Retained lens fragments obscured by bullous keratopathy: Anterior segment optical coherence tomography before and after endothelial keratoplasty

Purpose: To describe the use of anterior segment optical coherence tomography (AS-OCT) as an adjunct for detecting retained lens fragments in eyes with bullous keratopathy after cataract surgery, before and after endothelial keratoplasty, when corneal edema prevents their identification on slit-lamp examination and gonioscopy.

Observations: In one eye a fragment was seen intraoperatively during DSAEK but rolled away within the anterior chamber and could not be retrieved; inferior corneal edema recurred six months later against a well-apposed graft, repeat AS-OCT localized the fragment, and removal restored clarity. Three patients (two women, one man; ages 79-80 years) developed bullous keratopathy 2 months to 2 years after cataract surgery, with presenting visual acuities of 20/1000, 20/2000, and 20/100. Severe corneal edema precluded fragment identification by slit-lamp microscopy and by gonioscopy in all eyes, whereas AS-OCT (CASIA2) showed hyperreflective angle material that proved at surgery to be lens fragments. After fragment removal, edema persisted and was managed by endothelial keratoplasty (cultured human corneal endothelial cell transplantation in one eye; DSAEK in two). Final visual acuities were 20/20, 20/50, and 20/40. A custom high-density 256-radial-scan AS-OCT protocol samples the angle in 512 directions rather than 32, a geometric reduction in the circumferential sampling interval from approximately 1,080 μm to 67 μm.