- Email: [email protected]
Cyclodialysis cleft secondary to removal of an anterior chamber phakic intraocular lens
CASE REPORT
Cyclodialysis cleft secondary to removal of an anterior chamber phakic intraocular lens Edgar M. Espana, MD, Celso Tello, MD, Jeffrey M. Liebmann, MD, Robert Ritch, MD
We present a patient who had decreased visual acuity and hypotony in the left eye 2 months after removal of an anterior chamber phakic intraocular lens (pIOL). Gonioscopy demonstrated a cyclodialysis cleft at the 6 o’clock position in the region of the IOL footplate, which was confirmed by ultrasound biomicroscopy. A cyclodialysis cleft formation is one possible complication of pIOL removal. Careful gonioscopy evaluation before removal of pIOLs should be mandatory to assess the amount of fibrosis and the presence of synechia between the IOL and the surrounding tissues. J Cataract Refract Surg 2007; 33:542–544 Q 2007 ASCRS and ESCRS
Phakic intraocular lenses (pIOLs) are a current option for the correction of high degrees of ametropia. Over the past several years, many reports have demonstrated the safety and efficacy of pIOLs and compared them favorable with laser in situ keratomileusis. It is estimated that roughly 70 000 pIOLs have been implanted worldwide.1 Because pIOLs are close to the corneal endothelium of the anterior chamber, there is concern about their effect on long-term corneal endothelial survival.2–4 Most new pIOLs are implanted in young patients, and longterm follow-up for possible complications is needed. We present a patient in whom the removal of a pIOL because of progressive endothelial damage was complicated by a cyclodialysis cleft and persistent hypotony.
Accepted for publication September 27, 2006. From the Departments of Ophthalmology, the New York Eye and Ear Infirmary (Espana, Tello, Ritch) and the New York University School of Medicine (Liebmann) and Manhattan Eye, Ear and Throat (Liebmann), New York, and the Department of Ophthalmology, New York Medical College (Tello, Ritch), Valhalla, New York, USA. No author has a financial or proprietary interest in any material or method mentioned. Supported by the Vanu and Jayanthi Menon Research Fund of the New York Glaucoma Research Institute, New York, New York, USA. Corresponding author: Celso Tello, MD, New York Eye and Ear Infirmary, 310 East 14th Street, New York, New York 10003, USA. E-mail: [email protected].
542
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 48-year-old woman was referred for evaluation of hypotony in the left eye. In July 2003, she had bilateral implantation of pIOLs in the anterior chamber (model unknown) for correction of myopia. Postoperatively, the uncorrected visual acuity was 20/20 in both eyes. Two years later, the patient noted progressive blurred vision in both eyes; mild corneal edema and endothelial dysfunction were found by corneal pachymetry and specular microscopy. The patient was referred to us after removal of both pIOLs in January 2006 resulted in persistent hypotony in the left eye. The best corrected visual acuity (BCVA) was 20/25 in the right eye with 5.50 diopter (D) sphere and 20/80 in the left with 6.00 D sphere. Slitlamp examination was unremarkable in the right eye except for nylon sutures in the superior limbus. The right pupil was round and reactive to light, and gonioscopy showed a widely open anterior chamber angle. In the left eye, nylon sutures were present at the superior limbus without evidence of leaks. Intraocular pressure, measured by applanation tonometry, was 15 mm Hg in the right eye and 1 to 2 mm Hg in the left eye. A mild increase in corneal thickness was noted (Figure 1, A), and the anterior chamber was deep and quiet (Figure 1, B). Gonioscopy revealed a widely open anterior chamber angle with visualization of the ciliary body band and an apparent cyclodialysis cleft extending inferonasally for 1 clock hour (Figure 2, A). Corneal pachymetry was 585 mm in the right eye and 607 mm in the left eye (DGH 500 Pachette, DGH Technology, Inc.) Ultrasound biomicroscopy (UBM) (Figure 2, B) showed a small separation of the ciliary body from the scleral 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.09.044
CASE REPORT: HYPOTONY AFTER PIOL REMOVAL
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Figure 1. A: Slitlamp examination at the patient’s initial visit showed a deep anterior chamber with very little corneal edema in the left eye and the presence of slight lens sclerosis. B: Corneal edema was more evident at higher magnification.
spur and fluid in the suprachoroidal space. A piece of the haptic was also noted over the iris. Optic nerve examination and retinal examination were unremarkable. The diminished visual acuity in the left eye was ascribed to the presence of corneal edema. The cyclodialysis cleft auto sealed 1 week after our evaluation. This finding was confirmed by UBM.
