Ocular and Systemic Risk Factors Associated with Focal Opacification of Intraocular Lens after Endothelial Keratoplasty: Insights from a Case and Reviewed Literature

Purpose: To analyze the various ocular and systemic risk factors associated with focal opacification of intraocular lens (IOL) after endothelial keratoplasty (EK) with a descriptive case example. Materials and Methods: This was an interventional descriptive case study with a chronological literature analysis. Results: A 60-year-old female underwent uneventful EK along with peripheral iridectomy for pseudophakic corneal edema. She was diabetic and had a history of cystoid macular edema after cataract surgery, for which posterior sub-Tenon’s steroid injection was given. Following EK, the cornea cleared, and visual acuity improved to 20/50. In the early postoperative period after EK, she had an episode of raised intraocular pressure, which was controlled with antiglaucoma medications. In the follow-up course at 6 months, granular opacification of posterior chamber IOL was noted in the central part, which gradually progressed, causing a significant drop in vision. She underwent IOL exchange, and the explanted IOL was subjected to scanning electron microscopy and energy-dispersive X-ray studies, which revealed calcium phosphate. Conclusion: With the backdrop of the case described here and review of the existing literature, it can be concluded that the various factors responsible for IOL opacification are three-fold: First, IOL-material related; second, underlying systemic/ocular comorbidity-related predisposition; and third, ongoing inflammation in EK eyes. Further, the association of this complication in post-EK and non-EK eyes suggests that additional parameters, such as serum and intraocular calcium levels, clinical associations with posterior capsulotomy and peripheral iridectomy in affected eyes, and diabetes, could be the coexisting risk factors governing the underlying mechanisms and pathogenesis.