Abstract

1
Small incision Deep Lamellar Endothelial
Keratoplasty in a patient with Irido Corneal
Endothelial (ICE) syndrome
Dr Rajesh Fogla DNB, FRCS, MMed (Ophth) Senior
Consultant, Apollo Hospitals, Hyderabad, India.
dr_fogla_at_yahoo.com, www.corneaclinic.com

• Abstract
• Purpose To evaulate the result of small
  incision deep lamellar endothelial keratoplasty
  in a patient with iridocorneal endothelial
  (ICE)syndrome.   
• Methods Interventional case report. A 46 year old
  female, with ICE syndrome in the left eye.
  Through a 5.5mm scleral incision, a deep lamellar
  pocket was created across the cornea, followed by
  excision of 8.0mm disc of posterior lamellar
  corneal tissue. Same size lamellar donor disc was
  prepared and placed in position without the need
  of suture fixation.   
• Results Best corrected visual acuity improved
  from preoperative 20/120 to 20/40 at last follow
  up of 8 months. Specular microscopy was not
  possible preoperatively and central corneal
  thickness was noted to be 670 microns. At last
  follow up, specular microscopy revealed
  endothelial cell count of 2341 cells/mm2, and
  central corneal thickness of 590 microns. Her
  intraocular pressure was noted to be normal
  during the entire follow up. No complications
  were noted.   
• Conclusion Endothelial replacement surgery, such
  as small incision deep lamellar endothelial
  keratoplasty, allows successful replacement of
  dysfunctional endothelium in iridocorneal
  endothelial (ICE) syndrome. The replaced healthy
  endothelium may help to halt the progression of
  ICE syndrome.

2
Introduction Irido corneal endothelial (ICE)
syndrome - Primary corneal endothelial
abnormality1 - Endothelial cells proliferate to
form a cellular membrane that covers the
trabecular meshwork, resulting in peripheral
anterior synechiae - Results in corneal oedema,
synechial angle closure, alterations in the iris,
and glaucoma - High percentage of patients
(66)2 require anti-glaucoma surgery - 45
patients requiring more than one anti-glaucoma
procedure 2 - Corneal grafting is often necessary
to restore corneal clarity, 43 patients
requiring a repeat corneal graft in one study
3 Deep Lamellar Endothelial Keratoplasty (DLEK) -
Technique of endothelial keratoplasty using a
scleral pocket technique4 - Eliminates the need
for surface incisions or sutures - Faster visual
recovery and tectonically stronger globe. This
poster presents the outcome of small incision
DLEK procedure combined with phacoemulsification
and foldable intraocular lens implantation in a
patient with early ICE syndrome.
3
Case report 46 yrs old female Complains of
decrease in vision in her left eye associated
with early morning blurring of vision. Occasional
glare and haloes around lights Uncorrected visual
acuity - OD 20/20 , OS 20/120 Refraction and
Best corrected visual acuity (BCVA) OD Plano
(20/20) , OS -1.00 x 100 (20/120) Slit lamp
biomicroscopy OD normal, OS see Fig 1 a
b Intraocular pressure OD 13 mm Hg , OS 19 mm
Hg Fundus evaluation Normal both
eyes Ultrasonic central corneal pachymetry OD
526 microns, OS 670 microns Specular microscopy
OD 2960 cells/mm2 , OS no image possible Clinical
diagnosis Irido corneal endothelial (ICE)
syndrome OS
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Management Patient underwent phacoemulsification
with foldable single piece acrylic intraocular
lens implantation via a superior 2.8mm scleral
incision. This was followed by small incision
DLEK procedure via a 5.5mm temporal scleral
incision. Surgical steps were followed as
described by Terry et al.4 8mm disc of posterior
corneal tissue was replaced with donor disc of
same size Postoperatively the patient received
topical corticosteroids, antibiotics, tear
substitutes, similar to that following routine
full thickness penetrating keratoplasty
procedure.
Pre and postoperative clinical details of the
operated left eye
UCVA uncorrected visual acuity, BCVA best
(spectacle) corrected visual acuity, IOP
intraocular pressure in mm Hg
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Discussion In the later stages of ICE syndrome,
progressive synechial closure results in
uncontrolled or poorly controlled IOP. This is a
significant risk factor for graft failure for
patients undergoing penetrating
keratoplasty.3 Since endothelial abnormality is
the primary defect in ICE syndrome, replacing the
same with healthy donor endothelium in the early
stage of disease may prevent or retard the
synechial angle closure resulting from the
proliferation of abnormal endothelial
cells. Small incision DLEK procedure allows
successful replacement of dysfunctional
endothelium without the need for surface
incisions or sutures.4 In our case, patient
recovered good visual function following small
incision DLEK. No further progression of iris
abnormality was noted during the one year follow
up. Further follow up is necessary to assess long
term clinical outcome. Conclusion Small incision
DLEK procedure can be performed to replace the
dysfunctional endothelium in ICE syndrome. The
healthy donor endothelium may prevent or retard
further clinical progression of ICE syndrome.
9

• References
• Campbell DG, Shields MB, Smith TR. The corneal
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  atrophy. Am J Ophthalmol 1978 86 317
• Laganowski HC, Kerr Muir MG, Hitchings RA.
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  syndrome. Arch Ophthalmol 1992 110 346
• Alvin PT, Cohen EJ, Rapuano CJ. Penetrating
  keratoplasty in ICE syndrome. Cornea 2001 120
  134
• Terry MA, Ousley PJ. Small incision Deep Lamellar
  Endothelial Keratoplasty (DLEK) 6 months results
  in first prospective clinical study. Cornea 2005
  24 59