Descemet Stripping Automated Endothelial Keratoplasty In Eyes With Scleral-Fixated Intraocular Lenses

Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with scleral-fixated intraocular lenses (SFIOLs) is technically challenging due to absent capsular support and altered anterior chamber dynamics, which may compromise graft adherence and air tamponade stability. Evidence regarding outcomes in this high-risk subgroup remains limited. This study aimed to evaluate visual and anatomical outcomes and postoperative complications following DSAEK in eyes with scleral-fixated IOLs, with emphasis on cases utilizing a four-flanged fixation technique.

Single tertiary referral medical center in Israel.

This retrospective case series included 10 eyes of 10 patients who underwent DSAEK at Shamir Medical Center between 2022 and 2026. Six eyes had pre-existing scleral-fixated IOLs, and four underwent combined IOL exchange with scleral fixation and DSAEK (three posterior chamber and one anterior chamber exchanges).  Eight eyes underwent 4-point scleral fixation using a flange technique, and two underwent repositioning of subluxated C-loop IOLs using flanges. Evaluated outcomes included graft clarity, graft detachment and rebubbling, as well as best-corrected visual acuity (BCVA), central macular thickness (CMT), glaucoma medication burden, and other postoperative complications.

Mean age was 76.4±7.3 years; 80% were male. Mean follow-up was 9.2±6.8 months. Prior vitrectomy and glaucoma were present in 6 eyes (60%) each; mean preoperative IOP was 15.8±2.8 mmHg. Mean operative time was 71±36 minutes. Preoperative BCVA improved from 1.48±0.55 to 1.01±0.66 logMAR at last follow-up (≈4–5 Snellen lines). Rebubbling was required in 3 eyes (30%)—one for early air loss and two for 1-week detachment; pupillary block occurred in 3 (30%). Preoperative CME was present in 6 eyes (60%); mean CMT decreased from 395 to 328 µm. CME improved in 4 eyes, worsened in 2, and developed de novo in 1. One eye (10%) developed graft failure; mild edema persisted in 3 (30%). Glaucoma medications remained stable (0.5 to 0.43).

This study evaluated anatomically complex eyes that underwent scleral IOL fixation using a flange technique and were characterized by extensive ocular comorbidity. Overall graft survival and visual outcomes were favorable despite this high-risk profile. The rates of rebubbling and pupillary block were relatively high, underscoring the need for careful air management and close postoperative follow-up in this group. Glaucoma control remained stable, with no sustained increase in medication burden. In addition, most eyes with preexisting cystoid macular edema demonstrated anatomical improvement following surgery. Overall, DSAEK represents a viable surgical option in eyes with scleral-fixated IOLs despite their complexity.