DISCUSSION A variety of intraoperative and long-term complications have been reported with the implantation of pIOLs in the anterior or posterior chamber. Our patient developed a cyclodialysis cleft and hypotony after removal of an anterior segment pIOL. Whether fixated to the iris or the angle, pIOLs in the anterior chamber increase the risk for endothelial loss and corneal decompensation.4–6 In the longest followup of angle-fixated lenses with progressive endothelial loss, Alio´ et al.3 report that 17% of the corneal endothelial population was lost after 2 years. Although the mechanism responsible for the endothelial loss is thought to be constant or intermittent direct contact between the pIOL and the endothelium during eyelid blinking or rubbing, other mechanisms could be involved, including a noncontact inflammatory mechanism with secondary endothelial damage. Theoretically, a pIOL in the anterior chamber could cause inflammation detrimental to the corneal endothelium. Contact between the haptics and the trabecular meshwork or continuous rubbing of the iris against the pIOL during pupillary hippus and during accommodation can cause intraocular inflammation, trabecular meshwork damage, and increased IOP that will probably affect the endothelium in the long term.1
Figure 2. A: Gonioscopy showed a widely open angle in all quadrants. An area measuring approximately 1 clock hour with a wider ciliary body band was seen between 7 o’clock and 8 o’clock (black arrows). B: Ultrasound biomicroscopy confirmed the presence of the cyclodialysis cleft and demonstrated separation of the ciliary body from the scleral spur (black arrow), suprachoroidal fluid (white arrow), and the presence of a haptic piece (white star) embedded in the iris stroma.
Traumatic removal of the pIOL caused by fibrosis of the haptic to the iris stroma was the most probable cause of the cleft. Ciliary body clefts are generally reported following cataract extraction or trauma; however, other unusual causes are described in the literature. Esquenazi7 recently reported a case of cyclodialysis following the displacement of an anterior chamber IOL that migrated temporally and induced the cleft. Traditionally, clefts are treated medically with atropine sulfate and if no improvement is observed, laser photocoagulation to the cleft can be attempted. In some cases, surgical closure including scleral buckling and cryotherapy is the last option.8–11 The occurrence of a cyclodialysis cleft and the serious consequences of the subsequent hypotony must be considered among the most sight-threatening complications of IOL removal. We believe that gonioscopy
544
CASE REPORT: HYPOTONY AFTER PIOL REMOVAL
before removal of the IOL is essential to assess the degree of fibrosis and the presence of synechia and adhesions between the haptics and the surrounding tissues. To our knowledge, this is the first reported case of a cyclodialysis cleft after removal of an anterior chamber pIOL.
REFERENCES 1. Lovisolo CF, Reinstein DZ. Phakic intraocular lenses. Surv Ophthalmol 2005; 50:549–587 2. Pe´rez-Santonja JJ, Iradier MT, Sanz-Iglesias L, et al. Endothelial changes in phakic eyes with anterior chamber intraocular lenses to correct high myopia. J Cataract Refract Surg 1996; 22: 1017–1022 3. Alio´ JL, de la Hoz F, Pe´rez-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; 106:458–466 4. Pop M, Payette Y. Initial results of endothelial cell counts after Artisan lens for phakic eyes; an evaluation of the United States Food and Drug Administration Ophtec Study. Ophthalmology 2004; 111:309–317 5. Barraquer J. Anterior chamber plastic lenses. Results of and conclusions from five years’ experience. Trans Ophthalmol Soc UK 1959; 79:393–424
6. Frueh BE, Bo¨hnke M. Endothelial changes following refractive surgery. J Cataract Refract Surg 1996; 22:490–496 7. Esquenazi S. Management of a displaced angle-supported anterior chamber intraocular lens. Ophthalmic Surg Lasers Imaging 2006; 37:65–67 8. Maumenee AE, Stark WJ. Management of persistent hypotony after planned or inadvertent cyclodialysis. Am J Ophthalmol 1971; 71:320–327 9. Jewelewicz DA, Liebmann JM, Ritch R. The use of scleral transillumination to localize the extent of a cyclodialysis cleft. Ophthalmic Surg Lasers 1999; 30:571–574 10. Aminlari A, Callahan CE. Medical, laser, and surgical management of inadvertent cyclodialysis cleft with hypotony. Arch Ophthalmol 2004; 122:399–404 11. Mandava N, Kahook MY, Mackenzie DL, Olson JL. Anterior scleral buckling procedure for cyclodialysis cleft with chronic hypotony. Ophthalmic Surg Lasers Imaging 2006; 37:151– 153
First author: Edgar M. Espana, MD
