C L I N I C A L
A N D
E X P E R I M E N T A L
OPTOMETRY CLINICAL COMMUNICATION
Retinal detachment associated with posterior chamber phakic intraocular lens implantation Clin Exp Optom 2014; 97: 471–472 Mustapha Mushawiahti MSOphtal Andrew Shaw MRCOphth Daniel Chiu FRANZCO Royal Victorian Eye and Ear Hospital, Melbourne, Australia Email: [email protected]
Submitted: 2 November 2013 Revised: 18 February 2014 Accepted for publication: 7 March 2014 Refractive surgery has become a very popular method of visual correction among young myopic patients. Options range from laser in situ keratomielusis (LASIK) to the more invasive clear lens extraction (CLE) and phakic intraocular lens implantation (pIOL). Corneal surface reshaping or LASIK surgery remains the most common refractive surgery performed worldwide.1 Clear lens extraction surgery was once an option for unsuitable LASIK candidates; however, losing accommodation after the surgery is not an easy adaptation for young people. Phakic intraocular lens implantation involves insertion of a supplementary intraocular lens, while preserving the crystalline lens in its original position. Therefore, pIOL is a reasonable option for the same indication. The intraocular lens is either fixed at an angle, enclavated on the iris surface or implanted in the posterior chamber in between the iris and the lens.2 Posterior chamber pIOL is also known as implantable contact lens (ICL) and is gaining in popularity due to the continuous improvement in IOL design. Long-term visual outcomes are generally stable and predictable.3,4 Improvement of the pIOL design noticeably reduces anterior segment complications,5 such as cataract, endothelial cell loss, chronic glaucoma and uveitis. Posterior segment complications are rarely reported. In theory, preserving the crystalline lens in its original position renders fewer complications as compared to CLE in a young myopic patient. Although improvement of the pos-
DOI:10.1111/cxo.12153 terior chamber pIOL design helps in reducing anterior segment complications, the risk of posterior segment complications remains in this high-risk group of patients. This report represents a case of posterior segment complications after posterior chamber pIOL surgery. Here, we describe a case of retinal detachment in a 26-year-old man, who underwent posterior chamber pIOL surgery. The surgery was uneventful and his post-operative vision was good; however, two weeks after surgery, he presented with sudden loss of vision in the operated eye. Although an improved pIOL surgical design helps to reduce anterior segment complications, the risk of posterior segment complications remains in this high-risk group of patients. CASE REPORT A 26-year-old man had myopia (R -15.00 D and L -21.00 D) and was very keen to undergo refractive surgery after becoming intolerant to contact lenses. He was found to be unsuitable for LASIK surgery by his corneal surgeon, probably due to the very high refractive error. Details of the exclusion were not available as he was referred to us from another centre. He was scheduled for a bilateral posterior chamber pIOL implantation. Pre-operatively, multiple peripheral iridotomies were made in each eye to reduce the possible effects of pupil block. Surgery was performed on his left eye without intraoperative or early complication. The second eye was scheduled for surgery in a month. Two weeks after the procedure, he presented with sudden loss of vision in the surgically treated eye. Visual acuity was recorded as hand movements. An examination revealed subtotal rhegmatogenous retinal detachment involving the macula, which was associated with a superotemporal horse-shoe tear of the size of 2 clock hours. Posterior vitreous detachment (PVD) was also present. Retinal examination of the
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometrists Association Australia
fellow eye showed only peripheral pigmentary changes with no significant abnormal retinal degeneration. Posterior vitreous detachment was absent in the unoperated eye. A sutureless small-gauge (23G) vitrectomy and cryoretinopexy was performed on the left eye. Retinal view was excellent throughout the surgery and perfluorocarbon (C3F8 15 per cent) gas was used as an endotamponade at the end of the procedure. The patient was discharged a day after surgery with strict post-surgical instructions. Despite having multiple peripheral iridotomies, the patient had a few episodes of high intraocular pressure (IOP) after the detachment surgery. The IOP was recorded as high as 40 mmHg. There was no similar episode after the initial phakic IOL implantation. Gonioscopy showed a significant narrowing of the angle (grade 2), with scanty early peripheral anterior synechiae. The iridocorneal angle in the fellow eye was wide. The most likely cause for this condition may be the increased instability of the phakic lens