- Email: [email protected]
Ciliochoroidal effusions after neodymium:YAG posterior capsulotomy: Association with pre-existing glaucoma and uveitis
Ciliochoroidal effusions after neodymium: YAG posterior caps ulotomy: Association with pre-existing glaucoma and uveitis Alan R. Schaeffer, M.D. Dennis L. Ryll , M.D. Francis E. O'Donnell, Jr., M.D.
ABSTRACT Two patients with a history of glaucoma and a propensity for uveitis developed ciliochoroidal effusions fol1owing Nd:YAG laser posterior capsulotomy. Both patients experienced a waxing and waning course with eventual resolution of symptoms after a steroid regimen. The ciliochoroidal effusions were presumed to be secondary to uveitis induced by the YAG laser surgery. The role of glaucoma, previous surgeries, and an open posterior capsule is uncertain but may have predisposed these patients to ciliochoroidal detachment. We advise caution in performing YAG posterior capsulotomy in patients with glaucoma and a known propensity for uveitis.
cases,
instruments and notes
Key Words: ciliochoroidal effu ion , extracapsular cataract extraction , glaucoma, posterior cap ul opacification , trabeculectomy, trabeculoplasty, uveiti , YAG la er posterior capsulotomy
As Nd:YAG laser capsulotomies have proliferated , a number of complications have been reported. Persistent intraocular pressure (lOP) elevations 1 -3 in addition to elevated lOPs resulting in central retinal artery occlusions have been reported. 4 -6 Retinal complications include retinal detachment, !,6-9 cystoid macular edema,5 •8 and macular hole formation. 7 •8 Winslow and Taylors and Harris et al.IO suggest that the retinal detachments and macular edema result from discission of the posterior capsule rather than from mechanical disruption by the YAG laser. However, macular hole From the Deaconess Eye Institute and the Department of Ophthalmology, St. Louis University School of Medicine, St. Louis, Missouri . Reprint requests to Francis E. O'Donnell, Jr. , M.D., 3663 Lindell Boulevard, St. Louis, Missouri 63108.
J CATARACT REFRACT SURG-VOL
15, SEPTEMBER 1989
567
formation is believed to result from laser surgery. 8 Other adverse effects include posterior chamber lens damage,1·9 corneal injury,7,9,11 hemorrhage,l,7,9 and uveitis. 6 We present two patients who developed uveitis and ciliochoroidal effusions following YAG laser posterior capsulotomy. To our knowledge, ciliochoroidal effusions following this procedure have not been reported.
Case 1 A 75-year-old female was diagnosed with open angle glaucoma and cataracts on her initial visit in February 1983. Her visual acuity was 20170 in the right eye and 20/80 in the left. The presence of severe bilateral disc cupping and lOPs of25 mm Hg necessitated aggressive medical therapy. The lOPs were reduced to 18 mm Hg following bilateral argon laser trabeculoplasties. In May 1984, an extracapsular cataract extraction (ECCE) with posterior chamber lens implantation was performed on the left eye. The patient's visual acuity improved to 20/40 until her postoperative course was complicated by uveitis, hypotony, and posterior capsule opacification. The uveitis and hypotony resolved with topical steroids. No ciliochoroidal effusion was seen. In June 1984, a YAG laser posterior capsulotomy was performed using 16 spots of 3.1 mJ, and three weeks later a ciliochoroidal effusion was detected by indirect ophthalmoscopy. Her visual acuity was 20/40 and her lOP was 6 mm Hg. The ciliochoroidal effusion was presumed to be secondary to a low grade uveitis. After an oral and topical steroid trial, the detachment improved and the hypotony resolved. In July 1984, the uveitis relapsed without effusion and it was successfully treated topically. In September 1984, the visual acuity in her left eye improved to 20/25 with an lOP of 14 mm Hg. It has subsequently remained stable. Case 2 An 85-year-old female was diagnosed with glaucoma and cataracts in October 1983. The lOP was 27 mm Hg in the right eye and 26 mm Hg in the left; visual acuity was 20/60 in the right eye and 20170 in the left. Narrow anterior chamber angles and uncontrolled glaucoma necessitated bilateral argon laser iridotomies which were complicated by prolonged iritis in each eye. Continued lOP elevation required a trabeculectomy in the left eye. This was successfully performed without complication. An ECCE with posterior chamber lens implantation was performed on the left eye in January 1984. Subsequent posterior capsule opacification was treated with difficulty with the YAG laser in February 1984 using 75 spots of 4.5 mJ intensity. Visual acuity in this eye improved to 20/30. 568
