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Protrusion of a posterior chamber lens haptic into the anterior chamber through iris erosion
measuring ocular length, because of the difficulty of placing the scan plane through the fovea. Nevertheless, if the B-scan goes through the optic nerve head, which can readily be seen, the scan plane can not be very far from the fovea and an error of 3 mm is quite unlikely to occur. For several years, we have performed a B-scan on cases in which the cataract is sufficiently dense to prevent visualization of the posterior segment. Some people advocate performing a B-scan on every case before cataract surgery. We consider it wasteful of effort and expense to perform a B-scan on preoperative cataract cases in which the ophthalmologist can obtain a reasonable view of the fundus. Subsequent to these cases, we acquired a more advanced ultrasonic instrument (Sonometrics DBR 400 TM) that allows the operator to capture a tracing on the screen by pressing a foot switch. Once the tracing is thus "frozen," the gates can be manipulated at leisure. Judgments of these crucial settings need not be made under real-time pressure. As a result of the cases reported, we have altered our protocol. Technicians are now instructed to perform a B-scan ultrasonogram on any case in which the ophthalmologist has noted unusual vitreous opacities or in which there are more than trivial extraneous echoes within the vitreous, as seen on the A-scan. In the conduct of a busy practice, many datagathering tasks are delegated to technical assistants whose knowledge of normal and pathological physiology is not equal to that of the experienced ophthalmologist. It is essential, in these circumstances, to set up protocols that will preclude errors that might adversely affect patient care. Threshold conditions should be identified so assistants will know when to do supplementary tests and when to consult the ophthalmologist. REFERENCES 1. Sham mas HJ: Atlas of Ophthalmic Ultrasonography. St Louis, CV Mosby Co, 1983, pp 122-123 2. Ossoinig KC: Standardized echography: Basic principles, clinical applications, and results. Int Ophthalmol Clin 19(4):136-137, 1979
Protrusion of a posterior chamber lens haptic into the anterior chamber through iris erosion Varda Chen, M.D. Mordechai Rosner, M.D. Michael Blumenthal, M.D. Tel Hashomer, Israel
B TR T nt a ca ,ith protru ion of a ubluxat d p trior chamb r len haptic into til ant ri '" chamb r. \\01 pr
K
\
rd
iris roiol1, malposition d lo op, post ,rior 'hamh r illtrao 'u lar I ns. I rotrusion. Sli blt...,atiOl
Insult to the iris and angle structures are known complications of intraocular lens (IOL) implantation, especially iris-supported and anterior chamber IOLs and, rarely, posterior chamber lenses. 1 - 4 Contact between the posterior chamber IOL haptic and the posterior surface of the iris may cause forward displacement of the iris, 5 pigment dispersion with pigment epithelial defects and pigmentary glaucoma,3,6 or transient microhyphemas with visual obscurations. 7 Erosion of posterior chamber IOL polypropylene loops into the ciliary sulcus 5 and entrapment of a posterior chamber IOL haptic in an iridectomy site3,8 have been reported. This report describes a case in which a subluxated posterior chamber IOL haptic protruded through a full thickness iris erosion into the anterior chamber. CASE REPORT A 77-year-old male had an extracapsular cataract extraction in his left eye in June 1984. During cortical aspiration, a small radial tear was seen in the posterior capsule at 11 o'clock with a small amount of vitreous in the anterior chamber. A limited anterior vitrectomy was performed and a posterior chamber IOL (Intermedics, J-Ioop, 0 degrees, 13.5 mm) was inserted in the From the Maurice and Gabriela Goldschleger Eye Institute, TelAviv University Sackler Faculty of Medicine, Chaim Sheba Medical Center, Tel Hashomer, Israel. Reprint requests to Professor Michael Blumenthal, Maurice and Gabriela Goldschleger Eye Institute, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
J CATARACT REFRACT SURG-VOL 13, JANUARY 1987
65
ciliary sulcus with a 12-0'clock and 6-0'clock orientation (since no zonular tear was suspected). The IOL was not inserted in the capsular bag to avoid enlarging the tear in the posterior capsule. An iridectomy was not performed. At the end of the procedure and for the next three postoperative months, the IOL was centrally located and the visual acuity was 20/30. One year after the operation, during a routine examination, the IOL was found to be subluxated inferiorly. The superior border of the optic was just above the visual axis. One third of the superior loop was lying on the anterior surface of the peripheral iris at 9:30 to 10 o'clock. There was localized transillumination of the iris in this area. Gonioscopy disclosed an open angle heavily pigmented inferiorly and the site of the iris erosion by the superior haptic at 10 o'clock (Figure 1).
