• Cornea/External Disease

    Review of: Endothelial keratoplasty with anterior chamber intraocular lens versus secondary posterior chamber intraocular lens

    Woo J, Arundhati A, Chee S, et al. British Journal of Ophthalmology, February 2022

    Graft survival was assessed following Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with pseudophakic bullous keratopathy (PBK) and aphakic bullous keratopathy (ABK) in conjunction with an anterior chamber intraocular lens (ACIOL) vs secondary posterior chamber (PC) IOL. Patients were found in the Singapore Corneal Transplant Registry database. Outcomes were recorded after a mean observation period of 3.9 years.

    Study design

    This retrospective comparative cohort study analyzed clinical data from 82 consecutive eyes with pseudophakic bullous keratopathy or aphakic bullous keratopathy between 2008 and 2017. Before 2014, subjects received DSAEK with ACIOL retention or secondary ACIOL; after 2014, they received DSAEK with ACIOL exchange for PCIOL or secondary PCIOL. PCIOLs were either retropupillary iris-claw, glued intrascleral 3-piece, or sulcus 3-piece.


    Kaplan-Meier analysis showed that graft survival was superior in the PCIOL group compared to the ACIOL group over 5 years (year 1, 100% vs. 100% [n = 43/16]; year 3, 95% vs. 75% [n = 31/12]; year 5, 91% vs. 61% [n = 11/8]; p = 0.02). After adjusting for potential confounding factors, multivariate Cox regression analysis showed that the presence of an ACIOL was a significant risk factor for graft failure (hazard ratio 4.8). There were no significant differences between the PCIOL and ACIOL groups for the parameters of intraoperative complications, graft detachment, ocular hypertension, 1-year endothelial cell loss, and 1- and 3-year vision. There were more postoperative dislocations in the PCIOL group (5) than in the ACIOL group (0).


    In addition to its retrospective design, this study is limited by a small sample size, with 5-year follow-up comprising only 8 of the original 23 ACIOL patients and 11 of the original 59 PCIOL patients. However, this study reports the longest follow-up of DSAEK in the presence of ACIOLs, with a mean observation interval of 3.9 years. Lastly, this is a study of DSAEK, not Descemet Membrane Endothelial Keratoplasty.

    Clinical significance

    DSAEK in the presence of ACIOL has poorer graft survival over 5 years and a greater risk of failure. For eyes with PBK with ACIOL and aphakic bullous keratopathy, the authors recommend exchanging the ACIOL for a PCIOL or secondary PCIOL implantation at the time of DSAEK.