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Contact lens for failed pupilloplasty
CASE REPORT
Contact lens for failed pupilloplasty Carpi Olali, BMedSci, MBBS, FWACS, FRCS, Mustapha Mohammed, MD, Sohail Ahmed, MBBS, DO, FRCS, FRCOpth, Mohit Gupta, MBBS, FRCS
We present a case of a patient who had pupilloplasty for an atonic pupil following phacoemulsification cataract surgery. Postoperatively, the patient experienced glare that was not relieved by a neodymium:YAG laser capsulotomy. A cosmetic contact lens helped to resolve the symptoms. In cases of glare due to a large pupil, a painted cosmetic contact lens should be considered an option. J Cataract Refract Surg 2008; 34:1995–1996 Q 2008 ASCRS and ESCRS
We present a case report of a patient who had glare following pupilloplasty that was relieved by a painted cosmetic contact lens.
CASE REPORT A 75-year-old man was referred to our unit by his general practitioner for what was described as excessive bright light entering the right eye, which had gradually worsened over the previous 6 months. In 2003, retinal detachment surgery with vitrectomy had been performed in the right eye. A cataract developed 2 months postoperatively and was subsequently removed by phacoemulsification. However, a few months after the surgery, the patient realized that his right pupil was larger than the left and this was associated with intolerable glare. He was referred to a major eye center where purse-string pupilloplasty for an atonic pupil was performed. The symptoms resolved but in 2006, the glare started again and became progressively intolerable, with associated visual blurring. The patient was wearing a soft contact lens in the phakic left eye. The best corrected visual acuity (Snellen) was 6/48 in the right eye and 6/6 in the left eye. The exposed purse-string suture, with stromal atrophy and multiple areas of deficient tissue (iatrogenic polycoria), was in the iris margin of the right eye (Figure 1, top left). The posterior chamber intraocular lens (IOL) was in situ, but there was also significant posterior capsule opacification. The retina was flat; the left eye was normal, as was the intraocular pressure in both eyes.
Accepted for publication June 5, 2008. From the Department of Ophthalmology, Pilgrim Hospital, Boston, United Kingdom. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Mr. Carpi Olali, Department of Ophthalmology, Pilgrim Hospital, Boston, PE 21 9QS, United Kingdom. E-mail: [email protected]. Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
A neodymium:YAG laser posterior capsulotomy was performed in the right eye and improved the visual acuity to 6/7.5, but the glare persisted. Arrangements were then made to fit the right eye with a specially designed contact lens. The specifications of the contact lens (Cantor and Nissel) were water content 74%, 8.50 14.50 plano, and aperture diameter 4.5 mm. The contact lens had the same iris configuration as the left eye and was symmetrical to that eye (Figure 1, top right, bottom). Use of the contact lens resolved the ocular symptoms
DISCUSSION Pupils that are dilated and nonreactive often cause excessive glare since the aperture that controls the amount of light entering the eye becomes unregulated. If the opposite pupil is normal, the resulting pupil asymmetry may cause considerable cosmetic distress in some individuals. An iatrogenic atonic pupil can occur after surgical procedures such as cataract surgery and penetrating keratoplasty.1–3 In our patient, the damage to the pupil occurred after phacoemulsification surgery; although he had purse-string pupilloplasty, further progressive iris atrophy with resultant polycoria led to the recurrence of the ocular symptoms. Sutured pupilloplasty is known to have late complications such as suture-related cheese wiring, atrophy of the iris stroma, loss of iris tissue, and loss of intrinsic tone of the dilator muscle with resultant tissue breakdown. The use of cosmetic colored contact lenses for medical reasons is not new.4 These lenses are used for conditions such as congenital iris coloboma, cataract corneal scarring, posttraumatic iris damage, and albinism. However, other treatment modalities have to be considered in the light of factors such as acceptability, risks/potential complications, and reversibility of the procedure. Despite the stable suture in the pupil margin, because of the extent of the iris atrophy, our patient had to be fitted with a colored contact lens to 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.06.040
1995
1996
CASE REPORT: CONTACT LENS FOR FAILED PUPILLOPLASTY
pair fails, as in our case, use of a colored contact lens is a reasonable, flexible, and safe choice, especially if the patient is familiar with its use. REFERENCES
Figure 1. Top left: Photograph of the right eye before the contact lens showing the failed pupilloplasty. Top right: Photograph of the right eye with the cosmetic contact lens. Bottom: Photograph of both eyes showing the contact lens in the right eye matched with the iris configuration in the left eye.