post-vitrectomy, which might have pushed the IOL forward. Sequentially, this causes narrowing of the angle. The IOL was removed due to the uncontrollable IOP. Eventually, the IOP normalised without the need for anti-glaucoma medication. The retina remained stable and the lens was fairly clear throughout his last follow-up at six months after the vitrectomy. The patient’s vision at his last visit was 6/12. Due to the early complications of the operated eye, the planned surgery for the right eye was cancelled. DISCUSSION Suitability for LASIK has its own limitations due to the nature of the treatment which involves resculpting of the central cornea. This patient had a very high refractive error and the procedure is likely to exceed the safe limit for the residual cornea after LASIK. We did not have much detail on the
Clinical and Experimental Optometry 97.5 September 2014
471
Retinal detachment after refractive surgery Mustapha, Shaw and Chiu
pre-operative ocular biometry of the patient, as his surgery was done in a different centre. In general, the consensus for the residual stromal bed after LASIK surgery is 250 μm6 and the upper limit of high myopia should be within the range of -8.00 to -12.00.7,8 Corneal ectasia as a long-term complication of LASIK can be devastating and is irreversible. Therefore, LASIK was not a safe option for this particular patient who had myopia of more than -15.00 D. Other options of refractive surgery for high myopic individuals are clear lens extraction or pIOL implantation. Clear lens extraction in young myopic patients has always remained controversial. Replacement of a normal clear lens with an artificial IOL compromises the accommodative function of the eye.9 Retinal detachment in these patients has been reported to be as high as 2.1 per cent10 as compared to 0.4 per cent in general cataract surgery.11 Phakic intraocular lens implantation allows preservation of the crystalline lens and the accommodative function of the eye. The concept behind pIOL is that it creates a condition called ‘duophakia’ to preserve the original crystalline lens in its position, while the IOL is implanted in the eye. Theoretically, retention of the lens in its normal position reduces the risk of posterior segment complications as compared to clear lens extraction.12 A decade ago, during the early development of pIOL surgery, the risk of retinal detachment was reported to be 2.07 per cent;13 however, nowadays with better IOL design and improved surgical techniques, reports on posterior segment complications are very rare.14 In pIOL, the intraocular lens is either fixated at an angle, enclavated on the iris surface or implanted in the posterior chamber in between the iris and the lens. Commonly reported complications of pIOL implantation are the development of cataract, angle-closure glaucoma and decentration of the lens.4 The posterior chamber phakic intraocular lens is becoming an acceptable option due to the reduced risk of anterior segment complications,5 compared with the other options of pIOL. The improvement of the IOL design and the technique of surgery are noticeably making it a safe option.5 Most of the pIOL are performed in highly myopic patients with potentially long axial length of the eye. Despite preservation of the lens, movement of the lens iris diaphragm during surgery is unavoidable. The lens diaphragm movement may occur either during
the initial opening of the eye which causes sudden decompression of the anterior chamber or during surgical manipulation for IOL implantation. This movement might induce the development of acute posterior vitreous detachment, resulting in the horseshoe tear in this particular patient. Postoperative posterior vitreous detachment is common after cataract surgery and mostly is benign.15 However, in young high myopic patients with a strong vitreoretinal attachment, acute posterior vitreous detachment may easily lead to retinal complications. Despite successful retinal attachment surgery, the patient experienced a few episodes of post-operative high intraocular pressure and narrowing of the iridocorneal angle. A common cause of a rise in intraocular pressure immediately after pIOL is the development of pupillary block;16 however, the rise in intraocular pressure in this particular case occurred mainly after vitrectomy. These episodes could be due to some degree of IOL instability and partly contributed by the presence of gas in the vitreous cavity, which was used as an endotamponade. With minimal amount of peripheral anterior synechiae, removal of the IOL eventually normalises intraocular pressure. Interestingly, in our experience, the presence of a phakic intraocular lens does not hinder good dilatation of the pupil or a perfect view of the retina during vitrectomy. At the same time, the phakic intraocular lens was found to be very stable throughout the procedure.
