Refractive Surgical Problem:

Article Outline

• Copyright

A 51-year-old man who had previous penetrating corneal transplantation (penetrating keratoplasty [PKP]) for keratoconus in the right eye presented to his primary ophthalmologist 2 years later with a visually significant cataract. Because of high and relatively symmetric astigmatism, the patient had phacoemulsification with implantation of an Acrysof IQ toric intraocular lens (IOL) (SN60T7, Alcon Laboratories, Inc.) to correct post-PKP astigmatism.

After cataract surgery, the patient achieved an uncorrected distance visual acuity (UDVA) of 20/40 and a corrected distance visual acuity (CDVA) of 20/25 in the eye and he was very satisfied with his vision. Three months later, however, the patient presented with an episode of acute graft rejection. Despite treatment, the corneal graft failed.

After 4 months, the patient was referred with a visual acuity of counting fingers. The intraocular pressure (IOP) was 14 mm Hg, and slitlamp examination showed diffuse corneal graft edema and epithelial irregularity (Figure 1). Corneal topography showed some irregular astigmatism (Figure 2).

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1. 

  Diffuse corneal graft edema, epithelial irregularity, and an in-the-bag IOL.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 2. 

  Corneal topography after graft rejection.

Given the high-power toric IOL in the capsular bag and corneal graft failure, what would be your approach to treat this patient?