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A stable anterior chamber is a crucial factor to DSAEK. In aniridic patients with BDI lens, the anterior and posterior segment has direct communication at the periphery of the BDI lens. Maintenance of the air bubble in the anterior chamber would be problematic. Pressure equilibrium must be established on both sides of the BDI lens before the air bubble is introduced into the anterior chamber. Compared with traditional full-thickness keratoplasty, endothelial keratoplasty (EK) is a great breakthrough for the treatment of corneal endothelial disorders because this new technique maintains a more regular corneal anterior surface, preserves more corneal biomechanical tensile strength and provides more rapid visual rehabilitation. Descemet’s stripping with automated endothelial keratoplasty (DSAEK) is currently most favored procedure of EK, in which the donor disc dissection was performed with an automated microkeratome that allows smoother interface and more accurate control of graft thickness. A stable iris-lens diaphragm is essential to intraoperative donor unfolding and maintenance of air in the anterior chamber, and thus a critical factor for DSAEK. Although it was once considered as a relative contraindication, DSAEK has begun to be undertaken in patients in whom the iris-lens diaphragm was anatomically or functionally abnormal.1,2,3 In the past decade, patients with aniridia and aphakia/cataract were treated with black diaphragm intraocular (BDI) lens which is composed of a central optic surrounded by a black diaphragm and 2 haptics. This lens could alleviate the patients’ symptom of glare and photophobia and increase vision. However, this BDI lens differs from the natural iris-lens diaphragm for more rigidity and less compliance. Besides, the chamber anterior to the BDI lens has direct communication with the vitreous cavity at the gap between the diaphragm and haptics of the lens. Difficulties may be encountered in maintaining the air bubble in the anterior chamber. Herein, we present 3 consecutive cases of bullous keratopathy with BDI lens who underwent DSAEK, the etiologies included 1 congenital aniridia and 2 traumatic iris loss.

Descemet’s Stripping with Automated Endothelial Keratoplasty (DSAEK) in Patients with Black Diaphragm Intraocular (BDI) Lens