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March Consultation #2
CONSULTATION SECTION
Refractive Surgical Question Edited by Rudy M.M.A. Nuijts, MD, PhD
A 49-year-old man was referred for consultation because of intractable glare in the left eye after refractive surgery comprising phakic intraocular lens (pIOL) implantation. Preoperatively, the refraction was +4.25 1.00 43 in the right eye and +6.50 2.50 171 in the left eye. The preoperative central anterior chamber depth (ACD) (including corneal thickness) was 3.09 mm and 3.13 mm, respectively. In September 2009 and October 2009, Artisan irisfixated pIOLs were implanted. The spherical power was +4.50 D and +6.00 2.50 0 (enclavation angle 171 degrees) in the right eye and left eye, respectively. The surgical course was uneventful. A few hours after pIOL implantation, the intraocular pressure (IOP) increased to 35 mm Hg in the left eye despite the presence of an optically patent iridectomy. Treatment with IOP-reducing medication (eg, acetazolamide tablets, mannitol infusion) was started; however, the day after surgery, the IOP was 45 mm Hg, the anterior chamber was shallow, and a neodymium:YAG iridectomy was not feasible because of corneal edema. An additional surgical iridectomy was performed, after which the IOP remained low. On examination in January 2010, the uncorrected distance visual acuity (UDVA) was 20/20 in both eyes. The IOP was 12 mm Hg in the right eye and 8 mm Hg in the left eye. In the left eye (Figure 1), there was a dilated and atrophic pupil that did not react to light. There were anterior and posterior synechiae; however, the crystalline lens was clear. Slitlamp biomicroscopy of the right eye showed an adequately fixated pIOL, posterior synechiae, and a shallower anterior chamber (Figure 2). The central endothelial cell density (ECD) was 2540 cells/mm2 in the right eye and 1210 cells/mm2 in the left eye. Figure 3 shows anterior segment optical coherence tomography (OCT) of the right eye and left eye. Was this a correct indication for pIOL implantation? What would be your preferred treatment for the left
eye? What measures would you take for the right eye to increase the longevity of the corneal endothelium?
- In this case, hyperopic pIOLs were implanted in eyes with a “legal” ACD of 3.09 mm and 3.13 mm (from epithelium). Some surgeons advocate deeper chambers for pIOLs; however, in the present case the corneal cell loss is probably not attributed to the ACD because the endothelial cell count (ECC) in the right eye remained normal. More logically, the patient had an acute angle-closure event soon after surgery. The peripheral iridectomy was “optically” patent but apparently not functionally patent. Pressure normalized soon after surgical peripheral iridectomy, suggesting that pseudophakic pupillary block was indeed the mechanism. Shallowing of the anterior chamber and direct contact between the pIOL and the cornea resulted in a significant decrease in the ECC. The main question is whether the endothelial cell loss is progressive or a single, acute drop in cell count at the time of anterior chamber shallowing. The photographs of the left eye and the OCT suggest close proximity of the pIOL to the cornea on the nasal side. If cell loss is progressive (last cell count January 2010), the IOL must be removed. If cell density is stable and corrected distance visual acuity (CDVA) is still 20/20, with normal pressure, lens removal might be more traumatic to the eye than leaving the IOL in place. If the pIOL is to be removed, it might be advisable to perform crystalline lens removal and posterior chamber IOL implantation, combined with pupilloplasty if the pupil does not constrict. Otherwise, after pIOL removal alone, the patient will have anisometropia and a fixed dilated pupil. At the age of 49 years, after 2 intraocular operations, acute angle-closure
Figure 1. Slitlamp views of the left eye with marginal fixation of the iris-fixated pIOL (left) and extensive anterior and posterior synechiae formation (right).
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.01.008
475
476
CONSULTATION SECTION
Figure 2. Slitlamp view of the right eye with adequate fixation of the iris-fixated pIOL and posterior synechiae formation.
