Posterior Corneal Lamellar Detachment after Phacoemulsification in a Case of Anterior Lamellar Keratoplasty

A 39-year-old female with a history of automated anterior lamellar keratoplasty for a nebulomacular corneal opacity in the right eye presented with a gradually progressive decrease in vision two years ago. Presenting visual acuity (PVA) was 20/200, and a grade 3 nuclear cataract was noted.[1] The patient underwent coaxial phacoemulsification with posterior chamber intraocular lens implantation through a 2.2 mm clear corneal incision under peribulbar anesthesia. During the hydration of the incisions, the main port incision was noted to be leaky. A possible disruption in the graft–host lamellar interface was suspected intraoperatively, due to the inner lip of the main port incision opening in the lamellar interface. The incision was closed with two interrupted sutures of 10-0 nylon, and the globe was well-pressurized by forming the anterior chamber (AC) with balanced salt solution followed by the injection of an air bubble. On the postoperative day 1, PVA was 20/400 with mild graft edema, AC was well formed, and the air bubble was in the upper third of the AC. On the follow-up at two weeks, the patient reported further diminution of vision for seven days. PVA had decreased to “hand motion” close to the face, and there was significant graft edema along with presence of fluid between the anterior lamellar graft and posterior lamella leading to the formation of double AC, as observed on anterior segment optical coherence tomography (OCT) (Heidelberg Engineering GmbH, Heidelberg, Germany) [Figure 1]. Intracameral 14% perfluoropropane (C3F8) gas was injected, and supine posture was advised for one day. On the subsequent day, PVA was “counting fingers” at 1 m.