- Email: [email protected]
March consultation #9
692
CONSULTATION SECTION
- There are 2 considerations; that is, what to do now and what not to have done then. This is a case of blurred vision after 3 major procedures, with a stormy postoperative course after the supplemental IOL surgery. Current symptoms of blurred vision might represent an uncorrected refractive error or could be caused by persistent inflammation, manifested as pigment deposition and membrane formation. The patient now reports blurry vision; however, the CDVA was 20/25 with +1.75 1.50 95. Assuming this spectacle-plane refraction was still suboptimum, the blurry vision is probably due to surface issues or pupillary membrane and deposits. A rigid gas-permeable contact lens overrefraction will help determine the surface contribution. The membranes and pigmentation represent late inflammation, which has a long differential, including ocular lymphoma, systemic autoimmune disease, and low-grade infectious endophthalmitis. The timing of the inflammation immediately after implantation of the piggyback IOL suggests a toxic reaction to proteins or bacteria introduced at that time. One course of action would be to remove the original and piggyback IOLs. A core vitrectomy and removal of the membranes should also be done and the recovered material cultured and spun for cytology. A new 3-piece IOL could then be inserted and a variety of techniques used to stabilize it in the sulcus. The larger question is to understand the surgeon's and/or patient's goal in performing the supplemental IOL surgery. Voltaire (1694–1778) wrote, “Dans ses ecrits, un sage Italien Dit que le mieux est l'ennemi du bien.” (“In his writings, a wise Italian says that the best is the enemy of the good.”) Although it is difficult to criticize another surgeon's decisions because the information is incomplete and the patient's desires are not known, this case serves as a good teaching example. This 72-year-old man had PRK performed in the late 1980s. That was very early in the practice of excimer laser refractive surgery, and so it is possible that the ablation profile was somewhat crude with a small optical zone. The result after the initial cataract surgery was a CDVA of 20/30 with +3.00 1.25 64. Although we do not know the precataract CDVA, an outcome of 20/30 after an early-era high-correction PRK would be considered a good result. However, the residual hyperopic correction (SE +2.37 D) was viewed as suboptimum and the surgeon opted to reduce the refractive error, aiming for plano if not minimally myopic, using a +3.00 D
supplementary IOL. The problem is that the fellow eye had a CDVA of 20/20 with +2.75 1.50 90 (SE +2.00 D) (although the surgical history of the left eye is unknown). The patient's binocular result after the original cataract surgery was nearly symmetric hyperopia, almost no vertical induced anisophoria, and excellent spectacle-corrected vision. Even if the supplemental IOL surgery had been without complications, it likely would have left the eye with unacceptable aniseikonia and bifocal intolerance secondary to the vertical anisophoria. In this case it probably would have been better to heed Voltaire's warning. Michael W. Belin, MD Tucson, Arizona, USA Peter Zloty, MD Mobile, Alabama, USA
- This patient has several problems. First, a refractive surprise occurred after cataract surgery in an eye in which a previous corneal laser procedure had been performed to treat high myopia. Second, a sulcus add-on IOL that was implanted upsidedown is causing residual refraction that stems from the abnormal position of the add-on IOL (more posterior than planned) and glaucoma and, because of the proximity of both optics, has induced formation of an interlenticular membrane.1 Third, the visual quality in the eye in which cataract surgery was performed has deteriorated, probably secondary to a small, possibly eccentric, ablation of the high myopia and excessive flattening of the cornea after cornea laser surgery, explaining why with maximum refraction the CDVA does not correct to better than 20/30.2 Because the add-on IOL is the prime culprit in the current problems and does not alleviate the problems created by excessive oblateness of the cornea, I would recommend explanting the add-on IOL. This would also resolve the glaucoma caused by the add-on IOL haptic position and would allow resectioning of the interlenticular membrane. Assuming this to be a hydrophilic type of add-on IOL, even though it cannot be visualized with certainty from the photograph or on AS-OCT, explantation should be straightforward as follows: Explant the IOL through a 3.0 mm near clear incision, use an OVD to protect the anterior chamber, and mobilize the add-on IOL from its place (which should not be difficult because the edge of the optic is anterior-facing, which leaves room to enter
