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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 277-283

Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens

1 Department of Glaucoma, Anand Eye Institute, Hyderabad, Telangana, India
2 Department of Cornea, Anand Eye Institute, Hyderabad, Telangana, India
3 Department of Optometry, Anand Eye Institute, Hyderabad, Telangana, India

Date of Submission19-Feb-2022
Date of Decision02-May-2022
Date of Acceptance03-May-2022
Date of Web Publication30-Nov-2022

Correspondence Address:
Tarannum Mansoori
Department of Glaucoma, Anand Eye Institute, 7.147/1, Nagendra Nagar Colony, Habsiguda, Hyderabad - 500 007, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joco.joco_62_22

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Purpose: To assess the incidence of glaucoma after combined Descemet's stripping endothelial keratoplasty (DSEK) and retropupillary fixated iris-claw intraocular lens (IOL) implantation in the patients with bullous keratopathy (BK) who required secondary IOL or IOL exchange.
Methods: In this retrospective case series, medical records of 22 patients who underwent combined DSEK and retropupillary fixated iris-claw IOL implantation were evaluated. Preoperative vision, intraocular pressure (IOP), postoperative IOP at different time periods, and intraoperative and postoperative complications were analyzed.
Results: A total of 22 eyes of 22 patients (7 females and 15 males) were analyzed. The median age was 62 years, and the median duration of the postoperative follow-up was 106.5 days. The corrected distance visual acuity improved from a median of 1.85 logMAR to 1.68 logMAR. None of the patients had intraoperative complications. Three patients (13.6%) had dislocation of the donor tissue on the 1st postoperative day and were successfully rebubbled. Six eyes (27.3%) had graft failure and required penetrating keratoplasty. Eleven eyes (50%) had a sustained rise in the IOP, of which 2 (9.09%) had ocular hypertension and 9 eyes (40.9%) progressed to glaucoma.
Conclusions: DSEK combined with retropupillary fixated iris-claw lens is a good surgical option for the management of aphakic/pseudophakic BK in patients who require secondary IOL or IOL exchange. Regular IOP monitoring after the surgery is an essential, as there is a risk of IOP rise and glaucoma in the postoperative period. Clinicians should be vigilant and control the IOP to prevent glaucoma progression.

Keywords: Aphakia, Bullous keratopathy, Descemet's stripping endothelial keratoplasty, Glaucoma, Iris-claw intraocular lens, Secondary intraocular lens

How to cite this article:
Mansoori T, Mohan GP, Srirampur A, Pesala V. Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens. J Curr Ophthalmol 2022;34:277-83

How to cite this URL:
Mansoori T, Mohan GP, Srirampur A, Pesala V. Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens. J Curr Ophthalmol [serial online] 2022 [cited 2023 Jun 9];34:277-83. Available from: http://www.jcurrophthalmol.org/text.asp?2022/34/3/277/362464

  Introduction Top

Cataract surgery can accelerate the onset of corneal edema in patients with low endothelial counts, such as in patients with Fuchs endothelial dystrophy, iridocorneal endothelial syndrome, or endothelial inflammatory diseases as a result of iatrogenic surgical trauma. Correction of aphakia in the eyes with corneal endothelial decompensation and no capsular support or those requiring secondary intraocular lens (IOL) implantation or an IOL exchange poses a surgical challenge and has a significant risk of developing complications.[1],[2] Surgical options to correct aphakia include anterior chamber IOL (AC-IOL),[3] scleral-fixated IOL,[4] or retropupillary iris-fixated and posterior chamber IOL (PC-IOL).[5]

Bullous keratopathy (BK) after complicated cataract surgery is commonly associated with aphakia, IOL dislocations, or placement of an AC-IOL after unplanned intracapsular cataract extraction. Corneal endothelial decompensation and aphakia can be managed by penetrating keratoplasty (PK) combined with angle-supported AC-IOL,[6] scleral-fixated IOL,[7],[8],[9],[10] or retropupillary iris-claw IOL.[11],[12],[13],[14] Descemet's stripping endothelial keratoplasty (DSEK) has replaced PK as a primary surgical treatment for the management of endothelial diseases, such as Fuchs dystrophy and pseudophakic BK (PBK) or aphakic BK (ABK) and endothelial graft failure, as it has lower graft rejection and faster visual recovery.[15]

There are a few reports in the literature where combined DSEK and iris-fixated, PC-IOL was performed in the patients with aphakia and corneal edema.[16],[17],[18]

We describe the incidence of glaucoma in the patients who were managed with simultaneous DSEK and a retropupillary fixated iris-claw IOL procedure in the eyes with ABK/PBK, who required secondary IOL/IOL exchange.