CONCLUSION A large study on pIOL surgery may not be feasible today because non-invasive LASIK is far more widely performed. We hope this case report serves as a reminder to be vigilant for possible complications of refractive surgery in highly myopic patients. Therefore, expert evaluation and patient education are equally important in minimising the prospect of poor outcomes in cases with retinal complications. REFERENCES 1. Yu E, Jackson W. Recent advances in refractive surgery. CMAJ 1999; 160: 1329–1337. 2. Comaish IF, Lawless MA. Phakic intraocular lenses. Curr Opin Ophthalmol 2002; 13: 7–13. 3. Pesando PM, Ghiringhello MP, Di Meglio G, Fanton G. Posterior chamber phakic intraocular lens (ICL) for hyperopia: ten year follow up. J Cataract Refract Surg 2007; 33: 1579–1584.
Clinical and Experimental Optometry 97.5 September 2014
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4. Portaliou DM, Kymionis GD, Panagopoulous SI, Kalyvianaki MI, Grentzelos MA, Pallikaris IG. Long term results of phakic refractive lens implantation in eyes with high myopia. J Refract Surg 2011; 27: 787–791. 5. Lovisolo C, Reinstein D. Phakic intraocular lenses. Surv Ophthalmol 2005; 50: 549–587. 6. Wang Z, Chen J, Yang B. Posterior corneal surface topographic changes after laser in situ keratomileusis are related to residual corneal bed thickness. Ophthalmology 1999; 106: 406–409. 7. Yanoff M, Duker JS. Ophthalmology. 3rd ed. Edinburgh: Mosby Elsevier, 2009. p 186–201. 8. Alió JL, Muftuoglu O, Ortiz D, Pérez-Santonja JJ, Artola A, Ayala MJ, Garcia MJ et al. Ten-year follow-up of laser in situ keratomileusis for myopia of up to -10 Diopters. Am J Ophthalmol 2008; 145: 46–54. 9. Basic and Clinical Science Course, Section 13: Refractive Surgery (2011–2012 edition). American Academy of Ophthalmology, 2011–2012. p 125– 136. 10. Fernandez-Vega L, Alfonso J, Villacampa T. Clear lens extraction for the correction of high myopia. Ophthalmology 2003; 110: 2349–2354. 11. Olsen G, Olsen RJ. Update on a long-term prospective study of capsulotomy and retinal detachment rates after cataract surgery. J Cataract Refract Surg 2000; 26: 1017–1021. 12. Colin J, Robinet A, Cochener B. Retinal detachment after clear lens extraction for high myopia: seven-year follow up. Ophthalmology 1997; 104: 73–77. 13. Martinez-Castillo V, Boixadera A, Verdugo A, Elíes D, Coret A, Garcia-Arumi J. Rhegmatogenous retinal detachment in phakic eyes after posterior chamber phakic intraocular lens implantation for severe myopia. Ophthalmology 2005; 112: 580–585. 14. Kwok AK, Young AL, Bhende P, Lam DS. Retinal detachment in phakic eyes with anterior chamber intraocular lenses to correct severe myopia. Am J Ophthalmol 1999; 128: 395–396 15. Ripandelli G, Coppé A, Parisi V, Olzi D, Scassa C, Chiaravalloti A, Stirpe M. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmology 2007; 114: 692–697. 16. Bylsma SS, Zalta AH, Foley E, Osher RH. Phakic posterior chamber intraocular lens pupillary block. J Cataract Refract Surg 2002; 28: 2222–2228.
