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Purpose: To report two cases of bullous keratopathy following implantation of an iris-claw anterior chamber phakic intraocular lens (p-IOL), both of which required p-IOL explantation and subsequent endothelial keratoplasty.

Method: We reviewed two patients who developed corneal endothelial decompensation after implantation of Artiflex: iris-claw anterior chamber p-IOL. Clinical findings, endothelial cell density (ECD), surgical interventions, and postoperative outcomes were evaluated.

Result: Case 1: A 57-year-old female underwent bilateral Artiflex implantation at age 39. Six years postoperatively, a marked decrease of ECD in the left eye was noted (from 2,207 to 523 cells/mm²), and peripheral bullous keratopathy was observed. She underwent p-IOL explantation combined with phacoemulsification and intraocular lens implantation. Postoperatively, the bullous keratopathy worsened, and non-Descemet’s membrane stripping automated endothelial keratoplasty (nDSAEK) was performed, resulting in good visual recovery.

Case 2: A 48-year-old male had undergone bilateral Artiflex implantation at age 38 without subsequent follow up. He presented at age 47 with left ocular pain. Peripheral bullous keratopathy was noted, with a central ECD of 630 cells/mm² and ECD of 420 cells/mm² at the iris claw fixation site. He underwent p-IOL explantation combined with phacoemulsification and intraocular lens implantation, but postoperative worsening of bullous keratopathy necessitated nDSAEK. Postoperative visual outcomes were favorable.

Conclusions: Eyes implanted with iris claw anterior chamber p-IOLs require careful long-term monitoring due to the risk of progressive corneal endothelial cell loss. Once endothelial decompensation advances, p-IOL explantation and endothelial keratoplasty may become necessary. These cases underscore the importance of strict postoperative surveillance in patients with this type of p-IOL.