J CATARACT REFRACT
Three weeks later, the patient's left eye became painful. This was associated with an lOP of5 mm Hg, a visual acuity of20/40, and a shallow anterior chamber. The low bleb was unchanged. Indirect ophthalmoscopic examination revealed a ciliochoroidal effusion. The symptoms resolved with a regimen of topical and oral steroids. However, the effusion persisted. The presumed etiology of the effusion was uveitis. In May 1984 (five weeks later), the patient's symptoms of pain and decreased acuity (20170) recurred with an lOP of2 mm Hg. After another trial of steroids and drainage of the serous ciliochoroidal effusion, her vision improved to 20/25. The lOP stabilized and the pain subsided. No further ciliochoroidal effusion was seen. The patient has remained stable for almost three years. DISCUSSION Although ciliochoroidal effusions have not been reported following YAG capsulotomy, Prywes and LoPintoi2 reported this condition following attempted repair of a failed trabeculectomy with a YAG laser. In their case, the detachment may have been secondary to the heat or mechanical disruption generated by the laser since the ciliary body was adjacent to the target tissue. In our cases, the posterior capsulotomy sites were central and relatively distant from the uveal tract. The ciliochoroidal effusi~n was probably not a direct consequence of the YAG laser surgery. However, a uveitis induced by this procedure may have predisposed these patients to ciliochoroidal effusions. Both patients had displayed a propensity for postoperative uveitis. Moreover, both patients had a history of glaucoma. From our limited experience, we would suggest caution in performing YAG capsulotomy on glaucoma patients with a known propensity for postoperative uveitis. If a ciliochoroidal detachment occurs, topical and oral steroids can be effective and they may obviate surgical drainage. REFERENCES l. Terry AC, Stark WJ, \'laumenee AE, Fagadau W: NeodymiumYAG laser for posterior capsulotomy. Am ] Ophthalmol 96:716-720, 1983 2. Channell MM, Beckman H: Intraocular pressure changes after neodymium-YAG laser posterior caps ulotomy. Arch Ophthalmoll02:l024-1026, 1984 3. Richter CU, Arzeno G, Pappas HR, Steinert RF, et al: Intraocular pressure elevation following Nd:YAG laser posterior capsulotomy. Ophthalmology 92:636-640, 1985 4. Paylor R: Central retinal artery occlusion following YAG synechialysis. Arch Ophthalmol 103:325-326, 1985 5. Blackwell C, Hirst LW, Kinnas SJ: Neodymium-YAG capsulotomy and potential blindness. Am J Ophthalmol 98:521-522, 1984 6. Ficker LA, Steele ADM: Complications of Nd:YAG laser posterior capsulotomy. Trans Opthalmol Soc UK 104:529-532, 1985
SURG- VOL 15, SEPTEMBER 1989
7. Fastenberg DM, Schwartz PL, Lin HZ: Retinal detachment following neodymium-YAG laser capsulotomy. Am J Ophthalmol 97:288-291, 1984 8. Winslow RL, Taylor BC: Retinal complications following YAG laser capsulotomy. Ophthalmology 92:785-789, 1985 9. Nirankari VS, Richards RD: Complications associated with the use of the neodymium:YAG laser. Ophthalmology 92: 1371-1375, 1985 10. Harris WS, Herman WK, Fagadau WR: Management of the posterior capsule before and after the YAG laser. Trans Ophthalmol Soc UK 104:533-535, 1985 11. Sherrard ES, Kerr Muir MG: Damage to the corneal endothelium by Q-switched Nd:YAG laser posterior capsulotomy. Trans Ophthalmol Soc UK 104:524-528, 1985. 12. Prywes AS, LoPinto RJ: Temporary visual loss with ciliary body detachment and hypotony after attempted YAG laser repair of failed filtering surgery. Am J Ophthalmol 101:305-307, 1986
Erythropsia} phototoxicity associated with nonultraviolet-filtering intraocular lenses Harry M. Lawrence, M.D. Thomas R. Reynolds, M.D.
