“Surprise Box” In Penetrating Keratoplasty

Facing unexpected surprises in penetrating keratoplasty can be challenging and requires personalized surgical management.  We describe surgical management of damaged intra ocular lenses and residual crystalline lens material in penetrating keratoplasty.

Department of ophthalmology, Habib Thameur University hospital, Tunis.

Case1: a 27-year-old woman operated 10 years ago for traumatic cataract. She presented with advanced bullous keratopathy with total corneal opacification, visual acuity (VA) was limited to hand motions. Penetrating keratoplasty was indicated. After corneal trephination, a damaged PMMA IOL was gently removed, synechia were released, the residual annular crystalline ring was removed, anterior vitrectomy was done and we performed open sky retropupillary iris claw (RPIC) IOL implantation. Pupilloplasty was done and we sutured the donor cornea. At one month follow up, VA was 20/100 and corneal graft was clear.

Case2: A 42-year-old woman with a history of ocular surgery with iris claw implantation for ectopia lentis 6 years ago. She complained about diplopia, blurred vision and ocular redness. VA was limited to 20/200. Ophthalmic examination showed bullous keratopathy, decentered Iris claw IOL and correctopia. Penetrating keratoplasty with iris claw repositioning was indicated. After corneal trephination, we removed the Iris claw IOL that was damaged, and while exploring we found the ectopic lens behind the iridotomy. A Snellen hook was used to remove it, anterior vitrectomy and pupilloplasty were performed and we implanted a RPIC IOL before suturing the corneal graft. Post operatively the patient was satisfied, there was no diplopia, VA was 20/40 at one month and corneal graft was clear.

Peroperative discovery of damaged IOLs in penetrating keratoplasty requires combined “open-Sky” IOL exchange to ensure better visual outcome. The ophthalmologist has to be aware. IOL power calculation should be performed in all cases of penetrating keratoplasty even in pseudophakic eyes.

Financial disclosure of all authors: None