Sabah Saleh Jastaneiah, MD Consultant cornea and anterior segment department King Khaled Eye Specialist Hospital (KKESH) Riyadh, Saudi Arabia KKESH بسم اللة الرحمن الرحيم

On presentation 2

Not good candidate DSAEK cases include:  Corneal stroma opacification & good visual potential  Partial or complete aniridia  peripheral iridotomies  Pseudophakia with Zonular weakness That is because of difficulties in maintaining the air bubble intended for lenticule attachment  Presence of anterior chamber IOL (due to accelerated endothelial cells loss) 3

Two stage management plan was elected In the form of 1. Aniridia Intra-Ocular Lens (IOL) implantation followed by 2. DSAEK The main objective was to give him a chance to have the best long-term outcome to a DSAEK corneal graft, in addition to the benefit of an aniridia implant. At the same time the aniridia implant would make the DSAEK procedure possible. 4

The first procedure was done in April 2008  Scleral fixed aniridia IOL of +22.0D ( Morcher aniridia implant ®), model 67G, and 5 mm pupil zone was implanted under general anesthesia.  Patients own keratometry reading was taken with an intended under correction to achieve a target of - 2 diaopters in order to overcome the hyperopic shift after DSAEK. Slit lamb picture using retro illumination showing the clear 5 mm optic aniridia implant,jet black paraoptical zone and corneal edema with a good red reflex. 5

 Intra-operatively the air bubble was maintained in the anterior chamber and the DSAEK lenticule was in place.  Intraoperative challenges were mainly related to the hypotony. 6 Broad slit lamb photograph showing clear cornea and a black reflection from the aniridia implant with the central optical zone reflecting light

 The lenticule detached after surgery, air was injected twice with only partial improvement.  Third post operative day the lenticule spontaneously attached with slight decentration. 7 The cornea was clear with a slightly decentered graft

 DSAEK  DSAEK procedure challenges that include iris defects may be overcome by stepwise procedure planning  Aniridia implant supports reasonable amount of air in the anterior chamber especially if the posterior segment is well formed  Spontaneous attachment of the DSAEK lenticule is a possibility that should be considered before re- bubbling, or judging the graft as failed to attach. Time line in my case was 3 days post operatively. Thank you 8