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Cataractous Changes due to Posterior Chamber Flattening with a Posterior Chamber Phakic Intraocular Lens Secondary to the Administration of Pilocarpine
Cataractous Changes due to Posterior Chamber Flattening with a Posterior Chamber Phakic Intraocular Lens Secondary to the Administration of Pilocarpine Miguel J. Maldonado, MD, PhD,1 Julián García-Feijoó, MD, PhD,2 José Manuel Benítez Del Castillo, MD, PhD,2 Paula Teutsch, MD1 Objective: To present the first reported case of cataract formation as a consequence of instillation of pilocarpine in an eye with a posterior chamber phakic intraocular lens (IOL). Design: Interventional case report. Intervention: A 46-year-old man received a hyperopic implantable collamer lens (ICL) bilaterally. Main Outcome Measures: Determination of best-corrected visual acuity (BCVA); contrast sensitivity testing with and without glare; and intraocular pressure (IOP), specular endothelial cell, and slit-lamp examinations were performed serially. In addition, the distance between the ICL and crystalline lens was measured with optical coherence tomography. Results: Both eyes underwent uneventful ICL implantation for the correction of a manifest spherical equivalent of ⫹7 diopters (D) in the right eye and ⫹7.1 D in the left eye. The left eye was followed for 2 years without developing complications. The right eye, however, showed on the first postoperative day a fleckenlike opacification on the anterior pole of the crystalline lens after instillation on the operative day of 2% pilocarpine in an attempt to accelerate recovery from unwanted pupil dilation causing patient complaints of glare disability after surgery. Optical coherence tomography demonstrated complete contact of the ICL with the natural lens 24 hours postoperatively. Serial IOP measurements were always within the normal limits. The instillation of 1% cyclopentolate resulted in an increase in the ICL vault that measured 132 m 24 hours later. Three days after the completion of a 3-day course of topical 1% cyclopentolate, the opacification was less dense and demarcated, and a 124-m vault was measured. Three months postoperatively, the cataract was associated with a 3-line loss of BCVA and considerable degradation of the contrast sensitivity, especially at higher spatial frequencies and with a glare source, and corneal endothelial cell changes were within normal limits. One year after ICL implantation, the right eye had to undergo phacoemulsification and IOL implantation, which were uneventful. Conclusions: Posterior chamber flattening with resulting crystalline lens opacification can occur immediately after the instillation of pilocarpine in an eye with a hyperopic ICL. Therefore, caution should be taken with the administration of cholinergic agonists such as pilocarpine in patients with phakic IOLs, at least if they are hyperopic ICLs. Ophthalmology 2006;113:1283–1288 © 2006 by the American Academy of Ophthalmology.
Phakic intraocular implants can correct high myopia and hyperopia, with the advantages of reversibility, stability of the correction, and, to a great extent, preservation of accommodation.1–11 An increasing number of procedures are being perOriginally received: August 7, 2005. Accepted: March 15, 2006. Manuscript no. 2005-742. 1 Department of Ophthalmology, University Clinic, University of Navarra, Pamplona, Spain. 2 Ramón Castroviejo Institute of Ophthalmic Investigations, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain. The authors have no proprietary interest in the development or marketing of any instrument mentioned in the article, or competing ones. Correspondence to Miguel J. Maldonado, MD, PhD, Department of Ophthalmology, Clínica Universitaria, Av. Pío XII, 36, 31080 Pamplona, Spain. E-mail: [email protected]. © 2006 by the American Academy of Ophthalmology Published by Elsevier Inc.
formed because of the expectation of a superior quality of vision obtained with phakic intraocular lens (IOL) implantation with respect to keratorefractive surgery for the correction of high ametropias.12–15 However, induced cataract and glaucoma are at the heart of most concerns regarding these intraocular surgical procedures, especially for posterior chamber phakic IOLs (PCPIOLs).16 –26 We describe a (to the best of our knowledge) previously unreported complication related to the instillation of pilocarpine in an eye with a hyperopic PCPIOL.
Case Report A 46-year-old man sought refractive surgery. Visual acuities (VAs) were 20/20 in his right eye (⫹8.00 ⫺2.00 ⫻115°) and 20/20 in his left (⫹8.00 ⫺1.75 ⫻85°). The patient had initiated cortical ISSN 0161-6420/06/$–see front matter doi:10.1016/j.ophtha.2006.03.053
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Ophthalmology Volume 113, Number 8, August 2006 sclerotic changes but was visually asymptomatic, and contrast sensitivity test results (CSV-1000 HGT, Vector Vision, Dayton, OH) were normal at all spatial frequencies without or with glare (Table 1). The amplitude of accommodation was measured to be 2 diopters (D) in both eyes with the minus-lenses-to-blur method.27 There was absence of an iris pigment defect or iris transillumination. The endothelial cell status was adequate for implantable collamer lens (ICL) implantation in both eyes (Table 1). Anterior chamber depths (ACDs) from the corneal endothelial layer were 3 mm and 2.9 mm in the right eye and left eye, respectively, and the white-to-white distance was 11.1 mm in both eyes, as measured with an Orbscan II unit (Bausch & Lomb, Rochester, NY). Gonioscopy revealed open grade-III angles. Ultrasound axial length measurement yielded 21.8 mm and 21.9 mm in the right eye and left eye, respectively. Intraocular pressures (IOPs) were 15 mmHg in the right eye and 14 mmHg in the left eye, and anterior and posterior segment examinations were normal. The patient was informed of the different surgical options, and he preferred to correct his hyperopic error by PCPIOL implantation rather than by phacoemulsification with IOL implantation because he wanted to preserve the remaining accommodation and was concerned about the risk of possible night-driving vision problems as a conse-
Table 1. Preoperative and Postoperative Contrast Sensitivity and Endothelial Cell Analysis Data Preoperative Contrast sensitivity without glare Log CS (3 c/d) RE LE Log CS (6 c/d) RE LE Log CS (12 c/d) RE LE Log CS (18 c/d) RE LE Contrast sensitivity with glare Log CS (3 c/d) RE LE Log CS (6 c/d) RE LE Log CS (12 c/d) RE LE Log CS (18 c/d) RE LE Endothelial cell study Density (cells/mm2) RE LE Hexagonality (%) RE LE Coefficient of variation (%) RE LE
Postoperative*
1.79 1.79
1.18 1.63
1.85 1.85
1.56 1.85
1.54 1.40
1.08 1.54
1.11 1.26
0.65 1.26
1.63 1.63
1.18 1.49
1.70 1.56
0.90 1.38
1.40 1.40
0.90 1.26
1.11 0.98
0.48 0.85
2727 2695
2645 2598
56.3 56.5
55.6 55.9
36.8 35.8
37.5 37.8
c/d ⫽ cycles per degree; CS ⫽ contrast sensitivity; LE ⫽ left eye; RE ⫽ right eye. *3 mos.
