A 64-year-old female presented with gradual loss of vision in the right eye (OD) of one year duration. About six months ago, she had undergone intracapsular cataract extraction, anterior vitrectomy, and scleral fixation of intraocular lens (IOL) in the left eye (OS). At that time, she was suspected of iridocorneal endothelial syndrome (ICES).\nThe preoperative best corrected visual acuities (BCVA) were 20/400 OD, 20/30 OS. Intraocular pressures (IOP) in each eye were 15 mmHg by applanation. The Slit lamp biomicroscopy of both eyes (OU) showed clear cornea, deep and clear AC, and the angle was wide open. Both eyes had splitting of the anterior layers of the iris with fibrillar degeneration extending from 3 to 6 o' clock OD, and from 4 to 6 o' clock OS. Additionally, there was diffuse atrophy of iris from 11 to 1 o' clock OS (). The underlying iris pigment epithelium appeared intact with no transillumination defect. The clinical appearance was consistent with iridoschisis OU. The right eye showed nuclear and cortical cataract associated with posterior subcapsular cataract, and the left eye was pseudophakia. Specular microscopy of the OD revealed regular, hexagonal shape of endothelial cells without any abnormalities like bullae or guttae, and the endothelial cell count was 2865 cells/mm2. The rest of the ocular examination was normal.\nPupil dilation is performed using 3 drops of tropicamide 0.5% and phenylephrine hydrochloride 0.5% at 5-minute intervals 1 hour prior to surgery. Intraoperative pupillary diameter was about 5~6 mm. Topical anesthesia was applied using Alcaine® and 3% Lidocaine, and a paracentesis was done at 10 o' clock. A 2.75 mm main clear corneal incision was performed using the keratome blade. A dispersive ophthalmic viscosurgical device (OVD), sodium hyaluronate 3%-sodium chondroitin sulfate 4% (Viscoat®, Alcon) was injected through the clear corneal wound to stabilize the anterior chamber and protect the iris stroma by displacing aqueous from the AC and pushing the iris strands from the pupillary aperture. An anterior continuous curvilinear capsulorhexis not exceeding over the pupillary margin was performed using the 26 G needle and capsular forceps. After hydrodissection and hydrodelineation, careful phacoemulsification was performed (Allergan Sovereign® Phaco System, SOV680330) for nucleus removal with special care not to touch the iris tissue. Aspiration was used to clean residual cortical fibers from the capsular bag. When a loss of the protective effect of viscoelastic material was observed during surgery, Viscoat® was reinjected additionally to inhibit iris fibril movement with the BSS stream.\nThe maximum limit of the vacuum was 300 mmHg and the aspiration rate, 20 cc/mmHg. The height of the irrigation bottle is maintained less than 60 cm to minimize the turbulence within the chamber. Total US time was 48 seconds with a mean final rate of 10% of potency.\nThe capsular bag was inflated with viscoelastics, and a single-piece acrylic intraocular lens (Acry-Sof® SA60AT, Alcon) was inserted. The IOL was safely placed in the capsular bag and centered, followed by aspiration of the residual viscoelastics. If there were some movement of iris fibrils, additional viscoelastics was inserted.\nFinally, BSS Carbacol (carbachol 0.01%, Miostat®) was used to constrict the pupil.\nPostoperatively, the inflammatory response in the AC was moderate, some fibrillar materials were seen. The cornea showed some Descemet folds, and the pupil was round and undamaged ().\nOne week after surgery, the uncorrected visual acuity was 20/100 OD, and improved to 20/30 on the two weeks postoperative day. There were traces of cells in the AC, but no fibrillar materials were seen ().\nThe patient's last visit was 1 month after surgery when UCVA was 20/40, and BCVA 20/20. The cornea, AC and iris were clear and intact without any inflammatory sequalae.
A 76-year-old woman was referred to our hospital from one of our associated hospitals for a 1-month history of worsening vision and corneal oedema in the right eye. She had undergone laser iridotomy (LI) in both eyes at another hospital 9 months ago. She experienced progressive vision loss since a month before the referral.\nHer initial best-corrected visual acuity (BCVA) was 20/600 in the right eye and 20/30 in the left. Intraocular pressure was 10 mm Hg in both the eyes. Slit lamp examination revealed iridoschisis in both eyes. Corneal stromal oedema and Descemet's fold were more severe in the right eye than in the left (Fig. ). LI holes and moderate nuclear cataract were observed in both eyes. Endothelial cell density was 1,197 cells/mm2 in the left eye and immeasurable in the right. Iridoschisis was observed prominently in the inferior region of both eyes; the ITC index in the right and left eye was 23.6 and 24.4%, respectively.\nCataract surgery, followed by DSAEK, was planned for the right eye. Uncomplicated cataract surgery was performed with phacoemulsification and intraocular lens implantation. A twin light chandelier endoilluminator was used during surgery to support visibility [, ]; no other specialized techniques were performed besides routine cataract surgery. The ITC index in the right eye after cataract surgery was 4.7%. Subsequently, DSAEK was performed 2 weeks after cataract surgery using a pre-cut imported donor, with the pull-through technique using a Busin glide (Moria, Antony, France) and forceps (Moria USA, Doylestown, PA, USA), through a 5-mm temporal corneal incision with Descemet stripping after peripheral iridotomy. The patient's corneal oedema was treated and the BCVA at the third postoperative month was 20/25 (Fig. ). The ITC index was 0 after DSAEK.\nCorneal oedema of the left eye progressed, and the BCVA worsened to 20/50 1 year after surgery of the right eye (Fig. ). Therefore, the same surgeries were planned for the left. Cataract surgery for the left eye was performed without an endoilluminator because the stromal oedema in the left eye was not as severe as it was in the right eye. The ITC index became 6.9% after cataract surgery. Subsequently, the DSAEK was performed 1 month after cataract surgery. Her corneal oedema was treated, and the BCVA at the second postoperative month was 20/25 (Fig. ). Her ITC index was 0 after DSAEK. The AS-OCT images throughout the surgeries are shown in Figure . The changes in the ITC index are summarized in Table .