Video of the month | Jan 2024 | enVista® Toric IOL implantation in an eye with a DSAEK graft for Fuchs’ keratopathy - aiming for accuracy

Presented by: Dimitrios Sakellaris MD

Edited by: Penelope Burle de Politis MD

Descemet’s stripping automated endothelial keratoplasty (DSAEK) has been proved an effective technique in the management of Fuchs’ endothelial corneal dystrophy (FECD), with good levels of BSCVA and patient satisfaction. However, cataract formation may be accelerated after the grafting procedure. Moreover, handling post-DSAEK refractive shifts makes appropriate IOL choice a challenge.

Aside from the expected endothelial cell loss during phacoemulsification, which can pose a risk to a successful graft, cataract surgery in a previously operated eye comes with extra difficulties related to the anterior chamber and IOL stability. Getting a clear view, performing an ideally sized capsulorhexis, avoiding contact with the endothelium are all steps that increase the chances of long-term positive outcomes.

Toric IOLs are not usually preferred for the correction of astigmatism after endothelial keratoplasty, due to the unpredictability of postoperative corneal transparency. On the other hand, the speediness of rehabilitation and final visual acuity may justify the employment of toric IOLs in DSAEK-treated eyes with normal endothelial cell densities (ECD).

In this video, recorded in the main operating room of the Ophthalmica Eye Institute, in Thessaloniki, Greece, Dr. Dimitris Sakellaris, MD, performs phacoemulsification and enVista® Toric IOL implantation in the left eye of a 46-year-old male patient with moderate nuclear cataract 15 months after DSAEK for treatment of FECD. Preoperative refraction in that eye was +1.00 -2.00 @105°, and ECD was 2000 cells/mm2. The surgical steps and timing in the video are as follows: axis marking is carried out (00:01). A main incision and side ports are fashioned (00:40). Methylene blue is injected for better visualization of the capsule (00:45). The anterior chamber is filled with viscoelastic (00:48). A centered, round, medium-sized capsulorhexis is shaped (00:50). The nucleus is hydrodissected (01:12). Phacoemulsification is executed using low phaco parameters and avoiding every contact with the corneal endothelium (01:15). Mass aspiration is completed likewise (01:30). Viscoelastic is injected in preparation for the next step (01:56). The main incision is adjusted (02:10). The IOL is inserted (02:20) and gently rotated to its final axonal orientation (02:50). The viscoelastic is aspirated (03:15). The entries are sealed with intrastromal infiltration of saline solution (03:22). The procedure ends with a centered IOL stably and deeply positioned in the capsular bag (03:50).

“Perfection is not attainable, but if we chase perfection, we can catch excellence.” (Vince Lombardi)