and are caused by poor visualization of the loop during insertion or late rotation or migration of the IOL. 3,8 We present a case in which a posterior chamber lens haptic protruded into the anterior chamber through iris erosion. For a lens to shift, rotate, and erode through uveal tissue there must be an alteration in the IOL's tip-to-tip diameter, as by loop compression, or an alteration in the tissue supports, i.e., the zonules or capsule. In this case, we assume there was an intraoperative tear of the inferior zonules. This permitted inferior subluxation of the lens. The subluxated lens rotated counterclockwise while the superior haptic eroded through the iris into the anterior chamber. We believe that the anterior dislocation of a portion of the superior haptic through the iris prevented further subluxation. The management of loop malposition in this situation is similar to that of loop dislocation through an iridectomy and consisted of observation. Gonioscopy should be done to determine the exact position of the loop. Fibrosis may be associated with J-Iooped or C-Iooped haptics present in the anterior chamber angle. If there is evidence ofhyphema, iris angiography should be done to search for the source of the problem and to delineate the role of the malpositioned 100p. 8 In-the-bag fixation of posterior chamber IOLs is preferable when the capsular bag is intact because it protects the ciliary body and the iris from the haptics and prevents subluxation provided the zonules are not disrupted. 3,4 When the IOL is fixated in the ciliary sulcus, we recommend horizontal placement because it may limit inferior subluxation. REFERENCES
Fig. 1.
(Chen) Protrusion of a posterior chamber lens haptic into the anterior chamber as seen through a Goldmann gonioscopic lens.
The visual acuity was still 20/30; the intraocular pressure and endothelial cell count were normal. The patient was asymptomatic and denied any 'ocular trauma or ocular examination using a three-mirror lens since the cataract surgery.
DISCUSSION A malpositioned posterior chamber IOL loop is defined as one that is not located in the desired position whether it be in the ciliary sulcus or the capsular bag. This includes loops that have dislocated through an iridectomy or into the anterior chamber.3,8 There are reports of posterior chamber IOL loops causing deep erosion in the ciliary sulcus, 5 forward displacement of the iris, 5 and pigment epithelial defects. 3-6 Loops entrapped in an iridectomy site are a known problem 66
1. Keates RH, Ehrlich DR: "Lenses of chance": Complications of anterior chamber implants. Ophthalmology 85:408-414, 1978 2. Percival SPB, Das SK: UGH syndrome after posterior chamber lens implantation. Am Intra-Ocular Implant Soc J 9:200-201, 1983 3. Apple DJ, Mamalis N, Loftfield K, Googe JM, et al: Complications of intraocular lenses. A historical and histopathological review. Surv Ophthalmol 29:1-54, 1984 4. Apple DJ, Reidy JJ, Googe JM, Mamalis N, et al: A comparison of ciliary sulcus and capsular bag fixation of posterior chamber intraocular lenses. Am Intra-Ocular Implant Soc J 11:44-63, 1985 5. Apple DJ, Craythorn JM, Olson RJ, Little LE, et al: Anterior segment complications and neovascular glaucoma following implantation of a posterior chamber intraocular lens. Ophthalmology 91:403-419, 1984 6. Smith JP: Pigmentary open-angle glaucoma secondary to posterior chamber intraocular lens implantation and erosion of the iris pigment epithelium. Am Intra-Ocular Implant Soc J 11:174-176, 1985 7. Johnson SH, Kratz RP, Olson PF: Iris transillumination defect and microhyphema syndrome. Am Intra-Ocular Implant Soc J 10:425-428, 1984 8. Smith SG, Lindstrom RL: Malpositioned posterior chamber lenses: Etiology, prevention, and management. Am Intraocular Implant Soc J 11:584-591, 1985
J CATARACT REFRACT SURG-VOL 13, JANUARY 1987
Protrusion of a posterior chamber lens haptic into the anterior chamber through iris erosion Varda Chen, M.D. Mordechai Rosner, M.D. Michael Blumenthal, M.D. Tel Hashomer, Israel
B TR T nt a ca ,ith protru ion of a ubluxat d p trior chamb r len haptic into til ant ri '" chamb r. \\01 pr
K
\
rd
iris roiol1, malposition d lo op, post ,rior 'hamh r illtrao 'u lar I ns. I rotrusion. Sli blt...,atiOl
Insult to the iris and angle structures are known complications of intraocular lens (IOL) implantation, especially iris-supported and anterior chamber IOLs and, rarely, posterior chamber lenses. 1 - 4 Contact between the posterior chamber IOL haptic and the posterior surface of the iris may cause forward displacement of the iris, 5 pigment dispersion with pigment epithelial defects and pigmentary glaucoma,3,6 or transient microhyphemas with visual obscurations. 7 Erosion of posterior chamber IOL polypropylene loops into the ciliary sulcus 5 and entrapment of a posterior chamber IOL haptic in an iridectomy site3,8 have been reported. This report describes a case in which a subluxated posterior chamber IOL haptic protruded through a full thickness iris erosion into the anterior chamber. CASE REPORT A 77-year-old male had an extracapsular cataract extraction in his left eye in June 1984. During cortical aspiration, a small radial tear was seen in the posterior capsule at 11 o'clock with a small amount of vitreous in the anterior chamber. A limited anterior vitrectomy was performed and a posterior chamber IOL (Intermedics, J-Ioop, 0 degrees, 13.5 mm) was inserted in the From the Maurice and Gabriela Goldschleger Eye Institute, TelAviv University Sackler Faculty of Medicine, Chaim Sheba Medical Center, Tel Hashomer, Israel. Reprint requests to Professor Michael Blumenthal, Maurice and Gabriela Goldschleger Eye Institute, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
J CATARACT REFRACT SURG-VOL 13, JANUARY 1987
65
ciliary sulcus with a 12-0'clock and 6-0'clock orientation (since no zonular tear was suspected). The IOL was not inserted in the capsular bag to avoid enlarging the tear in the posterior capsule. An iridectomy was not performed. At the end of the procedure and for the next three postoperative months, the IOL was centrally located and the visual acuity was 20/30. One year after the operation, during a routine examination, the IOL was found to be subluxated inferiorly. The superior border of the optic was just above the visual axis. One third of the superior loop was lying on the anterior surface of the peripheral iris at 9:30 to 10 o'clock. There was localized transillumination of the iris in this area. Gonioscopy disclosed an open angle heavily pigmented inferiorly and the site of the iris erosion by the superior haptic at 10 o'clock (Figure 1).
