a 63-year - old male presented with complaints of gradually progressive painless diminution of vision in the left eye since last 1 year .
the patient had undergone left eye optical penetrating keratoplasty 10 years back for leucomatous corneal opacity post corneal ulcer , managed medically .
the patient presented to us with visual acuity of 6/36 in the left eye with astigmatism of 6.50 diopter cylinder ( dc ) at 30 and unaided visual acuity of 6/9 in the right eye .
slit - lamp examination of the left eye revealed clear , full thicknesscorneal graft of around 8 mm diameter with no graft edema , and cataract of nuclear colour ( nc ) and nuclear opalescence ( no ) of grade 4 .
early morning ultrasound pachymetry was 526 m for the left eye and 546 m for the right eye . a complete ophthalmological examination including refraction , pentacam for corneal topography , specular microscopy and pachymetry , biometry , iol selection and systemic investigations were performed .
preoperative , endothelial cell count was 1450 cells/ mm on specular microscopy . iol master keratometry readings of k1 44.25 d at 55 , k2 54.0 d at 145 with preoperative corneal astigmatism of + 9.75 dc at 145 and average keratometry reading of 49.13 d were used for iol power calculation . as per the calculation , the iol recommended was acrysof sn60t9 spherical equivalent + 6 d with residual cylindrical power of 5.48 d at 146 at the corneal plane [ fig . 1 ] .
the patient underwent clear corneal phacoemulsification using infiniti , ozil system after markings for acrysof toric iol , with special surgical considerations for the corneal graft .
incision was placed at 110 with acrysof toric iol marks aligned along 146. the preoperative 3 , 6 and 9 o clock markings were made with nuijts reference corneal marker under topical anaesthesia with the patient sitting upright .
intraoperatively , location of the corneal incision and axis of iol placement was marked using mendez ring and nuijts toric axis marker .
preoperative intraocular lens power calculation for acrysof sn60t9 was spherical equivalent + 6 d with residual cylindrical power of 5.48 d at 146 at the corneal plane two clear corneal side - port incisions were made at 2 and 9 o clock hour positions .
graft endothelium was coated with viscoat , alcon ( 3% sodium hyaluronate + 4% chondroitin sulfate ) and anterior chamber formed with healon gv , amo ( arshinoff soft shell technique ) .
triplanar clear corneal incision was made at 110. well - centered , approximately 5-mm continuous curvilinear capsulorrhexis was completed .
capsular bag was filled with healon gv and iol implanted into capsular bag with the axis of the iol aligned around 15 short of the final axis of alignment ( 146 ) .
viscoelastic removal was done along with final rotation of the iol , and the axis aligned [ fig . 2 ] .
postoperatively , the patient was reviewed on day 1 , 3 , 14 days , 6 weeks , 4  months and 10 months .
on the immediate postoperative day , the corneal graft was clear with well - formed anterior chamber with 1 + cellular reaction , and well - centered aligned iol with an intraocular pressure of 13 mmhg in goldmann applanation tonometer .
refraction 6 weeks postoperative was 2.0 dc at 20 , vision improving to 20/30 on snellen visual acuity chart .
the patient was examined at 10 months follow - up and has best - corrected visual acuity ( bcva ) of 20/30 and no rotation of toric iol [ fig . 3 ] .
capsular bag implanted toric intraocular lens ( iol ) at the end of surgery after viscoelastic removal .
note the position of toric iol marks on the optic postoperatively at 10 months , there was clear corneal graft and no rotation of intraocular lens was noted
at present , toric iol provides an effective management option for the correction of post - keratoplasty high astigmatism and cataract.[812 ] nuijts et al . implanted artisan phakic toric iol for the correction of post - keratoplasty high corneal astigmatism in 36 eyes of 35 patients and achieved an average of 88.8% reduction of astigmatism .
but there was continued loss of the endothelial cells till 3 years of follow - up .
reported the use of icl , a posterior chamber phakic toric iol , for post - keratoplasty astigmatism .
no serious complication or refractive shift occurred at 1 year post surgery follow - up .
the above authors have used phakic toric iols . in our patient with post - keratoplasty high corneal astigmatism with coexisting cataract , we used acrysof toric iol .
this patient achieved bcva of 6/9 with astigmatism of 2 dc at 20 ( astigmatism reduced to roughly one third ) with clear corneal graft .
the better refractive result than that calculated can be explained as after keratoplasty , the biomechanical response of the corneoscleral tissue to the incision may be somewhat unpredictable , and a greater variability in surgically induced astigmatism may be seen . in conclusion , acrysof toric iol provides excellent correction of post - keratoplasty high corneal astigmatism in patients with coexistent cataract .
 we report a 63-year - old male who had undergone left eye optical penetrating keratoplasty for central leucomatous corneal opacity 10 years earlier . 
 the eye had clear donor graft with residual astigmatism of 6.50 diopter cylinder ( dc ) at 30. the patient underwent clear corneal phacoemulsification with implantation of + 6.0 d spherical equivalent acrysof sn60t9 intraocular lens ( iol ) . 
 postoperatively , at 10 months , the patient had distance corrected visual acuity of 20/30 with 2.00 dc at 20. acrysof toric iol offers an effective treatment option for post - keratoplasty high corneal astigmatism in patients with cataract . 
Case Report
Discussion