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Reply: Surgical management of acute angle-closure glaucoma after toric ICL implantation
LETTERS
Surgical management of acute angle-closure glaucoma after toric ICL implantation Vetter et al.1 describe a case of acute angle-closure glaucoma (ACG) after implantation of a toric implantable contact lens (ICL) that was treated by extraction of the ICL, reversing the acute ACG. In our experience, cases of acute ACG following implantation of ICLs in patients who have had neodymium:YAG (Nd:YAG) laser iridotomies is best treated by a combination of miosis, oral or intravenous carbonic anhydrase inhibitors, and revision or creation of new Nd:YAG laser iridotomies using an Nd:YAG laser. This is a straightforward outpatient procedure that has resolved all our cases of acute ACG glaucoma in which pharmacologic agents have failed. Performing a Nd:YAG laser iridotomy results in a puff of pigment into the anterior chamber, as opposed to a puff of pigment between the ICL and the crystalline lens, redirecting the aqueous into the anterior chamber and breaking the angle closure. If a pigment puff is seen between the ICL and the crystalline lens during the Nd:YAG laser iridotomy, the angle closure is unlikely to be broken. Immediate deepening of the anterior chamber and lowering of the intraocular pressure indicate a break of the angle closure. In one of Apel’s cases, laser iridotomies were performed in a layer of virgin iris. This appears to be a much less invasive procedure than that described by Schipper,2 and I recommend this treatment prior to taking patients to the operating room for ICL removal. The mechanism of angle closure in cases of ICL implantation has not been fully explained but may be due to a combination of an ICL with a diameter that is too large and an ophthalmic viscosurgical device trapped between the ICL and the crystalline lens. Andrew Apel, MBBS, FRANZCO David Stephensen, FCLSA Brisbane, Queensland, Australia REFERENCES 1. Vetter JM, Tehrani M, Dick HB. Surgical management of acute angle-closure glaucoma after toric implantable contact lens implantation. J Cataract Refract Surg 2006; 32:1065–1067 2. Schipper I. Surgical management of acute angle-closure glaucoma after implantation of a toric ICL [letter]. J Cataract Refract Surg 2007; 33:563–564
REPLY: We agree with Apel and Stephensen about first applying a conservative approach. However, there were aspects of this particular case that made the situation unlikely to be corrected by conservative and Nd:YAG laser treatment only. Before the surgery, not 1 but 2 iridotomies were applied. The iridotomies were checked before surgery 1672
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
and judged to be patent, with excellent translucency. They were located 90 degrees apart, making simultaneous blockage by the ICL unlikely. As soon as the blockage occurred, intravenous carbonic anhydase inhibitors at maximum dosage as well as topical intraocular pressure (IOP)-lowering treatment and miotic pharmacologic agents were applied, with no effect on IOP or pupil size. Moreover, the patient was close to collapse and felt seriously ill. At the slitlamp examination in this acute phase, no signs of remaining ophthalmic viscosurgical device (OVD)-like tiny air bubbles, entrapped erythrocytes, or immobile cells were observed. Intraoperatively, no OVD efflux from behind the ICL was observed, making it unlikely that entrapped OVD was the reason for this specific problem. The acute ACG was caused solely by excessive anterior vaulting of the oversized ICL. No OVD was detected behind the ICL intraoperatively. The patient’s condition warranted the additional therapeutic alternative of explanting the ICL. Fortunately, the exchange for an iris-fixated phakic IOL corrected the situation and our patient is very satisfied.dJan M. Vetter, MD, Burkhard Dick, MD
Patching to prevent postoperative endophthalmitis The white paper by Nichamin et al.1 considers several possible associations between clear corneal cataract incisions and postoperative endophthalmitis. In his letter, Faulkner2 suggests the additional possibility of topical anesthesia playing a part by allowing forced blinking and contraction of the extraocular muscles in the very early postoperative period, thereby fostering the entry of extraocular fluid into the anterior chamber. With the adoption of topical anesthesia came the practice of leaving the eye unpatched, although sometimes protected with a shield. The combination of topical anesthesia and abandoning the patch may have fostered the increasing incidence of postoperative endophthalmitis. Through a reduction in blinking, patching the eye for 24 hours might offer a simpler solution than returning to block anesthesia or suturing the wound. Martin Spencer, MD Lantzville, British Columbia, Canada REFERENCES 1. Nichamin LD, Chang DF, Johnson SH, et al. ASCRS White Paper: what is the association between clear corneal cataract incisions and postoperative endophthalmitis? J Cataract Refract Surg 2006; 32:1556–1559 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2007.05.043