ABSTRACT Four patients with monocular erythropsia (seeing red) caused by excessive exposure to bright light are presented. Each patient had a nonultraviolet (UV)Hltering intraocular lens (IOL) in the involved eye; the fellow eye was either phakic or had a UV6ltering IOL. Each patient had seen a definite red hue to lights (moon, automobile headlights, etc.) only at night after prior prolonged exposure to highintensity sunlight and only in the eye with a non-UVHltering IOL. Key Words: aphakia, erythropsia, photoreceptors , photo toxicity, posterior chamber intraocular lens (pseudophakos), pseudophakia, shortwave blue light, ultraviol t filter, ultraviolet light
The controversy about the need for ultraviolet (UV)filtering substances in intraocular lenses continues. This report presents four patients who complained of seeing red (erythropsia) with one eye. In each case the involved eye had an intraocular lens (IOL) without a UV filter. While erythropsia may not be serious, it can cause considerable concern to patients and to ophthalmologists who do not understand its cause.
CASE REPORTS Case 1 A 63-year-old Caucasian female had uncomplicated extracapsular cataract surgery (nucleus expression with mechanical cortical aspiration) and posterior chamber IOL implantation in the right eye in March 1986, and in the left eye three and a half months later. An IOLAB From the Department of Ophthalmology, University of Tennessee College of Medicine, Chattanooga, Tennessee. Presented in part at the annual meeting ofthe Tennessee Academy of Ophthalmology, Memphis, April1988. Reprint requests to Harry M. Lawrence, M.D., 979 East Third Street, Suite 1210, Chattanooga, Tennessee 37403-2169.
J CATARACT REFRACT
SURG-VOL 15, SEPTEMBER 1989
569
ABSTRACT Two patients with a history of glaucoma and a propensity for uveitis developed ciliochoroidal effusions fol1owing Nd:YAG laser posterior capsulotomy. Both patients experienced a waxing and waning course with eventual resolution of symptoms after a steroid regimen. The ciliochoroidal effusions were presumed to be secondary to uveitis induced by the YAG laser surgery. The role of glaucoma, previous surgeries, and an open posterior capsule is uncertain but may have predisposed these patients to ciliochoroidal detachment. We advise caution in performing YAG posterior capsulotomy in patients with glaucoma and a known propensity for uveitis.
cases,
instruments and notes
Key Words: ciliochoroidal effu ion , extracapsular cataract extraction , glaucoma, posterior cap ul opacification , trabeculectomy, trabeculoplasty, uveiti , YAG la er posterior capsulotomy
As Nd:YAG laser capsulotomies have proliferated , a number of complications have been reported. Persistent intraocular pressure (lOP) elevations 1 -3 in addition to elevated lOPs resulting in central retinal artery occlusions have been reported. 4 -6 Retinal complications include retinal detachment, !,6-9 cystoid macular edema,5 •8 and macular hole formation. 7 •8 Winslow and Taylors and Harris et al.IO suggest that the retinal detachments and macular edema result from discission of the posterior capsule rather than from mechanical disruption by the YAG laser. However, macular hole From the Deaconess Eye Institute and the Department of Ophthalmology, St. Louis University School of Medicine, St. Louis, Missouri . Reprint requests to Francis E. O'Donnell, Jr. , M.D., 3663 Lindell Boulevard, St. Louis, Missouri 63108.