J CATARACT REFRACT SURG - VOL 41, MARCH 2015
CONSULTATION SECTION
using an OVD cannula). I do not usually cut these IOLs because they are very flexible. A good grasp with a forceps on the “shoulder” of the lens, where the haptic attaches to the optic, will allow smooth explantation; the IOL will fold up on itself in the incision. However, care must be taken to ensure the haptics are free to move to avoid disturbing the iris or the zonular apparatus. Then, the interlenticular membrane can be resected. After 6 weeks (after stabilization of refraction), I would correct the hyperopia by performing a laser-assisted subepithelial keratectomy procedure, including application of mitomycin-C (MMC) 0.02% for 12 seconds. This will fully correct the refractive error and will decrease the oblateness of the cornea, which now shows areas of excessive flattening (keratometry 33.0 D). The use of MMC will reduce haze formation and improve predictability and efficacy.3 Because of the patient's age, I would opt for an undercorrection of approximately 10% of the refraction to be ablated; however, this would be at the discretion of the surgeon and according to one's own nomograms. Ruth Lapid-Gortzak, MD, PhD Amsterdam, the Netherlands
REFERENCES 1. Werner L, Apple DJ, Pandey SK, Solomon KD, Snyder ME, Brint SF, Gayton JL, Shugar JK, Trivedi RH, Izak AM. Analysis of elements of interlenticular opacification. Am J Ophthalmol 2002; 133:320–326 2. Holladay JT, Dudeja DR, Chang J. Functional vision and corneal changes after laser in situ keratomileusis determined by contrast sensitivity, glare testing, and corneal topography. J Cataract Refract Surg 1999; 25:663–669 3. Leccisotti A. Mitomycin-C in hyperopic photorefractive keratectomy. J Cataract Refract Surg 2009; 35:682–687
- The problems in the right eye are the raised IOP and a residual postoperative refractive error after PRK, cataract removal, and posterior chamber IOL implantation followed by a supplementary IOL implantation. In retrospect, the cataract surgeon has most likely ignored that the patient had previous PRK to correct myopia of 7.5 D. Therefore, the eye was undercorrected after IOL implantation, a situation that would have been avoided had an appropriate IOL calculation formula for
693
post–excimer laser surgery corneas been used. A supplementary IOL is 1 option for correcting for refractive miscalculations after excimer laser surgery IOL implantation. This was the procedure of choice in this case. In my experience, supplementary IOL implantation can be very successful if performed correctly. One year after implantation of the supplementary IOL, this eye has a hyperopic refractive error, an increased IOP (lowered by the patient taking a synthetic analogue of prostaglandin F), a mild prepupillary membrane (Figure 2), and blurred vision. The AS-OCT image shows that the supplementary IOL was implanted upside-down, which could explain the outcome in this case. The peripheral part of the optic is pushing against the iris, which is inducing the pigment dispersion, which could also be the cause of the blurred vision. The Scheimpflug image of the right eye shows astigmatism of 1.2 D on the front corneal surface and of 0.2 D on the back corneal surface and a small, decentered optical zone in the eye with previous PRK. For treatment, I would suggest removing the supplementary IOL under OVD. The first option would be turning it around in the eye if enough space is detected intraoperatively. The second option would be a reimplantation after explantation of the IOL, which even can be done with the suggested injector for the Sulcoflex IOL. In both instances, the haptic should point clockwise. If this hydrophilic acrylic IOL (6.5 mm optic diameter and 14.0 mm overall diameter) has to be removed, the maneuver is usually very easy and can be performed uneventfully through the original wound. Correcting the orientation of the IOL could resolve the residual refraction error and the IOP problem. Astigmatism management also could be performed at the time of surgery, but I would wait to make this decision until the repositioning/reimplantation outcome and the patient's satisfaction with it are known. Because the Sulcoflex IOL presses against the posterior iris, the astigmatic situation can change after this intervention. If astigmatic management in the case is then required, incisional surgery, topography-guided excimer laser zone enlargement, and even a toric supplementary IOL as an exchange are options.
