**2.2 Case 2**

94 Keratoplasties – Surgical Techniques and Complications

implantation in 2003. Ophthalmic examination revealed a linear corneal scar, the majority of iris was absent except the nasal remnants adhering to the corneal endothelium. Ultrasound biomicroscopy (UBM) showed that the BDI lens was in the right position. Preoperative bestcorrected visual acuity in the left was counting fingers, and the intraocular pressure (IOP)

**A** 

**B** 

**D** 

Fig. 1. (case 1) UBM shows that BDI lens is at the right position of ciliary sulcus (A). Preoperative slit lamp photograph shows edematous cornea (B). AS-OCT shows bullea of the epithelium.The nasal iris remnant is adherent to the cornea (C). Postoperative slit lamp

**C** 

**E** 

photograph (D) and AS-OCT (E) shows a well apposed graft.

A 49-year-old woman present with DSAEK in her left eye, as history of bilateral congenital aniridia and cataract and lens implantation in 2002. On examination, pendular nystagmus. Preoperative best-corrected visual acuity was 0.12 in the right and 0.1 in the left, and the IOP was 17 mmHg in the right and 20mmHg in the left when using eye-drops. The left cornea

Fig. 2. (case 2) UBM shows iris remnants at periphery. The BDI lens is at the right position of ciliary sulcus (A). Postoperative slit lamp photograph (B) and AS-OCT (C) shows a well apposed graft.

Descemet's Stripping with Automated Endothelial Keratoplasty

**3. Discussion** 

was unfolded by the air bubble.

(DSAEK) in Patients with Black Diaphragm Intraocular (BDI) Lens 97

Most manipulations during the DSAEK surgery are performed in the anterior chamber. In addition, at the end of the surgery, air bubble is introduced into the anterior chamber to support the donor graft. Therefore, the stability of the anterior chamber is a critical factor in DSAEK. The natural iris-lens diaphragm is a barrier separating the anterior chamber from posterior vitreous cavity. Patients with anatomically or functionally anomalous iris-lens diaphragm are challenges to DSAEK. Small case series of DSAEK/DSEK were reported in patients with intraoperative floppy-iris syndrome, aphakic patients and aniridic aphakic patients.1,2,3 The results were largely favorable with some modification of the surgical technique. Bradley et al. described a suture-drag technique to minimize intraoperative donor endothelial trauma in patients with intraoperative floppy-iris syndrome.1 Price et al. used anchor suture securing the donor to the recipient to prevent the donor tissue from dropping down to the retina in aniridic aphakic eyes.2 However, since the main purpose of DSAEK is to improve vision, we think it should be more appropriate to correct aphakia and aniridia either prior to or at the same time with DSAEK surgery. Aniridic aphakic patients would benefit from BDI lens that could in some extent compensate optically the loss of iris and crystal lens. However, the BDI lens is not an ideal barrier to maintain a stable anterior chamber compared with the natural iris-lens diaphragm. There is gap between the haptics and the black diaphragm, especially in the traumatic cases without capsular remnants. Therefore, after a 5mm incision was made in DSAEK, the pressure in the anterior chamber will decrease, thus it is unavoidable that the liquefied vitreous humor will go through the gap into the anterior chamber and the pressure of the posterior segment will decline. Anterior irrigation during graft insertion is not enough to compensate this occult vitrous loss. In the presence of pressure difference between the anterior and posterior segment, when the air bubble was injected into the anterior chamber, it would easily go back to the vitreous cavity postoperatively just like what we observed in case 1 in which the graft was found partially detached and the air bubble was totally disappeared on the first postoperative day. Therefore, when DSAEK is considered in an aniridic patient with BDI lens, we recommend that the pressure difference should be balanced first before the donor

Glaucoma is a common complication for both traumatic and congenital aniridia. In the traumatic eye, the trabecular meshwork could easily be jeopardized in the presence of extensive loss of iris tissue. Likewise, anomalous development of the anterior chamber angle in congenital aniridia could result in progressive IOP elevation.4 In addition, the prevalence of glaucoma will further increased after BDI lens implantation.5,6 It was ascribed to the continuous irritation of the haptics and the diaphragm to the uveal remnants in congenital aniridia, which may alter the blood–aqueous barrier, accelerating glaucoma progression.<sup>5</sup> It was also proposed that the large size of the BDI lens may impair aqueous outflow by direct compression on the anterior chamber angle.6 In some cases the haptics of the lens were found not rest in the ciliary sulcus but in the anterior chamber angle.5 Therefore, use of type 67G BDI lens with smaller haptic diameter (12.5mm) was recommend.6 Glaucoma was observed in two of our patients (case 1 and case 2) before DSAEK, but could be controlled medically. During the postoperative follow-up, case 1 had a temporary IOP rise, and case 2 experienced a persistent hypertony that was successfully treated with cyclophotocoagulation. In our case series, all three patients were implanted with 67G BDI lens, and the UBM prior to DSAEK surgery showed the haptics of the lens were not in

had a ground glass appearance. UBM showed that the BDI lens was in the right position. The lens was sutured. DSAEK was uneventful. 1 month after DSAEK, the patient suffered an ocular hypertony that couldn't be controlled by medication. Ciliary body photocoagulation was undertaken to lower the IOP. The last follow-up visit was 2 month after DSAEK, her IOP was 12 mmHg, and visual acuity was 0.12.