J CATARACT REFRACT SURG-VOL
15, SEPTEMBER 1989
567
formation is believed to result from laser surgery. 8 Other adverse effects include posterior chamber lens damage,1·9 corneal injury,7,9,11 hemorrhage,l,7,9 and uveitis. 6 We present two patients who developed uveitis and ciliochoroidal effusions following YAG laser posterior capsulotomy. To our knowledge, ciliochoroidal effusions following this procedure have not been reported.
Case 1 A 75-year-old female was diagnosed with open angle glaucoma and cataracts on her initial visit in February 1983. Her visual acuity was 20170 in the right eye and 20/80 in the left. The presence of severe bilateral disc cupping and lOPs of25 mm Hg necessitated aggressive medical therapy. The lOPs were reduced to 18 mm Hg following bilateral argon laser trabeculoplasties. In May 1984, an extracapsular cataract extraction (ECCE) with posterior chamber lens implantation was performed on the left eye. The patient's visual acuity improved to 20/40 until her postoperative course was complicated by uveitis, hypotony, and posterior capsule opacification. The uveitis and hypotony resolved with topical steroids. No ciliochoroidal effusion was seen. In June 1984, a YAG laser posterior capsulotomy was performed using 16 spots of 3.1 mJ, and three weeks later a ciliochoroidal effusion was detected by indirect ophthalmoscopy. Her visual acuity was 20/40 and her lOP was 6 mm Hg. The ciliochoroidal effusion was presumed to be secondary to a low grade uveitis. After an oral and topical steroid trial, the detachment improved and the hypotony resolved. In July 1984, the uveitis relapsed without effusion and it was successfully treated topically. In September 1984, the visual acuity in her left eye improved to 20/25 with an lOP of 14 mm Hg. It has subsequently remained stable. Case 2 An 85-year-old female was diagnosed with glaucoma and cataracts in October 1983. The lOP was 27 mm Hg in the right eye and 26 mm Hg in the left; visual acuity was 20/60 in the right eye and 20170 in the left. Narrow anterior chamber angles and uncontrolled glaucoma necessitated bilateral argon laser iridotomies which were complicated by prolonged iritis in each eye. Continued lOP elevation required a trabeculectomy in the left eye. This was successfully performed without complication. An ECCE with posterior chamber lens implantation was performed on the left eye in January 1984. Subsequent posterior capsule opacification was treated with difficulty with the YAG laser in February 1984 using 75 spots of 4.5 mJ intensity. Visual acuity in this eye improved to 20/30. 568
J CATARACT REFRACT
Three weeks later, the patient's left eye became painful. This was associated with an lOP of5 mm Hg, a visual acuity of20/40, and a shallow anterior chamber. The low bleb was unchanged. Indirect ophthalmoscopic examination revealed a ciliochoroidal effusion. The symptoms resolved with a regimen of topical and oral steroids. However, the effusion persisted. The presumed etiology of the effusion was uveitis. In May 1984 (five weeks later), the patient's symptoms of pain and decreased acuity (20170) recurred with an lOP of2 mm Hg. After another trial of steroids and drainage of the serous ciliochoroidal effusion, her vision improved to 20/25. The lOP stabilized and the pain subsided. No further ciliochoroidal effusion was seen. The patient has remained stable for almost three years. DISCUSSION Although ciliochoroidal effusions have not been reported following YAG capsulotomy, Prywes and LoPintoi2 reported this condition following attempted repair of a failed trabeculectomy with a YAG laser. In their case, the detachment may have been secondary to the heat or mechanical disruption generated by the laser since the ciliary body was adjacent to the target tissue. In our cases, the posterior capsulotomy sites were central and relatively distant from the uveal tract. The ciliochoroidal effusi~n was probably not a direct consequence of the YAG laser surgery. However, a uveitis induced by this procedure