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quence of pseudophakic multifocal IOL implantation.28 Informed consent for the implantation of the ICL was obtained. The ICL power and dimensions required for each eye were calculated directly by Staar Surgical (Nidau, Switzerland) on the basis of the following variables: refraction, keratometry, ACD from the endothelial cell layer, and white-to-white distance. A ⫹10.5-D 11.5-mm-long model V3 ICL (Staar Surgical) was provided for each eye. The surgery of the left eye was scheduled first, and 1 week later was that of the fellow eye. For both eyes, on the day of surgery the patient took 15 mg of potassium clorazepate (Tranxilium, SanofiSynthélabo, S.A., Barcelona, Spain) and received topical 1% tropicamide (Alcon Cusí, Barcelona, Spain) and 10% phenylephrine (Alcon Cusí), after which an 0.4% oxibuprocaine and 1% tetracaine anesthetic (Alcon Cusí) was applied topically to the operative eye. During surgery, care was taken to prevent the surgical instruments from touching the anterior crystalline lens capsule. Lidocaine 1% (B. Braun Medical SA, Barcelona, Spain) along with 2% hydroxypropylmethylcellulose (Ocucoat, Bausch & Lomb) were injected into the anterior chamber (AC) through a paracentesis, as shown in Video 1 (available at http://aaojournal. org). The ICL was inspected under the operative microscope to see if there were any irregularities on the front and back surfaces. Using a Deitz forceps (Duckworth & Kent, Baldock, United Kingdom), the ICL was positioned in the lens injector cartridge (Staar MicroSTAAR injector, STAAR Surgical Co., Monrovia, CA) previously filled with hydroxypropylmethylcellulose. A small piece of a 3-mm-diameter sponge was placed in the insertion cartridge behind the ICL as protection from the injector arm, as shown in Video 2 (available at http://aaojurnal.org). The injector tip was then placed within a temporal clear corneal incision and pushed forward carefully until its beveled end was in the AC. The ICL was then gently injected in the AC and allowed to unfold slowly, anterior to the iris plane, ensuring proper orientation. The ICL was not inverted during insertion. Distal and then proximal footplates were placed carefully under the iris with a tucker (Duckworth & Kent), which resulted in the optic also being positioned behind the pupillary plane (video 3 [available at http://aaojournal.org]). Correct horizontal positioning of the ICL in the center of the pupillary zone was verified before an intraocular miotic was used to decrease pupil size. Gentle infusion of balanced salt solution was performed with a cannula situated not more centripetally than the iris margin, which pushed the viscoelastic material out of the posterior chamber (PC). This was followed by using an irrigation/aspiration cannula in the same fashion to complete removal of the viscoelastic agent. Acetylcholine chloride 1% (Alcon Cusí) was then injected into the AC to induce sufficient miosis to perform a peripheral iridectomy with a vitreous cutter in the upper peripheral iris, as shown in video 4 (available at http://aaojournal. org).29,30 The aspiration of the viscoelastic was completed while the infusion flow was regulated to avoid overfilling or flattening the AC. The wound was closed with a 10/0 nylon suture (video 5 [available at http://aaojournal.org]). The entire surgical procedure lasted 22 minutes in the right eye and 24 in the left eye. We prescribed topical 0.3% ciprofloxacin (Oftacilox, Alcon Cusí) and 1% dexamethasone (Maxidex, Alcon Cusí) 4 times daily for a total of 16 days. Before the patient was discharged, 2 hours after surgery, the patient was seated at the slit lamp. The left eye showed a pupil 5.5 mm in diameter, a centered implant with normal vaulting and no lens opacification, a deep AC with the typical postoperative tyndall scatter, and an IOP of 16 mmHg. The right eye showed a mydriasis of 7 mm, a deep AC, a properly centered ICL with adequate vaulting, and no lens opacities. The patency of the iridectomy was verified with both direct illumination and transillumination. Applanation tonometry detected 15 mmHg in the right eye. However,
Maldonado et al 䡠 Pilocarpine and Cataract after Phakic IOL Implantation the patient volunteered that seeing too much light entering into the right eye was bothersome. We prescribed topical 2% pilocarpine (Isopto Carpine 2%, Alcon Cusí) twice during the operative day in an attempt to reduce the remaining mydriasis sooner once the effect of the tropicamide was over and, therefore, to provide earlier and more comfortable visual recovery. The 24-hour postoperative examination was unremarkable for the left eye; pupil diameter measured 5 mm, the ICL vault was adequate, best-corrected VA (BCVA) was 20/25, and IOP measured 14 mmHg. However, the right eye showed a fleckenlike opacity and a tight implant adherence to the anterior capsule (Fig
1A). The pupil measured 3 mm; the iridectomy was completely permeable, with no ICL occlusion; and the AC was deep. The AC inflammatory response was 1⫹ flare, and trace 1⫹ cells were present.31 The IOP was 11 mmHg and BCVA 20/50. With optical coherence tomography,32,33 on the first postoperative day the vault measured 134 m on the left eye, whereas the right eye showed complete contact of the ICL with the crystalline lens (Fig 1B). Cyclopentolate 1% hydrochloride drops then were prescribed thrice a day during 3 days in an attempt to increase the space between the ICL and anterior capsule in the right eye (Fig 1C). One day after the instillation of cyclopentolate, the vault increased
Figure 1. Serial postoperative slit-lamp and optical coherence tomography (OCT) examinations of the right eye. A, One day after implantation of a hyperopic intraocular collamer lens (ICL) followed by instillation of 2% pilocarpine, the pupil is miotic, the surgical iridectomy is completely patent, and whitish anterior capsular lens opacities in the center of the pupillary zone can be seen. B, On the first postoperative day, complete central contact between the hyperopic ICL and anterior capsule of the crystalline lens can be demonstrated. One drop of 10% phenylephrine has been administered to examine a wider central pupillary area because the iris pigment blocks the OCT wavelength and prevents examination of the anatomic relationships behind it.32,33 C, One day after start of the treatment with 1% cyclopentolate eyedrops, dotlike focal opacification on the anterior pole of the natural lens can be observed. The incipient cortical sclerotic changes were present in the preoperative examination and did not cause visual degradation. D, Under topical 1% cyclopentolate treatment, a vault of 132 m is now measured. E, One week postoperatively and 3 days after the end of a 3-day course of 1% cyclopentolate eyedrops, the opacity in the anterior capsule has become less dense and not so circumscribed to the apex of the anterior pole of the natural lens. The pupil has been dilated with 10% phenylephrine to allow better comparison with the previous biomicroscopic examination. F, The corresponding optical coherence tomography scan now shows a 124-m-wide space between the ICL and crystalline lens.
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Ophthalmology Volume 113, Number 8, August 2006 to 132 m (Fig 1D). One week postoperatively, an appreciable decrease in opacity density was observed, and BCVA improved to 20/40 (Fig 1E). The ICL vault in the unaccommodated state was then 124 m (Fig 1F). Another course of 1% cyclopentolate was attempted thereafter, but it did not result in further decrease of the opacification. Three months after each procedure, vaulting between the anterior lens capsule and posterior surface of the ICL was biomicroscopically narrow in both eyes. Optical coherence tomography measurements revealed central vaults of 122 m and 110 m in the left eye and right eye, respectively. Whereas the natural lens was transparent in the left eye, central dotlike opacities were present in the right eye’s anterior capsule. Contrast sensitivity without glare worsened notably in the right eye with respect to the preoperative values, especially at the higher frequencies, and to a greater extent with a glare source (Table 1). Central endothelial cell parameters were similar in both eyes and did not show any unusual deterioration (Table 1). At the 1-year follow-up, examination revealed a clear lens with a 118-m vault in the left eye and an anterior subcapsular opacification of the crystalline lens with a 106-m vault in the right eye. Neither nuclear nor further cortical changes progressed with respect to the preoperative period. Best-corrected VAs were 20/20 (left eye) and 20/40 (right eye), and the patient continued to complain about loss of clarity and night vision disturbances, particularly during driving. Applanation tonometry measured 15 mmHg in the left eye and 17 mmHg in the right eye. Cataract surgery by phacoemulsification after explanting the ICL through a 3-mm incision was performed uneventfully in the right eye. We used the axial length measurement performed in the preoperative workup of any phakic IOL implantation, although the difference with the postoperative biometry was minimal (0.1 mm longer after ICL implantation). One year after ICL explantation and cataract extraction, his BCVA was 20/20, with a residual refractive error of ⫺0.25 ⫺0.50 ⫻95°. Both eyes were followed for 2 years after the ICL implantation.