Surgical management of acute angle-closure glaucoma after toric ICL implantation Vetter et al.1 describe a case of acute angle-closure glaucoma (ACG) after implantation of a toric implantable contact lens (ICL) that was treated by extraction of the ICL, reversing the acute ACG. In our experience, cases of acute ACG following implantation of ICLs in patients who have had neodymium:YAG (Nd:YAG) laser iridotomies is best treated by a combination of miosis, oral or intravenous carbonic anhydrase inhibitors, and revision or creation of new Nd:YAG laser iridotomies using an Nd:YAG laser. This is a straightforward outpatient procedure that has resolved all our cases of acute ACG glaucoma in which pharmacologic agents have failed. Performing a Nd:YAG laser iridotomy results in a puff of pigment into the anterior chamber, as opposed to a puff of pigment between the ICL and the crystalline lens, redirecting the aqueous into the anterior chamber and breaking the angle closure. If a pigment puff is seen between the ICL and the crystalline lens during the Nd:YAG laser iridotomy, the angle closure is unlikely to be broken. Immediate deepening of the anterior chamber and lowering of the intraocular pressure indicate a break of the angle closure. In one of Apel’s cases, laser iridotomies were performed in a layer of virgin iris. This appears to be a much less invasive procedure than that described by Schipper,2 and I recommend this treatment prior to taking patients to the operating room for ICL removal. The mechanism of angle closure in cases of ICL implantation has not been fully explained but may be due to a combination of an ICL with a diameter that is too large and an ophthalmic viscosurgical device trapped between the ICL and the crystalline lens. Andrew Apel, MBBS, FRANZCO David Stephensen, FCLSA Brisbane, Queensland, Australia REFERENCES 1. Vetter JM, Tehrani M, Dick HB. Surgical management of acute angle-closure glaucoma after toric implantable contact lens implantation. J Cataract Refract Surg 2006; 32:1065–1067 2. Schipper I. Surgical management of acute angle-closure glaucoma after implantation of a toric ICL [letter]. J Cataract Refract Surg 2007; 33:563–564
REPLY: We agree with Apel and Stephensen about first applying a conservative approach. However, there were aspects of this particular case that made the situation unlikely to be corrected by conservative and Nd:YAG laser treatment only. Before the surgery, not 1 but 2 iridotomies were applied. The iridotomies were checked before surgery 1672
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
and judged to be patent, with excellent translucency. They were located 90 degrees apart, making simultaneous blockage by the ICL unlikely. As soon as the blockage occurred, intravenous carbonic anhydase inhibitors at maximum dosage as well as topical intraocular pressure (IOP)-lowering treatment and miotic pharmacologic agents were applied, with no effect on IOP or pupil size. Moreover, the patient was close to collapse and felt seriously ill. At the slitlamp examination in this acute phase, no signs of remaining ophthalmic viscosurgical device (OVD)-like tiny air bubbles, entrapped erythrocytes, or immobile cells were observed. Intraoperatively, no OVD efflux from behind the ICL was observed, making it unlikely that entrapped OVD was the reason for this specific problem. The acute ACG was caused solely by excessive anterior vaulting of the oversized ICL. No OVD was detected behind the ICL intraoperatively. The patient’s condition warranted the additional therapeutic alternative of explanting the ICL. Fortunately, the exchange for an iris-fixated phakic IOL corrected the situation and our patient is very satisfied.dJan M. Vetter, MD, Burkhard Dick, MD
Patching to prevent postoperative endophthalmitis The white paper by Nichamin et al.1 considers several possible associations between clear corneal cataract incisions and postoperative endophthalmitis. In his letter, Faulkner2 suggests the additional possibility of topical anesthesia playing a part by allowing forced blinking and contraction of the extraocular muscles in the very early postoperative period, thereby fostering the entry of extraocular fluid into the anterior chamber. With the adoption of topical anesthesia came the practice of leaving the eye unpatched, although sometimes protected with a shield. The combination of topical anesthesia and abandoning the patch may have fostered the increasing incidence of postoperative endophthalmitis. Through a reduction in blinking, patching the eye for 24 hours might offer a simpler solution than returning to block anesthesia or suturing the wound. Martin Spencer, MD Lantzville, British Columbia, Canada REFERENCES 1. Nichamin LD, Chang DF, Johnson SH, et al. ASCRS White Paper: what is the association between clear corneal cataract incisions and postoperative endophthalmitis? J Cataract Refract Surg 2006; 32:1556–1559 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2007.05.043