I agree with E. S. Malbran and colleagues that one of the most dangerous
aspects of the combined triple procedure is the period during which the cataract
is removed using an open sky approach. They offer an alternative technique1 whereby phacoemulsification is performed either
via the graft-host junction through an incompletely trephined donor button
or through a separate limbal incision. Although this approach offers the opportunity
to remove the cataract within a closed system, there are several concerns.
The first is visualization of the anterior segment. With mild or moderate
corneal edema or in patients with keratoconus, it may be possible to perform
capsulorrhexis and phacoemulsification with intraocular lens implantation
through a de-epithelialized, slightly edematous cornea. With more significant
corneal opacities, however, such as those seen in stromal scarring or lipid
keratopathy, visualization of the capsule and lens is frequently not sufficient
to allow safe phacoemulsification. In these situations, cataract removal as
part of a staged procedure, performed with a clear cornea that provides an
optimal view of the lens capsule and cataract, is preferred.
Hamill MB. In Favor of the Triple Procedure. Arch Ophthalmol. 2001;119(8):1224. doi: