Descemet Membrane Endothelial Keratoplasty Combined With Secondary Sulcus Hydrophobic Intraocular Lens Implantation

Fuchs’ endothelial dystrophy is a hereditary disease with progressive destruction of the corneal endothelium often manifesting during the fifth or sixth life decade. Owing to the loss of endothelial pump function, a stromal oedema emerges causing the main symptom of visual blurring. With regard to treatment options, the Descemet membrane endothelial keratoplasty (DMEK) procedure can often entirely reverse the patients’ visual troubles. In few cases it might happen, that pseudophakic patients show a previously unplanned anisometropia due to difficult intraocular lens (IOL)-calculation caused by corneal changes in thickness and keratometry due to the oedema. Therefore, refractive correction can be needed.

A 74-year-old woman with Fuchs' endothelial dystrophy was referred to the Eye Clinic Sulzbach – where examinations and surgery were performed – with symptoms of visual blurring and headache. She had undergone DMEK in the right eye 6 months ago and phacoemulsification with hydrophilic IOL implantation in both eyes 7 years ago. The patient consented in publication of her case.

Initial examination showed a pseudophakic left eye after YAG capsulotomy with corneal oedema and guttae. The right cornea was clear with an adherent DMEK graft. Endothelial cell density (ECD) was normal with 1587 cells/mm² on the right, but unmeasurable on the left. Vertex corneal thickness (VCT) was increased to 590 µm on the left and normal at 546 µm on the right. Unexpectedly, refraction was +5.25 D/–1.00 D × 68° and +0.75 D/–1.50 D × 120°, left and right, respectively, with a corrected distance visual acuity (CDVA) of 0.3 LogMAR left and 0 LogMAR right. Therefore, a surgical procedure merging DMEK and anisometropia correction using an additional hydrophobic monofocal IOL for implantation in the sulcus ciliaris was scheduled. The Barrett Rx Piggy Back IOL Formula was used to calculate the IOL power with a target refraction of –0.75 D on the left eye. DMEK was performed as one–time intervention with the implantation of the +8 D AcrySof MA60AC IOL in the left eye. At 2 months postoperatively, refraction was –0.25/–1.75 × 62° in the left eye and CDVA was 0.1 LogMAR. There was no IOL delocalization or decentration. The left cornea had a juvenile endothelial cell pattern and restored ECD of 1920 cells/mm². At 10 months postoperatively, refraction was +0.75/–1.25 × 54° and +1.50/–1.50 × 119° in the left and right eye, respectively. CDVA was 0 LogMAR in both eyes. ECD amounted 1778 cells/mm² and 1388 cells/mm², left and right respectively. VCT decreased to 553 µm on the left eye.

In pseudophakic and anisometropic patients with Fuchs’ dystrophy, a refractive correction can be needed. This can be done by contact lenses which necessitates good compliance, IOL exchange which can be critical owing to capsular bag susceptibility after YAG capsulotomy or by implantation of an add-on IOL. Here the postoperative hyperopic shift has to be considered. The add-on IOL is usually implanted in the sulcus ciliaris which is efficacious, predictable, reversible and safe, although complications as pigmentary dispersion syndrome or endothelial injury may be conceivable. Here we show, that DMEK can be combined with sulcus IOL implantation in a one–time procedure to correct hyperopia in pseudophakia with very satisfying clinical results.