Eyes with an anterior chamber intraocular lens (ACIOL) that develop pseudophakic bullous keratopathy (PBK) or aphakic bullous keratopathy (ABK) and subsequently undergo Descemet stripping automated endothelial keratoplasty (DSAEK) have poorer graft survival than those with a posterior chamber IOLs (PCIOL), according to an investigation published in BMC Ophthalmology. The study’s authors recommend performing intraocular lens (IOL) exchange or secondary PCIOL implantation, or both, combined with endothelial keratoplasty in favor of the retention or secondary implantation of an ACIOL.

Researchers examined clinical data from 82 eyes of 82 consecutive patients diagnosed with PBK or ABK and who then underwent either DSAEK with a retained or secondary ACIOL, or DSAEK with an IOL exchange or a secondary PCIOL, including reteropupillary iris-claw IOL, intrascleral fixated IOL and sulcus IOL.

All surgical procedures were performed under general anesthesia and, in cases where lens exchange was indicated, the exchange was performed before DSAEK in the same procedure. For ACIOL exchanges, the ACIOL was first explanted, followed by anterior vitrectomy and closure of large iris defects as indicated. In the group that received a retropupillary iris-claw IOL, two models of polymethyl methacrylate (PMMA) IOLs were used.  

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The study looked at graft survival rates and complications including graft survival, retention, and intraocular pressure (IOP) for up to 5 years after the surgery. Results indicated that the presence of an ACIOL was more significantly associated with graft failure (P =.012) compared with the PCIOL. Meanwhile, no significant difference was observed in graft detachment rates or IOP levels between the two groups. The researchers also reported 5 cases (9.3%) of IOL subluxation or dislocation with the pupillary iris claw and intrascleral-fixated IOL.

Based on the results, the researchers have recommended that surgeons favor the PCIOL in PBK and ABK patients. For patients with an ACIOL, an IOL exchange and/or a secondary PCIOL implantation was recommended for patients undergoing DSEK. 

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Woo J, Arundhati A, Chee S, et al. Endothelial keratoplasty with anterior chamber intraocular lens versus secondary posterior chamber intraocular lens. BMC Ophthalmol. Published online October 28, 2020. doi: 10.1136/bjophthalmol-2020-316711.