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Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 265-267

If you never try, you will never know: Customized toric intraocular lens with trabeculectomy, is it feasible? A case report

1 Glaucoma Service, Narayana Nethralaya-2, Bangalore, Karnataka, India
2 Cornea and Refractive Service, Narayana Nethralaya-2, Bangalore, Karnataka, India

Date of Submission31-Oct-2020
Date of Acceptance23-Dec-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Sushma Tejwani
Narayana Nethralaya- 2, Narayana Health City Campus, Bommasandra, Hosur Road, Bangalore - 560 099, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_3408_20

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Glaucoma surgeries are rarely combined with toric intraocular lenses (IOL) to address the astigmatism in a glaucoma patient. We report a case of a young woman with glaucoma secondary to steroid usage post femtosecond laser assisted keratoplasty for progressive keratoconus. The patient was operated for combined trabeculectomy with phacoemulsification and a customized toric IOL was implanted. Postoperatively the patient maintained good uncorrected visual acuity and stable intraocular pressure. Toric IOLs can provide a safe and convenient way of correcting high astigmatism and can be successfully combined with trabeculectomy to provide a better visual outcome.

Keywords: Astigmatism, combined phacoemulsification with trabeculectomy, customized toric intraocular lenses, postkeratoplasty glaucoma

How to cite this article:
Tejwani S, Matalia H, Mehta P. If you never try, you will never know: Customized toric intraocular lens with trabeculectomy, is it feasible? A case report. Indian J Ophthalmol Case Rep 2021;1:265-7

How to cite this URL:
Tejwani S, Matalia H, Mehta P. If you never try, you will never know: Customized toric intraocular lens with trabeculectomy, is it feasible? A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Aug 3];1:265-7. Available from: https://www.ijoreports.in/text.asp?2021/1/2/265/312410

Glaucoma is a serious complication following penetrating keratoplasty with the reported incidence of 9 to 31% in the early postoperative period and 18 to 35% in later phase.[1] Many of these cases are refractory to medication, and up to 38% may need surgeries like trabeculectomy, glaucoma shunt or cyclophotocoagulation, depending on the patient's clinical profile.[2]

High astigmatism (>5 D) have been reported in almost 35% patients after femtosecond enabled keratoplasty (FLEK) in the early phase that tends to stabilize over time.[3] Toric IOLs are a fairly precise method of correcting high astigmatism postkeratoplasty. With the advantage of customization it is possible to achieve better accuracy even in higher astigmatism (>6 D) in terms of visual acuity, refractive error and patient satisfaction.[4] Use of toric IOLs along with trabeculectomy is controversial due to possibility of zonular weakness, poor pupil responses and keratometric changes from the surgical procedure.[5] On PubMed search, we found a single case reported by Gibbons et al.[6] where phaco-trabeculectomy with toric IOL and limbal relaxing incisions was used to correct 5 D astigmatism.

We present a case of postkeratoplasty glaucoma with cataract and high astigmatism (10 D) treated with trabeculectomy combined with phacoemulsification and customized toric IOL.

  Case Report Top

A 26-year-old woman presented with sudden blurring of vision in right eye (RE) with past history of having undergone scleral buckling at the age of 14 years and FLEK for advanced keratoconus 4 months before presentation.

The corrected distance visual acuity (CDVA) in the RE was 6/60, intraocular pressure (IOP) was 46 mm Hg, corneal graft was edematous and the cup disc ratio was 0.7. She was diagnosed with acute endothelial graft rejection and postkeratoplasty glaucoma in RE. She was started on beta blocker and alpha agonist eye drops for the raised IOP. Systemic and topical steroids were given for the graft rejection. At 2 months follow-up the graft recovered but she had developed cataract and glaucoma secondary to steroid usage. Perimetry in the RE showed incomplete biarcuate field defects suggestive of moderately advanced glaucoma. For the next 4 years she maintained IOP of 18–20 mm Hg with three medications and CDVA of 6/18.