glaucoma (ACG), and posterior synechiae, the patient may require cataract surgery within a few years. The compromised cornea may not tolerate a third operation. My approach would be to recheck the ECC, CDVA, and IOP. If there were no changes, close follow-up only would be required. If the endothelial cell loss is progressive, I would remove the pIOL, remove the lens (refractive lens exchange [RLE]), implant a posterior chamber IOL, and constrict the pupil. If corneal decompensation occurs, the patient should be treated by Descemet-stripping automated endothelial keratoplasty (DSAEK). The right eye should be closely monitored, but no intervention is indicated at this time. Ehud Assia, MD Kfar-Saba, Israel
- The optical correction of hyperopia using pIOLs is still controversial. Although hyperopic patients may have a great advantage from pIOL implantation, the risk for glaucoma cannot be avoided in all circumstances. In addition, hyperopic eyes frequently present with a shallow anterior chamber and/or narrow chamber angles, which are definite contraindications to pIOL implantation. On the contrary, in this case the central ACD, including corneal thickness, was above 3.0 mm. Even in the absence of further information about the axial length (AL) and about the status of the chamber angle, this distance indicates there is no risk for ACG. Taking into account the lens transparency and the probable unwillingness of the patient to have RLE, we can conclude that the indication for pIOL implantation was correct. It is less clear what happened at surgery that was uneventful in 1 eye but that was followed by high IOP elevation in the other eye. Based on a patent
Figure 3. Anterior segment OCT of the right eye (top) and the left eye (bottom) showing a crowded anterior chamber with increased lens rise.
iridectomy, the most probable cause of the IOP elevation is that some ophthalmic viscosurgical device remained behind the iris and occluded the iridectomy, causing an iridectomy block with the lens optic concurrently causing pupillary block. Although a second iridectomy solved the problem on the following day, corneal endothelium damage and iris damage with Urrets-Zavalia syndrome developed. Despite this time course and the unsatisfying anatomic outcome, the eye has good UDVA and glare is the only remaining problem from the patient's viewpoint. The low endothelial cell count is an additional problem from the surgeon's viewpoint. The glare could be reduced with tinted spectacles or contact lenses, although the patient had had surgery to remove optical correction and might refuse them. Should this be the case, we should resist the idea of trying some surgical reduction in pupil diameter. It never worked in my hands. I believe the only option here would be RLE and IOL implantation. I would also implant an artificial iris ring. I would choose a black ring to avoid 3 colors behind the cornea and implant 2 rings adequately shifted to avoid slits. After surgery, the glare will probably disappear; however, the endothelial problem will remain, an additional factor favoring prompt pIOL removal. In the long-term, the endothelium in the left eye will require replacement and that of the right eye
J CATARACT REFRACT SURG - VOL 39, MARCH 2013
Refractive Surgical Question Edited by Rudy M.M.A. Nuijts, MD, PhD
A 49-year-old man was referred for consultation because of intractable glare in the left eye after refractive surgery comprising phakic intraocular lens (pIOL) implantation. Preoperatively, the refraction was +4.25 1.00 43 in the right eye and +6.50 2.50 171 in the left eye. The preoperative central anterior chamber depth (ACD) (including corneal thickness) was 3.09 mm and 3.13 mm, respectively. In September 2009 and October 2009, Artisan irisfixated pIOLs were implanted. The spherical power was +4.50 D and +6.00 2.50 0 (enclavation angle 171 degrees) in the right eye and left eye, respectively. The surgical course was uneventful. A few hours after pIOL implantation, the intraocular pressure (IOP) increased to 35 mm Hg in the left eye despite the presence of an optically patent iridectomy. Treatment with IOP-reducing medication (eg, acetazolamide tablets, mannitol infusion) was started; however, the day after surgery, the IOP was 45 mm Hg, the anterior chamber was shallow, and a neodymium:YAG iridectomy was not feasible because of corneal edema. An additional surgical iridectomy was performed, after which the IOP remained low. On examination in January 2010, the uncorrected distance visual acuity (UDVA) was 20/20 in both eyes. The IOP was 12 mm Hg in the right eye and 8 mm Hg in the left eye. In the left eye (Figure 1), there was a dilated and atrophic pupil that did not react to light. There were anterior and posterior synechiae; however, the crystalline lens was clear. Slitlamp biomicroscopy of the right eye showed an adequately fixated pIOL, posterior synechiae, and a shallower anterior chamber (Figure 2). The central endothelial cell density (ECD) was 2540 cells/mm2 in the right eye and 1210 cells/mm2 in the left eye. Figure 3 shows anterior segment optical coherence tomography (OCT) of the right eye and left eye. Was this a correct indication for pIOL implantation? What would be your preferred treatment for the left
eye? What measures would you take for the right eye to increase the longevity of the corneal endothelium?