  Methods Top

A retrospective chart review of the medical records of all the consecutive cases of DSEK and iris-claw PC-IOL implantation was carried out. All the surgeries were performed between September 2017 and December 2020 by a single surgeon. Internal Anand Eye Institute Review Board approval was obtained, and the study was carried out in accordance with the tenets of the Declaration of Helsinki for research involving human subjects.

All patients had given written informed consent for the surgery. Inclusion criteria were all the eyes that underwent DSEK and iris-claw PC-IOL implantation for ABK or PBK and that required secondary IOL or IOL exchange. Patients who had undergone DSEK and iris-claw PC-IOL implantation concurrent with vitreoretinal surgery (for retinal detachment) or glaucoma shunt implant or those who underwent DSEK with PC-IOL implantation in sulcus were excluded. Data were collected on indication for surgery, preoperative and postoperative evaluations including corrected distance visual acuity (CDVA), slit-lamp examination, fundus examination, preoperative B-scan, preoperative and postoperative intraocular pressure (IOP) at the follow-up visits, measured with Goldmann applanation tonometry (GAT), intraoperative complications, gonioscopy (wherever performed and feasible), optic disc findings, number of antiglaucoma medication (AGM) required, and surgery required to control the IOP. Ocular pathology and comorbidities were also noted.

Iris-claw lens (Excelens, PIC 5580 model; Excel optics [P] Limited, Chennai, Tamil Nadu, India) is a monofocal, single-piece biconvex poly methyl methacrylate IOL, 8 mm in length and has an optical zone of 5.5 mm. The haptics have fine fissures, in which the iris tissue is enclaved. IOL power was calculated using Sanders-Retzlaff-Kraff T formula, with a constant of 117.2, as per the manufacturer's recommendation.

Surgical technique

All procedures were performed by one experienced surgeon (A.S.) using the same surgical protocol in all cases. Under peribulbar anesthesia, the host corneal epithelium was debrided. A superior, sclera-corneal tunnel incision was used to explant the AC-IOL, and a 20-gauge vitrector was used to perform anterior vitrectomy. Cases with posterior-dislocated IOL underwent three-port pars plana vitrectomy and retrieval of IOL from the vitreous. Iris-claw IOL was introduced, manipulated to align the long axis horizontally, and enclaved behind the iris at 3 and 9 o'clock position. A peripheral iridectomy was performed. The donor corneal tissue in each case was precut in the eye bank using an automated microkeratome system. Standard criteria for the selection of corneal tissue for endothelial keratoplasty were followed. Central descemetorhexis of 7.5 mm diameter was done. An 8 mm diameter donor lenticule was trephined, pushed into the AC over a lens glide, manipulated into an appropriate position, and positioned with an air bubble placed in the AC. After centering the graft, the AC was completely filled with air. After 10 min, the air bubble was reduced to approximately 80% of the size of the endothelial graft. The scleral wound was sutured with 10-0 nylon sutures, and a bandage contact lens (BCL) was placed at the end of the surgery.

Postoperatively, all the patients were prescribed topical prednisolone acetate 1% starting with 8 times/day and gradually tapered to twice daily over 9 months and moxifloxacin 0.5% four times/day, which tapered over 6 weeks. Patients were asked to come for follow-up at 1 day, 1 week, 1 month, and subsequently at 2 monthly intervals. BCL was removed after a week following the surgery. If any patient was noted to have a rise in the IOP ≥22 mmHg, they were switched over to topical 0.5% loteprednol etabonate or fluorometholone, and AGM was added to the medical regimen for the management of raised IOP. Glaucoma diagnosis was made based on IOP ≥22 mmHg, glaucomatous optic nerve damage (documented increase in the cup-to-disc ratio, neuroretinal rim thinning), and corresponding visual field defect on Swedish interactive threshold algorithm standard, 24–2 Humphrey visual field.

Statistical analysis was performed using the SPSS version 16 (SPSS/IBM Inc., Chicago, Illinois, USA). Snellen's CDVA was converted to logMAR to allow averaging for the analysis. Kolmogorov–Smirnov test was used to test the distribution of continuous variables. As none of the measures followed a normal distribution, descriptive statistics included median and interquartile range (IQR) for the nonnormally distributed variables. Wilcoxon signed-rank test was used to compare preoperative and postoperative variables.