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometrists Association Australia
A N D
E X P E R I M E N T A L
OPTOMETRY CLINICAL COMMUNICATION
Retinal detachment associated with posterior chamber phakic intraocular lens implantation Clin Exp Optom 2014; 97: 471–472 Mustapha Mushawiahti MSOphtal Andrew Shaw MRCOphth Daniel Chiu FRANZCO Royal Victorian Eye and Ear Hospital, Melbourne, Australia Email: [email protected]
Submitted: 2 November 2013 Revised: 18 February 2014 Accepted for publication: 7 March 2014 Refractive surgery has become a very popular method of visual correction among young myopic patients. Options range from laser in situ keratomielusis (LASIK) to the more invasive clear lens extraction (CLE) and phakic intraocular lens implantation (pIOL). Corneal surface reshaping or LASIK surgery remains the most common refractive surgery performed worldwide.1 Clear lens extraction surgery was once an option for unsuitable LASIK candidates; however, losing accommodation after the surgery is not an easy adaptation for young people. Phakic intraocular lens implantation involves insertion of a supplementary intraocular lens, while preserving the crystalline lens in its original position. Therefore, pIOL is a reasonable option for the same indication. The intraocular lens is either fixed at an angle, enclavated on the iris surface or implanted in the posterior chamber in between the iris and the lens.2 Posterior chamber pIOL is also known as implantable contact lens (ICL) and is gaining in popularity due to the continuous improvement in IOL design. Long-term visual outcomes are generally stable and predictable.3,4 Improvement of the pIOL design noticeably reduces anterior segment complications,5 such as cataract, endothelial cell loss, chronic glaucoma and uveitis. Posterior segment complications are rarely reported. In theory, preserving the crystalline lens in its original position renders fewer complications as compared to CLE in a young myopic patient. Although improvement of the pos-
DOI:10.1111/cxo.12153 terior chamber pIOL design helps in reducing anterior segment complications, the risk of posterior segment complications remains in this high-risk group of patients. This report represents a case of posterior segment complications after posterior chamber pIOL surgery. Here, we describe a case of retinal detachment in a 26-year-old man, who underwent posterior chamber pIOL surgery. The surgery was uneventful and his post-operative vision was good; however, two weeks after surgery, he presented with sudden loss of vision in the operated eye. Although an improved pIOL surgical design helps to reduce anterior segment complications, the risk of posterior segment complications remains in this high-risk group of patients. CASE REPORT A 26-year-old man had myopia (R -15.00 D and L -21.00 D) and was very keen to undergo refractive surgery after becoming intolerant to contact lenses. He was found to be unsuitable for LASIK surgery by his corneal surgeon, probably due to the very high refractive error. Details of the exclusion were not available as he was referred to us from another centre. He was scheduled for a bilateral posterior chamber pIOL implantation. Pre-operatively, multiple peripheral iridotomies were made in each eye to reduce the possible effects of pupil block. Surgery was performed on his left eye without intraoperative or early complication. The second eye was scheduled for surgery in a month. Two weeks after the procedure, he presented with sudden loss of vision in the surgically treated eye. Visual acuity was recorded as hand movements. An examination revealed subtotal rhegmatogenous retinal detachment involving the macula, which was associated with a superotemporal horse-shoe tear of the size of 2 clock hours. Posterior vitreous detachment (PVD) was also present. Retinal examination of the
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometrists Association Australia
fellow eye showed only peripheral pigmentary changes with no significant abnormal retinal degeneration. Posterior vitreous detachment was absent in the unoperated eye. A sutureless small-gauge (23G) vitrectomy and cryoretinopexy was performed on the left eye. Retinal view was excellent throughout the surgery and perfluorocarbon (C3F8 15 per cent) gas was used as an endotamponade at the end of the procedure. The patient was discharged a day after surgery with strict post-surgical instructions. Despite having multiple peripheral iridotomies, the patient had a few episodes of high intraocular pressure (IOP) after the detachment surgery. The IOP was recorded as high as 40 mmHg. There was no similar episode after the initial phakic IOL implantation. Gonioscopy showed a significant narrowing of the angle (grade 2), with scanty early peripheral anterior synechiae. The iridocorneal angle in the fellow eye was wide. The most likely cause for this condition may be the