Gotta Change It All

To report the management of a challenging case of penetrating keratoplasty (PK) combined with IOL exchange and artificial iris implantation.

Private practice in Belo Horizonte, Brazil.

A 56-year-old woman presented with decreased vision and light sensitivity in the left eye that had a penetrating injury after a car accident 30 years ago. Her right eye has a congenital foveal scar that limits vision to 20/60. The left eye sees hand-movement only. Biomicroscopy shows a partially opaque cornea due to some scarring and edema. There is also a significant amount of iris loss with some iris remnants infero-temporal. A single-piece PMMA IOL is dislocated inferiorly. B-scan shows a viable posterior segment, and it was decided to proceed with surgery for this eye.

The dislocated lens was dialed into the AC before trephination of the cornea. Next, the new 3-piece IOL was fixated into the artificial iris with the help of guiding needles. Polytetrafluoroethylene (PTFE) sutures were placed into the artificial iris, 90º away from the point of IOL fixation. The cornea was then excised and the IOL removed. The PTFE sutures were passed into a pair of partial scleral grooves that were created 2 mm posterior and parallel to the limbus, 180º apart from each other. With the anterior vitrector, the iris remnants were removed with an open-sky approach. The IOL-artificial iris complex was fixated and the graft was sutured in place with 16 interrupted 10-0 nylon sutures.

The patient had an uneventful post-operative course and she reports improvement in her vision (20/200 best-corrected) and a significant improvement in light sensitivity.

This case shows an alternative technique to manage complex anterior segment reconstruction using a three-piece IOL, artificial iris and a corneal transplant. This technique has the advantage of performing some critical steps outside the eye and fixating the lens/iris complex combined in a single point to the sclera.