Sir,

Flieringa ring is useful for globe maintenance during penetrating keratoplasty. There are few articles on the techniques of Flieringa ring fixation. Flieringa ring is indicated in eyes that are aphakic, postvitrectomy, for combined procedures, and in infants and children with low scleral rigidity.1

Fixation ring is usually secured with interrupted sutures (eg 7-0 Vicryl® Ethicon Inc., USA). The eye is mobilised by grasping the conjunctiva and episclera with a pair of toothed forceps (eg Castroviejo 0.3 mm). The bites should be short, radially orientated and placed directly beneath the ring.2 As direct visualisation of the sclera is not possible, the needle is usually driven ‘blindly by feel’ through conjunctiva, episclera, and superficial sclera.3, 4 Undesirable subconjunctival haemorrhage is not uncommon and more seriously, inadvertent globe penetration may occur, particularly for the occasional or inexperienced surgeons.

Our modification consists of four small radial conjunctival incisions (in each of the four quadrants) over the intended sites for suture placement of any chosen ring size. The subconjunctival tissue is undermined and freed to expose the underlying sclera. This modification allows for direct visualisation of sclera, facilitating precision in suture placement and access for accurate haemostasis (thus avoiding the unsightly red eye after an uneventful elegant corneal graft procedure). The risk of globe perforation is thus minimised. At the completion of keratoplasty, the four radial incisions do not require suturing and may be coapted as necessary. We would like to recommend this modification to junior or trainee surgeons for consideration.