Cyclodialysis cleft secondary to removal of an anterior chamber phakic intraocular lens Edgar M. Espana, MD, Celso Tello, MD, Jeffrey M. Liebmann, MD, Robert Ritch, MD
We present a patient who had decreased visual acuity and hypotony in the left eye 2 months after removal of an anterior chamber phakic intraocular lens (pIOL). Gonioscopy demonstrated a cyclodialysis cleft at the 6 o’clock position in the region of the IOL footplate, which was confirmed by ultrasound biomicroscopy. A cyclodialysis cleft formation is one possible complication of pIOL removal. Careful gonioscopy evaluation before removal of pIOLs should be mandatory to assess the amount of fibrosis and the presence of synechia between the IOL and the surrounding tissues. J Cataract Refract Surg 2007; 33:542–544 Q 2007 ASCRS and ESCRS
Phakic intraocular lenses (pIOLs) are a current option for the correction of high degrees of ametropia. Over the past several years, many reports have demonstrated the safety and efficacy of pIOLs and compared them favorable with laser in situ keratomileusis. It is estimated that roughly 70 000 pIOLs have been implanted worldwide.1 Because pIOLs are close to the corneal endothelium of the anterior chamber, there is concern about their effect on long-term corneal endothelial survival.2–4 Most new pIOLs are implanted in young patients, and longterm follow-up for possible complications is needed. We present a patient in whom the removal of a pIOL because of progressive endothelial damage was complicated by a cyclodialysis cleft and persistent hypotony.
Accepted for publication September 27, 2006. From the Departments of Ophthalmology, the New York Eye and Ear Infirmary (Espana, Tello, Ritch) and the New York University School of Medicine (Liebmann) and Manhattan Eye, Ear and Throat (Liebmann), New York, and the Department of Ophthalmology, New York Medical College (Tello, Ritch), Valhalla, New York, USA. No author has a financial or proprietary interest in any material or method mentioned. Supported by the Vanu and Jayanthi Menon Research Fund of the New York Glaucoma Research Institute, New York, New York, USA. Corresponding author: Celso Tello, MD, New York Eye and Ear Infirmary, 310 East 14th Street, New York, New York 10003, USA. E-mail: [email protected].
542
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 48-year-old woman was referred for evaluation of hypotony in the left eye. In July 2003, she had bilateral implantation of pIOLs in the anterior chamber (model unknown) for correction of myopia. Postoperatively, the uncorrected visual acuity was 20/20 in both eyes. Two years later, the patient noted progressive blurred vision in both eyes; mild corneal edema and endothelial dysfunction were found by corneal pachymetry and specular microscopy. The patient was referred to us after removal of both pIOLs in January 2006 resulted in persistent hypotony in the left eye. The best corrected visual acuity (BCVA) was 20/25 in the right eye with 5.50 diopter (D) sphere and 20/80 in the left with 6.00 D sphere. Slitlamp examination was unremarkable in the right eye except for nylon sutures in the superior limbus. The right pupil was round and reactive to light, and gonioscopy showed a widely open anterior chamber angle. In the left eye, nylon sutures were present at the superior limbus without evidence of leaks. Intraocular pressure, measured by applanation tonometry, was 15 mm Hg in the right eye and 1 to 2 mm Hg in the left eye. A mild increase in corneal thickness was noted (Figure 1, A), and the anterior chamber was deep and quiet (Figure 1, B). Gonioscopy revealed a widely open anterior chamber angle with visualization of the ciliary body band and an apparent cyclodialysis cleft extending inferonasally for 1 clock hour (Figure 2, A). Corneal pachymetry was 585 mm in the right eye and 607 mm in the left eye (DGH 500 Pachette, DGH Technology, Inc.) Ultrasound biomicroscopy (UBM) (Figure 2, B) showed a small separation of the ciliary body from the scleral 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.09.044
CASE REPORT: HYPOTONY AFTER PIOL REMOVAL
543
Figure 1. A: Slitlamp examination at the patient’s initial visit showed a deep anterior chamber with very little corneal edema in the left eye and the presence of slight lens sclerosis. B: Corneal edema was more evident at higher magnification.
spur and fluid in the suprachoroidal space. A piece of the haptic was also noted over the iris. Optic nerve examination and retinal examination were unremarkable. The diminished visual acuity in the left eye was ascribed to the presence of corneal edema. The cyclodialysis cleft auto sealed 1 week after our evaluation. This finding was confirmed by UBM.
