1. Outcomes of Descemet Stripping Automated Endothelial Keratoplasty in patients with a Pre-Existing Anterior Chamber Intraocular Lens
S. Elderkin1A, E. Tu1A, J. Sugar1A, S. Reddy1A, A. Kadakia1B, R. Ramaswamy1B, Djalilian1A 
AOphthalmology, BMedical School, 1Univ of Illinois Eye and Ear Infirmary, Chicago, IL;
Abstract
Results (con’d)
Purpose:  This study was performed to evaluate the outcome of Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) in patients with a retained anterior chamber intraocular lens (ACIOL).
Methods: Retrospective review of 11 patients with corneal decompensation an ACIOL who underwent DSAEK in the 2 year period. All patients except one had an open loop style ACIOLs, and in all cases, there was adequate anterior chamber depth. At the time of surgery, 6 patients had a temporary suture to secure their graft, 2 of which were retained from the suture method and the other 4 were placed additionally. Postoperatively, the rate of donor detachment, graft clarity, corneal pachymetry and visual acuity were noted. 
This was one of the 5 patients who did not have a suture holding the graft. The dislocated graft was successfully reattached with an air bubble.
The mean follow up period was 12 months (range mos). By 6 months, all patients had experienced at least a 2 line improvement in their visual acuity except for patient #6 who had limited visual potential and patient #3, whose graft never completely cleared (primary graft failure). Patient #3 had required excessive manipulation intraoperatively to unfold the graft and therefore was considered iatrogenic failure. This patient has subsequently undergone a repeat DSAEK and at the 4 month follow-up was found to have a clear graft with UCVA of 20/70 and a CCT of 675µm (data not included).
The final visual acuities in most patients were limited because of comorbidities (listed below). None of the 11 patients experienced acute graft rejection.
In all patients except patient #3, the central corneal thickness (CCT) after DSAEK was lower compared to before surgery. The mean thickness pre-operatively was 910 µm (range µm). The average CCT at the last recorded follow-up for the 10 successful cases was 668µm (range µm). (Fig 1). A
Introduction
Fig 1:  Patient #10 below after DSAEK demonstrating existing ACIOL and a clear graft
Endothelial keratoplasty (EK) is now the preferred treatment for patients with symptomatic corneal edema whose pathology is limited to the endothelium.1, 2 It has several advantages over penetrating keratoplasty, most notably, a more rapid visual recovery, less induced astigmatism, and greater resistance to trauma post-operatively. Currently, the most popular technique for EK is the Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK).1, 2 Pseudophakic corneal edema is one of the most common indications for DSAEK. However, most reported cases involve patients with posterior chamber lenses.1, 2 Patients with an ACIOL and corneal endothelial decompensation, however, may also be candidates for DSAEK. Typically, if the ACIOL is felt to be directly responsible for the endothelial failure, an IOL exchange is indicated either prior to or at the time of DSAEK. However, in cases where the ACIOL is not considered the primary reason for the endothelial decompensation and there is adequate anterior chamber depth, it may be more desirable to leave the ACIOL in place.
The presence of the ACIOL, however, can pose additional challenges during DSAEK. Specifically, it can interfere with the surgical placement of the donor graft while making it difficult to maintain an air bubble in the anterior chamber. Given these challenges some surgeons may lean towards exchanging the IOL prior to DSAEK in patients with an ACIOL.3 This series examines the early outcomes of DSAEK in patients with adequate anterior chamber where the ACIOL was left in place.
Summary
    This series confirms previous smaller reports that for select patients with corneal decompensation and an ACIOL, DSAEK without IOL exchange may be a viable alternative in order to minimize the risks of an IOL exchange. These patients include those with adequate anterior chamber depth whose risk of subsequent damage by the ACIOL is minimal. Moreover, this series demonstrates that the use of a suture, either as part of the insertion technique or as a “safety suture” at the end of the case may help reduce the risk of graft detachment without any significant adverse effects on the short term results. Further long term studies, including endothelial cell counts, are necessary to further confirm these results. 
Patient
Age
Detached Day1?
Clear or Failed?
VA Pre, Post
U or BCVA
Comorbidities
Pachy (6mos)
Follow-up (mos.) 1 55 N
Clear
3, 20/100
UCVA
PDR, Fuchs
715 25 2 81
2, 20/50
BCVA
none
670 12 3 76
Edema
20/200, 20/100
ACG
973 4 77 Y
20/400, 20/70 RD
603 21 5 65
CF, 20/200
Acantham, RD, Prior PK
785 6 64
20/400, 20/300
Uveitic Glaucoma
676 17 7 78
20/300, 20/50
Glaucoma
725 8 85
20/400, 20/200
ARMD
660 13 9 70
20/200, 20/50
623 10 73
Chronic CME
595 11
CF, 20/60
Prior PK
Results
    A total of 11 eyes were identified and the clinical features of each patient are summarized in Table 1. The mean age at the time of DSAEK was 72 years (range 55 to 85 years). The time from ACIOL to DSAEK ranged from 6 months to 30 years. All patients except for one had an open loop style ACIOLs, patient #7, who had a closed loop ACIOL which had led to corneal decompensation over the course of 30 years. The primary etiology of the corneal decompensation in the other patients included complicated cataract surgery, multiple intraocular procedures, graft failure, and Fuchs dystrophy. There were no major intraoperative complications. There was one complete graft dislocation into the anterior chamber on POD 1 (#4).
Table 1. Patients who underwent DSAEK from 10/06 to 11/08
References
1. Price MO, Price FW. Descemet's stripping endothelial keratoplasty. Curr Opin Ophthalmol 2007 Jul;18(4):290-4.
2. Terry MA, Shamie N, Chen ES, Hoar KL, Friend DJ. Endothelial keratoplasty a simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block Ophthalmology 2008 Jul;115(7):
3. Wylegala E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg 2008 Oct;34(10):