I Forgot About My Anterior Chamber Intraocular Lenses! - The Consequences Of Poor Monitoring

Anterior Chamber Intraocular Lenses (AC IOLs) were designed for phakic and aphakic indications, however, the development of serious postoperative complications has gradually discouraged their use. Once implanted, patients require careful monitoring to prevent irreversible anatomical damage and progressive corneal decompensation.

Ophthalmology Department, King's College Hospital NHS Foundation Trust, London, United Kingdom.

We present a 50-year-old male with a history of myopia and myopic astigmatism who underwent bilateral phakic IOL implantation in 2012 in a private clinic. His preoperative refraction was in the Right Eye (RE) -6.75 sph -1.25D cyl at 5º and in the Left Eye (LE) -6.50 sph -1.50D cyl at 161º. Preoperative pachymetry measured 498 um in the RE and 503um in the LE.

He presented to the Eye Casualty with a one-month history of painful RE with deterioration of vision. He had been treated for suspected herpetic stromal keratitis with systemic antivirals and topical steroids. Visual Acuity (VA) was 6/36 in the RE and 6/6 in the LE. The Intraocular pressures were normal. Slit lamp examination revealed RE Bullous keratopathy and mild corneal oedema in the LE; both eyes had soft acrylic AC IOLs. The patient reported a similar episode one year prior, which had temporarily resolved with Nepafenac drops.

Significant corneal decompensation was noted in the RE, alongside high anisometropia and early cataract changes, more significant in the RE. Given the progressive endothelial failure, early surgical intervention was necessary. The RE AC IOL was explanted, followed by the LE AC IOL explantation weeks later. The RE developed end-stage decompensation requiring combined endothelial keratoplasty (EK) and phacoemulsification plus intraocular lens implantation, while the LE corneal oedema resolved after AC IOL explantation.

This case highlights the consequences of insufficient monitoring in patients with AC IOL. Progressive Endothelial Cell (EC) loss can lead to irreversible corneal decompensation. According to AAO guidelines, explantation should be considered when EC density drops below 1500 cells/mm² or when there is more than 30 percent EC loss. Regular endothelial assessments and timely intervention, including early lens explantation when indicated, are essential to prevent sight-threatening complications and optimise surgical outcomes.