Simultaneous Surgery for Corneal Edema and Aphakia: DSEK and Placement of a Retropupillary Iris Claw Lens

Outcomes of Secondary Intraocular Lens Implantation and Descemet Stripping Endothelial Keratoplasty-Comparing Staged Versus Combined Surgical Approach

PURPOSE

The aim of this study was to compare the outcomes of staged versus combined surgical approach for secondary intraocular lens (IOL) implantation and Descemet stripping endothelial keratoplasty (DSEK).

METHODS

This is a retrospective review of 124 eyes from 124 patients who underwent either staged or combined secondary IOL implantation in addition to DSEK over a 5-year period at 2 academic tertiary referral centers, between January 1, 2014, and October 1, 2019. Corrected distance visual acuity (CDVA), presence of graft detachment, primary graft failure (PGF), and cystoid macular edema were documented and analyzed.

RESULTS

The CDVA for the 1- to 2- month follow-up period was significantly better in the staged group compared with the combined group ( P = 0.011). By the postoperative 6- to 9-month follow-up period, there was no significant difference in the CDVA between the groups ( P = 0.591). There was no significant difference in the incidence of PGF or graft detachment between the 2 groups ( P > 0.05). In addition, there was no significant difference in the CDVA or rate of postoperative complications between the different methods of IOL fixation.

CONCLUSIONS

The short-term visual outcomes were significantly better in eyes that underwent staged secondary IOL implantation and DSEK versus the combined surgical approach, although the difference was no longer present at 6 to 9 months. There was no difference in the rate of PGF or graft detachment between the 2 groups.

Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens

Purpose

To assess the incidence of glaucoma after combined Descemet's stripping endothelial keratoplasty (DSEK) and retropupillary fixated iris-claw intraocular lens (IOL) implantation in the patients with bullous keratopathy (BK) who required secondary IOL or IOL exchange.

Methods

In this retrospective case series, medical records of 22 patients who underwent combined DSEK and retropupillary fixated iris-claw IOL implantation were evaluated. Preoperative vision, intraocular pressure (IOP), postoperative IOP at different time periods, and intraoperative and postoperative complications were analyzed.

Results

A total of 22 eyes of 22 patients (7 females and 15 males) were analyzed. The median age was 62 years, and the median duration of the postoperative follow-up was 106.5 days. The corrected distance visual acuity improved from a median of 1.85 logMAR to 1.68 logMAR. None of the patients had intraoperative complications. Three patients (13.6%) had dislocation of the donor tissue on the 1^st postoperative day and were successfully rebubbled. Six eyes (27.3%) had graft failure and required penetrating keratoplasty. Eleven eyes (50%) had a sustained rise in the IOP, of which 2 (9.09%) had ocular hypertension and 9 eyes (40.9%) progressed to glaucoma.

Conclusions

DSEK combined with retropupillary fixated iris-claw lens is a good surgical option for the management of aphakic/pseudophakic BK in patients who require secondary IOL or IOL exchange. Regular IOP monitoring after the surgery is an essential, as there is a risk of IOP rise and glaucoma in the postoperative period. Clinicians should be vigilant and control the IOP to prevent glaucoma progression.

Endothelial keratoplasty with anterior chamber intraocular lens versus secondary posterior chamber intraocular lens

AIM

To describe the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with an anterior chamber intraocular lens (ACIOL) compared to secondary posterior chamber (PC) IOL.

METHODS

This was a retrospective comparative cohort study. The clinical data of 82 eyes from 82 consecutive patients with pseudophakic (PBK) or aphakic bullous keratopathy (ABK) who either underwent DSAEK with retained or secondary ACIOL (n=23) or DSAEK with IOL exchange and/or secondary PCIOL (retropupillary iris-claw IOL, n=25; intrascleral-fixated IOL, n=29; or sulcus IOL, n=5) were analysed. The main outcome measures were graft survival and complications up to 5 years.

RESULTS

The graft survival in the secondary PCIOL group was superior than the ACIOL group over 5 years (year 1, 100.0% vs 100.0%; year 3, 94.7% vs 75.0%; year 5, 91.1% vs 60.6%, p=0.022). The presence of an ACIOL was a significant risk factor associated with graft failure (HR, 4.801; 95% CI, 1.406 to 16.396, p=0.012) compared to a secondary PCIOL. There was no significant difference in the rate of graft detachment and elevated intraocular pressure between the groups. There were five cases (9.3%) of IOL subluxation or dislocation in the retropupillary iris-claw and intrascleral-fixated IOL groups.

CONCLUSIONS

Eyes that underwent DSAEK with ACIOL in situ had poorer long-term graft survival compared with those with secondary PCIOL. Intraocular lens exchange was not associated with a higher complication rate. In ABK or PBK eyes with ACIOL, we recommend performing IOL exchange and/or secondary PCIOL implantation combined with endothelial keratoplasty.

Combined DSAEK and intraocular lens flipping with retropupillary fixation in a patient with anterior chamber iris-claw intraocular lens and corneal edema

An 84-year-old monocular woman was referred to our institution for the management of corneal decompensation in her only eye, the right eye. The patient had secondary implantation of an anterior chamber iris-claw intraocular lens (IOL) for IOL dislocation in the setting of pseudoexfoliation syndrome 2 years before presentation. Descemet-stripping automated endothelial keratoplasty (DSAEK) combined with retropupillary repositioning of the iris-claw IOL using a flipping technique was performed for the treatment of corneal edema. No intraoperative or postoperative complications occurred. Six months postoperatively, the corneal graft was attached and clear and the retropupillary iris-claw IOL was well positioned. The uncorrected distance visual acuity and corrected distance visual acuity improved from counting fingers preoperatively to 20/200 and 20/63, respectively, after surgery. Combined DSAEK and retropupillary refixation of a prepupillary iris-claw IOL using the flipping technique was a safe technique in this patient with corneal decompensation.

Combined Pupilloplasty and Retropupillary Iris-Claw Intraocular Lens Implantation with DSAEK in a Patient with Traumatic Iridoplegia, Aphakia and Corneal Decompensation

Purpose

To report the management of a patient with traumatic mydriasis, aphakia and corneal decompensation with a triple procedure: simultaneous pupilloplasty and retropupillary iris-claw intraocular lens (IOL) implantation combined with Descemet stripping automated endothelial keratoplasty (DSAEK).

Results

An 88-year-old woman was referred to our Institute for consultation on her left eye. The patient had undergone surgical removal of the IOL, without re-implantation, in her left eye 10 months prior to presentation due to traumatic IOL dislocation. At the time of examination, corrected distance visual acuity was counting fingers and intraocular pressure was 10 mmHg. Slit-lamp examination revealed iridoplegia, aphakia and corneal edema. The patient underwent simultaneous pupilloplasty and retropupillary iris-claw IOL implantation combined with DSAEK. Six months postoperatively, the corneal graft was attached and clear, the iris was well reconstructed and almost round, and the iris-claw IOL was in place.

Conclusions

Simultaneous pupilloplasty and retropupillary iris-claw IOL implantation combined with DSAEK was shown to be a safe surgical technique in a patient with traumatic mydriasis, aphakia and corneal decompensation.