surgery (left) and the same patient after 6 months of pdek with glued iol surgery (right). note the white cornea is becoming clear (right). (below) anterior segment optical coherence tomography scan showing good adhesion of the graft on the inner side of cornea. this is a combination of pre-descemet's endothelial keratoplasty (pdek) and glued iol (fig 8). this combined procedure helps to perform two procedures simultaneously, thereby limiting the number of the patient's post-operative hospital visits. pdek is a kind of endothelial keratoplasty (corneal or eye transplantation), where the pre-descemet's layer (pdl), along with descemet's membrane (dm) and endothelium, is transplanted. the normal cornea has from the front to the back the following layers: epithelium bowman's layer stroma pre-descemet's layer descemet's membrane endothelium for the human eye to see, the cornea, the front window of the eye, should be transparent. for that to happen, the inside corneal layer, the endothelium, pumps water from the cornea so that the cornea remains transparent and light can pass into the eye. if the endothelium is bad, the cornea retains a lot of water and becomes damaged, which is called bullous keratoplasty. thus pdek helps in replacing the non-functional endothelium. on 4 september 2013, amar agarwal, in collaboration with harminder dua, performed the first pdek surgery technique and demonstrated the significance of the pre-descemets layer in corneal transplantation. the initial surgery was performed for pseudophakic bullous keratopathy. though donor eyes of all age groups were used in the initial pdek cases, there was a marked difference in eyes with young donor corneas, which resulted in better corneal clarity and visual outcome. this paved the way for the difference of pdek using young donors and the importance of the endothelial viability. glued iol can also be performed with various other corneal transplantation / keratoplasty procedures, such as descemet's membrane endothelial keratoplasty (dmek), descemet's stripping endothelial keratoplasty (dsek), and penetrating keratoplasty (pk). this glued iol technique would be useful in many clinical situations in which scleral-fixated iols are indicated, such as luxated iol, dislocated iol, zonulopathy, or secondary iol implantation. in a case with a dislocated posterior chamber, such as pmma iol, the same iol can be repositioned, thereby reducing the need for further manipulation. externalization of the greater part of the haptics along the curvature stabilizes the axial positioning of the iol and thereby prevents any iol tilt. there is less incidence of uveitis-glaucoma-hyphema syndrome in a fibrin glue–assisted iol implantation, as compared with a sutured scleral-fixated iol implantation. in the former, the iol is well stabilized and stuck onto the scleral bed, and thereby has decreased intraocular mobility; in the latter, there is increased possibility of iol movement or persistent rub over the ciliary body. visually significant complications due to late subluxation, which has been known to occur in sutured scleral-fixated iols, may also be prevented, as sutures are avoided in this technique. moreover, the frequent complications of secondary iol implantation—such as secondary glaucoma, cystoid macular edema, or bullous keratopathy—were not seen in any patients. another important advantage of this technique is the prevention of suture-related complications, such as suture erosion, suture knot exposure, or dislocation of iol after suture disintegration or broken suture. the other advantages of this technique are the rapidity and ease of surgery. the technique eliminates tying the difficult-to-handle 10-0 prolene suture to the iol haptic eyelets, the time required to ensure good centration before tying down the knots, and the time required for suturing scleral flaps and closing the conjunctiva, thus significantly reducing total time in surgery. it is also easier and does not require much surgical expertise to use the 25-gauge forceps to grasp and exteriorize the haptic. fibrin glue takes only 20 seconds to act in the scleral bed, and it helps in adhesion and hemostasis. fibrin glue has been shown to provide airtight closure, and by the time the fibrin starts degrading, surgical adhesions would have already occurred in the scleral bed.