Sabah Saleh Jastaneiah, MD Consultant cornea and anterior segment department King Khaled Eye Specialist Hospital (KKESH) Riyadh, Saudi Arabia KKESH On presentation 2 Not good candidate DSAEK cases include: Corneal stroma opacification & good visual potential Partial or complete aniridia peripheral iridotomies Pseudophakia with Zonular weakness That is because of difficulties in maintaining the air bubble intended for lenticule attachment Presence of anterior chamber IOL (due to accelerated endothelial cells loss) 3 Two stage management plan was elected In the form of 1. Aniridia Intra-Ocular Lens (IOL) implantation followed by 2. DSAEK The main objective was to give him a chance to have the best long-term outcome to a DSAEK corneal graft, in addition to the benefit of an aniridia implant. At the same time the aniridia implant would make the DSAEK procedure possible. 4 The first procedure was done in April 2008 Scleral fixed aniridia IOL of +22.0D ( Morcher aniridia implant ), model 67G, and 5 mm pupil zone was implanted under general anesthesia. Patients own keratometry reading was taken with an intended under correction to achieve a target of - 2 diaopters in order to overcome the hyperopic shift after DSAEK. Slit lamb picture using retro illumination showing the clear 5 mm optic aniridia implant,jet black paraoptical zone and corneal edema with a good red reflex. 5 Intra-operatively the air bubble was maintained in the anterior chamber and the DSAEK lenticule was in place. Intraoperative challenges were mainly related to the hypotony. 6 Broad slit lamb photograph showing clear cornea and a black reflection from the aniridia implant with the central optical zone reflecting light The lenticule detached after surgery, air was injected twice with only partial improvement. Third post operative day the lenticule spontaneously attached with slight decentration. 7 The cornea was clear with a slightly decentered graft DSAEK DSAEK procedure challenges that include iris defects may be overcome by stepwise procedure planning Aniridia implant supports reasonable amount of air in the anterior chamber especially if the posterior segment is well formed Spontaneous attachment of the DSAEK lenticule is a possibility that should be considered before re- bubbling, or judging the graft as failed to attach. Time line in my case was 3 days post operatively. Thank you 8