A Complex Case Of Traumatic Graft Host Junction Dehiscence With Extrusion Of Iol Leading To A Failed Graft With Aphakia And Absent Iris Support Managed With Penetrating Keratoplasty Combined With Modified Yamane Technique Of Scleral Fixated Iol

To describe a complex case of combined penetrating keratoplasty with Modified Yamane technique of Scleral fixated intraocular in a patient with failed graft and traumatic partial aniridia. 

In this case, we wish to discuss a surgical alternative to visually rehabilitate a case with a failed opacified graft, absent iris support, traumatic aphakia in a single setting 

A 72 year old one eyed gentleman who was a known case of lattice dystrophy and underwent penetrating keratoplasty(PK) + cataract surgery + IOL in RE in 2011,was doing well with a BCVA of 20/80 since then,presented to the emergency department with traumatic graft host junction(GHJ) dehiscence from 5 to 1 o clock position and extrusion of IOL.The LE was amblyopic with a BCVA of CFCF and a central corneal scar.

He underwent wound resuturing with anterior vitrectomy and was left aphakic in the primary surgery.The globe tectonicity was restored but his graft subsequently became oedematous and  failed necessitating a repeat surgery.His BCVA was improving to 20/80 with a contact lens trial.

We decided to perform combined PK with scleral fixated IOL in view of absent iris support.Instead of a traditional rail roading technique,we decided to go ahead with a Modifed Yamane Technique with a 3 piece IOL.It is easier to perform for a anterior segment surgeon than a traditional SFIOL obviating the difficulty of poor visibility and need for prolene sutures.Surgery was succesful and at his 3 week follow up visit,he was doing well with a BCVA of 20/125, stable and centered IOL with a clear and compact graft.

In this case,we wish to highlight the case selection and surgical technique of combined PK with Modifed Yamane technique of SFIOL.

Performing a combined surgery of keratoplasty with a secondary intraocular lens implantation can provide quicker visual rehabilitation especially in complex eyes of one eyed patients. The choice of IOL and surgical technique can be daunting for a anterior segment surgeon 

The choices of secondary IOL include a ACIOL, SFIOL and Iris fixated IOL depending on the presence of iris and capsular support.

Traditional rail roading technique of SFIOL can be very challenging in the setting of a failed graft. On the other hand, employing the modified Yamane technique of SFIOL implantation combined with penetrating keratoplasty gives a more predictable surgical approach for the corneal and cataract surgeon alike.