An Eye-Spinning Journey Of Refractivity And Keratotomies: Challenges Encountered In Exchanging A Displaced Artisan Phakic Iol In A Patient With 16 Radial Keratotomies, Cataract And Low Endothelial Cell Count

Radial keratotomy patients present unique refractive and surgical safety challenges due to the flattened corneal profile and corneal frailty around keratotomies. Uniquely these challenges on the cornea are exacerbated by the presence of a displaced phakic iris-claw intraocular lens (Artisan model) which can further affect the cornea such as by decreasing endothelial cell count. After careful biometry planning the surgery must delicately balance around both protecting the corneal endothelium and preventing any keratotomy from opening intraoperatively. Only after these tasks can the surgeon briefly rest.    

Retrospective case report detailing the challenges we encountered in the exchange of a displaced Artisan phakic IOL in a highly-myopic radial keratotomies patient.

A 48 year-old patient had first undergone bilateral radial keratotomy surgery for myopia correction, after which additional intraocular correction was provided using bilateral phakic intraocular lenses (PIOL) of the Artisan iris-claw model. The patient presented with decreased right eye vision due to PIOL displacement and nuclear cataract. IOP was 14mm Hg with the patient presenting a patent iridectomy. Endothelial cell count measured 703 cells/mm² for OD and 1331 cells/mm² for OS. Biometry was performed using Heidelberg Engineering Anterion device equipped with the latest available formulas. After comparing standard formulas, Barret True K and other resources a 19.00 D monofocal 1-piece hydrophobic IOL was selected. Surgically we performed a 6 mm wide tunneled scleral incision through which the PIOL was explanted. This incision was then sutured. For continuation we performed an under-limbus tunneled 2.4 mm main incision into healthy cornea to avoid the keratectomies and two paracenteses. After successful phacoemulsification of the cataract a keratotomy dehiscence was noted adjacent to the incision upon retracting the phaco probe. Under viscoelastic protection we elected to first implant the IOL and then suture the dehiscent keratotomy. A further suture was placed on the main incision. Postoperative evolution produced surprising refractive result of +0.25 spherical and -0.25 cylinder, mild corneal oedema under treatment and VA improvement from 20/400 to 20/200 Snellen.

Our case took us through a journey of overcoming several unique challenges: first the biometry planning, then explanting the relatively rigid anterior chamber PIOL trough scleral incision, then phacoemulsification in poor visibility conditions only to face a keratotomy dehiscence. In our eye-spinning experience of under-keratotomies surgery we found both surgical unpredictability and hope through a good result despite the unexpected challenges.