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A 43-year-old female presented with sudden monocular diplopia and blurred vision OD for 4 days. Three years prior in Peru she had undergone successful implantation of bilateral Artiflex (Ophtec, Groningen, The Netherlands) phakic intraocular lenses (pIOL) for high myopia. The patient denied any recent or previous trauma. On examination, her Snellen uncorrected distance visual acuity (UDVA) was 20/30 OD and 20/50 OS. Intraocular pressures (IOPs) were normal in both eyes (13 mm Hg OD, 12 mm Hg OS). Slit-lamp examination showed clear cornea with no anterior chamber reaction evident. The nasal clip of the OD Artiflex pIOL was loose, causing the pIOL to hang inferiorly (Fig. 1). The temporal haptic remained fixed at the 9-o’clock position. Signs of iris atrophy were evident at the previous site of enclavation, and a peripheral iridotomy was patent superiorly.
Three days after presentation, the patient underwent successful repositioning of the dislocated pIOL. A 2.75-mm keratome was used to make a 12-o’clock corneal incision. Side ports were created using a 15-degree blade at 10 o’clock and 2 o’clock. Miochol (Iolab Pharmaceuticals, Claremont, Calif.) was injected to minimize pupil size followed by a cohesive viscoelastic to form the anterior chamber. A Sinskey hook was used to reposition the dislocated pIOL. The pIOL was held in place using a pIOL implantation forceps through the 12-o’clock incision. The dislocated haptic was re-enclavated using the enclavation needle through the side ports. The 12-o’clock corneal incision was closed using 3 interrupted 10–0 nylon sutures. Irrigation of the anterior chamber through the main incision using a 3-mL syringe with balanced salt solution was performed to clear the viscoelastic. Postoperatively, the patient used topical moxifloxacin 0.5% and dexamethasone 0.1% qid and combination 2% dorzolamide HCl and 0.5% timolol maleate ophthalmic solution drops bid for 1 week.
The patient was followed at 1 day, 1 week, 1 month, 2 months, and 9 months postoperatively. At day 1 postoperatively, her diplopia had resolved. At 9 months, UDVA was 20/40 OD, manifest refraction of –1.00 –0.50 × 17 yielded best corrected vision of 20/25, and IOP was normal. Slit-lamp examination showed a stable and centred Artiflex lens and clear cornea (Fig. 2).
Phakic IOL implantation has become an effective and safe procedure for refractive correction, particularly in patients not suitable for LASIK and phototherapeutic keratectomy. The Artisan lens (Ophtec, Groningen, The Netherlands) was the original lens in the iris-claw pIOL family. It has a 5.0- to 6.0-mm polymethylmethacrylate lens (PMMA) optic with PMMA haptics. However, a corneal incision up to 6.2 mm in length is required for insertion. The Artiflex pIOL is a foldable version capable of being inserted through a 3.2-mm sutureless incision and uses a 6-mm silicone optic with PMMA haptics.
Given the longer history of the Artisan pIOL, the majority of literature concerning the complications associated with iris-claw pIOLs is derived from this older model. These studies often do not make the distinction between early and late spontaneous dislocation, traumatic and spontaneous dislocation, or the type of iris-claw pIOL in mixed cohorts. Titiyal et al.
reported 1 Artiflex lens (2.4%) dislocation twice nasally (unspecified time) without evidence of trauma.
The precise causes of spontaneous dislocation of iris-fixed pIOLs are unclear. In early spontaneous dislocation, surgical factors are likely to play a significant role. The surgeon must ensure adequate amounts of iris tissue are securing the haptics, whereas avoiding endothelium and crystalline lens contact. Stulting et al.
noted that in their 662 cases of Artisan implantation, half of the adverse events and cases needing repositioning (31/61) involved the first 10 cases performed by each surgeon.
Late spontaneous dislocation of an iris-claw pIOL likely involves atrophy of the enclavated iris tissue caused by pressure exerted by the implant’s haptic. In their report on Artisan pIOLs, Titiyal et al.
found evidence of iris tissue depigmentation and atrophy at the enclavation sites in 29.4% of eyes, and all cases of spontaneous dislocation showed signs of atrophy. Several other reports have also detected atrophy by the Artisan iris-claw haptics, including El Danasoury et al.
reported a case where unrecognized damage to a haptic in a challenging enclavation procedure led to disenclavation in an Artisan iris-claw pIOL 4 weeks later. This was successfully repaired by suturing the damaged haptic to the iris. In exceptional circumstances where no replacement lenses are available and leaving the patient aphakic for a later surgery is contraindicated, this alternative procedure may be appropriate.
The presence of a dislocated pIOL is easily spotted by slit-lamp examination. The importance in recognizing its occurrence lies in educating the patient about identification of symptoms to prompt early medical examination before more serious complications occur. This includes corneal endothelial damage and cataract formation from rubbing of the implant against the cornea and lens, respectively. Harsum et al.
reported a case of an Artisan late spontaneous dislocation with delayed seeking of medical attention resulting in corneal decompensation requiring an endothelial graft. Symptoms may be mild with no significant loss in visual acuity, as in our patient whose primary complaint was monocular-diplopia and as reported by Singhal and Sridhar
in 2 cases of Artisan late spontaneous dislocation. No studies have examined the recurrence of these complications.
In conclusion, this case highlights the possibility of late spontaneous dislocation of an Artiflex lens as a rare complication in iris-claw pIOL implantation, as well as the importance of educating patients to identify symptoms and seek medical treatment even in the absence of obvious trauma to prevent further complications.
Outcomes of reenclavation of subluxated iris-fixated phakic intraocular lenses: comparison with primary surgery outcomes.