J CATARACT REFRACT SURG - VOL 41, MARCH 2015
Thomas Kohnen, MD, PhD, FEBO Frankfurt, Germany
CONSULTATION SECTION
- There are 2 considerations; that is, what to do now and what not to have done then. This is a case of blurred vision after 3 major procedures, with a stormy postoperative course after the supplemental IOL surgery. Current symptoms of blurred vision might represent an uncorrected refractive error or could be caused by persistent inflammation, manifested as pigment deposition and membrane formation. The patient now reports blurry vision; however, the CDVA was 20/25 with +1.75 1.50 95. Assuming this spectacle-plane refraction was still suboptimum, the blurry vision is probably due to surface issues or pupillary membrane and deposits. A rigid gas-permeable contact lens overrefraction will help determine the surface contribution. The membranes and pigmentation represent late inflammation, which has a long differential, including ocular lymphoma, systemic autoimmune disease, and low-grade infectious endophthalmitis. The timing of the inflammation immediately after implantation of the piggyback IOL suggests a toxic reaction to proteins or bacteria introduced at that time. One course of action would be to remove the original and piggyback IOLs. A core vitrectomy and removal of the membranes should also be done and the recovered material cultured and spun for cytology. A new 3-piece IOL could then be inserted and a variety of techniques used to stabilize it in the sulcus. The larger question is to understand the surgeon's and/or patient's goal in performing the supplemental IOL surgery. Voltaire (1694–1778) wrote, “Dans ses ecrits, un sage Italien Dit que le mieux est l'ennemi du bien.” (“In his writings, a wise Italian says that the best is the enemy of the good.”) Although it is difficult to criticize another surgeon's decisions because the information is incomplete and the patient's desires are not known, this case serves as a good teaching example. This 72-year-old man had PRK performed in the late 1980s. That was very early in the practice of excimer laser refractive surgery, and so it is possible that the ablation profile was somewhat crude with a small optical zone. The result after the initial cataract surgery was a CDVA of 20/30 with +3.00 1.25 64. Although we do not know the precataract CDVA, an outcome of 20/30 after an early-era high-correction PRK would be considered a good result. However, the residual hyperopic correction (SE +2.37 D) was viewed as suboptimum and the surgeon opted to reduce the refractive error, aiming for plano if not minimally myopic, using a +3.00 D
supplementary IOL. The problem is that the fellow eye had a CDVA of 20/20 with +2.75 1.50 90 (SE +2.00 D) (although the surgical history of the left eye is unknown). The patient's binocular result after the original cataract surgery was nearly symmetric hyperopia, almost no vertical induced anisophoria, and excellent spectacle-corrected vision. Even if the supplemental IOL surgery had been without complications, it likely would have left the eye with unacceptable aniseikonia and bifocal intolerance secondary to the vertical anisophoria. In this case it probably would have been better to heed Voltaire's warning. Michael W. Belin, MD Tucson, Arizona, USA Peter Zloty, MD Mobile, Alabama, USA
- This patient has several problems. First, a refractive surprise occurred after cataract surgery in an eye in which a previous corneal laser procedure had been performed to treat high myopia. Second, a sulcus add-on IOL that was implanted upsidedown is causing residual refraction that stems from the abnormal position of the add-on IOL (more posterior than planned) and glaucoma and, because of the proximity of both optics, has induced formation of an interlenticular membrane.1 Third, the visual quality in the eye in which cataract surgery was performed has deteriorated, probably secondary to a small, possibly eccentric, ablation of the high myopia and excessive flattening of the cornea after cornea laser surgery, explaining why with maximum refraction the CDVA does not correct to better than 20/30.2 Because the add-on IOL is the prime culprit in the current problems and does not alleviate the problems created by excessive oblateness of the cornea, I would recommend explanting the add-on IOL. This would also resolve the glaucoma caused by the add-on IOL haptic position and would allow resectioning of the interlenticular membrane. Assuming this to be a hydrophilic type of add-on IOL, even though it cannot be visualized with certainty from the photograph or on AS-OCT, explantation should be straightforward as follows: Explant the IOL through a 3.0 mm near clear incision, use an OVD to protect the anterior chamber, and mobilize the add-on IOL from its place (which should not be difficult because the edge of the optic is anterior-facing, which leaves room to enter