Discussion Lens epithelial cells have no repair ability; thus, cell damage leads to lens opacification.34 It is postulated that early cataract formation may result from either surgical trauma or lack of space between the ICL and the crystalline lens.23 We believe, after a thorough review of the existing literature by a detailed Medline search, that this is the first reported case of cataract development due to PC flattening with a PCPIOL secondary to the administration of pilocarpine. Intraoperative lens trauma typically occurs during prolonged and difficult surgical procedures associated with a narrow pupil and extensive manipulations, such as those cases necessitating ICL removal and reinsertion due to IOL flipping, and also can be associated with a surgeon’s learning curve.19,35 Conversely, our surgeries on both of the patient’s eyes were straightforward, procedures lasted ⬍25 minutes, and the surgeon, who had a surgical experience exceeding 100 ICL procedures, took extreme care not to touch the crystalline lens. In fact, endothelial cell changes (Table 1) are representative of typical uneventful procedures.1,17,36,37 In our case, we found ICL contact with the anterior capsule after the instillation of pilocarpine, and only in the eye that received it, despite existing great similarity between both eyes in terms of anatomy and surgical procedures. We
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used 2% pilocarpine in the right eye to try to reverse excessive mydriasis sooner, as other authors have previously reported.29,30 It is not our common practice, but this patient complained significantly about the glare and photophobia due to the remarkable postoperative mydriasis. There is a considerable effect of pilocarpine on the AC, lens thickness, and resultant accommodation, even in the presbyope,27,38 and this appears to be stronger in subjects with light irides.27 Petternel et al11 demonstrated that instillation of 2% pilocarpine after ICL implantation decreased the vault by a mean of 71 m. This reduction was remarkably larger than the average decrease associated with accommodation at 30 cm and at the subjective near point—12.7 m and 7.7 m, respectively.11 Petternel et al suggest that whereas during accommodation the significant forward movement of the anterior lens pole is accompanied by ICL vaulting as a consequence of ciliary body contraction, after application of pilocarpine the anterior lens pole moves forward and the ICL shifts backwards as a result of miosis of the pupil.11 Central vaulting has been associated with cataract formation in myopic ICL implantation.20,23,39,40 Gonvers et al20 found that all the lens opacities occurred when central vaulting was ⱕ90 m and appeared after 3 months postoperatively. However, not all the eyes in the same range of vaulting and age developed lens opacities with a similar follow-up, which suggests that other factors such the degree of ametropia may influence cataractogenesis.20 Remarkably, they encountered no contact between the ICL and crystalline lens, even peripherally, when the central vaulting was ⱖ150 m.20 The central vaults in our patient were within these 2 limits, except for immediately after the instillation of pilocarpine in the right eye, when no vault existed. García-Feijoó et al,16 using ultrasound biomicroscopy, found central contact between the ICL and the crystalline lens in 16.6% of eyes that had undergone myopic phakic implantation. During pupillary activity and accommodation, there is a potential risk of ICL–lens touching at the rim of the shoulder in myopic ICLs and at the center in hyperopic ICLs, which are the thickest parts of the ICL.3,24 JiménezAlfaro et al17 found central contact between the ICL and crystalline lens in 15% of cases, whereas peripheral contact was present in 60% of them. In a contact zone, Wiechens et al41 found an acellular substance by scanning electron microscopy but no migration of cells such as those appearing during an active inflammatory process, hypothesizing that impaired oxygen supply and altered lens metabolism were leading causes of anterior subcapsular opacification. A similar mechanism may have occurred acutely in our patient’s right eye. Although less information is available on hyperopic than myopic ICL implantantion, the design of the IOL and anatomy of the hyperopic eye may influence the time course of the development of certain complications.9,10,19,42,43 SánchezGaleana et al19 reported a higher incidence of lens opacities in eyes receiving hyperopic ICLs (12%) than in eyes receiving myopic ICLs (7%). They also found that the mean preoperative manifest spherical equivalent in patients who did not develop lens opacities was lower (⫹6.2 D) than that
Maldonado et al 䡠 Pilocarpine and Cataract after Phakic IOL Implantation in those who did (⫹8.6 D). Most of them were anterior subcapsular, of the dotlike focal, combined dot and stripe– shaped focal, or diffuse appearance, the last being the only one visually significant for symptoms such as glare, halos, and BCVA loss.19 None of them appeared in the first postoperative week, and the mean follow-up time for the diagnosis was 125 days. In their series, only the shortest hyperopic ICL (11 mm) was associated with narrow vaulting and lens opacities, which caused visual degradation.19 In the current case, the nonexistent vault observed under the effect of the pilocarpine could have provoked the opacity by mechanical irritation of the anterior capsule or by obstruction of the aqueous humor circulation toward the anterior surface of the crystalline lens during a possible cupping effect.18 A centrally thicker biconcave hyperopic ICL (i.e., 583 m for a ⫹10.5-D ICL vs. 110 m for a ⫺10.5-D ICL)44 also may have played a role in decreasing the PC space, thus increasing the risk of adherence to the anterior capsule. The improvement observed 1 week after the cycloplegic treatment could result from increasing the gap between the ICL and anterior capsule (Fig 1C–F), and does not favor the hypothesis of intraoperative trauma. The concomitant topical administration of mydriatics such as phenylephrine or tropicamide and the miotic pilocarpine is regarded to be a most effective provocative test in closed-angle glaucoma suspects because pupillary block is thus maximized by creating a mid-dilated pupil with full sphincter muscle tone.45,46 The opacity in our patient was flecken in appearance, which may support the speculation that it resulted from a significant IOP rise.47 However, our patient did not experience pain or transient visual deterioration, IOP measurements were normal, and iridectomy was ample, permeable, and not occluded by the implant. The implantation of AC phakic IOLs (ACPIOLs) is thought to induce less iatrogenic cataract than PCPIOLs because the gap behind the IOL is greater.48 However, contact between ACPIOLs and the crystalline lens under physiological conditions also has been demonstrated.49 Therefore, it cannot be completely ruled out that a similar complication may happen after the instillation of pilocarpine in eyes with AC phakic lenses. In conclusion, this case suggests that particular caution must be taken with the instillation of pilocarpine in an eye with a phakic implant, especially in hyperopic eyes with PCPIOLs. The increasing incidence of phakic intraocular procedures warrants education regarding management and prevention of potential complications. It may be advisable to perform preoperative biometry and axial length measurements on all patients undergoing phakic IOL implantation to be prepared for the event that one such situation as the one encountered in this case, or from another etiology, arises requiring phacoemulsification. In addition to improving the accuracy of the current methods of measuring the anterior segment (i.e., white-to-white distance), further refinements in the calculated dimensions and design of the PCPIOLs may prevent 2 chief complications so far encountered, iatrogenic cataract and glaucoma. The former may appear as a consequence of PC flattening with a PCPIOL secondary to the administration of pilocarpine alone, in light of this report and previous studies,11 and the latter may be provoked if
pilocarpine is administered after the instillation of a mydriatic agent.45,46 Pilocarpine is routinely used not only topically in glaucoma therapy, but also systemically for the treatment of dry eye and mouth.50 Physicians and eye care providers therefore should be fully aware of these possible complications. Finally, it is possible that patients with PCPIOLs should be included in the list of precautions regarding the administration of cholinergic agonists such as pilocarpine.