and are caused by poor visualization of the loop during insertion or late rotation or migration of the IOL. 3,8 We present a case in which a posterior chamber lens haptic protruded into the anterior chamber through iris erosion. For a lens to shift, rotate, and erode through uveal tissue there must be an alteration in the IOL's tip-to-tip diameter, as by loop compression, or an alteration in the tissue supports, i.e., the zonules or capsule. In this case, we assume there was an intraoperative tear of the inferior zonules. This permitted inferior subluxation of the lens. The subluxated lens rotated counterclockwise while the superior haptic eroded through the iris into the anterior chamber. We believe that the anterior dislocation of a portion of the superior haptic through the iris prevented further subluxation. The management of loop malposition in this situation is similar to that of loop dislocation through an iridectomy and consisted of observation. Gonioscopy should be done to determine the exact position of the loop. Fibrosis may be associated with J-Iooped or C-Iooped haptics present in the anterior chamber angle. If there is evidence ofhyphema, iris angiography should be done to search for the source of the problem and to delineate the role of the malpositioned 100p. 8 In-the-bag fixation of posterior chamber IOLs is preferable when the capsular bag is intact because it protects the ciliary body and the iris from the haptics and prevents subluxation provided the zonules are not disrupted. 3,4 When the IOL is fixated in the ciliary sulcus, we recommend horizontal placement because it may limit inferior subluxation. REFERENCES
Fig. 1.
(Chen) Protrusion of a posterior chamber lens haptic into the anterior chamber as seen through a Goldmann gonioscopic lens.
The visual acuity was still 20/30; the intraocular pressure and endothelial cell count were normal. The patient was asymptomatic and denied any 'ocular trauma or ocular examination using a three-mirror lens since the cataract surgery.
DISCUSSION A malpositioned posterior chamber IOL loop is defined as one that is not located in the desired position whether it be in the ciliary sulcus or the capsular bag. This includes loops that have dislocated through an iridectomy or into the anterior chamber.3,8 There are reports of posterior chamber IOL loops causing deep erosion in the ciliary sulcus, 5 forward displacement of the iris, 5 and pigment epithelial defects. 3-6 Loops entrapped in an iridectomy site are a known problem 66
1. Keates RH, Ehrlich DR: "Lenses of chance": Complications of anterior chamber implants. Ophthalmology 85:408-414, 1978 2. Percival SPB, Das SK: UGH syndrome after posterior chamber lens implantation. Am Intra-Ocular Implant Soc J 9:200-201, 1983 3. Apple DJ, Mamalis N, Loftfield K, Googe JM, et al: Complications of intraocular lenses. A historical and histopathological review. Surv Ophthalmol 29:1-54, 1984 4. Apple DJ, Reidy JJ, Googe JM, Mamalis N, et al: A comparison of ciliary sulcus and capsular bag fixation of posterior chamber intraocular lenses. Am Intra-Ocular Implant Soc J 11:44-63, 1985 5. Apple DJ, Craythorn JM, Olson RJ, Little LE, et al: Anterior segment complications and neovascular glaucoma following implantation of a posterior chamber intraocular lens. Ophthalmology 91:403-419, 1984 6. Smith JP: Pigmentary open-angle glaucoma secondary to posterior chamber intraocular lens implantation and erosion of the iris pigment epithelium. Am Intra-Ocular Implant Soc J 11:174-176, 1985 7. Johnson SH, Kratz RP, Olson PF: Iris transillumination defect and microhyphema syndrome. Am Intra-Ocular Implant Soc J 10:425-428, 1984 8. Smith SG, Lindstrom RL: Malpositioned posterior chamber lenses: Etiology, prevention, and management. Am Intraocular Implant Soc J 11:584-591, 1985
J CATARACT REFRACT SURG-VOL 13, JANUARY 1987