J CATARACT REFRACT SURG - VOL 41, MARCH 2015
CONSULTATION SECTION
using an OVD cannula). I do not usually cut these IOLs because they are very flexible. A good grasp with a forceps on the “shoulder” of the lens, where the haptic attaches to the optic, will allow smooth explantation; the IOL will fold up on itself in the incision. However, care must be taken to ensure the haptics are free to move to avoid disturbing the iris or the zonular apparatus. Then, the interlenticular membrane can be resected. After 6 weeks (after stabilization of refraction), I would correct the hyperopia by performing a laser-assisted subepithelial keratectomy procedure, including application of mitomycin-C (MMC) 0.02% for 12 seconds. This will fully correct the refractive error and will decrease the oblateness of the cornea, which now shows areas of excessive flattening (keratometry 33.0 D). The use of MMC will reduce haze formation and improve predictability and efficacy.3 Because of the patient's age, I would opt for an undercorrection of approximately 10% of the refraction to be ablated; however, this would be at the discretion of the surgeon and according to one's own nomograms. Ruth Lapid-Gortzak, MD, PhD Amsterdam, the Netherlands
REFERENCES 1. Werner L, Apple DJ, Pandey SK, Solomon KD, Snyder ME, Brint SF, Gayton JL, Shugar JK, Trivedi RH, Izak AM. Analysis of elements of interlenticular opacification. Am J Ophthalmol 2002; 133:320–326 2. Holladay JT, Dudeja DR, Chang J. Functional vision and corneal changes after laser in situ keratomileusis determined by contrast sensitivity, glare testing, and corneal topography. J Cataract Refract Surg 1999; 25:663–669 3. Leccisotti A. Mitomycin-C in hyperopic photorefractive keratectomy. J Cataract Refract Surg 2009; 35:682–687
- The problems in the right eye are the raised IOP and a residual postoperative refractive error after PRK, cataract removal, and posterior chamber IOL implantation followed by a supplementary IOL implantation. In retrospect, the cataract surgeon has most likely ignored that the patient had previous PRK to correct myopia of 7.5 D. Therefore, the eye was undercorrected after IOL implantation, a situation that would have been avoided had an appropriate IOL calculation formula for
693
post–excimer laser surgery corneas been used. A supplementary IOL is 1 option for correcting for refractive miscalculations after excimer laser surgery IOL implantation. This was the procedure of choice in this case. In my experience, supplementary IOL implantation can be very successful if performed correctly. One year after implantation of the supplementary IOL, this eye has a hyperopic refractive error, an increased IOP (lowered by the patient taking a synthetic analogue of prostaglandin F), a mild prepupillary membrane (Figure 2), and blurred vision. The AS-OCT image shows that the supplementary IOL was implanted upside-down, which could explain the outcome in this case. The peripheral part of the optic is pushing against the iris, which is inducing the pigment dispersion, which could also be the cause of the blurred vision. The Scheimpflug image of the right eye shows astigmatism of 1.2 D on the front corneal surface and of 0.2 D on the back corneal surface and a small, decentered optical zone in the eye with previous PRK. For treatment, I would suggest removing the supplementary IOL under OVD. The first option would be turning it around in the eye if enough space is detected intraoperatively. The second option would be a reimplantation after explantation of the IOL, which even can be done with the suggested injector for the Sulcoflex IOL. In both instances, the haptic should point clockwise. If this hydrophilic acrylic IOL (6.5 mm optic diameter and 14.0 mm overall diameter) has to be removed, the maneuver is usually very easy and can be performed uneventfully through the original wound. Correcting the orientation of the IOL could resolve the residual refraction error and the IOP problem. Astigmatism management also could be performed at the time of surgery, but I would wait to make this decision until the repositioning/reimplantation outcome and the patient's satisfaction with it are known. Because the Sulcoflex IOL presses against the posterior iris, the astigmatic situation can change after this intervention. If astigmatic management in the case is then required, incisional surgery, topography-guided excimer laser zone enlargement, and even a toric supplementary IOL as an exchange are options.
J CATARACT REFRACT SURG - VOL 41, MARCH 2015
Thomas Kohnen, MD, PhD, FEBO Frankfurt, Germany