  Results Top

Of the 22 patients analyzed, 15 were male and 7 were female. The median age was 62 years (IQR: 60, 73.75), and the median duration of the postoperative follow-up was 106.5 days (IQR: 35, 423.75), of which six patients had regular follow-up till 3 years. The median duration between primary cataract surgery and DSEK combined with iris-claw IOL was 18 (IQR: 7, 90) months [Table 1].
Table 1: Descriptive analysis of the study participants

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Patient's ocular pathologies and comorbidities are presented in [Table 2]. [Table 3] shows the patient's characteristics, preoperative and postoperative visual outcomes, IOP, and AGM required postoperatively.
Table 2: Indications for surgery and ocular pathology in the patients, who underwent Descemet's stripping endothelial keratoplasty and retropupillary iris-claw intraocular lens implantation

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Table 3: Preoperative and postoperative corrected distance visual acuity and intraocular pressure of the patients who underwent Descemet's stripping endothelial keratoplasty and retropupillary iris-claw intraocular lens implantation

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The most frequent indication for the surgery was PBK (n = 12), of which 11 eyes had AC-IOL [Figure 1]a and one eye had PC-IOL in the AC [Figure 2a]. Six eyes had ABK, and four eyes had ABK and posterior IOL dislocation.
Figure 1: (a) Preoperative slit-lamp photograph showing corneal stromal edema and the presence of an anterior chamber intraocular lens. (b) Postoperative slit-lamp photograph, 4 months after the surgery, shows an attached and clear Descemet's stripping endothelial keratoplasty graft and a well-centered retropupillary iris-claw intraocular lens

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Postsurgical median CDVA improved to 1.68 logMAR (IQR: 0.95, 1.81) when compared with the presurgical median CDVA of 1.85 logMAR (IQR: 1.75, 2) (P = 0.03). The median preoperative IOP was 12 mmHg (IQR: 12, 14), and the median postoperative IOP was 18 mmHg (IQR: 12, 20). The median postoperative IOP did not change significantly compared to preoperative IOP in all the patients (P = 0.06). The mean IOP change was −5.8 ± 10.82 mmHg on comparing preoperative IOP to the IOP recorded at the last follow-up visit.

Preoperatively, only one eye (case 21) had raised IOP and was started on dorzolamide timolol fixed drug combination twice daily and oral acetazolamide thrice daily till the surgery was performed. Case 2 developed raised IOP and secondary glaucoma postoperatively but developed retinal detachment during the follow-up, and at the last follow-up visit, the eye was digitally soft and the IOP was not recordable on GAT as it was <0 mmHg [Table 3]. Eleven eyes (50%) had a sustained rise in the IOP, of which 2 eyes (9.1%) had ocular hypertension and 9 eyes (40.9%) showed progression to glaucoma. Of these, nine eyes had the IOP controlled with AGM, and 2 eyes required Ahmed glaucoma valve implantation for control of IOP, as these patients were noncompliant with the AGM. Gonioscopy was not performed preoperatively because of bullous keratopathy which precluded visualization of angle structures. Postoperatively in the 11 eyes which developed raised IOP, gonioscopic data were available for the five patients, of which four eyes had documented open angles in all the quadrants and one eye had three-quadrant synechial angle closure. In six patients, gonioscopy was not performed as they had developed graft edema which hampered visualization of angle structures.

None of the patients had intraoperative complications. Three patients (13.6%) presented with a dislocation of the donor tissue, which occurred on the 1st postoperative day and was successfully rebubbled. During the follow-up period, six eyes (27.3%) had graft failure, of which one eye had perforated corneal ulcer, and all these eyes required PK. Endothelial cell density data were not available for any of the patients. However, clinically, 16 eyes had clear corneal lenticule and well-positioned iris-claw IOL at the last follow-up visit [Figure 1]b and [Figure 2]b.
Figure 2: (a) Preoperative slit-lamp photograph showing corneal edema with Descemet's membrane folds, and a posterior chamber intraocular lens in the anterior chamber. (b) Postoperative slit-lamp photograph showing clear cornea, clear Descemet's stripping endothelial keratoplasty graft with a retropupillary fixed iris-claw lens in situ

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None of the factors such as axial length (P = 0.6), AC depth (P = 0.2), IOL power (P = 0.14), or duration between surgeries (P = 0.36) predicted postoperative rise in IOP. [Figure 3] shows the Kaplan–Meier plot with the percentage of eyes that had a raised IOP, as defined by the study criteria.
Figure 3: Kaplan–Meier plot showing the percentage of eyes that had raised intraocular pressure (mmHg) after the surgery

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  Discussion Top

In our study, we describe good visual outcomes after retropupillar iris-claw IOL implantation and DSEK. To the best of our knowledge, this is the largest case series of DSEK and concurrent retropupillary iris-claw IOL implantation with a long duration of follow-up. We did not observe any cases of IOL dislocation or decentration in the postoperative period. Postoperative complications included graft detachment in three eyes (13.6%) and were successfully reattached with a rebubbling procedure. Six eyes (27.3%) had graft failure and required PK.

