Surreal image depicting the AC-IOL decision in endothelial keratoplasty.

AC-IOLs: To Remove or Not to Remove? A Critical Look at Endothelial Keratoplasty Outcomes

Reese Marlowe in Health & Wellness December 2025 • 4 min read.

"Navigating the complexities of managing anterior chamber intraocular lenses (AC-IOLs) during endothelial keratoplasty for optimal patient outcomes."

Endothelial keratoplasty (EK) has revolutionized the treatment of corneal endothelial dysfunction, offering improved visual rehabilitation compared to penetrating keratoplasty. However, the presence of an anterior chamber intraocular lens (AC-IOL) introduces a layer of complexity. The question of whether to remove or retain the AC-IOL during EK remains a topic of considerable debate among surgeons.

A recent letter to the editor sparked renewed discussion on this contentious issue, specifically addressing an article on endothelial keratoplasty in eyes with retained angle-supported intraocular lenses. The core of the debate centers on balancing the potential benefits of AC-IOL removal, such as restoring more natural anterior segment anatomy, against the risks associated with additional surgical manipulation.

This article delves into the arguments surrounding AC-IOL management during EK, examining factors that influence surgical decisions and exploring the impact of AC-IOL retention or removal on graft survival and overall visual outcomes. Understanding these nuances is crucial for surgeons seeking to optimize results and minimize complications in this challenging patient population.

AC-IOL Removal: Weighing the Pros and Cons

Surreal image depicting the AC-IOL decision in endothelial keratoplasty.

The decision to remove or retain an AC-IOL during EK is not a one-size-fits-all approach. Several factors must be considered, including the AC-IOL's stability, its impact on anterior chamber anatomy, and the patient's overall ocular health. Proponents of AC-IOL removal argue that it restores a more natural anterior segment, potentially leading to improved long-term graft survival.

On the other hand, retaining a stable AC-IOL may be the less invasive option, reducing surgical time and minimizing the risk of complications associated with IOL exchange or repositioning. When the AC-IOL is well-positioned and not causing significant anatomical distortion, leaving it in situ can simplify the EK procedure and potentially expedite visual recovery.

Potential Benefits of AC-IOL Removal:
- Restoration of normal anterior segment anatomy
- Reduced risk of endothelial cell damage from AC-IOL contact
- Potential for improved long-term graft survival
Potential Benefits of AC-IOL Retention:
- Reduced surgical time and invasiveness
- Lower risk of complications associated with IOL exchange
- Faster visual recovery in selected cases

Ultimately, the decision hinges on a careful assessment of individual patient factors and a thorough understanding of the potential risks and benefits associated with each approach. In situations where the AC-IOL is unstable, causing corneal touch, or significantly distorting the anterior chamber angle, removal is generally recommended. However, in cases with a stable, well-positioned AC-IOL and a deep anterior chamber, retention may be a viable option.

Making the Informed Surgical Decision

The management of AC-IOLs during endothelial keratoplasty requires a nuanced and individualized approach. While the debate regarding removal versus retention continues, a thorough understanding of the potential benefits and risks associated with each strategy is paramount. By carefully evaluating patient-specific factors and employing meticulous surgical technique, surgeons can optimize outcomes and improve the lives of patients undergoing this complex procedure. Further research, particularly long-term studies, will undoubtedly shed more light on this topic and refine surgical decision-making in the future.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1007/s10792-018-1022-z, Alternate LINK

Title: Response To The Letter To The Editor By Tsatsos Et Al. “To Remove Or Not To Remove (The Ac-Iol)? This Is The Question. Letter Regarding Article Endothelial Keratoplasty In Eyes With A Retained Angle-Supported Intraocular Lens By Droutsas Et Al.”

Subject: Ophthalmology

Journal: International Ophthalmology

Publisher: Springer Science and Business Media LLC

Authors: Konstantinos Droutsas, Apostolos Lazaridis, George Kymionis, Klio Chatzistefanou, Dimitris Papaconstantinou, Walter Sekundo, Chryssanthi Koutsandrea

Published: 2018-10-22

Everything You Need To Know

What is the primary challenge when performing endothelial keratoplasty (EK) on a patient who already has an anterior chamber intraocular lens (AC-IOL)?

The main challenge lies in deciding whether to remove or retain the existing anterior chamber intraocular lens (AC-IOL) during endothelial keratoplasty (EK). This decision involves weighing the potential benefits of AC-IOL removal, such as restoring natural anterior segment anatomy and reducing endothelial cell damage, against the risks of additional surgery like IOL exchange or repositioning. Factors like the AC-IOL's stability, its impact on the anterior chamber anatomy, and the patient's overall ocular health must be carefully considered.

What are the potential advantages of removing an anterior chamber intraocular lens (AC-IOL) during endothelial keratoplasty (EK)?

Removing an anterior chamber intraocular lens (AC-IOL) during endothelial keratoplasty (EK) can restore a more natural anterior segment anatomy, potentially reducing the risk of endothelial cell damage from AC-IOL contact. This may also improve long-term graft survival. However, it's crucial to note that AC-IOL removal adds complexity to the procedure and may not always be necessary or advisable.

Under what circumstances might it be preferable to retain an anterior chamber intraocular lens (AC-IOL) during endothelial keratoplasty (EK)?

Retaining an anterior chamber intraocular lens (AC-IOL) may be preferable when the AC-IOL is stable, well-positioned, and not causing significant distortion of the anterior chamber angle. This approach reduces surgical time and invasiveness, lowering the risk of complications associated with IOL exchange. In these cases, retaining the AC-IOL can lead to faster visual recovery.

What factors should a surgeon evaluate to make an informed decision about whether to remove or retain an AC-IOL during endothelial keratoplasty, and why is this evaluation so important?

Surgeons must consider the AC-IOL's stability, its impact on anterior chamber anatomy, and the patient's overall ocular health. If the AC-IOL is unstable or causing corneal touch, removal is generally recommended. A stable, well-positioned AC-IOL with a deep anterior chamber may be retained. This individualized approach is vital because it directly impacts graft survival, visual outcomes, and the overall success of the endothelial keratoplasty procedure.

How does the decision to remove or retain an anterior chamber intraocular lens (AC-IOL) during endothelial keratoplasty (EK) reflect a broader trend in surgical decision-making?

The AC-IOL management decision during endothelial keratoplasty reflects a move towards personalized medicine in surgery. Instead of a one-size-fits-all approach, surgeons are increasingly considering individual patient factors to optimize outcomes. This is similar to trends in other surgical fields where minimally invasive techniques and tailored treatments are becoming more common. It highlights the importance of balancing potential benefits against risks based on a patient's specific condition and anatomy.