Endothelial Keratoplasty Combined With Iris Fixated Intraocular Lens In The Management Of Complex Pseudophakic Bullous Keratopathy: Surgical Considerations

Pseudophakic and aphakic corneal edema are one of the most common indications for endothelial keratoplasty in the developing world. Visual rehabilitation in these patients is dependent on a combination of endothelial keratoplasty alongwith suitably fixed secondary intraocular lens. This case report highlights the important advantages of iris fixated IOLs over anterior chamber and scleral fixated lenses.

A 73 years female hailing from a rural area presented to the Cornea and Anterior segment services of our tertiary care centre in South India. She had been previously undergone a complicated cataract surgery elsewhere 15 years ago. However, she reported satisfactory visual acuity with optical correction until about 6 months ago.

A 73 years female presented with painful diminution of vision in the right eye for the past 6 months.On examination, she was found to have best corrected visual acuity of hand movements, with diffuse stromal edema with bullae suggestive of pseudophakic bullous keratopathy. Posterior chamber intraocular lens appeared to be in place. Ultrasound B scan showed no significant findings in the posterior segment. The patient was planned for Descemet Membrane Endothelial Keratoplasty (DMEK). On table, the PCIOL appeared to be subluxated inferiorly with inadequate capsular support. IOL explantation followed by retrofixated iris claw lens implantation was performed. Following this, DMEK was completed. Postoperatively, vision improved to 20/250 at 3 days with a well attached lenticule and resolving corneal edema. Iris fixated IOL was stable.

Iris claw IOL was chosen because problems such as inadequate space in the AC, graft dislocation into the vitreous cavity are effectively solved by iris fixated lenses, which are easier to insert while maintaining a deep anterior chamber. At the same time, the surface of the IOL is flush with the iris, preventing posterior dislocation of the graft. Also, this position of the IOL is closest to the physiological nodal point, making it the best optical solution.

In the absence of adequate bag support, ACIOL, iris fixated IOLs and scleral fixated IOLs are options for visual rehabilitation. ACIOL reduces the available space in the anterior chamber for manipulation of the graft and increases the risk of contact of IOL with the graft, increasing endothelial damage as well as graft tear, which contribute to graft detachment and early failure. Scleral fixation is technically challenging for anterior segment surgeons with a risk of posterior graft dislocation into the vitreous cavity. This case report highlights the important advantages of iris fixated IOLs over anterior chamber and scleral fixated lenses. Therefore, they are an effective and safe option in combination with endothelial keratoplasty.