ABSTRACT keratotomy1. It is characterized by corneal stromal

 ABSTRACT : PURPOSE: To report a case of pseudophakic bullous keratopathy with seclusio pupillae treatedsurgically with combined DSAEK , synechiolysis and pupilloplasty.OBSERVATION: A 71 year old man with a history of cataract surgery in OU and diminution ofvision post surgery in OD since 3 years was diagnosed with pseudophakic bullouskeratopathy. He  underwent DSAEK withsynechiolysis and pupilloplasty. Post operative anterior segment and fundusexamination was performed. CONCLUSION: Post surgery lenticule was well attached with round pupil . Vision improved to finger counting at 2 metrestwo weeks post surgery in OD.

 INTRODUCTION:Pseudophakic bullous keratopathy(PBK) is aserious complication of intraocular lens implantation. Bullouskeratopathy may occur in around 1 to 2% of the patients undergoing cataractsurgery, which is about two to four million patients worldwide1. Itcan also occur in patients who undergo trabeculectomy, intraocular lens scleralfixation, anterior chamber lens implants for aphakic correction and highametropia, after argon laser, radial keratotomy1. Itis characterized by corneal stromal edema with epithelial and subepithelialbullae due to cell loss and endothelial decompensation. Progressive stromal edema eventually leads to bullouskeratopathy.

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Themain cause of bullous keratopathy is the loss of endothelial cells due tosurgical trauma, especially in cataract surgery at sixth decade patients, withor without lens implantation1,2. More recently, long-term follow-up hasrevealed the existence of progressive changes in corneal endothelium followingintraocular lens insertion. The pathogenesis of this phenomenon is not clear, whilepersistent low grade inflammation and intermittent contact of the implant withthe corneal endothelium are considered probable contributory mechanisms. Certain IOL designs, particularly iris-clip lenses(iris-fixated lenses with the optic anterior to the iris) and closed-loopflexible anterior chamber lenses, are associated with increased risk of cornealdecompensation.. The introduction of posterior chamber lenses,improved design and quality control of lenses, use of sodium hyaluronate duringsurgery and better training of surgeons have all contributed to a decline incorneal complications, at least in the first few years after this procedure. Patients with underlyingcorneal endothelial dysfunction such as Fuchs corneal dystrophy are at greaterrisk for developing postoperative corneal edema.

Otherintraop  factors include localizedincrease of temperature associated with the phacoemulsification probe leading  to thermal damage to adjacent corneal tissue,damage to the endothelium can be caused by high irrigation or aspiration ratesthat can result in turbulent flow with lens particles connected with it3.Also, the duration of phacoemulsification used during the surgery is veryimportant because the ultrasound energy is associated with the production offree radicals, which are reactive species with one or more unpaired electronsin their outer orbits and can damage the corneal endothelium by oxidative stress3.Other etiologies include endothelial dystrophies such as Fuchs dystrophy,In order to minimize the occurrence,ophthalmic surgeons are subjecting their patients to preoperative, clinicalspecular microscopy to obtain information concerning the morphologic  status of corneal endothelium. Here we reporta case of pseudophakic bullous keratopathy with seclusio pupillae who was treated surgically by DSAEK withpupilloplasty. CASE REPORT : A71 year old male presented with gradual decreased vision in OD since 3 years.Patient gives history of cataract surgery OD 10 years before and that of OS 4years before.

Patient gives a systemic history of hypertension and Type iidiabetes mellitus since 11years and was on treatment for the same. Visualacuity in OD was perception of light with projection of rays being accurate.Best corrected visual acuity in OS was 20/20. Anterior segment examination inOD showed corneal decompensation and total posterior synechiae with small pupiland PCIOL which suggested a diagnosis of pseudophakic bullous keratopathy.

Bscan showed echo free vitreous cavity with normal RCS complex and optic nervehead. OS anterior segment and fundus examination showed no abnormality.     SURGICALPROCEDURE: Peribulbaranaesthesia was given prior to the surgery. Intraoperatively prior to theroutine DSAEK procedure synechiolysis was done using a dialer .