References 1. ICL in Treatment of Myopia (ITM) Study Group. United States Food and Drug Administration clinical trial of the implantable collamer lens (ICL) for moderate to high myopia. Three-year follow-up. Ophthalmology 2004;111:1683–92. 2. Zaldivar R, Davidorf JM, Oscherow S. Posterior chamber phakic intraocular lens for myopia of ⫺8 to ⫺19 diopters. J Refract Surg 1998;14:294 –305. 3. Lackner B, Pieh S, Schmidinger G, et al. Outcome after treatment of ametropia with implantable contact lenses. Ophthalmology 2003;110:2153– 61. 4. BenEzra D, Cohen E, Karshai I. Phakic posterior chamber intraocular lens for the correction of anisometropia and treatment of amblyopia. Am J Ophthalmol 2000;130:292– 6. 5. Pineda-Fernandez A, Jaramillo J, Vargas J, et al. Phakic posterior chamber intraocular lens for high myopia. J Cataract Refract Surg 2004;30:2277– 83. 6. Alió JL, de la Hoz F, Pérez-Santonja JJ, et al. Phakic anterior chamber lenses for the correction of myopia: a 7-year cumulative analysis of complications in 263 cases. Ophthalmology 1999;106:458 – 66. 7. Baikoff G, Arne JL, Bokobza Y, et al. Angle-fixated anterior chamber phakic intraocular lens for myopia of ⫺7 to ⫺19 diopters. J Refract Surg 1998;14:282–93. 8. Menezo JL, Peris-Martínez C, Cisneros AL, Martínez-Costa R. Phakic intraocular lenses to correct high myopia: Adatomed, Staar, and Artisan. J Cataract Refract Surg 2004; 30:33– 44. 9. Davidorf JM, Zaldivar R, Oscherow S. Posterior chamber phakic intraocular lens for hyperopia of ⫹4 to ⫹11 diopters. J Refract Surg 1998;14:306 –11. 10. Pesando PM, Ghiringhello MP, Tagliavacche P. Posterior chamber collamer phakic intraocular lens for myopia and hyperopia. J Refract Surg 1999;15:415–23. 11. Petternel V, Koppl CM, Dejaco-Ruhswurm I, et al. Effect of accommodation and pupil size on the movement of a posterior chamber lens in the phakic eye. Ophthalmology 2004;111: 325–31. 12. Malecaze FJ, Hulin H, Bierer P, et al. A randomized paired eye comparison of two techniques for treating moderately high myopia: LASIK and Artisan phakic lens. Ophthalmology 2002;109:1622–30. 13. Alio JL. Advances in phakic intraocular lenses: indications, efficacy, safety, and new designs. Curr Opin Ophthalmol 2004;15:350 –7. 14. Sarver EJ, Sanders DR, Vukich JA. Image quality in myopic eyes corrected with laser in situ keratomileusis and phakic intraocular lens. J Refract Surg 2003;19:397– 404. 15. Nio YK, Jansonius NM, Wijdh RH, et al. Effect of methods of myopia correction on visual acuity, contrast sensitivity, and depth of focus. J Cataract Refract Surg 2003;29:2082–95. 16. García-Feijoó J, Jiménez-Alfaro I, Cuiña-Sardiña R, et al. Ultrasound biomicroscopy examination of posterior chamber
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17.
18.
19. 20. 21. 22.
23. 24. 25. 26. 27. 28.
29. 30. 31. 32. 33.
phakic intraocular lenses position. Ophthalmology 2003; 110:163–72. Jiménez-Alfaro I, Benítez del Castillo JM, García-Feijoo J, et al. Safety of posterior chamber phakic intraocular lenses for the correction of high myopia: anterior segment changes after posterior chamber phakic intraocular lens implantation. Ophthalmology 2001;108:90 –9. Menezo JL, Peris-Martínez C, Cisneros-Lanuza AL, MartínezCosta R. Rate of cataract formation in 343 highly myopic eyes after implantation of three types of phakic intraocular lenses. J Refract Surg 2004;20:317–24. Sánchez-Galeana CA, Smith RJ, Sanders DR, et al. Lens opacities after posterior chamber phakic intraocular lens implantation. Ophthalmology 2003;110:781–5. Gonvers M, Bornet C, Othenin-Girard P. Implantable contact lens for moderate to high myopia: relationship of vaulting to cataract formation. J Cataract Refract Surg 2003;29:918 –24. Lackner B, Pieh S, Schmidinger G, et al. Long-term results of implantation of phakic posterior chamber intraocular lenses. J Cataract Refract Surg 2004;30:2269 –76. Gonvers M, Othenin-Girard P, Bornet C, Sickenberg M. Implantable contact lens for moderate to high myopia: short-term follow-up of 2 models. J Cataract Refract Surg 2001;27: 380 – 8. Kohnen T. Cataract formation after implantation of myopic phakic posterior chamber IOLs. J Cataract Refract Surg 2004; 30:2245– 6. Trindade F, Pereira F. Cataract formation after posterior chamber phakic intraocular lens implantation. J Cataract Refract Surg 1998;24:1661–3. Bylsma SS, Zalta AH, Foley E, Osher RH. Phakic posterior chamber intraocular lens pupillary block. J Cataract Refract Surg 2002;28:2222– 8. Brandt JD, Mockovak ME, Chayet A. Pigmentary dispersion syndrome induced by a posterior chamber phakic refractive lens. Am J Ophthalmol 2001;131:260 –3. Ostrin LA, Glasser A. Accommodation measurements in a prepresbyopic and presbyopic population. J Cataract Refract Surg 2004;30:1435– 44. Dick HB, Krummenauer F, Schwenn O, et al. Objective and subjective evaluation of photic phenomena after monofocal and multifocal intraocular lens implantation. Ophthalmology 1999;106:1878 – 86. Hoyos JE, Dementiev DD, Cigales M, et al. Phakic refractive lens experience in Spain. J Cataract Refract Surg 2002;28: 1939 – 46. Uusitalo RJ, Aine E, Sen NH, Laatikainen L. Implantable contact lens for high myopia. J Cataract Refract Surg 2002; 28:29 –36. ICL in Treatment of Myopia (ITM) Study Group. Postoperative inflammation after implantation of the implantable contact lens, Ophthalmology 2003;110:2335– 41. Bechmann M, Ullrich S, Thiel MJ, et al. Imaging of posterior chamber phakic intraocular lens by optical coherence tomography. J Cataract Refract Surg 2002;28:360 –3. Baikoff G, Lutun E, Ferraz C, Wei J. Static and dynamic analysis of the anterior segment with optical coherence tomography. J Cataract Refract Surg 2004;30:1843–50.
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34. Davson H. Physiology of the Eye. 5th ed. Elmsford, NY: Pergamon; 1990:767– 82. 35. Implantable Contact Lens in Treatment of Myopia (ITM) Study Group. U.S. Food and Drug Administration clinical trial of the implantable contact lens for moderate to high myopia. Ophthalmology 2003;110:255– 66. 36. Edelhauser HF, Sanders DR, Azar R, et al. Corneal endothelial assessment after ICL implantation. J Cataract Refract Surg 2004;30:576 – 83. 37. Dejaco-Ruhswurm I, Scholz U, Pieh S, et al. Long-term endothelial changes in phakic eyes with posterior chamber intraocular lenses. J Cataract Refract Surg 2002;28:1589 –93. 38. Abramson DH, Franzen LA, Coleman DJ. Pilocarpine in the presbyope: demonstration of an effect on the anterior chamber and lens thickness. Arch Ophthalmol 1973;89:100 –2. 39. Kohnen T, Kasper T, Bühren J, Fechner PU. Ten-year follow-up of a ciliary sulcus-fixated silicone phakic posterior chamber intraocular lens. J Cataract Refract Surg 2004;30:2431– 4. 40. Baumeister M, Buhren J, Kohnen T. Position of anglesupported, iris-fixated, and ciliary sulcus-implanted myopic phakic intraocular lenses evaluated by Scheimpflug photography. Am J Ophthalmol 2004;138:723–31. 41. Wiechens B, Winter M, Haigis W, et al. Bilateral cataract after phakic posterior chamber top hat-style silicone intraocular lens. J Refract Surg 1997;13:392–7. 42. García-Feijoó J, Hernández-Matamoros JL, Castillo-Gómez A, et al. High-frequency ultrasound biomicroscopy of silicone posterior chamber phakic intraocular lens for hyperopia. J Cataract Refract Surg 2003;29:1940 – 6. 43. Baumeister M, Buhren J, Schnitzler EM, et al. Scheimpflugfotografische Untersuchungen nach Implantation phaker Vorder- und Hinterkammer-Intraokularlinsen: Erste Erfahrungen. Klin Monatsbl Augenheilkd 2001;218:125–30. 44. Hoffer KJ. Measuring the ultrasound axial length in biphakic eyes (IOLs in phakic eyes). In: Shammas HJ, ed. Intraocular Lens Power Calculations. Thorofare, NJ: SLACK Inc.; 2004: 173– 81. 45. Mapstone R. Provocative tests in closed-angle glaucoma. Br J Ophthalmol 1976;60:115–9. 46. Mapstone R. Dilating dangerous pupils. Br J Ophthalmol 1977;61:517–24. 47. Au Eong KG, Chua EC, Yip CC, et al. Hypopyon—an unusual sign in acute angle-closure glaucoma. Int Ophthalmol 1993; 17:127–9. 48. Pop M, Payette Y, Mansour M. Ultrasound biomicroscopy of the Artisan phakic intraocular lens in hyperopic eyes. J Cataract Refract Surg 2002;28:1799 – 803. 49. Baikoff G, Lutun E, Wei J, Ferraz C. Contact between 3 phakic intraocular lens models and the crystalline lens: an anterior chamber optical coherence tomography study. J Cataract Refract Surg 2004;30:2007–12. 50. Vivino FB, Al-Hashimi I, Khan Z, et al. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjogren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. Arch Intern Med 1999;159: 174 – 81.
