Purpose: To report the potential risk of severe positive vitreous pressure during combined penetrating keratoplasty, cataract extraction, and intraocular lens implantation (triple procedure), using positive end-expiratory pressure (PEEP) during general endotracheal anesthesia.
Methods: This is a case report of a 32-year-old man and a 48-year-old man who underwent penetrating keratoplasty, extracapsular lens extraction, and intraocular lens implantation during which severe positive posterior pressure was encountered during the open-sky lens extraction.
Results: In both cases, severe posterior vitreous pressure against an intact posterior capsule hindered intraocular lens implantation during the triple procedure. Despite exhaustive search for the cause of posterior pressure, no other risk factors were found other than the use of PEEP.
Conclusions: During open-sky procedures, PEEP may be a risk factor for severe positive posterior vitreous pressure. Given the rising use of PEEP, surgeons should be aware and cautious of this potential complication.
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