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Surgical management of acute angle-closure glaucoma after toric implantable contact lens implantation
J CATARACT REFRACT SURG - VOL 32, JUNE 2006
Surgical management of acute angle-closure glaucoma after toric implantable contact lens implantation Jan M. Vetter, MD, Mana Tehrani, MD, H. Burkhard Dick, MD
A case of pupillary block after implantation of an implantable contact lens (ICL) is reported, and surgical management and prevention are discussed. In a myopic patient, the best corrected visual acuity in the right eye was 20/50 with ÿ15.50 ÿ3.00 175. After uneventful implantation of an ICL, painful acute glaucoma developed with an intraocular pressure beyond measurable values. Apparent anterior vaulting of the ICL suggested a sizing problem. In a situation of a mid-wide dilated pupil, immediate explantation of the ICL was performed. Then, using a preoperative iris photography as guidance, an anterior chamber iris-claw toric phakic intraocular lens was implanted. On postoperative examination, the anterior chamber was deep, the angle open, the natural lens clear, and uncorrected visual acuity was 20/40. J Cataract Refract Surg 2006; 32:1065–1067 Q 2006 ASCRS and ESCRS
The implantable contact lens (ICL) is a toric posterior chamber phakic intraocular lens (pIOL) developed by Staar Surgical to correct myopia, hyperopia, and astigmatism. After several lens-design modifications, the currently available ICL has been reported to achieve good refractive outcomes.1,2 CASE REPORT After successful implantation of a toric pIOL in the left eye, a myopic patient had surgery in the right eye to correct myopic astigmatism of ÿ16.50 ÿ3.00 175. On preoperative examination, the best corrected visual acuity was 20/50. Using the IOLMaster (Carl Zeiss), the white-to-white distance was 12.0 mm, the anterior chamber depth was 3.7 mm, and the axial length was 28.40 mm. The scotopic pupil size was 6.33 mm measured with the Procyon pupillometer P2000SA (Procyon Instruments). One week before surgery, 2 peripheral neodymium:YAG (Nd:YAG) iridotomies were successfully performed at 10:30 and 2 o’clock. Transilluminescence was confirmed 1 day
Accepted for publication November 26, 2005. From the Department of Ophthalmology, Johannes Gutenberg University, Mainz, Germany. None of the authors has a financial or proprietary interest in any material or method mentioned. Reprint requests to Jan M. Vetter, MD, Johannes Gutenberg University, Department of Ophthalmology, Langenbeckstrasse 1 55131 Mainz, Germany. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
before surgery. One day after implantation of a ÿ23.00 C3.00 90 ICL (Version T-ICM V4, total diameter 13.0 mm) at a target axis of 175 degrees in the right eye, the patient reported pain and blepharospasm. The intraocular pressure (IOP) was higher than 80 mm Hg, and the anterior chamber was completely obliterated (Figure 1). The ICL was clearly vaulted anteriorly with neither remnants of ophthalmic viscosurgical device (OVD) nor the natural lens visible directly behind the ICL. Hence, a sizing problem was obvious and immediate explantation of the ICL was performed under general anesthesia. Intraoperatively, intracameral injection of suprarenine failed to show any mydriatic effect on the mid-wide dilated pupil. A highly viscous space-creating OVD sodium hyaluronate 2.3% (Healon5) was injected to deepen the anterior chamber but egressed immediately via the paracentesis without significant effect on chamber depth. In this situation, a nonpenetrating positioning recess in the nasal optic-haptic junction area of the ICL (Figure 2, A) was accessed with a Sinskey hook (Figure 2, B) and the ICL was shifted and bulged temporally. This maneuver, coming from anterotemporal direction, did not only prevent the ICL from touching the endothelium but also pulled the nasal haptic toward the center of the cornea and the rim of the iris. At first, the superior part of the nasal haptic was luxated into the anterior chamber using an iris spatula as a fulcrum (Figure 2, C). The inferior nasal haptic was then rotated into the anterior chamber with the Sinskey hook alone. After further rotation, the ICL folded itself during the explantation via the sclerocorneal tunnel incision at 12 o’clock. After this incision was enlarged to 5.2 mm, a standby toric iris-claw pIOL (Verisyse, AMO; optic diameter 5 mm) of ÿ16.50 ÿ2.50 0 was implanted. A corneal marking of the target axis had not been possible before surgery, but the preoperative iris photograph allowed the exact localization of the target axis via 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2006.02.028
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CASE REPORTS: SURGICAL MANAGEMENT OF GLAUCOMA WITH TORIC ICLS
could be observed. The pIOL was stable and centered. The natural lens showed no signs of cataract formation (Figure 3). DISCUSSION
Figure 1. Acute angle-closure glaucoma occurring on day 1 after uncomplicated implantation of a toric phakic ICL. The anterior chamber is fully obliterated, and the ICL is vaulted anteriorly. The IOP was higher than 80 mm Hg.