Phakic intraocular implants can correct high myopia and hyperopia, with the advantages of reversibility, stability of the correction, and, to a great extent, preservation of accommodation.1–11 An increasing number of procedures are being perOriginally received: August 7, 2005. Accepted: March 15, 2006. Manuscript no. 2005-742. 1 Department of Ophthalmology, University Clinic, University of Navarra, Pamplona, Spain. 2 Ramón Castroviejo Institute of Ophthalmic Investigations, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain. The authors have no proprietary interest in the development or marketing of any instrument mentioned in the article, or competing ones. Correspondence to Miguel J. Maldonado, MD, PhD, Department of Ophthalmology, Clínica Universitaria, Av. Pío XII, 36, 31080 Pamplona, Spain. E-mail: [email protected]. © 2006 by the American Academy of Ophthalmology Published by Elsevier Inc.
formed because of the expectation of a superior quality of vision obtained with phakic intraocular lens (IOL) implantation with respect to keratorefractive surgery for the correction of high ametropias.12–15 However, induced cataract and glaucoma are at the heart of most concerns regarding these intraocular surgical procedures, especially for posterior chamber phakic IOLs (PCPIOLs).16 –26 We describe a (to the best of our knowledge) previously unreported complication related to the instillation of pilocarpine in an eye with a hyperopic PCPIOL.
Case Report A 46-year-old man sought refractive surgery. Visual acuities (VAs) were 20/20 in his right eye (⫹8.00 ⫺2.00 ⫻115°) and 20/20 in his left (⫹8.00 ⫺1.75 ⫻85°). The patient had initiated cortical ISSN 0161-6420/06/$–see front matter doi:10.1016/j.ophtha.2006.03.053
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Ophthalmology Volume 113, Number 8, August 2006 sclerotic changes but was visually asymptomatic, and contrast sensitivity test results (CSV-1000 HGT, Vector Vision, Dayton, OH) were normal at all spatial frequencies without or with glare (Table 1). The amplitude of accommodation was measured to be 2 diopters (D) in both eyes with the minus-lenses-to-blur method.27 There was absence of an iris pigment defect or iris transillumination. The endothelial cell status was adequate for implantable collamer lens (ICL) implantation in both eyes (Table 1). Anterior chamber depths (ACDs) from the corneal endothelial layer were 3 mm and 2.9 mm in the right eye and left eye, respectively, and the white-to-white distance was 11.1 mm in both eyes, as measured with an Orbscan II unit (Bausch & Lomb, Rochester, NY). Gonioscopy revealed open grade-III angles. Ultrasound axial length measurement yielded 21.8 mm and 21.9 mm in the right eye and left eye, respectively. Intraocular pressures (IOPs) were 15 mmHg in the right eye and 14 mmHg in the left eye, and anterior and posterior segment examinations were normal. The patient was informed of the different surgical options, and he preferred to correct his hyperopic error by PCPIOL implantation rather than by phacoemulsification with IOL implantation because he wanted to preserve the remaining accommodation and was concerned about the risk of possible night-driving vision problems as a conse-
Table 1. Preoperative and Postoperative Contrast Sensitivity and Endothelial Cell Analysis Data Preoperative Contrast sensitivity without glare Log CS (3 c/d) RE LE Log CS (6 c/d) RE LE Log CS (12 c/d) RE LE Log CS (18 c/d) RE LE Contrast sensitivity with glare Log CS (3 c/d) RE LE Log CS (6 c/d) RE LE Log CS (12 c/d) RE LE Log CS (18 c/d) RE LE Endothelial cell study Density (cells/mm2) RE LE Hexagonality (%) RE LE Coefficient of variation (%) RE LE
Postoperative*
1.79 1.79
1.18 1.63
1.85 1.85
1.56 1.85
1.54 1.40
1.08 1.54
1.11 1.26
0.65 1.26
1.63 1.63
1.18 1.49
1.70 1.56
0.90 1.38
1.40 1.40
0.90 1.26
1.11 0.98
0.48 0.85
2727 2695
2645 2598
56.3 56.5
55.6 55.9
36.8 35.8
37.5 37.8
c/d ⫽ cycles per degree; CS ⫽ contrast sensitivity; LE ⫽ left eye; RE ⫽ right eye. *3 mos.