increased instability of the phakic lens post-vitrectomy, which might have pushed the IOL forward. Sequentially, this causes narrowing of the angle. The IOL was removed due to the uncontrollable IOP. Eventually, the IOP normalised without the need for anti-glaucoma medication. The retina remained stable and the lens was fairly clear throughout his last follow-up at six months after the vitrectomy. The patient’s vision at his last visit was 6/12. Due to the early complications of the operated eye, the planned surgery for the right eye was cancelled. DISCUSSION Suitability for LASIK has its own limitations due to the nature of the treatment which involves resculpting of the central cornea. This patient had a very high refractive error and the procedure is likely to exceed the safe limit for the residual cornea after LASIK. We did not have much detail on the
Clinical and Experimental Optometry 97.5 September 2014
471
Retinal detachment after refractive surgery Mustapha, Shaw and Chiu
pre-operative ocular biometry of the patient, as his surgery was done in a different centre. In general, the consensus for the residual stromal bed after LASIK surgery is 250 μm6 and the upper limit of high myopia should be within the range of -8.00 to -12.00.7,8 Corneal ectasia as a long-term complication of LASIK can be devastating and is irreversible. Therefore, LASIK was not a safe option for this particular patient who had myopia of more than -15.00 D. Other options of refractive surgery for high myopic individuals are clear lens extraction or pIOL implantation. Clear lens extraction in young myopic patients has always remained controversial. Replacement of a normal clear lens with an artificial IOL compromises the accommodative function of the eye.9 Retinal detachment in these patients has been reported to be as high as 2.1 per cent10 as compared to 0.4 per cent in general cataract surgery.11 Phakic intraocular lens implantation allows preservation of the crystalline lens and the accommodative function of the eye. The concept behind pIOL is that it creates a condition called ‘duophakia’ to preserve the original crystalline lens in its position, while the IOL is implanted in the eye. Theoretically, retention of the lens in its normal position reduces the risk of posterior segment complications as compared to clear lens extraction.12 A decade ago, during the early development of pIOL surgery, the risk of retinal detachment was reported to be 2.07 per cent;13 however, nowadays with better IOL design and improved surgical techniques, reports on posterior segment complications are very rare.14 In pIOL, the intraocular lens is either fixated at an angle, enclavated on the iris surface or implanted in the posterior chamber in between the iris and the lens. Commonly reported complications of pIOL implantation are the development of cataract, angle-closure glaucoma and decentration of the lens.4 The posterior chamber phakic intraocular lens is becoming an acceptable option due to the reduced risk of anterior segment complications,5 compared with the other options of pIOL. The improvement of the IOL design and the technique of surgery are noticeably making it a safe option.5 Most of the pIOL are performed in highly myopic patients with potentially long axial length of the eye. Despite preservation of the lens, movement of the lens iris diaphragm during surgery is unavoidable. The lens diaphragm movement may occur either during
the initial opening of the eye which causes sudden decompression of the anterior chamber or during surgical manipulation for IOL implantation. This movement might induce the development of acute posterior vitreous detachment, resulting in the horseshoe tear in this particular patient. Postoperative posterior vitreous detachment is common after cataract surgery and mostly is benign.15 However, in young high myopic patients with a strong vitreoretinal attachment, acute posterior vitreous detachment may easily lead to retinal complications. Despite successful retinal attachment surgery, the patient experienced a few episodes of post-operative high intraocular pressure and narrowing of the iridocorneal angle. A common cause of a rise in intraocular pressure immediately after pIOL is the development of pupillary block;16 however, the rise in intraocular pressure in this particular case occurred mainly after vitrectomy. These episodes could be due to some degree of IOL instability and partly contributed by the presence of gas in the vitreous cavity, which was used as an endotamponade. With minimal amount of peripheral anterior synechiae, removal of the IOL eventually normalises intraocular pressure. Interestingly, in our experience, the presence of a phakic intraocular lens does not hinder good dilatation of the pupil or a perfect view of the retina during vitrectomy. At the same time, the phakic intraocular lens was found to be very stable throughout the procedure.