guiding iris structures such as crypts, pigmentations, and blood vessels. The iris-claw lens was then enclavated at the target axis of 175 degrees. There were no complications during or after this second surgical procedure. The postoperative IOP in the right eye was 16 mm Hg, and uncorrected visual acuity was 20/40. The scotopic pupil size in the right eye was 5.79 mm horizontally and 6.10 mm vertically, leading to moderate night vision complaints. There were no signs of atrophy on the optic nerve on funduscopy, and mean deviation in postoperative static perimetry (ÿ3.5 dB) did not increase over preoperative findings (ÿ8.5 dB). One year later, only minimal changes of corneal astigmatism
Figure 2. Dislocation of the ICL from the posterior into the anterior chamber. A recess (A) in the nasal optic–haptic junction is used to compress the longitudinal axis of the lens with a Sinskey hook (B). An iris spatula is used to assist the dislocation (C).
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To our knowledge, this is the first report describing an anteriorly vaulted ICL in combination with acute angleclosure glaucoma requiring explantation of the ICL followed by implantation of a toric iris-claw pIOL. According to recent studies, acute angle-closure glaucoma is a known complication in ICL implantations, occurring in 0% to 11% of cases.1–4 However, all these cases could be managed without explantation of the ICL, mainly by enlarging the Nd:YAG iridotomy1,3 or by performing an iridectomy.4 In our patient, the blockage in the pupil area happened 1 day after implantation of the toric ICL due to a sizing problem. We used the white-to-white distance measured by the IOLMaster to estimate the required ICL size. Recent studies indicate a considerable variation between the whiteto-white distances obtained by the IOLMaster and the Orbscan II topography system (Bausch & Lomb),5 and there is poor correlation between these white-to-white distances and the sulcus-to-sulcus diameter in vivo5,6 and postmortem.7 Thus, a more precise preoperative determination of intraocular dimensions, especially of the sulcus-to-sulcus distance, is recommended to prevent intraoperative sizing errors, which might result in unwanted postoperative complications. This might be achieved using very-high-frequency ultrasound biometry (Artemis, Ultralink). Once the mentioned complication has occurred after ICL implantation, we suggest the described surgical technique as an effective option to achieve dislocation of the ICL into the anterior chamber where it can be retrieved. Compression of the longitudinal axis and control of the distance between lens and endothelium are crucial.
Figure 3. Postoperative result. The toric anterior chamber pIOL is enclavated at a target axis of 175 degrees. There is no evidence of cataract formation.
J CATARACT REFRACT SURG - VOL 32, JUNE 2006
CASE REPORTS: SURGICAL MANAGEMENT OF GLAUCOMA WITH TORIC ICLS
We conclude that advances in preoperative determination of intraocular dimensions are needed for the prevention of complications of pIOL implantation such as acute angle-closure glaucoma due to inadequate pIOL sizing. Furthermore, preoperative iris photography and availability of a standby pIOL improve the management of these complications as much as the described surgical strategies.