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quence of pseudophakic multifocal IOL implantation.28 Informed consent for the implantation of the ICL was obtained. The ICL power and dimensions required for each eye were calculated directly by Staar Surgical (Nidau, Switzerland) on the basis of the following variables: refraction, keratometry, ACD from the endothelial cell layer, and white-to-white distance. A ⫹10.5-D 11.5-mm-long model V3 ICL (Staar Surgical) was provided for each eye. The surgery of the left eye was scheduled first, and 1 week later was that of the fellow eye. For both eyes, on the day of surgery the patient took 15 mg of potassium clorazepate (Tranxilium, SanofiSynthélabo, S.A., Barcelona, Spain) and received topical 1% tropicamide (Alcon Cusí, Barcelona, Spain) and 10% phenylephrine (Alcon Cusí), after which an 0.4% oxibuprocaine and 1% tetracaine anesthetic (Alcon Cusí) was applied topically to the operative eye. During surgery, care was taken to prevent the surgical instruments from touching the anterior crystalline lens capsule. Lidocaine 1% (B. Braun Medical SA, Barcelona, Spain) along with 2% hydroxypropylmethylcellulose (Ocucoat, Bausch & Lomb) were injected into the anterior chamber (AC) through a paracentesis, as shown in Video 1 (available at http://aaojournal. org). The ICL was inspected under the operative microscope to see if there were any irregularities on the front and back surfaces. Using a Deitz forceps (Duckworth & Kent, Baldock, United Kingdom), the ICL was positioned in the lens injector cartridge (Staar MicroSTAAR injector, STAAR Surgical Co., Monrovia, CA) previously filled with hydroxypropylmethylcellulose. A small piece of a 3-mm-diameter sponge was placed in the insertion cartridge behind the ICL as protection from the injector arm, as shown in Video 2 (available at http://aaojurnal.org). The injector tip was then placed within a temporal clear corneal incision and pushed forward carefully until its beveled end was in the AC. The ICL was then gently injected in the AC and allowed to unfold slowly, anterior to the iris plane, ensuring proper orientation. The ICL was not inverted during insertion. Distal and then proximal footplates were placed carefully under the iris with a tucker (Duckworth & Kent), which resulted in the optic also being positioned behind the pupillary plane (video 3 [available at http://aaojournal.org]). Correct horizontal positioning of the ICL in the center of the pupillary zone was verified before an intraocular miotic was used to decrease pupil size. Gentle infusion of balanced salt solution was performed with a cannula situated not more centripetally than the iris margin, which pushed the viscoelastic material out of the posterior chamber (PC). This was followed by using an irrigation/aspiration cannula in the same fashion to complete removal of the viscoelastic agent. Acetylcholine chloride 1% (Alcon Cusí) was then injected into the AC to induce sufficient miosis to perform a peripheral iridectomy with a vitreous cutter in the upper peripheral iris, as shown in video 4 (available at http://aaojournal. org).29,30 The aspiration of the viscoelastic was completed while the infusion flow was regulated to avoid overfilling or flattening the AC. The wound was closed with a 10/0 nylon suture (video 5 [available at http://aaojournal.org]). The entire surgical procedure lasted 22 minutes in the right eye and 24 in the left eye. We prescribed topical 0.3% ciprofloxacin (Oftacilox, Alcon Cusí) and 1% dexamethasone (Maxidex, Alcon Cusí) 4 times daily for a total of 16 days. Before the patient was discharged, 2 hours after surgery, the patient was seated at the slit lamp. The left eye showed a pupil 5.5 mm in diameter, a centered implant with normal vaulting and no lens opacification, a deep AC with the typical postoperative tyndall scatter, and an IOP of 16 mmHg. The right eye showed a mydriasis of 7 mm, a deep AC, a properly centered ICL with adequate vaulting, and no lens opacities. The patency of the iridectomy was verified with both direct illumination and transillumination. Applanation tonometry detected 15 mmHg in the right eye. However,
Maldonado et al 䡠 Pilocarpine and Cataract after Phakic IOL Implantation the patient volunteered that seeing too much light entering into the right eye was bothersome. We prescribed topical 2% pilocarpine (Isopto Carpine 2%, Alcon Cusí) twice during the operative day in an attempt to reduce the remaining mydriasis sooner once the effect of the tropicamide was over and, therefore, to provide earlier and more comfortable visual recovery. The 24-hour postoperative examination was unremarkable for the left eye; pupil diameter measured 5 mm, the ICL vault was adequate, best-corrected VA (BCVA) was 20/25, and IOP measured 14 mmHg. However, the right eye showed a fleckenlike opacity and a tight implant adherence to the anterior capsule (Fig
1A). The pupil measured 3 mm; the iridectomy was completely permeable, with no ICL occlusion; and the AC was deep. The AC inflammatory response was 1⫹ flare, and trace 1⫹ cells were present.31 The IOP was 11 mmHg and BCVA 20/50. With optical coherence tomography,32,33 on the first postoperative day the vault measured 134 m on the left eye, whereas the right eye showed complete contact of the ICL with the crystalline lens (Fig 1B). Cyclopentolate 1% hydrochloride drops then were prescribed thrice a day during 3 days in an attempt to increase the space between the ICL and anterior capsule in the right eye (Fig 1C). One day after the instillation of cyclopentolate, the vault increased
Figure 1. Serial postoperative slit-lamp and optical coherence tomography (OCT) examinations of the right eye. A, One day after implantation of a hyperopic intraocular collamer lens (ICL) followed by instillation of 2% pilocarpine, the pupil is miotic, the surgical iridectomy is completely patent, and whitish anterior capsular lens opacities in the center of the pupillary zone can be seen. B, On the first postoperative day, complete central contact between the hyperopic ICL and anterior capsule of the crystalline lens can be demonstrated. One drop of 10% phenylephrine has been administered to examine a wider central pupillary area because the iris pigment blocks the OCT wavelength and prevents examination of the anatomic relationships behind it.32,33 C, One day after start of the treatment with 1% cyclopentolate eyedrops, dotlike focal opacification on the anterior pole of the natural lens can be observed. The incipient cortical sclerotic changes were present in the preoperative examination and did not cause visual degradation. D, Under topical 1% cyclopentolate treatment, a vault of 132 m is now measured. E, One week postoperatively and 3 days after the end of a 3-day course of 1% cyclopentolate eyedrops, the opacity in the anterior capsule has become less dense and not so circumscribed to the apex of the anterior pole of the natural lens. The pupil has been dilated with 10% phenylephrine to allow better comparison with the previous biomicroscopic examination. F, The corresponding optical coherence tomography scan now shows a 124-m-wide space between the ICL and crystalline lens.
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Ophthalmology Volume 113, Number 8, August 2006 to 132 m (Fig 1D). One week postoperatively, an appreciable decrease in opacity density was observed, and BCVA improved to 20/40 (Fig 1E). The ICL vault in the unaccommodated state was then 124 m (Fig 1F). Another course of 1% cyclopentolate was attempted thereafter, but it did not result in further decrease of the opacification. Three months after each procedure, vaulting between the anterior lens capsule and posterior surface of the ICL was biomicroscopically narrow in both eyes. Optical coherence tomography measurements revealed central vaults of 122 m and 110 m in the left eye and right eye, respectively. Whereas the natural lens was transparent in the left eye, central dotlike opacities were present in the right eye’s anterior capsule. Contrast sensitivity without glare worsened notably in the right eye with respect to the preoperative values, especially at the higher frequencies, and to a greater extent with a glare source (Table 1). Central endothelial cell parameters were similar in both eyes and did not show any unusual deterioration (Table 1). At the 1-year follow-up, examination revealed a clear lens with a 118-m vault in the left eye and an anterior subcapsular opacification of the crystalline lens with a 106-m vault in the right eye. Neither nuclear nor further cortical changes progressed with respect to the preoperative period. Best-corrected VAs were 20/20 (left eye) and 20/40 (right eye), and the patient continued to complain about loss of clarity and night vision disturbances, particularly during driving. Applanation tonometry measured 15 mmHg in the left eye and 17 mmHg in the right eye. Cataract surgery by phacoemulsification after explanting the ICL through a 3-mm incision was performed uneventfully in the right eye. We used the axial length measurement performed in the preoperative workup of any phakic IOL implantation, although the difference with the postoperative biometry was minimal (0.1 mm longer after ICL implantation). One year after ICL explantation and cataract extraction, his BCVA was 20/20, with a residual refractive error of ⫺0.25 ⫺0.50 ⫻95°. Both eyes were followed for 2 years after the ICL implantation.
