**1. Introduction**

92 Keratoplasties – Surgical Techniques and Complications

[18] Mehta JS, Shilbayeh R, Por YM, Cajucom-Uy H, Beuerman RW, Tan DT. Femtosecond

keratoplasty. J Cataract Refract Surg. 2008 Nov;34(11):1970-5

laser creation of donor ornea buttons for Descemet-stripping endothelial

A stable anterior chamber is a crucial factor to DSAEK. In aniridic patients with BDI lens, the anterior and posterior segment has direct communication at the periphery of the BDI lens. Maintenance of the air bubble in the anterior chamber would be problematic. Pressure equilibrium must be established on both sides of the BDI lens before the air bubble is introduced into the anterior chamber.

Compared with traditional full-thickness keratoplasty, endothelial keratoplasty (EK) is a great breakthrough for the treatment of corneal endothelial disorders because this new technique maintains a more regular corneal anterior surface, preserves more corneal biomechanical tensile strength and provides more rapid visual rehabilitation. Descemet's stripping with automated endothelial keratoplasty (DSAEK) is currently most favored procedure of EK, in which the donor disc dissection was performed with an automated microkeratome that allows smoother interface and more accurate control of graft thickness.

A stable iris-lens diaphragm is essential to intraoperative donor unfolding and maintenance of air in the anterior chamber, and thus a critical factor for DSAEK. Although it was once considered as a relative contraindication, DSAEK has begun to be undertaken in patients in whom the iris-lens diaphragm was anatomically or functionally abnormal.1,2,3

 In the past decade, patients with aniridia and aphakia/cataract were treated with black diaphragm intraocular (BDI) lens which is composed of a central optic surrounded by a black diaphragm and 2 haptics. This lens could alleviate the patients' symptom of glare and photophobia and increase vision. However, this BDI lens differs from the natural iris-lens diaphragm for more rigidity and less compliance. Besides, the chamber anterior to the BDI lens has direct communication with the vitreous cavity at the gap between the diaphragm and haptics of the lens. Difficulties may be encountered in maintaining the air bubble in the anterior chamber. Herein, we present 3 consecutive cases of bullous keratopathy with BDI lens who underwent DSAEK, the etiologies included 1 congenital aniridia and 2 traumatic iris loss.

#### **2. Case report**

#### **2.1 Case 1**

A 50-year-old man present with bullous keratopathy in his left eye. He had a history of left corneal laceration in 2000, and underwent black diaphragm intraocular (BDI) lens

Descemet's Stripping with Automated Endothelial Keratoplasty

**2.2 Case 2** 

**A** 

**B** 

apposed graft.

(DSAEK) in Patients with Black Diaphragm Intraocular (BDI) Lens 95

was controlled within normal limit with medication. DSAEK was uneventful. However, on the first postoperative day the upper part of the graft was observed detached and the air bubble was invisible in the anterior chamber. Graft reattachment surgery was performed. The eye was first inflated to the normal pressure with balanced salt solution (BSS) that was injected into both the vitreous cavity and the anterior chamber. After that, the anterior chamber was inserted with 0.15ml viscoelastic (Healon GV) followed by filtered air bubble. The patient was instructed to maintain a face-up position for at least 4 hours. The graft was successfully reattached after this procedure. Anterior segment optical coherence tomography (AS-OCT, Visante; Carl Zeiss Meditec, Dublin, California) showed a well apposed graft. The left eye increased to 0.3. The IOP was normal postoperatively. But it rose to 43mmHg around one month postoperatively. It was controlled to normal by medically.

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

**C** 

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)

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

was controlled within normal limit with medication. DSAEK was uneventful. However, on the first postoperative day the upper part of the graft was observed detached and the air bubble was invisible in the anterior chamber. Graft reattachment surgery was performed. The eye was first inflated to the normal pressure with balanced salt solution (BSS) that was injected into both the vitreous cavity and the anterior chamber. After that, the anterior chamber was inserted with 0.15ml viscoelastic (Healon GV) followed by filtered air bubble. The patient was instructed to maintain a face-up position for at least 4 hours. The graft was successfully reattached after this procedure. Anterior segment optical coherence tomography (AS-OCT, Visante; Carl Zeiss Meditec, Dublin, California) showed a well apposed graft. The left eye increased to 0.3. The IOP was normal postoperatively. But it rose to 43mmHg around one month postoperatively. It was controlled to normal by medically.
