Outcomes Of Secondary Scleral-Fixated Intraocular Lens Implantation And Descemet Membrane Endothelial Keratoplasty: A Comparative Analysis Of Staged Versus Combined Surgical Approaches

To comparatively evaluate clinical and graft-related outcomes between eyes undergoing staged scleral-fixated intraocular lens (SFIOL) implantation followed by DMEK and those undergoing combined SFIOL implantation with DMEK for the management of aphakic bullous keratopathy (ABK).

Single-center retrospective comparative study conducted at a tertiary referral cornea and anterior segment unit.

Among 498 DMEK procedures performed between 2015 and 2024 with ≥6 months follow-up, 23 eyes were included. Patients were classified by surgical approach: Group 1 underwent sequential SFIOL implantation followed by DMEK, and Group 2 underwent simultaneous SFIOL and DMEK in a single session. Pre- and postoperative assessments included corrected distance visual acuity (CDVA, logMAR), endothelial cell density (ECD; EM-4000, Tomey, Japan), and central corneal thickness (CCT; Sirius, CSO, Italy). Graft detachment, re-bubbling, graft failure, survival, and postoperative complications were recorded and analyzed.

The two groups were comparable in terms of age, sex, baseline CDVA, baseline CCT, donor ECD, and follow-up duration (p>0.05 for all). At final follow-up, percentage ECD loss (58.7% vs 51.7%, p=0.20), percentage CCT change (26.6% vs 32.9%, p=1.00), and percentage CDVA improvement (35.5% in both groups, p=0.63) did not differ between groups. Graft failure occurred in 41.7% vs 45.5% (p=1.00), re-bubbling in 25.0% vs 36.4% (p=0.66), and graft detachment in 25.0% vs 45.5% (p=0.40). CME (8.3% vs 27.3%, p=0.31) and glaucoma (8.3% vs 18.2%, p=0.59) were similar; keratitis occurred only in Group 2 (18.2%, p=0.21), and IOL dislocation only in Group 1 (8.3%, p=1.00).Mean graft survival was 28.8 ± 26.4 and 31.6 ± 42.1 months in Group 1 and 2 (p=0.85).

Staged and combined scleral fixation with DMEK demonstrated comparable visual, pachymetric, endothelial, and graft survival outcomes. DMEK combined with SFIOL implantation appears to be a feasible and effective option in the management of aphakic bullous keratopathy. Furthermore, the combined approach may help minimize the need for multiple procedures and follow-up visits. This may be particularly advantageous in elderly patients with systemic comorbidities, where avoiding an additional surgical intervention and anesthesia exposure could be beneficial.