Retain Or Explant? Strategic Removal Of Anterior Chamber Phakic Iol Prior To Vitrectomy In A Young High Myope With Cataract And Full-Thickness Macular Hole

To evaluate the surgical dilemma of retaining versus explanting an anterior chamber iris-claw phakic intraocular lens (AC pIOL) in a young highly myopic patient presenting with visually significant cataract and full-thickness macular hole (FTMH), and to describe the clinical reasoning of a sequential anterior–posterior surgical approach.

Secondary Eye Clinic 

A 31-year-old highly myopic patient with bilateral AC iris-claw pIOL implantation 12 years prior to examination presented with progressive visual decline in the left eye. Uncorrected visual acuity was 0.05 (Snellen) and Best Corrected Visual Acuity (BCVA) was 0.1 (S −3.00 C −0.50×70). Slit-lamp examination revealed a well-centered AC pIOL and nuclear cataract. Endothelial cell density was borderline for age, raising concern for cumulative intraocular stress. OCT macula confirmed FTMH.

Two surgical approaches were considered: combined phaco-vitrectomy with retained pIOL or sequential anterior–posterior approach. In this case a sequential strategy was performed. The AC pIOL was explanted, followed by phacoemulsification and posterior chamber IOL implantation. Pars plana vitrectomy with internal limiting membrane peeling and gas tamponade was subsequently performed.

Explantation of pIOL facilitated anterior chamber access, enhanced capsulorhexis control, and reduced endothelial manipulation during subsequent vitreoretinal surgery. Cataract removal restored media clarity, allowing precise posterior segment visualization and membrane peeling. At one month, OCT macula confirmed complete anatomical macular hole closure. Postoperative BCVA improved to 0.4. No intraoperative complications or postoperative endothelial decompensation were observed.

Retaining an AC pIOL during combined anterior–posterior surgery may increase surgical complexity, anterior chamber crowding, and corneal endothelial stress. In this case, sequential explantation provides safer and improves surgical visualization for posterior segment surgery in young high myopes with long-term refractive implants. Strategic surgical sequencing may optimize both anatomical and functional outcomes in complex anterior-posterior segment cases.