Wylegala and Tarnawska[1] published a case series of 11 eyes that had undergone DSEK combined with AC-IOL removal and scleral-fixated IOL implantation. They noted a 27% graft dislocation rate with no primary graft failures and a mean endothelial cell loss of 36%.

Retropupillary iris-fixated IOL implantation is an alternative to scleral-fixated IOL implantation in aphakic patients without capsular support, as it is technically more challenging, whereas iris-fixated IOL implantation seems to have a short learning curve and relatively easy to perform for these eyes.[5]

In 2011, Karimian and Sadoughi[17] first reported a novel procedure of DSEK with posterior iris-claw IOL implantation in ABK and PBK. There are few data in the literature on DSEK with simultaneous iris-claw IOL implantation.[16],[17],[18] Vélez et al.[16] reported a case series of nine eyes (mean age, 72.1 years) with ABK that had undergone concurrent retropupillary iris-claw IOL implantation (Artisan; Ophtec, Groningen, The Netherlands) and DSEK. They reported a mean postoperative CDVA of 0.60 logMAR, 14.3% graft dislocation rate, and no significant endothelial cell loss between the 1st month and 6th month after the surgery. In their case series, none of the patients developed postsurgical ocular hypertension, over a mean follow-up duration of 7.7 months. Cagini et al.[18] reported good surgical outcomes in the three cases of simultaneous DSEK and aphakic iris-fixated IOL implantation in patients with ABK.

Various mechanisms can cause IOP elevation after DSEK surgery, such as preexisting glaucoma, retained viscoelastics, steroid responder, damage to trabecular outflow mechanisms, loss of angle support, and synechial angle closure. In our study, only one patient had preexisting glaucoma, preoperative gonioscopy was not performed because of BK, and postoperatively, one patient (out of 4) had synechial angle closure. Unfortunately, gonioscopic data were not available for 18 eyes. Previous study has demonstrated a role of steroid-induced IOP elevation following DSEK.[19] We postulate that steroid-induced glaucoma could be the major reason for IOP elevation in our study. Our patients were treated with topical prednisolone acetate for 1 year, as long as no steroid-induced IOP elevation occurred, and switched over to less potent topical loteprednol etabonate or fluorometholone. AGM was added to the medical regimen for the management of raised IOP. As a peripheral iridectomy was performed in all the eyes, we did not find any case of secondary pupillary block glaucoma in our study. Eleven eyes (50%) had a sustained rise in the IOP, and 9 eyes (40.9%) progressed to glaucoma. Of these, nine eyes had IOP controlled with AGM, and 2 eyes required Ahmed glaucoma valve implantation, at 2 and 3 months, respectively, after the surgery.

These two patients had irregular follow-up and were noncompliant with AGM. The measurement of IOP has been an additional critical point in cases of BK, as precise measurement of the IOP with GAT was not possible preoperatively because of corneal irregularity and increased corneal thickness, which can influence the validity of GAT measurement.

Limitations of our study include its retrospective design, lack of control group (as it was a noncomparative study), variable duration of follow-up, and the corneal endothelial cell density was not measured for any of the patients. Although limited by its noncomparative, retrospective design, this series provides valuable information on 22 eyes with retropupillary iris-fixated IOL implanted concurrent with DSEK, for visual rehabilitation. Our follow-up rate was approximately 60% at 1 year and 27% at 3 years which is more than the other reported case series, although a greater long-term follow-up would have been desirable. However, a significant proportion of the patients in this series were referred from outstation and returned to have follow-up with the primary surgeon.

