(1) Could a secondary IOL implant be a choice for the future?
A secondary IOL implantation would certainly be important to consider due to the following reasons:
• This is a 9-year-old child, compliance with care regimes for wearing a contact lens long term would be challenging in this age group with risk of infections and inflammatory keratitis.
• A contact lens provides about 8 to 10 hours of corrected vision; the child would be uncorrected for the rest of the day. While the child is older and amblyopia may not be a major concern, functionally it does limits activities and a normal lifestyle.
• A contact lens over a penetrating graft could cause more hypoxic changes than in an un-operated eye. This may not be an issue short term but would be so in the long term with reducing endothelial cell counts.
(2) Supposing a secondary IOL implant is preferred, when would it be preferable?
Since a secondary IOL in this situation cannot provide toric correction, the timing of surgery is not dictated by the timing of suture removal and can be planned based on the success of the contact lens wear.
(3) Which surgical IOL solution would you prefer?
I would prefer a scleral fixated IOL, either sutured or by externalization of the haptics for multiple reasons :
• An iris fixation would be challenging due to the dense membrane posteriorly, making the iris much more rigid. This would make fixating a lens with claws challenging as sufficient iris tissue may not be enclavated. A similar challenge is likely to be faced with both anterior iris or iris retrofixation.
• Since the crystalline lens was lost during the trauma, sulcus fixation would not be possible.
• Angle fixation could compromise the endothelium of the graft and in the long term in a young individual, lead to angle changes and glaucoma.
(4) Supposing a secondary IOL implant is preferred; there is a possibility of irregular astigmatism. What other options can you suggest as an alternative to CL?
An IOL will not be able to correct for irregular astigmatism. I would wait for all sutures to be removed and perform a topography guided surface ablation with an excimer laser to smoothen the surface to achieve correction of irregular astigmatism.
(5) Do you think it is important to correct near vision? If so, how?
Near vision correction may not be important in this scenario, as the contralateral eye should suffice in providing adequate near vision. My goal would to be achieve the best possible distance vision correction.
(6) Do you agree with the surgical choice of the Mushroom PK? The choice of a mushroom keratoplasty is an excellent one, maximizing the protection of the host endothelium, while reducing the impact of sutures and graft host junction on astigmatism. The only downside might be when eventually the graft fails, performing an endothelial keratoplasty might be more challenging as the posterior graft host junction being more central, may impact graft adherence due to prominent posterior graft host junction.