reduce his symptoms. Modification of the sutures was not an option for the above reason, and alternatives such as corneal tattooing5 and replacement of the existing IOL with one that had a clear center with an opaque periphery6 were not considered superior to the contact lens and were associated with a higher risk for complications. Therefore, when an initial pupil re-
1. Lam S, Beck RW, Hall D, Creighton JB. Atonic pupil after cataract surgery. Ophthalmology 1989; 96:589–590 2. Urrets-Zavalia A Jr. Fixed, dilated pupil, iris atrophy and secondary glaucoma; a distinct clinical entity following penetrating keratoplasty in keratoconus. Am J Ophthalmol 1963; 56:257–265 3. Gasset AR. Fixed dilated pupil following penetrating keratoplasty in keratoconus (Castroviejo syndrome). Ann Ophthalmol 1977; 9:623–628 4. Meshel LG. Prosthetic contact lenses. In: Dabezies OH Jr, ed, Contact Lenses; the CLAO Guide to Basic Science and Clinical Practice, 2nd ed. Boston, MA, Little Brown and Company, 1990; 59.1–59.9 5. Reed JW. Corneal tattooing to reduce glare in cases of traumatic iris loss. Cornea 1994; 13:401–405 6. Sundmacher R, Reinhard T, Althaus C. Black-diaphragm intraocular lens for correction of aniridia. Ophthalmic Surg 1994; 25:180– 185
First author: Carpi Olali, BMedSci, MBBS, FWACS, FRCS Pilgrim Hospital, Boston, United Kingdom
J CATARACT REFRACT SURG - VOL 34, NOVEMBER 2008
Contact lens for failed pupilloplasty Carpi Olali, BMedSci, MBBS, FWACS, FRCS, Mustapha Mohammed, MD, Sohail Ahmed, MBBS, DO, FRCS, FRCOpth, Mohit Gupta, MBBS, FRCS
We present a case of a patient who had pupilloplasty for an atonic pupil following phacoemulsification cataract surgery. Postoperatively, the patient experienced glare that was not relieved by a neodymium:YAG laser capsulotomy. A cosmetic contact lens helped to resolve the symptoms. In cases of glare due to a large pupil, a painted cosmetic contact lens should be considered an option. J Cataract Refract Surg 2008; 34:1995–1996 Q 2008 ASCRS and ESCRS
We present a case report of a patient who had glare following pupilloplasty that was relieved by a painted cosmetic contact lens.
CASE REPORT A 75-year-old man was referred to our unit by his general practitioner for what was described as excessive bright light entering the right eye, which had gradually worsened over the previous 6 months. In 2003, retinal detachment surgery with vitrectomy had been performed in the right eye. A cataract developed 2 months postoperatively and was subsequently removed by phacoemulsification. However, a few months after the surgery, the patient realized that his right pupil was larger than the left and this was associated with intolerable glare. He was referred to a major eye center where purse-string pupilloplasty for an atonic pupil was performed. The symptoms resolved but in 2006, the glare started again and became progressively intolerable, with associated visual blurring. The patient was wearing a soft contact lens in the phakic left eye. The best corrected visual acuity (Snellen) was 6/48 in the right eye and 6/6 in the left eye. The exposed purse-string suture, with stromal atrophy and multiple areas of deficient tissue (iatrogenic polycoria), was in the iris margin of the right eye (Figure 1, top left). The posterior chamber intraocular lens (IOL) was in situ, but there was also significant posterior capsule opacification. The retina was flat; the left eye was normal, as was the intraocular pressure in both eyes.
