Main outcome measures were graft survival rate, improvement in BCVA by two lines, intraoperative and postoperative complications, IOL position, and IOL suture status.

Surgeries were performed under general anesthesia. The literature describes the details of PKP and scleral fixation procedures [14]. In most cases, the donor cornea was sutured to the recipient cornea using 16 interrupted sutures. The donor material supplied by the Central Bank in Riyadh was imported, evaluated, preserved, and provided by international agencies. In the present study, TYPE 66 IOL (Morcher, Germany) single-piece, all-polymethylmethacrylate (PMMA) biconvex lens with an overall length of 13 mm, optic size of 6.5 mm, and suture eyelets at the apices of the haptics were used.

The steps involved in IOL implantation are summarized as follows: A conjunctival peritomy and either a scleral groove or a lamellar scleral flap were made at the site of the intended suture fixation. After trephining the host cornea button, the problematic IOL (if present) was explanted, and the posterior chamber IOL (PCIOL) was implanted using an open-sky approach. In many cases, anterior vitrectomy has been performed using an automated instrument with a fiber-optic light pipe to illuminate the vitreous. Thorough anterior vitrectomy is necessary to prevent anterior vitreous prolapse around the IOL optic or through peripheral iridectomy sites, vitreous-induced displacement of the IOL, or vitreous incarceration into the scleral suture tracks. Iris adhesions were lysed whenever warranted, and large iris defects were repaired using 10 − 0 poly-propylene suture iridoplasty. CIF-4 needle 1516 (Ethicon Inc., Somerville, NJ, USA) with a 20-cm, double-armed 10–0 polypropylene (Prolene) suture was used for transscleral PCIOL fixation. This needle is longer and less cumbersome than short needles such as the TG-140 microneedle, designed for transscleral fixation via a limbal, cataract-style wound. The open-sky approach facilitates access to the ciliary sulcus using a CIF-4 needle 1516. The polypropylene suture was tied to the apex of the PCIOL haptic using either a girth hitch, necessitating a double-ended suture, or a single-ended stitch. The sutures were passed outward through the ciliary sulcus and sclera at around 0.8–0.9 mm posterior to the limbus. The PCIOL was positioned in the posterior chamber with haptics in the sulcus and placed in an oblique meridian (usually 2:00 and 8:00) to avoid the involvement of the long posterior ciliary arteries and nerves. After positioning the PCIOL, the sutures were tightened before tying. With the girth hitch, the double-ended sutures were tied in a mattress-like fashion. Using the single-stitch method, a single suture was tied onto itself after taking a second partial-thickness pass through the sclera. The knots were covered with conjunctival flaps or lamellar partial-thickness scleral flaps.

Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) 28.0 software (IBM Inc., Chicago, IL). Categorical variables were presented in frequencies and percentages, and continuous variables were presented as means ± standard deviation. The Chi-squared test was used to examine the differences between categorical variables. Kaplan-Meier survival plot was used to illustrate overall survival period for all included grafts. All results were considered to be statistically significant at P < 0.05.