CONCLUSION A large study on pIOL surgery may not be feasible today because non-invasive LASIK is far more widely performed. We hope this case report serves as a reminder to be vigilant for possible complications of refractive surgery in highly myopic patients. Therefore, expert evaluation and patient education are equally important in minimising the prospect of poor outcomes in cases with retinal complications. REFERENCES 1. Yu E, Jackson W. Recent advances in refractive surgery. CMAJ 1999; 160: 1329–1337. 2. Comaish IF, Lawless MA. Phakic intraocular lenses. Curr Opin Ophthalmol 2002; 13: 7–13. 3. Pesando PM, Ghiringhello MP, Di Meglio G, Fanton G. Posterior chamber phakic intraocular lens (ICL) for hyperopia: ten year follow up. J Cataract Refract Surg 2007; 33: 1579–1584.
Clinical and Experimental Optometry 97.5 September 2014
472
4. Portaliou DM, Kymionis GD, Panagopoulous SI, Kalyvianaki MI, Grentzelos MA, Pallikaris IG. Long term results of phakic refractive lens implantation in eyes with high myopia. J Refract Surg 2011; 27: 787–791. 5. Lovisolo C, Reinstein D. Phakic intraocular lenses. Surv Ophthalmol 2005; 50: 549–587. 6. Wang Z, Chen J, Yang B. Posterior corneal surface topographic changes after laser in situ keratomileusis are related to residual corneal bed thickness. Ophthalmology 1999; 106: 406–409. 7. Yanoff M, Duker JS. Ophthalmology. 3rd ed. Edinburgh: Mosby Elsevier, 2009. p 186–201. 8. Alió JL, Muftuoglu O, Ortiz D, Pérez-Santonja JJ, Artola A, Ayala MJ, Garcia MJ et al. Ten-year follow-up of laser in situ keratomileusis for myopia of up to -10 Diopters. Am J Ophthalmol 2008; 145: 46–54. 9. Basic and Clinical Science Course, Section 13: Refractive Surgery (2011–2012 edition). American Academy of Ophthalmology, 2011–2012. p 125– 136. 10. Fernandez-Vega L, Alfonso J, Villacampa T. Clear lens extraction for the correction of high myopia. Ophthalmology 2003; 110: 2349–2354. 11. Olsen G, Olsen RJ. Update on a long-term prospective study of capsulotomy and retinal detachment rates after cataract surgery. J Cataract Refract Surg 2000; 26: 1017–1021. 12. Colin J, Robinet A, Cochener B. Retinal detachment after clear lens extraction for high myopia: seven-year follow up. Ophthalmology 1997; 104: 73–77. 13. Martinez-Castillo V, Boixadera A, Verdugo A, Elíes D, Coret A, Garcia-Arumi J. Rhegmatogenous retinal detachment in phakic eyes after posterior chamber phakic intraocular lens implantation for severe myopia. Ophthalmology 2005; 112: 580–585. 14. Kwok AK, Young AL, Bhende P, Lam DS. Retinal detachment in phakic eyes with anterior chamber intraocular lenses to correct severe myopia. Am J Ophthalmol 1999; 128: 395–396 15. Ripandelli G, Coppé A, Parisi V, Olzi D, Scassa C, Chiaravalloti A, Stirpe M. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmology 2007; 114: 692–697. 16. Bylsma SS, Zalta AH, Foley E, Osher RH. Phakic posterior chamber intraocular lens pupillary block. J Cataract Refract Surg 2002; 28: 2222–2228.
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometrists Association Australia
