MANAGEMENT OF POST-PENETRATING KERATOPLASTY (PKP) ASTIGMATISM WITH SIMULTANEOUS IN-THE-BAG MONOFOCAL IOL PLUS IN-THE-SULCUS TORIC IOL

To report the case of a 42-year-old woman with high post-penetrating keratoplasty (PKP) astigmatism after suture removal, corrected using a monofocal in-the-bag intraocular lens (IOL) combined with a primary in-the-sulcus toric IOL. This case is compared to existing literature on the management of post-PKP astigmatism.

Post-keratoplasty astigmatism management is complex and requires careful consideration of various approaches. Outcomes can vary based on surgical technique, surgeon experience, and individual patient factors. There are multiple strategies available that can enhance astigmatism correction, with the combination of a monofocal in-the-bag IOL and an in-sulcus toric IOL demonstrating efficacy as a primary procedure.

Assessment included uncorrected visual acuity (UCA), subjective refraction, slit lamp biomicroscopy (SLBM), fundoscopy, optical coherence tomography (OCT), Pentacam for corneal topography, IOL Master 700 for monofocal IOL calculations, and Raytrace for toric IOL calculations.

A 42-year-old woman with a history of contact lens-related Pseudomonas corneal ulcer perforation in the left eye underwent a full-thickness tectonic graft 7 years earlier. She presented with decreased visual acuity (VA) of 6/9 in the right eye (RE) and 6/60 in the left eye (LE), with intraocular pressures of 15 mmHg and 16 mmHg, respectively. The examination revealed a clear LE graft, with no remaining sutures and a mild posterior subcapsular cataract. Pentacam imaging indicated oblique astigmatism of 5.6 D at 151º in the LE. IOL calculations for the monofocal lens were performed using the IOL Master 700 and the SRKT formula. Additionally, the Raytrace toric IOL calculator was used to target a spherical equivalent (SE) of 0 for the sulcus toric IOL.The patient underwent left eye phacoemulsification and implantation of both the monofocal in-the-bag IOL and the toric sulcus IOL, achieving an excellent visual acuity of 0.00 one week post-surgery. This case underscores the effectiveness of combining monofocal and toric IOLs in managing post-keratoplasty astigmatism.

Managing astigmatism following penetrating keratoplasty can be challenging, requiring a thorough consideration of both conservative and surgical options. Literature suggests various techniques that may enhance visual outcomes after suture removal. Primary cataract surgery combining a monofocal in-the-bag IOL and a toric sulcus IOL appears to be a safe and effective option. Since keratoconus primarily affects younger patients, they are likely to require multiple corneal transplants throughout their lifetime. In such cases, the primary sulcus toric intraocular lens (IOL) can be explanted and replaced to address any residual astigmatism following the second transplant. Predicting refractive outcomes in post-PKP patients is complex, and surgeons must be mindful of potential biometric errors and their implications.