A Tale Of Two Lenses In The Eye - A Rare Case Of Double Lens Management In A Combined Corneal And Vitreo-Retinal Surgery

To report an unusual presentation of a patient, with the presence of both anterior chamber intra-ocular lens and a dislocated crystalline lens in the vitreous cavity, who subsequently developed corneal decompensation. We aim to highlight the importance of early intervention and combined  management between the corneal and vitreo-retinal teams. 

A government restructured tertiary-referral public hospital in Singapore.

A 56 year old Chinese gentleman on routine follow up for glaucoma reported having right eye surgery performed in a private institution a few years earlier. At presentation, an anterior chamber intraocular lens was seen in his right eye with a dislocated crystalline lens in the vitreous cavity. The cornea was clear and fundus examination revealed a cup-disc ratio of 0.85. Intraocular pressure was controlled in low teens with a single glaucoma agent. The patient’s findings remained stable till 5 years later, when his right eye Snellen visual acuity dropped from 6/9 to counting-fingers secondary to bullous keratopathy and cystoid macular oedema. He initially opted for medical treatment but with limited success. After 12 months he progressed to severe bullous keratopathy and subsequently underwent right eye temporary keratoprosthesis, anterior chamber intraocular lens removal, pars plana vitrectomy, crystalline lens removal, scleral-fixation of intraocular lens and penetrating keratoplasty; a collaborative surgery between the corneal and vitreo-retinal teams. The surgery was a success with patient currently undergoing visual rehabilitation for his right eye.

Temporary keratoprosthesis is an invaluable tool that allows good visualisation for vitreo-retinal surgery in patients with corneal opacities. A partial open-sky technique may be safely employed for scleral fixation of an intraocular lens implant. Finally, corneal transplantation can be successfully performed, allowing a patient to undergo comprehensive eye rehabilitation surgery in one sitting.