Eyeworld

WINTER 2025 | EYEWORLD | 21 Contact Taravati: taravati@uw.edu References 1. Deshmukh R, et al. Post- penetrating keratoplasty astigmatism. Surv Ophthalmol. 2022;67:1200–1228. 2. Fares U, et al. Management of post-keratoplasty astigma- tism. J Cataract Refract Surg. 2012;38:2029–2039. 3. Ribeiro BB, et al. Long term efficacy and safety of iris-claw phakic intraocular lens in the management of post kerato- plasty astigmatism. J Cataract Refract Surg. 2025. Online ahead of print. significant difference in ages of both grafts and patients between groups. Most importantly, the cumulative effect of endothelial cell injury serves as a caution in patient selection. The authors made a point to select patients who failed spectacles and contact lenses, with extensive discussion on higher chances of corneal endothelial failure postop. Limitations of this study include a small number of surgeons (3) without a standardized surgical protocol. Different-sized incisions and IOL types were used. Importantly, the Artisan lens is a rigid, non-foldable lens, whereas the Artiflex lens is a rigid, foldable lens, which could lead to differences in surgical handling and therefore affect primary and secondary out- comes of this study. Also, it is unclear whether ECD measurements were standardized between patients. Measuring ECD from a single frame for each patient instead of an average of multiple ECD measurements could affect accuracy. Future directions include posterior chamber pIOL to preserve endothelial cell count. How- ever, the authors decided against its use due to concern over lens complications, as there is no strong data regarding vault prediction in PK eyes. Further research could determine if poste- rior chamber pIOL reduces the rate of ECL. This study is limited by its retrospective na- ture and small sample size. There were only 11 patients in the PK group, compared to 38 in the DALK group. In addition, there was a difference in follow-up time periods between PK eyes and DALK eyes, limiting the ability to draw conclu- sions on longer-term safety. Conclusion In this retrospective case series, Riberio et al. described the refractive outcomes and effica- cy of iris-claw pIOL in eyes with prior PK and DALK. They found that the procedure had acceptable safety indices at all postop time points, with the majority of eyes experiencing stability of or an improvement in CDVA. Addi- tionally, approximately 64% of eyes globally had residual astigmatism of <1.0 D associated with the demonstrated reduction in the average horizontal astigmatic vector. This present series characterizes iris-claw pIOL as a viable surgical option for post-PK and post-DALK astigmatism, with minimal adverse events over a 10-year total follow-up period. functional vision for those having difficulty tolerating spectacle correction due to aniseiko- nia or contact lens use. PIOL re-establishes functional vision, as nearly 80% of patients had preop UCVA worse than 20/200. At 10 years, nearly half of the cohort still had greater than 20/32 UCVA. The authors demonstrated that 2/3 of patients achieved postop UCVA equal to or better than preop CDVA. Compared to unop- erated eyes undergoing pIOL, there was more refractive undercorrection. The authors pointed out several factors that may contribute to this finding, including: 1) difficulty refracting kera- toplasty eyes, and 2) graft remodeling changes over time secondary to ectasia and scarring (the authors pointed to a shift in keratometry over 10 years). Despite this, based on the authors' data, astigmatic outcomes were highly predict- able. Half the patients were within 0.5 D of refractive cylinder, with 78% within 5 degrees of final refraction. Vector analysis confirmed a significant reduction in astigmatic magnitude and dispersion. Furthermore, wavefront analysis did not show an increase in higher order aberra- tions postop. Short- and long-term safety are important considerations when adopting new surgical techniques. The authors reported no intraopera- tive complications. In terms of long-term safety, one patient underwent pIOL explantation due to ECL. No patients developed cataract during the follow-up window. However, there was a higher rate of ECL in the study cohort than keratoplasty patients who did not undergo pIOL and normal eyes that underwent pIOL alone. In particular, there was an average annual 9.34% ECL loss in the PK + pIOL group compared to the 5.5% with PK alone. The authors suggested DALK + pIOL as a safer alternative, as a smaller rise in ECL was seen in the study group com- pared to the expected ECL in DALK (3.07% vs 2.3%, respectively). The measurement of ECL loss as a percentage rather than absolute may also exaggerate the difference between the two groups, as the average ECD in the PK group was much less compared to DALK. The reported 9.34% loss in the PK group vs. 3.07% loss in the DALK group suggests triple the loss; however, the difference in absolute loss of ECD may be similar. Though the authors make compari- sons in ECL in the PK vs. DALK groups, these comparisons are limited due to the statistically

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