Refractive Intraocular Lens Exchange - The Journey Of Visual Recovery In A Myopic Pseudophakic Patient With Anisometropia And Low Endothelial Cell Count

To present the complex surgical strategy for IOL exchange of a single piece intraocular lens for refractive purposes (high hyperopia in a highly anisometropic  eye), in a myopic, pseudophakic 74 year old patient with a low endothelial cell count, with inadequate capsular support.

Clinical Emergency Eye Hospital Bucharest, BUCHAREST, ROMANIA

Ophthalmological examination and paraclinical investigations revealed a clinically significant anisometropia, for which refractive exchange of the IOL was decided upon. A low endothelial cell count was also noticed (<1000). IOL explantation was performed, followed by secondary three piece IOL implantation in sulcus. Instability of the lens prompted a third intervention for scleral fixation of the previously implanted three piece IOL. 

The first surgical step towards the IOL exchange, the explantation of the single piece IOL, was performed successfully, however, during the surgery, a posterior capsular rent was noticed. Due to this, a three piece IOL was placed in the sulcus, with a very good postoperative visual outcome of BCVA of 1. Ten months later, visual acuity loss with a subsequent IOL subluxation was noticed, most likely due to the anatomic particularities of the anterior segment, prompting us to perform a sutureless scleral fixation technique of the previously sulcus-implanted three piece IOL.

For the ophthalmic surgeon, maintaining anterior segment anatomy is the main desired outcome in cataract surgery. However, myopic, complex eyes can pose significant challenges due to their particular anatomy. In this case, where the endothelial cell count is particularly low (<1000), we evaluated that sutureless scleral fixation using the Agarwal Scharioth technique is the best long term solution, providing very good IOL stability, should a DMEK be needed further down the line, in case of endothelial decompensation.