   Pupilloplasty was done to increase the sizeof the pupil, using a vitrector to cut the pupil 4 mm vertically and 3mmhorizontally resulting  a vertically ovalpupil. A temporal clear corneal incision was made and a descemetorrhexis of 7.5mm size was made using a reverse sinskey hook. Donor cornea trephined to 8.0 mmsize. The trephined lenticule was introduced into the anterior chamber usingsheet glide. Air bubble injected into anterior chamber to attach the lenticuleto the host stroma .

Wounds closed using 10-0 nylon sutures. RESULTS:Postsurgery donor lenticule was well adhered to the host stroma with graft oedema .Pupil was noted to be 5 mm and vertically oval . Patient was started on hourly topical steroid andantibiotic medications post operatively. Graft odema subsided within twoweeks post surgery. Patient had a vision of finger counting at  2metres .Fundusexamination OD  showed mild temporal disc pallorwith normal macula and tessellated background.   DISCUSSION:Treatment options for pseudophakic bullous keratopathy includes bothmedical and surgical management.

Medical management included instillation of topicalhypertonic agents such as sodium chloride (5%), anti-inflammatory drugs,topical and/ or systemic antiglaucoma medications, because increased IOP cancompromise endothelial cell function, corticosteroids, lubricants andsometimes, due to the pain experienced by the patients, therapeutic contactlenses to improve symptoms3 .Corneal transplantationis still the gold standard treatment for bullous keratopathy patients, as itprovides symptomatic relief and visual rehabilitation4 . Penetrating keratoplasty is a full-thickness cornealtransplant procedure. It is considered as the criterion standard transplant surgeryby many surgeons worldwide.  Partial thickness corneal surgery has evolvedrapidly in the past two decades, replacing penetrating kera­toplasty. Otherpartial thick­ness procedures for treating PBK include posterior lamellarkeratoplasties like Deep lamellar endothelial keratoplasty(DLEK), Descemetstripping endothelial kera­toplasty(DSEK ), Descemet strippingautomated endothelial keratoplasty (DSAEK), Descemet membrane endo­thelialkeratoplasty (DMEK), Descemet membrane automated endothelial keratoplasty.

Otherlow cost treatment options include Anterior stromal puncture (ASP),Phototherapeutic keratectomy (PTK) and amniotic membrane transplant. DSAEK  is amodified technique of Descemet strip­ping endothelial keratoplasty, where amicrokeratome is used for the donor dissection5.  In theprocedure, Descemet membrane and endothelium are stripped from the host corneaand replaced with a donor button consisting of posterior stroma, Descemetmembrane, and endothelium. DMEK is a technique where only Descemet membrane andendothelium are used to replace host tissue of Descemet membrane andendothelium without posterior stroma. Among all partial thickness procedures, DSAEK isthe most common type of endothelial keratoplasty performed worldwide5.

 Posterior pathologies where DSAEK are indicated includeFuchs endothelial dystrophy, pseudophakic and aphakic corneal edema,endothelial decompensation,failed grafts, iridocorneal endothelial syndrome, and posterior polymorphouscorneal dystrophy.Advantages of DSAEK include that it allows vision improvement to6/9 to 6/12, has a lower rejection rate than penetrating keratoplasty, resultsin faster visual rehabilitation, uses a small incision and astigmatic neutralsurgery, and maintains globe integrity and less wound dehiscence6.However, DSAEK may still limit the best-corrected vision due to the donorlamellar interface.Pupilloplastyprocedures  can be used to close an iris defect, make a fixed dilatedpupil smaller, center a pupil on a diffractive multifocal IOL, close acongenital iris coloboma, close a large symptomatic peripheral iridectomy oriridotomy, or round up an irregular pupil. In DSAEK they help to configure thestructure of the anterior chamber (AC) that facilitates the endothelialkeratoplasty (EK) procedure by providing anatomical and functional support bymaintaining the AC depth for graft unrolling and adherence.

Where as in ourcase the indication of pupilloplasty was to increase the size of the pupil postsynechiolysis which aided in a better view of the position of the PCIOL( whichwas noted to be in the sulcus) and the evaluation of the posterior segmentwhich would help in deciding the visual prognosis of the patient.CONCLUSION:Patientspresenting with PBK along with posterior synechiae and small/irregular pupilswhich give a poor view of the posterior segment can be managed with combinedprocedure of DSAEK with synechiolysis and pupilloplasty. This also helps inrounding up the  pupil which wouldminimize the glare problems experienced by patients due to irregular pupils.