REFERENCES 1. Pineda-Fernandez A, Jaramillo J, Vargas J, et al. Phakic posterior chamber intraocular lens for high myopia. J Cataract Refract Surg 2004; 30:2277–2283
2. Sanders DR, Brown DC, Martin RG, et al. Implantable contact lens for moderate to high myopia: phase 1 FDA clinical study with 6 month follow-up. J Cataract Refract Surg 1998; 24:607–611 3. Bloomenstein MR, Dulaney DD, Barnet RW, Perkins SA. Posterior chamber phakic intraocular lens for moderate myopia and hyperopia. Optometry 2002; 73:435–446 4. Uusitalo RJ, Aine E, Sen NH, Laatikainen L. Implantable contact lens for high myopia. J Cataract Refract Surg 2002; 28:29–36 5. Baumeister M, Terzi E, Ekici Y, Kohnen T. Comparison of manual and automated methods to determine horizontal corneal diameter. J Cataract Refract Surg 2004; 30:374–380 6. Pop M, Payette Y, Mansour M. Predicting sulcus size using ocular measurements. J Cataract Refract Surg 2001; 27:1033–1038 7. Werner L, Izak AM, Pandey SK, et al. Correlation between different measurements within the eye relative to phakic intraocular lens implantation. J Cataract Refract Surg 2004; 30:1982–1988
J CATARACT REFRACT SURG - VOL 32, JUNE 2006
1067
Surgical management of acute angle-closure glaucoma after toric implantable contact lens implantation Jan M. Vetter, MD, Mana Tehrani, MD, H. Burkhard Dick, MD
A case of pupillary block after implantation of an implantable contact lens (ICL) is reported, and surgical management and prevention are discussed. In a myopic patient, the best corrected visual acuity in the right eye was 20/50 with ÿ15.50 ÿ3.00 175. After uneventful implantation of an ICL, painful acute glaucoma developed with an intraocular pressure beyond measurable values. Apparent anterior vaulting of the ICL suggested a sizing problem. In a situation of a mid-wide dilated pupil, immediate explantation of the ICL was performed. Then, using a preoperative iris photography as guidance, an anterior chamber iris-claw toric phakic intraocular lens was implanted. On postoperative examination, the anterior chamber was deep, the angle open, the natural lens clear, and uncorrected visual acuity was 20/40. J Cataract Refract Surg 2006; 32:1065–1067 Q 2006 ASCRS and ESCRS
The implantable contact lens (ICL) is a toric posterior chamber phakic intraocular lens (pIOL) developed by Staar Surgical to correct myopia, hyperopia, and astigmatism. After several lens-design modifications, the currently available ICL has been reported to achieve good refractive outcomes.1,2 CASE REPORT After successful implantation of a toric pIOL in the left eye, a myopic patient had surgery in the right eye to correct myopic astigmatism of ÿ16.50 ÿ3.00 175. On preoperative examination, the best corrected visual acuity was 20/50. Using the IOLMaster (Carl Zeiss), the white-to-white distance was 12.0 mm, the anterior chamber depth was 3.7 mm, and the axial length was 28.40 mm. The scotopic pupil size was 6.33 mm measured with the Procyon pupillometer P2000SA (Procyon Instruments). One week before surgery, 2 peripheral neodymium:YAG (Nd:YAG) iridotomies were successfully performed at 10:30 and 2 o’clock. Transilluminescence was confirmed 1 day
Accepted for publication November 26, 2005. From the Department of Ophthalmology, Johannes Gutenberg University, Mainz, Germany. None of the authors has a financial or proprietary interest in any material or method mentioned. Reprint requests to Jan M. Vetter, MD, Johannes Gutenberg University, Department of Ophthalmology, Langenbeckstrasse 1 55131 Mainz, Germany. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
before surgery. One day after implantation of a ÿ23.00 C3.00 90 ICL (Version T-ICM V4, total diameter 13.0 mm) at a target axis of 175 degrees in the right eye, the patient reported pain and blepharospasm. The intraocular pressure (IOP) was higher than 80 mm Hg, and the anterior chamber was completely obliterated (Figure 1). The ICL was clearly vaulted anteriorly with neither remnants of ophthalmic viscosurgical device (OVD) nor the natural lens visible directly behind the ICL. Hence, a sizing problem was obvious and immediate explantation of the ICL was performed under general anesthesia. Intraoperatively, intracameral injection of suprarenine failed to show any mydriatic effect on the mid-wide dilated pupil. A highly viscous space-creating OVD sodium hyaluronate 2.3% (Healon5) was injected to deepen the anterior chamber but egressed immediately via the paracentesis without significant effect on chamber depth. In this situation, a nonpenetrating positioning recess in the nasal optic-haptic junction area of the ICL (Figure 2, A) was accessed with a Sinskey hook (Figure 2, B) and the ICL was shifted and bulged temporally. This maneuver, coming from anterotemporal direction, did not only prevent the ICL from touching the endothelium but also pulled the nasal haptic toward the center of the cornea and the rim of the iris. At first, the superior part of the nasal haptic was luxated into the anterior chamber using an iris spatula as a fulcrum (Figure 2, C). The inferior nasal haptic was then rotated into the anterior chamber with the Sinskey hook alone. After further rotation, the ICL folded itself during the explantation via the sclerocorneal tunnel incision at 12 o’clock. After this incision was enlarged to 5.2 mm, a standby toric iris-claw pIOL (Verisyse, AMO; optic diameter 5 mm) of ÿ16.50 ÿ2.50 0 was implanted. A corneal marking of the target axis had not been possible before surgery, but the preoperative iris photograph allowed the exact localization of the target axis via 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2006.02.028
1065
CASE REPORTS: SURGICAL MANAGEMENT OF GLAUCOMA WITH TORIC ICLS
could be observed. The pIOL was stable and centered. The natural lens showed no signs of cataract formation (Figure 3). DISCUSSION
Figure 1. Acute angle-closure glaucoma occurring on day 1 after uncomplicated implantation of a toric phakic ICL. The anterior chamber is fully obliterated, and the ICL is vaulted anteriorly. The IOP was higher than 80 mm Hg.
