Two-Piece Mushroom Penetrating Keratoplasty With “Pull-Through” Technique to Manage High Vitreous Pressure in Infant Eyes

Purpose: To describe the surgical technique for 2-piece mushroom penetrating keratoplasty using the “pull-through” technique in infant eyes. Methods: Using a 250-mm microkeratome head, the donor cornea was split into anterior and posterior lamella, which were then punched to 8.0 to 8.5 and 6.0 mm, respectively. After partial trephination of the host cornea (depth = 250 mm, diameter = 7.5–8.0 mm), anterior stromal keratectomy was performed. Another partial-thickness trephination (6.0-mm diameter) was performed on the residual bed, which was then opened full thickness for about 1 o’clock hour at 12, 3, 6 and 9 o’clock positions. The donor anterior lamella was fixated with 4 cardinal sutures over the host residual bed that had been partially opened. Using corneal scissors, the central 6.0-mm trephination of the residual host cornea was completed full thickness and removed under the sutured donor anterior lamella. Descemet stripping automated endothelial keratoplasty microforceps were then inserted under the anterior lamella to grasp and deliver the donor posterior lamella into the anterior chamber through the pull-through technique. Suturing of the anterior lamella was completed with 12 additional interrupted stitches. Results: Surgery was performed in 7 eyes with Peters anomaly between 2 and 12 months. No intraoperative complications were recorded. All grafts were clear at the last follow-up. All patients were able to fix and follow. Conclusions: In infant eyes, fixation of a large anterior lamella over a smaller partially excised recipient cornea allows selective exchange of the centrally diseased host cornea under “semiclosed system” conditions, overcoming the threat of expulsion of intraocular structures posed by excessive vitreous pressure and possibly minimizing donor endothelial trauma.