However after that she was lost to follow up for 3 years. Later she presented with drop in visual acuity to 1/60 with IOP of 18 mm Hg in RE. The graft was clear but the cataract had progressed significantly. Aberrometry using iTrace (Tracey Technologies Corp., Texas) showed significant higher total aberrations [Figure 1]. Corneal tomography on Pentacam, (Oculus, Wetzlar, Germany) showed 6.4D astigmatism [Figure 2]. IOL power calculation including surgeon's factor for trabeculectomy, using Holladay 2 formula, revealed a 10 D cylindrical power. Since in the commercially available toric IOLs the highest cylindrical power was 5.0D, phacoemulsification with customized Smart toric IOL (Ultima Smart Toric, Caregroup, India) of +5.0 D sphere with 10 D cylinder at 8° was planned along with trabeculectomy. Combined surgery was opted due to low vision and poor compliance to AGM. Trabeculectomy was performed from superior approach and phacoemulsification was done from temporal clear corneal approach at the same time. The IOL was implanted at 0° and 180° axis as it was a smart customized toric lens with an inbuilt toricity at 8°. On the first postoperative day there was diffuse bleb, deep anterior chamber and well centered IOL. The visual acuity was 6/60 and the IOP was 6 mm Hg. Subsequently, the postoperative period was uneventful, and aberrometry showed markedly reduced total aberrations [Figure 3] with no significant change in corneal topography. At 1-year follow-up, CDVA in the RE was 6/24 with –0.50 D cylinder at 75° axis. IOP was controlled without medication and visual fields were stable [Figure 4].
Figure 1: Preoperative aberrometry showing high internal and total aberrations

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Figure 2: Preoperative Scheimpflug imaging showing high astigmatism

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Figure 3: Postoperative aberrometry after 1 week of surgery showing reduced internal and total aberrations

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Figure 4: Perimetry (Humphrey) reports showing the visual field defects before (a) and after 1 year (b) of phaco-trabeculectomy

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  Discussion Top

Postkeratoplasty patients often have multiple issues that need to be addressed like cataract and glaucoma, particularly after a rejection episode. Our patient in addition had high astigmatism as well to make the situation worse.

Different options are available to correct postkeratoplasty astigmatism that include spectacles, contact lenses, astigmatic keratotomy, limbal relaxing incisions or toric IOLs. Very high cylindrical power has a better chance of correction with the toric IOLs. However, combining a filtration procedure with toric IOL surgery is a challenge as the astigmatism can be unpredictable due to change in axial length, tight sutures, excessive cautery, internal sclerostomy affecting corneal edge, wound remodeling with MMC use and anterior chamber depth changes causing IOL rotation.[7] Therefore, a patient with astigmatism of less than 2D is not an ideal candidate for such a combined surgery. But glaucoma patients with higher astigmatism affecting the quality of vision should be given an option to correct the same during cataract surgery.

The use of premium IOLs in a glaucoma patient has been debatable in the past decade. The problems of small pupil size, loss of contrast sensitivity, advanced visual field defects and possible needs of multiple glaucoma surgeries have restricted the use of such lenses especially toric IOLs. Brown et al.[8] found that the visual outcomes between advanced glaucoma and non-glaucoma patients were similar with toric IOL implantation. However combining a glaucoma surgery with cataract surgery along with toric IOLs is rarely reported.[6] A careful planning including surgeon's factor for induced astigmatism with trabeculectomy is necessary for achieving an optimal outcome.

Our patient had very high astigmatism along with progressive glaucoma that significantly affected her quality of life.

  Conclusion Top

Our case shows the importance of visual rehabilitation of a patient along with glaucoma surgery to achieve optimal outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zemba M, Stamate AC. Glaucoma after penetrating keratoplasty. Rom J Ophthalmol 2017;61:159-65.  Back to cited text no. 1
Yildrim N, Gursoy H, Sahin A, Ozer A, Colak E. Glaucoma after penetrating keratoplasty: Incidence, risk factors, and management. J Ophthalmol 2011;2011:951294.  Back to cited text no. 2
Farid M, Steinert RF, Gaster RN, Chamberlain W, Lin A. Comparison of penetrating keratoplasty performed with a femtosecond laser Zig-Zag incision versus conventional blade trephination. Ophthalmology 2009;116:1638-43.  Back to cited text no. 3
Srinivasan S, Ting DS, Lyall DA. Implantation of a customized toric intraocular lens for correction of postkeratoplasty astigmatism. Eye 2013;27:531-7.  Back to cited text no. 4
Ichhpujani P, Bhartiya S, Sharma A. Premium IOLs in glaucoma. J Curr Glaucoma Pract 2013;7:54-7.  Back to cited text no. 5
Gibbons A. Use of a toric intraocular lens and a Limbal-Relaxing incision for the management of astigmatism in combined glaucoma and cataract surgery. Case Rep Ophthalmol 2016;7:96-102.  Back to cited text no. 6
Delbeke H, Stalmans I, Vandewalle E, Zeyen T. The effect of trabeculectomy on astigmatism. J Glaucoma 2016;25:e308-12.  Back to cited text no. 7
Brown RH, Zhong L, Bozeman CW, Lynch MG. Toric intraocular lens outcomes in patients with glaucoma. J Refract Surg 2015;31:366-72.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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