may have predisposed these patients to ciliochoroidal effusions. Both patients had displayed a propensity for postoperative uveitis. Moreover, both patients had a history of glaucoma. From our limited experience, we would suggest caution in performing YAG capsulotomy on glaucoma patients with a known propensity for postoperative uveitis. If a ciliochoroidal detachment occurs, topical and oral steroids can be effective and they may obviate surgical drainage. REFERENCES l. Terry AC, Stark WJ, \'laumenee AE, Fagadau W: NeodymiumYAG laser for posterior capsulotomy. Am ] Ophthalmol 96:716-720, 1983 2. Channell MM, Beckman H: Intraocular pressure changes after neodymium-YAG laser posterior caps ulotomy. Arch Ophthalmoll02:l024-1026, 1984 3. Richter CU, Arzeno G, Pappas HR, Steinert RF, et al: Intraocular pressure elevation following Nd:YAG laser posterior capsulotomy. Ophthalmology 92:636-640, 1985 4. Paylor R: Central retinal artery occlusion following YAG synechialysis. Arch Ophthalmol 103:325-326, 1985 5. Blackwell C, Hirst LW, Kinnas SJ: Neodymium-YAG capsulotomy and potential blindness. Am J Ophthalmol 98:521-522, 1984 6. Ficker LA, Steele ADM: Complications of Nd:YAG laser posterior capsulotomy. Trans Opthalmol Soc UK 104:529-532, 1985
SURG- VOL 15, SEPTEMBER 1989
7. Fastenberg DM, Schwartz PL, Lin HZ: Retinal detachment following neodymium-YAG laser capsulotomy. Am J Ophthalmol 97:288-291, 1984 8. Winslow RL, Taylor BC: Retinal complications following YAG laser capsulotomy. Ophthalmology 92:785-789, 1985 9. Nirankari VS, Richards RD: Complications associated with the use of the neodymium:YAG laser. Ophthalmology 92: 1371-1375, 1985 10. Harris WS, Herman WK, Fagadau WR: Management of the posterior capsule before and after the YAG laser. Trans Ophthalmol Soc UK 104:533-535, 1985 11. Sherrard ES, Kerr Muir MG: Damage to the corneal endothelium by Q-switched Nd:YAG laser posterior capsulotomy. Trans Ophthalmol Soc UK 104:524-528, 1985. 12. Prywes AS, LoPinto RJ: Temporary visual loss with ciliary body detachment and hypotony after attempted YAG laser repair of failed filtering surgery. Am J Ophthalmol 101:305-307, 1986
Erythropsia} phototoxicity associated with nonultraviolet-filtering intraocular lenses Harry M. Lawrence, M.D. Thomas R. Reynolds, M.D.
ABSTRACT Four patients with monocular erythropsia (seeing red) caused by excessive exposure to bright light are presented. Each patient had a nonultraviolet (UV)Hltering intraocular lens (IOL) in the involved eye; the fellow eye was either phakic or had a UV6ltering IOL. Each patient had seen a definite red hue to lights (moon, automobile headlights, etc.) only at night after prior prolonged exposure to highintensity sunlight and only in the eye with a non-UVHltering IOL. Key Words: aphakia, erythropsia, photoreceptors , photo toxicity, posterior chamber intraocular lens (pseudophakos), pseudophakia, shortwave blue light, ultraviol t filter, ultraviolet light
The controversy about the need for ultraviolet (UV)filtering substances in intraocular lenses continues. This report presents four patients who complained of seeing red (erythropsia) with one eye. In each case the involved eye had an intraocular lens (IOL) without a UV filter. While erythropsia may not be serious, it can cause considerable concern to patients and to ophthalmologists who do not understand its cause.
CASE REPORTS Case 1 A 63-year-old Caucasian female had uncomplicated extracapsular cataract surgery (nucleus expression with mechanical cortical aspiration) and posterior chamber IOL implantation in the right eye in March 1986, and in the left eye three and a half months later. An IOLAB From the Department of Ophthalmology, University of Tennessee College of Medicine, Chattanooga, Tennessee. Presented in part at the annual meeting ofthe Tennessee Academy of Ophthalmology, Memphis, April1988. Reprint requests to Harry M. Lawrence, M.D., 979 East Third Street, Suite 1210, Chattanooga, Tennessee 37403-2169.
J CATARACT REFRACT
SURG-VOL 15, SEPTEMBER 1989
569