Discussion Lens epithelial cells have no repair ability; thus, cell damage leads to lens opacification.34 It is postulated that early cataract formation may result from either surgical trauma or lack of space between the ICL and the crystalline lens.23 We believe, after a thorough review of the existing literature by a detailed Medline search, that this is the first reported case of cataract development due to PC flattening with a PCPIOL secondary to the administration of pilocarpine. Intraoperative lens trauma typically occurs during prolonged and difficult surgical procedures associated with a narrow pupil and extensive manipulations, such as those cases necessitating ICL removal and reinsertion due to IOL flipping, and also can be associated with a surgeon’s learning curve.19,35 Conversely, our surgeries on both of the patient’s eyes were straightforward, procedures lasted ⬍25 minutes, and the surgeon, who had a surgical experience exceeding 100 ICL procedures, took extreme care not to touch the crystalline lens. In fact, endothelial cell changes (Table 1) are representative of typical uneventful procedures.1,17,36,37 In our case, we found ICL contact with the anterior capsule after the instillation of pilocarpine, and only in the eye that received it, despite existing great similarity between both eyes in terms of anatomy and surgical procedures. We
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used 2% pilocarpine in the right eye to try to reverse excessive mydriasis sooner, as other authors have previously reported.29,30 It is not our common practice, but this patient complained significantly about the glare and photophobia due to the remarkable postoperative mydriasis. There is a considerable effect of pilocarpine on the AC, lens thickness, and resultant accommodation, even in the presbyope,27,38 and this appears to be stronger in subjects with light irides.27 Petternel et al11 demonstrated that instillation of 2% pilocarpine after ICL implantation decreased the vault by a mean of 71 m. This reduction was remarkably larger than the average decrease associated with accommodation at 30 cm and at the subjective near point—12.7 m and 7.7 m, respectively.11 Petternel et al suggest that whereas during accommodation the significant forward movement of the anterior lens pole is accompanied by ICL vaulting as a consequence of ciliary body contraction, after application of pilocarpine the anterior lens pole moves forward and the ICL shifts backwards as a result of miosis of the pupil.11 Central vaulting has been associated with cataract formation in myopic ICL implantation.20,23,39,40 Gonvers et al20 found that all the lens opacities occurred when central vaulting was ⱕ90 m and appeared after 3 months postoperatively. However, not all the eyes in the same range of vaulting and age developed lens opacities with a similar follow-up, which suggests that other factors such the degree of ametropia may influence cataractogenesis.20 Remarkably, they encountered no contact between the ICL and crystalline lens, even peripherally, when the central vaulting was ⱖ150 m.20 The central vaults in our patient were within these 2 limits, except for immediately after the instillation of pilocarpine in the right eye, when no vault existed. García-Feijoó et al,16 using ultrasound biomicroscopy, found central contact between the ICL and the crystalline lens in 16.6% of eyes that had undergone myopic phakic implantation. During pupillary activity and accommodation, there is a potential risk of ICL–lens touching at the rim of the shoulder in myopic ICLs and at the center in hyperopic ICLs, which are the thickest parts of the ICL.3,24 JiménezAlfaro et al17 found central contact between the ICL and crystalline lens in 15% of cases, whereas peripheral contact was present in 60% of them. In a contact zone, Wiechens et al41 found an acellular substance by scanning electron microscopy but no migration of cells such as those appearing during an active inflammatory process, hypothesizing that impaired oxygen supply and altered lens metabolism were leading causes of anterior subcapsular opacification. A similar mechanism may have occurred acutely in our patient’s right eye. Although less information is available on hyperopic than myopic ICL implantantion, the design of the IOL and anatomy of the hyperopic eye may influence the time course of the development of certain complications.9,10,19,42,43 SánchezGaleana et al19 reported a higher incidence of lens opacities in eyes receiving hyperopic ICLs (12%) than in eyes receiving myopic ICLs (7%). They also found that the mean preoperative manifest spherical equivalent in patients who did not develop lens opacities was lower (⫹6.2 D) than that
Maldonado et al 䡠 Pilocarpine and Cataract after Phakic IOL Implantation in those who did (⫹8.6 D). Most of them were anterior subcapsular, of the dotlike focal, combined dot and stripe– shaped focal, or diffuse appearance, the last being the only one visually significant for symptoms such as glare, halos, and BCVA loss.19 None of them appeared in the first postoperative week, and the mean follow-up time for the diagnosis was 125 days. In their series, only the shortest hyperopic ICL (11 mm) was associated with narrow vaulting and lens opacities, which caused visual degradation.19 In the current case, the nonexistent vault observed under the effect of the pilocarpine could have provoked the opacity by mechanical irritation of the anterior capsule or by obstruction of the aqueous humor circulation toward the anterior surface of the crystalline lens during a possible cupping effect.18 A centrally thicker biconcave hyperopic ICL (i.e., 583 m for a ⫹10.5-D ICL vs. 110 m for a ⫺10.5-D ICL)44 also may have played a role in decreasing the PC space, thus increasing the risk of adherence to the anterior capsule. The improvement observed 1 week after the cycloplegic treatment could result from increasing the gap between the ICL and anterior capsule (Fig 1C–F), and does not favor the hypothesis of intraoperative trauma. The concomitant topical administration of mydriatics such as phenylephrine or tropicamide and the miotic pilocarpine is regarded to be a most effective provocative test in closed-angle glaucoma suspects because pupillary block is thus maximized by creating a mid-dilated pupil with full sphincter muscle tone.45,46 The opacity in our patient was flecken in appearance, which may support the speculation that it resulted from a significant IOP rise.47 However, our patient did not experience pain or transient visual deterioration, IOP measurements were normal, and iridectomy was ample, permeable, and not occluded by the implant. The implantation of AC phakic IOLs (ACPIOLs) is thought to induce less iatrogenic cataract than PCPIOLs because the gap behind the IOL is greater.48 However, contact between ACPIOLs and the crystalline lens under physiological conditions also has been demonstrated.49 Therefore, it cannot be completely ruled out that a similar complication may happen after the instillation of pilocarpine in eyes with AC phakic lenses. In conclusion, this case suggests that particular caution must be taken with the instillation of pilocarpine in an eye with a phakic implant, especially in hyperopic eyes with PCPIOLs. The increasing incidence of phakic intraocular procedures warrants education regarding management and prevention of potential complications. It may be advisable to perform preoperative biometry and axial length measurements on all patients undergoing phakic IOL implantation to be prepared for the event that one such situation as the one encountered in this case, or from another etiology, arises requiring phacoemulsification. In addition to improving the accuracy of the current methods of measuring the anterior segment (i.e., white-to-white distance), further refinements in the calculated dimensions and design of the PCPIOLs may prevent 2 chief complications so far encountered, iatrogenic cataract and glaucoma. The former may appear as a consequence of PC flattening with a PCPIOL secondary to the administration of pilocarpine alone, in light of this report and previous studies,11 and the latter may be provoked if
pilocarpine is administered after the instillation of a mydriatic agent.45,46 Pilocarpine is routinely used not only topically in glaucoma therapy, but also systemically for the treatment of dry eye and mouth.50 Physicians and eye care providers therefore should be fully aware of these possible complications. Finally, it is possible that patients with PCPIOLs should be included in the list of precautions regarding the administration of cholinergic agonists such as pilocarpine.
References 1. ICL in Treatment of Myopia (ITM) Study Group. United States Food and Drug Administration clinical trial of the implantable collamer lens (ICL) for moderate to high myopia. Three-year follow-up. Ophthalmology 2004;111:1683–92. 2. Zaldivar R, Davidorf JM, Oscherow S. Posterior chamber phakic intraocular lens for myopia of ⫺8 to ⫺19 diopters. J Refract Surg 1998;14:294 –305. 3. Lackner B, Pieh S, Schmidinger G, et al. Outcome after treatment of ametropia with implantable contact lenses. Ophthalmology 2003;110:2153– 61. 4. BenEzra D, Cohen E, Karshai I. Phakic posterior chamber intraocular lens for the correction of anisometropia and treatment of amblyopia. Am J Ophthalmol 2000;130:292– 6. 5. Pineda-Fernandez A, Jaramillo J, Vargas J, et al. Phakic posterior chamber intraocular lens for high myopia. J Cataract Refract Surg 2004;30:2277– 83. 6. Alió JL, de la Hoz F, Pérez-Santonja JJ, et al. Phakic anterior chamber lenses for the correction of myopia: a 7-year cumulative analysis of complications in 263 cases. Ophthalmology 1999;106:458 – 66. 7. Baikoff G, Arne JL, Bokobza Y, et al. Angle-fixated anterior chamber phakic intraocular lens for myopia of ⫺7 to ⫺19 diopters. J Refract Surg 1998;14:282–93. 8. Menezo JL, Peris-Martínez C, Cisneros AL, Martínez-Costa R. Phakic intraocular lenses to correct high myopia: Adatomed, Staar, and Artisan. J Cataract Refract Surg 2004; 30:33– 44. 9. Davidorf JM, Zaldivar R, Oscherow S. Posterior chamber phakic intraocular lens for hyperopia of ⫹4 to ⫹11 diopters. J Refract Surg 1998;14:306 –11. 10. Pesando PM, Ghiringhello MP, Tagliavacche P. Posterior chamber collamer phakic intraocular lens for myopia and hyperopia. J Refract Surg 1999;15:415–23. 11. Petternel V, Koppl CM, Dejaco-Ruhswurm I, et al. Effect of accommodation and pupil size on the movement of a posterior chamber lens in the phakic eye. Ophthalmology 2004;111: 325–31. 12. Malecaze FJ, Hulin H, Bierer P, et al. A randomized paired eye comparison of two techniques for treating moderately high myopia: LASIK and Artisan phakic lens. Ophthalmology 2002;109:1622–30. 13. Alio JL. Advances in phakic intraocular lenses: indications, efficacy, safety, and new designs. Curr Opin Ophthalmol 2004;15:350 –7. 14. Sarver EJ, Sanders DR, Vukich JA. Image quality in myopic eyes corrected with laser in situ keratomileusis and phakic intraocular lens. J Refract Surg 2003;19:397– 404. 15. Nio YK, Jansonius NM, Wijdh RH, et al. Effect of methods of myopia correction on visual acuity, contrast sensitivity, and depth of focus. J Cataract Refract Surg 2003;29:2082–95. 16. García-Feijoó J, Jiménez-Alfaro I, Cuiña-Sardiña R, et al. Ultrasound biomicroscopy examination of posterior chamber
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17.