DISCUSSION A variety of intraoperative and long-term complications have been reported with the implantation of pIOLs in the anterior or posterior chamber. Our patient developed a cyclodialysis cleft and hypotony after removal of an anterior segment pIOL. Whether fixated to the iris or the angle, pIOLs in the anterior chamber increase the risk for endothelial loss and corneal decompensation.4–6 In the longest followup of angle-fixated lenses with progressive endothelial loss, Alio´ et al.3 report that 17% of the corneal endothelial population was lost after 2 years. Although the mechanism responsible for the endothelial loss is thought to be constant or intermittent direct contact between the pIOL and the endothelium during eyelid blinking or rubbing, other mechanisms could be involved, including a noncontact inflammatory mechanism with secondary endothelial damage. Theoretically, a pIOL in the anterior chamber could cause inflammation detrimental to the corneal endothelium. Contact between the haptics and the trabecular meshwork or continuous rubbing of the iris against the pIOL during pupillary hippus and during accommodation can cause intraocular inflammation, trabecular meshwork damage, and increased IOP that will probably affect the endothelium in the long term.1
Figure 2. A: Gonioscopy showed a widely open angle in all quadrants. An area measuring approximately 1 clock hour with a wider ciliary body band was seen between 7 o’clock and 8 o’clock (black arrows). B: Ultrasound biomicroscopy confirmed the presence of the cyclodialysis cleft and demonstrated separation of the ciliary body from the scleral spur (black arrow), suprachoroidal fluid (white arrow), and the presence of a haptic piece (white star) embedded in the iris stroma.
Traumatic removal of the pIOL caused by fibrosis of the haptic to the iris stroma was the most probable cause of the cleft. Ciliary body clefts are generally reported following cataract extraction or trauma; however, other unusual causes are described in the literature. Esquenazi7 recently reported a case of cyclodialysis following the displacement of an anterior chamber IOL that migrated temporally and induced the cleft. Traditionally, clefts are treated medically with atropine sulfate and if no improvement is observed, laser photocoagulation to the cleft can be attempted. In some cases, surgical closure including scleral buckling and cryotherapy is the last option.8–11 The occurrence of a cyclodialysis cleft and the serious consequences of the subsequent hypotony must be considered among the most sight-threatening complications of IOL removal. We believe that gonioscopy
544
CASE REPORT: HYPOTONY AFTER PIOL REMOVAL
before removal of the IOL is essential to assess the degree of fibrosis and the presence of synechia and adhesions between the haptics and the surrounding tissues. To our knowledge, this is the first reported case of a cyclodialysis cleft after removal of an anterior chamber pIOL.
REFERENCES 1. Lovisolo CF, Reinstein DZ. Phakic intraocular lenses. Surv Ophthalmol 2005; 50:549–587 2. Pe´rez-Santonja JJ, Iradier MT, Sanz-Iglesias L, et al. Endothelial changes in phakic eyes with anterior chamber intraocular lenses to correct high myopia. J Cataract Refract Surg 1996; 22: 1017–1022 3. Alio´ JL, de la Hoz F, Pe´rez-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; 106:458–466 4. Pop M, Payette Y. Initial results of endothelial cell counts after Artisan lens for phakic eyes; an evaluation of the United States Food and Drug Administration Ophtec Study. Ophthalmology 2004; 111:309–317 5. Barraquer J. Anterior chamber plastic lenses. Results of and conclusions from five years’ experience. Trans Ophthalmol Soc UK 1959; 79:393–424
6. Frueh BE, Bo¨hnke M. Endothelial changes following refractive surgery. J Cataract Refract Surg 1996; 22:490–496 7. Esquenazi S. Management of a displaced angle-supported anterior chamber intraocular lens. Ophthalmic Surg Lasers Imaging 2006; 37:65–67 8. Maumenee AE, Stark WJ. Management of persistent hypotony after planned or inadvertent cyclodialysis. Am J Ophthalmol 1971; 71:320–327 9. Jewelewicz DA, Liebmann JM, Ritch R. The use of scleral transillumination to localize the extent of a cyclodialysis cleft. Ophthalmic Surg Lasers 1999; 30:571–574 10. Aminlari A, Callahan CE. Medical, laser, and surgical management of inadvertent cyclodialysis cleft with hypotony. Arch Ophthalmol 2004; 122:399–404 11. Mandava N, Kahook MY, Mackenzie DL, Olson JL. Anterior scleral buckling procedure for cyclodialysis cleft with chronic hypotony. Ophthalmic Surg Lasers Imaging 2006; 37:151– 153
First author: Edgar M. Espana, MD