Although the air bubble management and graft unfolding after donor insertion can prove to be technically challenging, DSEK combined with a retropupillary fixated iris-claw lens is a feasible option for the management of ABK/PBK, who require secondary IOL or IOL exchange. Our study shows the need for regular IOP monitoring after the surgery, and one must be aware of high incidence of IOP rise and glaucoma in the postoperative period and need for clinician to be vigilant and educate the patients regarding the same.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wylegała E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg 2008;34:1708-14.  Back to cited text no. 1
Shah AK, Terry MA, Shamie N, Chen ES, Phillips PM, Hoar KL, et al. Complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty with intraocular lens exchange. Am J Ophthalmol 2010;149:390-7.e1.  Back to cited text no. 2
Sawada T, Kimura W, Kimura T, Suga H, Ohte A, Yamanishi S, et al. Long-term follow-up of primary anterior chamber intraocular lens implantation. J Cataract Refract Surg 1998;24:1515-20.  Back to cited text no. 3
Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg 2008;34:1433-8.  Back to cited text no. 4
Mansoori T, Agraharam SG, Sannapuri S, Manwani S, Balakrishna N. Surgical outcomes of retropupillary-fixated iris-claw intraocular lens. J Curr Ophthalmol 2020;32:149-53.  Back to cited text no. 5
Zaidman GW, Goldman S. A prospective study on the implantation of anterior chamber intraocular lenses during keratoplasty for pseudophakic and aphakic bullous keratopathy. Ophthalmology 1990;97:757-62.  Back to cited text no. 6
Heidemann DG, Dunn SP. Transsclerally sutured intraocular lenses in penetrating keratoplasty. Am J Ophthalmol 1992;113:619-25.  Back to cited text no. 7
Kandarakis AS, Doulas KG, Amariotakis AG. Penetrating keratoplasty and transsclerally suture-fixated intraocular lenses. J Refract Surg 1996;12:S304-6.  Back to cited text no. 8
Djalilian AR, Anderson SO, Fang-Yen M, Lane SS, Holland EJ. Long-term results of transsclerally sutured posterior chamber lenses in penetrating keratoplasty. Cornea 1998;17:359-64.  Back to cited text no. 9
Nottage JM, Bhasin V, Nirankari VS. Long-term safety and visual outcomes of transscleral sutured posterior chamber IOLs and penetrating keratoplasty combined with transscleral sutured posterior chamber IOLs. Trans Am Ophthalmol Soc 2009;107:242-50.  Back to cited text no. 10
Kanellopoulos AJ. Penetrating keratoplasty and Artisan iris-fixated intraocular lens implantation in the management of aphakic bullous keratopathy. Cornea 2004;23:220-4.  Back to cited text no. 11
Rijneveld WJ, Beekhuis WH, Hassman EF, Dellaert MM, Geerards AJ. Iris claw lens: Anterior and posterior iris surface fixation in the absence of capsular support during penetrating keratoplasty. J Refract Corneal Surg 1994;10:14-9.  Back to cited text no. 12
Akpek EK, Altan-Yaycioglu R, Karadayi K, Christen W, Stark WJ. Long-term outcomes of combined penetrating keratoplasty with iris-sutured intraocular lens implantation. Ophthalmology 2003;110:1017-22.  Back to cited text no. 13
Farjo AA, Rhee DJ, Soong HK, Meyer RF, Sugar A. Iris-sutured posterior chamber intraocular lens implantation during penetrating keratoplasty. Cornea 2004;23:18-28.  Back to cited text no. 14
Price MO, Fairchild KM, Price DA, Price FW Jr. Descemet's stripping endothelial keratoplasty five-year graft survival and endothelial cell loss. Ophthalmology 2011;118:725-9.  Back to cited text no. 15
Vélez FM, Mannis MJ, Izquierdo L Jr., Sánchez JG, Velásquez LF, Rojas S. Simultaneous surgery for corneal edema and aphakia: DSEK and placement of a retropupillary iris claw lens. Cornea 2014;33:197-200.  Back to cited text no. 16
Karimian F, Sadoughi MM. Air-assisted Descemet-stripping automated endothelial keratoplasty with posterior chamber iris-fixation of aphakic iris-claw intraocular lens. J Cataract Refract Surg 2011;37:224-8.  Back to cited text no. 17
Cagini C, Fiore T, Leontiadis A, Biondi L, Leaci R, Delfini E, et al. Simultaneous Descemet stripping automated endothelial keratoplasty and aphakic iris-fixated intraocular lens implantation: A case series. Cornea 2011;30:1167-9.  Back to cited text no. 18
Maier AK, Klamann MK, Torun N, Gonnermann J, Schroeter J, Joussen AM, et al. Intraocular pressure elevation and post-DSEK glaucoma after Descemet's stripping endothelial keratoplasty. Graefes Arch Clin Exp Ophthalmol 2013;251:1191-8.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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