Management of postoperative hypotony with fibrin glue following scleral tunnel-based explantation of pIOL and simultaneous ICL implantation: A case report.

RATIONALE: Long-term implantation of anterior phakic intraocular lenses (pIOLs) can lead to progressive corneal endothelial cell loss, ultimately necessitating explantation. Although scleral tunnel approaches reduce corneal trauma during lens exchange, postoperative hypotony due to wound microleakage is an uncommon but vision-threatening complication. This report aims to present the 1st documented clinical case in which fibrin glue was successfully used to seal microleakage-induced hypotony following pIOL explantation and simultaneous toric implantable collamer lens (ICL) implantation.

PATIENT CONCERNS: A 36-year-old woman presented 12 years after bilateral Artiflex pIOL implantation with progressive corneal endothelial cell loss in the right eye (1886 cells/mm² vs 2612 cells/mm² in the left eye).

DIAGNOSES: Corneal endothelial decompensation secondary to long-term anterior pIOL implantation, and early postoperative hypotony (intraocular pressure, 7 mm Hg) caused by aqueous leakage from a scleral tunnel incision.

INTERVENTIONS: The anterior pIOL was explanted via a 12 o'clock scleral tunnel (approximately 3.0 mm wide and 5-6 mm long) and replaced with a toric ICL using the soft-shell technique. Persistent postoperative hypotony was initially managed with resuturing but required fibrin glue application to definitively seal a microleak.

OUTCOMES: After fibrin glue application, the intraocular pressure increased to 14 mm Hg the following day and remained stable throughout follow-up. At 1 month, the uncorrected visual acuity was 20/20, and corneal endothelial cell density stabilized at 1751 cells/mm² without further complications.

LESSONS: In cases where repeat suturing fails to control hypotony after scleral tunnel-based lens exchange, fibrin glue offers a minimally invasive, rapid, and effective alternative to restore wound integrity. Early detection of endothelial damage and the use of a low-trauma scleral tunnel approach can help preserve corneal health during pIOL-to-ICL transitions. However, as this is a single case, further evidence is needed to confirm the durability and safety of this approach in broader clinical settings.