Advertisement

Late spontaneous dislocation of a silicone iris-claw phakic intraocular lens

      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.
      Figure thumbnail gr1
      Fig. 1Slit-lamp photo of patient’s right eye at presentation, 3 years after original phakic intraocular lens (pIOL) implantation. Note the loose nasal clip of the Artiflex pIOL causing the lens to be dislocated inferiorly.
      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).
      Figure thumbnail gr2
      Fig. 2Slit-lamp photo of patient’s right eye 9 months after repositioning of the dislocated Artiflex silicone phakic intraocular lens.
      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.
      • Titiyal J.S.
      • Sharma N.
      • Mannan R.
      • Pruthi A.
      • Vajpayee R.B.
      Outcomes of reenclavation of subluxated iris-fixated phakic intraocular lenses: comparison with primary surgery outcomes.
      reported the incidence rate of spontaneous dislocation at 7.3% in Artisan pIOL eyes in their series. Akcay et al.
      • Akcay L.
      • Eser I.
      • Kaplan A.T.
      • Taskiran-Comez A.
      • Dogan O.K.
      Phakic anterior chamber lenses in very high myopia: an 18-month follow up.
      showed dislocation (unspecified type) in 3.2% of Artiflex eyes, whereas Kwitko and Stolz
      • Kwitko S.
      • Stolz A.P.
      Iris-claw (Artisan/Artiflex) phakic intraocular lenses for high myopia and high hyperopia.
      found spontaneous dislocation (mixed Artisan and Artiflex cohort; unspecified model) in 2.4% of iris-claw pIOL eyes. Van Philips
      • van Philips L.A.
      High and low contrast visual acuity after artiflex phakic intraocular lens implantation for the correction of myopia.
      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.
      • Stulting R.D.
      • John M.E.
      • Maloney R.K.
      • et al.
      Three-year results of Artisan/Verisyse phakic intraocular lens implantation. Results of the United States Food and Drug Administration clinical trial.
      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.
      • Titiyal J.S.
      • Sharma N.
      • Mannan R.
      • Pruthi A.
      • Vajpayee R.B.
      Outcomes of reenclavation of subluxated iris-fixated phakic intraocular lenses: comparison with primary surgery outcomes.
      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.
      • El Danasoury M.A.
      • El Maghraby A.
      • Gamali T.O.
      Comparison of iris-fixed Artisan lens implantation with excimer laser in situ keratomileusis in correcting myopia between -9.00 and -19.50 diopters: a randomized study.
      (27.9%), Benedetti et al.
      • Benedetti S.
      • Casamenti V.
      • Benedetti M.
      Long-term endothelial changes in phakic eyes after Artisan intraocular lens implantation to correct myopia: five-year study.
      (16.3%), and Saxena et al.
      • Saxena R.
      • Landesz M.
      • Noordzij B.
      • Luyten G.P.
      Three-year follow-up of the Artisan phakic intraocular lens for hypermetropia.
      (11.8%), whereas others have found no evidence of iris atrophy.
      • Coullet J.
      • Guell J.L.
      • Fournie P.
      • et al.
      Iris-supported phakic lenses (rigid vs foldable version) for treating moderately high myopia: randomized paired eye comparison.
      • Huang D.
      • Schallhorn S.C.
      • Sugar A.
      • et al.
      Phakic intraocular lens implantation for the correction of myopia: a report by the American Academy of Ophthalmology.
      • Tehrani M.
      • Dick H.B.
      Short-term follow-up after implantation of a foldable iris-fixated intraocular lens in phakic eyes.
      Excessive manipulation of the iris tissue during enclavation may also predispose the iris tissue to atrophy. Rai et al.
      • Rai A.S.
      • Varma D.K.
      • Ahmed I.K.
      Suture fixation of iris-claw intraocular lens.
      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.
      • Rai A.S.
      • Varma D.K.
      • Ahmed I.K.
      Suture fixation of iris-claw intraocular lens.
      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.
      • Harsum S.
      • Tossounis C.
      • Tappin M.J.
      Spontaneous dislocation of an Artisan phakic IOL causing corneal decompensation requiring an endothelial graft.
      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
      • Singhal S.
      • Sridhar M.S.
      Late spontaneous dislocation (disenclavation) of iris-claw intraocular lenses.
      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.

      References

        • Titiyal J.S.
        • Sharma N.
        • Mannan R.
        • Pruthi A.
        • Vajpayee R.B.
        Outcomes of reenclavation of subluxated iris-fixated phakic intraocular lenses: comparison with primary surgery outcomes.
        J Cataract Refract Surg. 2010; 36: 577-581
        • Akcay L.
        • Eser I.
        • Kaplan A.T.
        • Taskiran-Comez A.
        • Dogan O.K.
        Phakic anterior chamber lenses in very high myopia: an 18-month follow up.
        Clin Experiment Ophthalmol. 2012; 40: 275-281
        • Kwitko S.
        • Stolz A.P.
        Iris-claw (Artisan/Artiflex) phakic intraocular lenses for high myopia and high hyperopia.
        Expert Rev Ophthal. 2011; 6: 505-512
        • van Philips L.A.
        High and low contrast visual acuity after artiflex phakic intraocular lens implantation for the correction of myopia.
        J Refract Surg. 2010; 26: 423-429
        • Stulting R.D.
        • John M.E.
        • Maloney R.K.
        • et al.
        Three-year results of Artisan/Verisyse phakic intraocular lens implantation. Results of the United States Food and Drug Administration clinical trial.
        Ophthalmology. 2008; 115 (e1): 464-472
        • El Danasoury M.A.
        • El Maghraby A.
        • Gamali T.O.
        Comparison of iris-fixed Artisan lens implantation with excimer laser in situ keratomileusis in correcting myopia between -9.00 and -19.50 diopters: a randomized study.
        Ophthalmology. 2002; 109: 955-964
        • Benedetti S.
        • Casamenti V.
        • Benedetti M.
        Long-term endothelial changes in phakic eyes after Artisan intraocular lens implantation to correct myopia: five-year study.
        J Cataract Refract Surg. 2007; 33: 784-790
        • Saxena R.
        • Landesz M.
        • Noordzij B.
        • Luyten G.P.
        Three-year follow-up of the Artisan phakic intraocular lens for hypermetropia.
        Ophthalmology. 2003; 110: 1391-1395
        • Coullet J.
        • Guell J.L.
        • Fournie P.
        • et al.
        Iris-supported phakic lenses (rigid vs foldable version) for treating moderately high myopia: randomized paired eye comparison.
        Am J Ophthalmol. 2006; 142: 909-916
        • Huang D.
        • Schallhorn S.C.
        • Sugar A.
        • et al.
        Phakic intraocular lens implantation for the correction of myopia: a report by the American Academy of Ophthalmology.
        Ophthalmology. 2009; 116: 2244-2258
        • Tehrani M.
        • Dick H.B.
        Short-term follow-up after implantation of a foldable iris-fixated intraocular lens in phakic eyes.
        Ophthalmology. 2005; 112: 2189-2195
        • Rai A.S.
        • Varma D.K.
        • Ahmed I.K.
        Suture fixation of iris-claw intraocular lens.
        J Cataract Refract Surg. 2012; 38: 743-745
        • Harsum S.
        • Tossounis C.
        • Tappin M.J.
        Spontaneous dislocation of an Artisan phakic IOL causing corneal decompensation requiring an endothelial graft.
        Eye. 2010; 24: 1292
        • Singhal S.
        • Sridhar M.S.
        Late spontaneous dislocation (disenclavation) of iris-claw intraocular lenses.
        J Cataract Refract Surg. 2005; 31: 1441-1443