Cataract surgery after Descemet stripping endothelial keratoplasty
A 37-year-old male underwent endothelial keratoplasty in the right eye for primary graft failure following large diameter (11.5 mm) therapeutic penetrating keratoplasty. The therapeutic penetrating keratoplasty was done for advanced fungal keratitis 6 months prior to DSAEK. Following therapeutic keratoplasty, there was no recurrence infection. The graft was edematous with 10 intact sutures covered by conjunctiva, the anterior chamber was deep with few peripheral anterior synechiae, pupil showed posterior synechiae, and lens showed early nuclear sclerosis. The intraocular pressure was within normal range throughout the postoperative period.\nDSAEK was done using Moria microkeratome system (Moria/Microtek Inc., Doylestown, PA, USA) with a 350- mm head. Considering the patient's age and the absence of significant cataract, simultaneous cataract surgery was deferred. The endothelial cell density of the donor cornea was of 2272 cells/mm2. The posterior lamellar graft was inserted by the push-in technique using the sheet IOL glide (BD Medical-Ophthalmic Systems, Franklin Lakes, NJ USA) protecting the endothelium with sodium hyaluronate 1%. The graft clarity recovered in 1 month after the surgery. At 3 months postoperative visit, the graft was clear; however, a significant progression of cataract was noted. The vision was 20/400 due to a nuclear cataract of grade 2+. The patient underwent uneventful phacoemulsification with IOL implantation 3 months after DSAEK. Pre-operative evaluation by confocal microscopy (Nidek, Confoscan 4) revealed an endothelial count of 1937 cells/mm.[] Biometry was performed using the keratometry readings obtained from Orbscan II (Bausch and Lomb's, Florida, USA) and IOL power was calculated for a postoperative targeted refraction of –0.5 diopters of myopia.\nA superior scleral incision approach was used. Synechiolysis was done and phacoemulsification was performed by the stop and chop technique. Irrigation was kept off while inserting the phaco handpiece into the anterior chamber to avoid dislodging the graft. During surgery, a dispersive ophthalmic viscosurgical device (hydroxypropyl methylcellulose 2%, Viscomet, Sun Pharmaceuticals Industries Ltd., India) was used to protect the endothelium. A foldable, acrylic IOL was implanted in- the bag. The phaco time used was 15 seconds.\nOn the first postoperative day, vision was 20/160, improving to 20/80, and the graft was compact [Figs. and ]. He was treated with ofloxacin 0.3% eyedrops 6 times/day for a week and prednisolone acetate 1% eyedrops 8 times/day for the initial 1 week, followed by tapering of one drop a week and finally maintained on 3 times/day. One month after the cataract surgery, his vision was 20/50. At the last visit, 3 months later, the graft was compact and the best corrected visual acuity was 20/30 with a –0.75 D Sph/–1.50 D Cyl at 160°. shows the visual acuity, donor thickness [assessed by anterior segment Optical Coherence Tomography (OCT), Visante: Carl Zeiss, Germany] and visual acuity pre- and post-cataract surgery. shows the changes in the endothelial cell density.