Accepted for publication June 5, 2008. From the Department of Ophthalmology, Pilgrim Hospital, Boston, United Kingdom. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Mr. Carpi Olali, Department of Ophthalmology, Pilgrim Hospital, Boston, PE 21 9QS, United Kingdom. E-mail: [email protected]. Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
A neodymium:YAG laser posterior capsulotomy was performed in the right eye and improved the visual acuity to 6/7.5, but the glare persisted. Arrangements were then made to fit the right eye with a specially designed contact lens. The specifications of the contact lens (Cantor and Nissel) were water content 74%, 8.50 14.50 plano, and aperture diameter 4.5 mm. The contact lens had the same iris configuration as the left eye and was symmetrical to that eye (Figure 1, top right, bottom). Use of the contact lens resolved the ocular symptoms
DISCUSSION Pupils that are dilated and nonreactive often cause excessive glare since the aperture that controls the amount of light entering the eye becomes unregulated. If the opposite pupil is normal, the resulting pupil asymmetry may cause considerable cosmetic distress in some individuals. An iatrogenic atonic pupil can occur after surgical procedures such as cataract surgery and penetrating keratoplasty.1–3 In our patient, the damage to the pupil occurred after phacoemulsification surgery; although he had purse-string pupilloplasty, further progressive iris atrophy with resultant polycoria led to the recurrence of the ocular symptoms. Sutured pupilloplasty is known to have late complications such as suture-related cheese wiring, atrophy of the iris stroma, loss of iris tissue, and loss of intrinsic tone of the dilator muscle with resultant tissue breakdown. The use of cosmetic colored contact lenses for medical reasons is not new.4 These lenses are used for conditions such as congenital iris coloboma, cataract corneal scarring, posttraumatic iris damage, and albinism. However, other treatment modalities have to be considered in the light of factors such as acceptability, risks/potential complications, and reversibility of the procedure. Despite the stable suture in the pupil margin, because of the extent of the iris atrophy, our patient had to be fitted with a colored contact lens to 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.06.040
1995
1996
CASE REPORT: CONTACT LENS FOR FAILED PUPILLOPLASTY
pair fails, as in our case, use of a colored contact lens is a reasonable, flexible, and safe choice, especially if the patient is familiar with its use. REFERENCES
Figure 1. Top left: Photograph of the right eye before the contact lens showing the failed pupilloplasty. Top right: Photograph of the right eye with the cosmetic contact lens. Bottom: Photograph of both eyes showing the contact lens in the right eye matched with the iris configuration in the left eye.
reduce his symptoms. Modification of the sutures was not an option for the above reason, and alternatives such as corneal tattooing5 and replacement of the existing IOL with one that had a clear center with an opaque periphery6 were not considered superior to the contact lens and were associated with a higher risk for complications. Therefore, when an initial pupil re-
1. Lam S, Beck RW, Hall D, Creighton JB. Atonic pupil after cataract surgery. Ophthalmology 1989; 96:589–590 2. Urrets-Zavalia A Jr. Fixed, dilated pupil, iris atrophy and secondary glaucoma; a distinct clinical entity following penetrating keratoplasty in keratoconus. Am J Ophthalmol 1963; 56:257–265 3. Gasset AR. Fixed dilated pupil following penetrating keratoplasty in keratoconus (Castroviejo syndrome). Ann Ophthalmol 1977; 9:623–628 4. Meshel LG. Prosthetic contact lenses. In: Dabezies OH Jr, ed, Contact Lenses; the CLAO Guide to Basic Science and Clinical Practice, 2nd ed. Boston, MA, Little Brown and Company, 1990; 59.1–59.9 5. Reed JW. Corneal tattooing to reduce glare in cases of traumatic iris loss. Cornea 1994; 13:401–405 6. Sundmacher R, Reinhard T, Althaus C. Black-diaphragm intraocular lens for correction of aniridia. Ophthalmic Surg 1994; 25:180– 185
First author: Carpi Olali, BMedSci, MBBS, FWACS, FRCS Pilgrim Hospital, Boston, United Kingdom
J CATARACT REFRACT SURG - VOL 34, NOVEMBER 2008