Case report: Two-step procedure manages bullous keratopathy and high myopia

In a case of bullous keratopathy after phakic IOL implant for high myopia, lens extraction and PK achieved good results.

Issue: December 1, 2005

ByJared Schultz

LISBON — A two-step process of IOL explantation, combining lens extraction and penetrating keratoplasty, is a possible solution for bullous keratopathy and refractive error after phakic IOL implantation, according to two Italian surgeons.

Emilio Balestrazzi, MD, and Luigi Mosca, MD, said during the European Society of Cataract and Refractive Surgeons meeting that implantation of a phakic IOL to correct myopia of more than 20 D is “not the optimal solution.” It can lead to bullous keratopathy, as it did in a 27-year-old woman who was referred to them from another hospital.

The patient experienced keratopathy after undergoing a complicated implantation of a phakic iris-fixed IOL for a refractive error of –21 D.

Dr. Balestrazzi and Dr. Mosca used a two-step procedure, and the patient was able to achieve a refraction of +3.50 cylinder, equaling a visual acuity of 0.6.

“The postoperative result shows the safety and effectiveness of this two-step surgical choice,” they said.

Clinical image of left eye shows bullous keratopathy and graft failure with phakic IOL still in anterior chamber. Uncorrected visual acuity is light perception.	Ultrasound image of anterior segment shows thinning of the anterior chamber and iris-fixed IOL over the lens.
Images: Balestrazzi E, Mosca L

Surgical process

According to the surgeons, the patient was implanted with phakic IOLs in both eyes in May 2000 to correct refractive errors of –21 D in the left eye and –18 D in the right.

The IOL in the left eye became displaced, and 8 months later, she underwent PK for bullous keratopathy without explantation of the IOL. This resulted in graft failure 1 year later, as well as shallow anterior chamber depth and secondary glaucoma.

Clinical image 6 months after anterior chamber IOL explantation, extracapsular cataract extraction and penetrating keratoplasty. A clear graft resulted. Best corrected visual acuity is +3.50 cylinder × 145° = 0.6.

Image: Balestrazzi E, Mosca L

Dr. Balestrazzi and Dr. Mosca saw the patient in October 2003, and they performed a trabeculectomy with mitomycin C to reduce IOP.

In February 2005, once a good target pressure was achieved, they performed a second PK along with IOL explantation and cataract removal, achieving a final visual acuity of 0.6, which has remained stable.

“The patient was happy first for the aesthetic result and then for the visual result,” they said.

Simpler solution

Dr. Balestrazzi and Dr. Mosca said the take-home message is that in some cases a phakic IOL may not be indicated for high myopes and that a lens extraction could achieve the desired result.

“Because she had 21 D of myopia, it would be better to perform only the phacoemulsification of the lens to reach the same refractive effect without all these problems,” they said.

They also said that it was a mistake to leave the phakic IOL in the eye when the first PK was performed because it created the high IOP and shallow anterior chamber that resulted in the implant becoming stuck in the cornea.

“We’re not against anterior chamber IOLs to correct refractive errors, but in this case probably it was not the right choice,” they said.

For Your Information:

Emilio Balestrazzi, MD, and Luigi Mosca, MD, can be reached at Universita Cattolica del Sacro Cuore, Clinica Oculistica, Policlincio “A. Gemelli,” Largo Agostino Gemelli 8, 00168 Rome, Italy; 39-06-30156008; fax: 39-06-3051247; e-mail: emilio.balestrazzi@rm.unicatt.it.

Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses geographically on Europe and the Asia-Pacific region.