Iridocorneal Endothelial Syndrome Surgical Challenge

To describe the surgical approach to a complex case of Iridocorneal Endothelial Syndrome over time, using intraoperative and postoperative anterior segment optical coherence tomography captures, surgical images and videos.

Iridocorneal Endothelial Syndrome requires a multidisciplinary therapeutic approach. Corneal endothelial cells proliferate and migrate through the anterior chamber angle and towards the iris surface. Both progression to glaucoma and corneal decompensation can be parallel events that require close communication between corneologists and glaucomatologists to decide the optimal treatment. This is the description of a clinical surgical case in a tertiary hospital in Barcelona, Spain.

We describe the case of a 78-year-old woman diagnosed with Iridocorneal Endothelial Syndrome after cataract surgery in the left eye and initial diagnosis of primary angle-closure glaucoma. Subsequently, the patient underwent several surgical interventions in that eye that included a trabeculectomy, an Ahmed valve implantation, an iris biopsy, a Descemet Stripping Endothelial Keratoplasty (DSAEK), a goniosynechiolysis associated with central vitretomy and an iridoplasty. However, almost three years after the diagnosis, the patient presented visual acuity of counting fingers at 20 centimeters and corneal decompensation with diffuse edema, grade 3 athalamia and 360º anterior synechiae with intraocular pressure of 22mmHg under treatment with hypotensive drugs. It was decided to perform a joint intervention in which goniosynechiolysis associated with re-DSAEK and extraction of iridocorneal membranes was performed. Two days after the intervention, the patient presented a transparent cornea with an wider angle, minimal remains of iridocorneal membrane in the anterior chamber angle and a visual acuity of 0.1.

This complex case reports the different therapeutic decisions in a patient with Iridochroneal Endothelial Syndrome from a surgical point of view. Knowing the anatomy and pathophysiology of this entity is essential to find the optimal approach. Pathological anatomy, intraoperative and postoperative anterior segment optical coherence tomography, and digital imaging and video show the beauty of this syndrome and help to understand how these patients should be treated.