18.
19. 20. 21. 22.
23. 24. 25. 26. 27. 28.
29. 30. 31. 32. 33.
phakic intraocular lenses position. Ophthalmology 2003; 110:163–72. Jiménez-Alfaro I, Benítez del Castillo JM, García-Feijoo J, et al. Safety of posterior chamber phakic intraocular lenses for the correction of high myopia: anterior segment changes after posterior chamber phakic intraocular lens implantation. Ophthalmology 2001;108:90 –9. Menezo JL, Peris-Martínez C, Cisneros-Lanuza AL, MartínezCosta R. Rate of cataract formation in 343 highly myopic eyes after implantation of three types of phakic intraocular lenses. J Refract Surg 2004;20:317–24. Sánchez-Galeana CA, Smith RJ, Sanders DR, et al. Lens opacities after posterior chamber phakic intraocular lens implantation. Ophthalmology 2003;110:781–5. Gonvers M, Bornet C, Othenin-Girard P. Implantable contact lens for moderate to high myopia: relationship of vaulting to cataract formation. J Cataract Refract Surg 2003;29:918 –24. Lackner B, Pieh S, Schmidinger G, et al. Long-term results of implantation of phakic posterior chamber intraocular lenses. J Cataract Refract Surg 2004;30:2269 –76. Gonvers M, Othenin-Girard P, Bornet C, Sickenberg M. Implantable contact lens for moderate to high myopia: short-term follow-up of 2 models. J Cataract Refract Surg 2001;27: 380 – 8. Kohnen T. Cataract formation after implantation of myopic phakic posterior chamber IOLs. J Cataract Refract Surg 2004; 30:2245– 6. Trindade F, Pereira F. Cataract formation after posterior chamber phakic intraocular lens implantation. J Cataract Refract Surg 1998;24:1661–3. Bylsma SS, Zalta AH, Foley E, Osher RH. Phakic posterior chamber intraocular lens pupillary block. J Cataract Refract Surg 2002;28:2222– 8. Brandt JD, Mockovak ME, Chayet A. Pigmentary dispersion syndrome induced by a posterior chamber phakic refractive lens. Am J Ophthalmol 2001;131:260 –3. Ostrin LA, Glasser A. Accommodation measurements in a prepresbyopic and presbyopic population. J Cataract Refract Surg 2004;30:1435– 44. Dick HB, Krummenauer F, Schwenn O, et al. Objective and subjective evaluation of photic phenomena after monofocal and multifocal intraocular lens implantation. Ophthalmology 1999;106:1878 – 86. Hoyos JE, Dementiev DD, Cigales M, et al. Phakic refractive lens experience in Spain. J Cataract Refract Surg 2002;28: 1939 – 46. Uusitalo RJ, Aine E, Sen NH, Laatikainen L. Implantable contact lens for high myopia. J Cataract Refract Surg 2002; 28:29 –36. ICL in Treatment of Myopia (ITM) Study Group. Postoperative inflammation after implantation of the implantable contact lens, Ophthalmology 2003;110:2335– 41. Bechmann M, Ullrich S, Thiel MJ, et al. Imaging of posterior chamber phakic intraocular lens by optical coherence tomography. J Cataract Refract Surg 2002;28:360 –3. Baikoff G, Lutun E, Ferraz C, Wei J. Static and dynamic analysis of the anterior segment with optical coherence tomography. J Cataract Refract Surg 2004;30:1843–50.
1288
34. Davson H. Physiology of the Eye. 5th ed. Elmsford, NY: Pergamon; 1990:767– 82. 35. Implantable Contact Lens in Treatment of Myopia (ITM) Study Group. U.S. Food and Drug Administration clinical trial of the implantable contact lens for moderate to high myopia. Ophthalmology 2003;110:255– 66. 36. Edelhauser HF, Sanders DR, Azar R, et al. Corneal endothelial assessment after ICL implantation. J Cataract Refract Surg 2004;30:576 – 83. 37. Dejaco-Ruhswurm I, Scholz U, Pieh S, et al. Long-term endothelial changes in phakic eyes with posterior chamber intraocular lenses. J Cataract Refract Surg 2002;28:1589 –93. 38. Abramson DH, Franzen LA, Coleman DJ. Pilocarpine in the presbyope: demonstration of an effect on the anterior chamber and lens thickness. Arch Ophthalmol 1973;89:100 –2. 39. Kohnen T, Kasper T, Bühren J, Fechner PU. Ten-year follow-up of a ciliary sulcus-fixated silicone phakic posterior chamber intraocular lens. J Cataract Refract Surg 2004;30:2431– 4. 40. Baumeister M, Buhren J, Kohnen T. Position of anglesupported, iris-fixated, and ciliary sulcus-implanted myopic phakic intraocular lenses evaluated by Scheimpflug photography. Am J Ophthalmol 2004;138:723–31. 41. Wiechens B, Winter M, Haigis W, et al. Bilateral cataract after phakic posterior chamber top hat-style silicone intraocular lens. J Refract Surg 1997;13:392–7. 42. García-Feijoó J, Hernández-Matamoros JL, Castillo-Gómez A, et al. High-frequency ultrasound biomicroscopy of silicone posterior chamber phakic intraocular lens for hyperopia. J Cataract Refract Surg 2003;29:1940 – 6. 43. Baumeister M, Buhren J, Schnitzler EM, et al. Scheimpflugfotografische Untersuchungen nach Implantation phaker Vorder- und Hinterkammer-Intraokularlinsen: Erste Erfahrungen. Klin Monatsbl Augenheilkd 2001;218:125–30. 44. Hoffer KJ. Measuring the ultrasound axial length in biphakic eyes (IOLs in phakic eyes). In: Shammas HJ, ed. Intraocular Lens Power Calculations. Thorofare, NJ: SLACK Inc.; 2004: 173– 81. 45. Mapstone R. Provocative tests in closed-angle glaucoma. Br J Ophthalmol 1976;60:115–9. 46. Mapstone R. Dilating dangerous pupils. Br J Ophthalmol 1977;61:517–24. 47. Au Eong KG, Chua EC, Yip CC, et al. Hypopyon—an unusual sign in acute angle-closure glaucoma. Int Ophthalmol 1993; 17:127–9. 48. Pop M, Payette Y, Mansour M. Ultrasound biomicroscopy of the Artisan phakic intraocular lens in hyperopic eyes. J Cataract Refract Surg 2002;28:1799 – 803. 49. Baikoff G, Lutun E, Wei J, Ferraz C. Contact between 3 phakic intraocular lens models and the crystalline lens: an anterior chamber optical coherence tomography study. J Cataract Refract Surg 2004;30:2007–12. 50. Vivino FB, Al-Hashimi I, Khan Z, et al. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjogren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. Arch Intern Med 1999;159: 174 – 81.