guiding iris structures such as crypts, pigmentations, and blood vessels. The iris-claw lens was then enclavated at the target axis of 175 degrees. There were no complications during or after this second surgical procedure. The postoperative IOP in the right eye was 16 mm Hg, and uncorrected visual acuity was 20/40. The scotopic pupil size in the right eye was 5.79 mm horizontally and 6.10 mm vertically, leading to moderate night vision complaints. There were no signs of atrophy on the optic nerve on funduscopy, and mean deviation in postoperative static perimetry (ÿ3.5 dB) did not increase over preoperative findings (ÿ8.5 dB). One year later, only minimal changes of corneal astigmatism
Figure 2. Dislocation of the ICL from the posterior into the anterior chamber. A recess (A) in the nasal optic–haptic junction is used to compress the longitudinal axis of the lens with a Sinskey hook (B). An iris spatula is used to assist the dislocation (C).
1066
To our knowledge, this is the first report describing an anteriorly vaulted ICL in combination with acute angleclosure glaucoma requiring explantation of the ICL followed by implantation of a toric iris-claw pIOL. According to recent studies, acute angle-closure glaucoma is a known complication in ICL implantations, occurring in 0% to 11% of cases.1–4 However, all these cases could be managed without explantation of the ICL, mainly by enlarging the Nd:YAG iridotomy1,3 or by performing an iridectomy.4 In our patient, the blockage in the pupil area happened 1 day after implantation of the toric ICL due to a sizing problem. We used the white-to-white distance measured by the IOLMaster to estimate the required ICL size. Recent studies indicate a considerable variation between the whiteto-white distances obtained by the IOLMaster and the Orbscan II topography system (Bausch & Lomb),5 and there is poor correlation between these white-to-white distances and the sulcus-to-sulcus diameter in vivo5,6 and postmortem.7 Thus, a more precise preoperative determination of intraocular dimensions, especially of the sulcus-to-sulcus distance, is recommended to prevent intraoperative sizing errors, which might result in unwanted postoperative complications. This might be achieved using very-high-frequency ultrasound biometry (Artemis, Ultralink). Once the mentioned complication has occurred after ICL implantation, we suggest the described surgical technique as an effective option to achieve dislocation of the ICL into the anterior chamber where it can be retrieved. Compression of the longitudinal axis and control of the distance between lens and endothelium are crucial.
Figure 3. Postoperative result. The toric anterior chamber pIOL is enclavated at a target axis of 175 degrees. There is no evidence of cataract formation.
J CATARACT REFRACT SURG - VOL 32, JUNE 2006
CASE REPORTS: SURGICAL MANAGEMENT OF GLAUCOMA WITH TORIC ICLS
We conclude that advances in preoperative determination of intraocular dimensions are needed for the prevention of complications of pIOL implantation such as acute angle-closure glaucoma due to inadequate pIOL sizing. Furthermore, preoperative iris photography and availability of a standby pIOL improve the management of these complications as much as the described surgical strategies.
REFERENCES 1. Pineda-Fernandez A, Jaramillo J, Vargas J, et al. Phakic posterior chamber intraocular lens for high myopia. J Cataract Refract Surg 2004; 30:2277–2283
2. Sanders DR, Brown DC, Martin RG, et al. Implantable contact lens for moderate to high myopia: phase 1 FDA clinical study with 6 month follow-up. J Cataract Refract Surg 1998; 24:607–611 3. Bloomenstein MR, Dulaney DD, Barnet RW, Perkins SA. Posterior chamber phakic intraocular lens for moderate myopia and hyperopia. Optometry 2002; 73:435–446 4. Uusitalo RJ, Aine E, Sen NH, Laatikainen L. Implantable contact lens for high myopia. J Cataract Refract Surg 2002; 28:29–36 5. Baumeister M, Terzi E, Ekici Y, Kohnen T. Comparison of manual and automated methods to determine horizontal corneal diameter. J Cataract Refract Surg 2004; 30:374–380 6. Pop M, Payette Y, Mansour M. Predicting sulcus size using ocular measurements. J Cataract Refract Surg 2001; 27:1033–1038 7. Werner L, Izak AM, Pandey SK, et al. Correlation between different measurements within the eye relative to phakic intraocular lens implantation. J Cataract Refract Surg 2004; 30:1982–1988
J CATARACT REFRACT SURG - VOL 32, JUNE 2006
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