- In this case, hyperopic pIOLs were implanted in eyes with a “legal” ACD of 3.09 mm and 3.13 mm (from epithelium). Some surgeons advocate deeper chambers for pIOLs; however, in the present case the corneal cell loss is probably not attributed to the ACD because the endothelial cell count (ECC) in the right eye remained normal. More logically, the patient had an acute angle-closure event soon after surgery. The peripheral iridectomy was “optically” patent but apparently not functionally patent. Pressure normalized soon after surgical peripheral iridectomy, suggesting that pseudophakic pupillary block was indeed the mechanism. Shallowing of the anterior chamber and direct contact between the pIOL and the cornea resulted in a significant decrease in the ECC. The main question is whether the endothelial cell loss is progressive or a single, acute drop in cell count at the time of anterior chamber shallowing. The photographs of the left eye and the OCT suggest close proximity of the pIOL to the cornea on the nasal side. If cell loss is progressive (last cell count January 2010), the IOL must be removed. If cell density is stable and corrected distance visual acuity (CDVA) is still 20/20, with normal pressure, lens removal might be more traumatic to the eye than leaving the IOL in place. If the pIOL is to be removed, it might be advisable to perform crystalline lens removal and posterior chamber IOL implantation, combined with pupilloplasty if the pupil does not constrict. Otherwise, after pIOL removal alone, the patient will have anisometropia and a fixed dilated pupil. At the age of 49 years, after 2 intraocular operations, acute angle-closure
Figure 1. Slitlamp views of the left eye with marginal fixation of the iris-fixated pIOL (left) and extensive anterior and posterior synechiae formation (right).
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.01.008
475
476
CONSULTATION SECTION
Figure 2. Slitlamp view of the right eye with adequate fixation of the iris-fixated pIOL and posterior synechiae formation.
glaucoma (ACG), and posterior synechiae, the patient may require cataract surgery within a few years. The compromised cornea may not tolerate a third operation. My approach would be to recheck the ECC, CDVA, and IOP. If there were no changes, close follow-up only would be required. If the endothelial cell loss is progressive, I would remove the pIOL, remove the lens (refractive lens exchange [RLE]), implant a posterior chamber IOL, and constrict the pupil. If corneal decompensation occurs, the patient should be treated by Descemet-stripping automated endothelial keratoplasty (DSAEK). The right eye should be closely monitored, but no intervention is indicated at this time. Ehud Assia, MD Kfar-Saba, Israel
- The optical correction of hyperopia using pIOLs is still controversial. Although hyperopic patients may have a great advantage from pIOL implantation, the risk for glaucoma cannot be avoided in all circumstances. In addition, hyperopic eyes frequently present with a shallow anterior chamber and/or narrow chamber angles, which are definite contraindications to pIOL implantation. On the contrary, in this case the central ACD, including corneal thickness, was above 3.0 mm. Even in the absence of further information about the axial length (AL) and about the status of the chamber angle, this distance indicates there is no risk for ACG. Taking into account the lens transparency and the probable unwillingness of the patient to have RLE, we can conclude that the indication for pIOL implantation was correct. It is less clear what happened at surgery that was uneventful in 1 eye but that was followed by high IOP elevation in the other eye. Based on a patent
Figure 3. Anterior segment OCT of the right eye (top) and the left eye (bottom) showing a crowded anterior chamber with increased lens rise.
iridectomy, the most probable cause of the IOP elevation is that some ophthalmic viscosurgical device remained behind the iris and occluded the iridectomy, causing an iridectomy block with the lens optic concurrently causing pupillary block. Although a second iridectomy solved the problem on the following day, corneal endothelium damage and iris damage with Urrets-Zavalia syndrome developed. Despite this time course and the unsatisfying anatomic outcome, the eye has good UDVA and glare is the only remaining problem from the patient's viewpoint. The low endothelial cell count is an additional problem from the surgeon's viewpoint. The glare could be reduced with tinted spectacles or contact lenses, although the patient had had surgery to remove optical correction and might refuse them. Should this be the case, we should resist the idea of trying some surgical reduction in pupil diameter. It never worked in my hands. I believe the only option here would be RLE and IOL implantation. I would also implant an artificial iris ring. I would choose a black ring to avoid 3 colors behind the cornea and implant 2 rings adequately shifted to avoid slits. After surgery, the glare will probably disappear; however, the endothelial problem will remain, an additional factor favoring prompt pIOL removal. In the long-term, the endothelium in the left eye will require replacement and that of the right eye
J CATARACT REFRACT SURG - VOL 39, MARCH 2013