Phakic corneal decompensation with cataract after bioptics: management challenges

A woman in her early 50s presented with diminution of vision, photophobia, pain and watering in right eye for 8 months. She had previously undergone radial keratotomy (RK) in the right eye, followed by bilateral angle-supported phakic intraocular lens (pIOL) implantation. On examination, 16 RK incisions were present in the right eye, with corneal decompensation, rigid angle-supported pIOL in situ, senile cataract and uncorrected distance visual acuity (UDVA) of counting fingers. Three major challenges were accurate biometry, incision management during phacoemulsification with rigid pIOL in situ and keratoplasty in the presence of RK incisions. Swept source optical coherence tomography-based optical biometer and Barrett Universal II formula were used for intraocular lens (IOL) power calculation. First-stage phacoemulsification was performed with pIOL in situ, followed by IOL implantation and pIOL explant via the same incision. Second-stage Descemet stripping automated endothelial keratoplasty (DSAEK) was performed after 1 week; DSAEK prevented splicing of RK incisions. Postoperative UDVA was 20/200, improving to 20/60 with semiscleral contact lens.