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Management of pupillary seclusion and occlusion of an iris enclaved intraocular lens

      The phakic intraocular lens (PIOL) is intended to treat large refractive errors of patients who are considered poor candidates for corneal refractive surgery.
      • Hassaballa MA
      • Macky TA
      Phakic intraocular lenses outcomes and complications: Artisan vs Visian ICL.
      ,
      • Tahzib NG
      • Nuijts RM
      • Wu WY
      • Budo CJ
      Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia; ten-year follow-up results.
      Phakic intraocular lens (IOLs) are generally categorized into 3 types: angle-supported, iris-fixated, and posterior-chamber IOLs.
      • Tahzib NG
      • Nuijts RM
      • Wu WY
      • Budo CJ
      Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia; ten-year follow-up results.
      ,
      • Jonker SMR
      • Berendschot TTJM
      • Ronden AE
      • Saelens IEY
      • Bauer NJC
      • Nuijts RMMA
      Long-term endothelial cell loss in patients with artisan myopia and artisan toric phakic intraocular lenses: 5 and 10 year results.
      The Artisan (Ophtec BV, Groningen, The Netherlands) and Verisyse (Abbott Laboratories, Lake Bluff, Ill) PIOLs are iris fixated and have a proven track record of safety.
      • Tahzib NG
      • Nuijts RM
      • Wu WY
      • Budo CJ
      Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia; ten-year follow-up results.
      ,
      • Maloney RK
      • Nguyen LH
      • John ME
      Artisan phakic intraocular lens for myopia: short-term results of a prospective, multicenter study; the Artisan Lens Study Group.
      Tahzib et al conducted a 10-year retrospective study of the Artisan PIOL for moderate to high myopic correction and reported that it is stable, predictable, and safe under a strict selection criterion.
      • Tahzib NG
      • Nuijts RM
      • Wu WY
      • Budo CJ
      Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia; ten-year follow-up results.
      Potential complications of iris-fixated PIOLs include pigment dispersion, cataract formation, and progressive loss of corneal endothelial cell count.
      • Hassaballa MA
      • Macky TA
      Phakic intraocular lenses outcomes and complications: Artisan vs Visian ICL.
      ,
      • Moshirfar M
      • Holz HA
      • Davis DK
      Two-year follow-up of the Artisan/Verisyse iris-supported phakic intraocular lens for the correction of high myopia.
      Glares and halos have also been reported to be potential issues.
      • Tahzib NG
      • Nuijts RM
      • Wu WY
      • Budo CJ
      Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia; ten-year follow-up results.
      Endothelial cell count loss, in particular, is associated with a shallower anterior chamber and smaller distance between the central and peripheral edge of the PIOL and the corneal endothelium.
      • Jonker SMR
      • Berendschot TTJM
      • Ronden AE
      • Saelens IEY
      • Bauer NJC
      • Nuijts RMMA
      Long-term endothelial cell loss in patients with artisan myopia and artisan toric phakic intraocular lenses: 5 and 10 year results.
      Jonker et al conducted a 5- and 10-year prospective, clinical cohort study in patients receiving an Artisan myopia and Artisan toric PIOLs and concluded that there is significant linear chronic endothelial cell count loss.
      • Jonker SMR
      • Berendschot TTJM
      • Ronden AE
      • Saelens IEY
      • Bauer NJC
      • Nuijts RMMA
      Long-term endothelial cell loss in patients with artisan myopia and artisan toric phakic intraocular lenses: 5 and 10 year results.
      We describe a case of complete pupillary seclusion and occlusion secondary to iris-enclaved polymethyl methacrylate (PMMA) PIOL implantation (Artisan Aphakia Model 205, Ophtec BV, Groningen, The Netherlands) and the surgical techniques involved in addressing this unusual presentation.
      A 51-year-old woman developed progressive, bilateral decrease in vision 1 year after bilateral Artisan PIOL implantation for the management of progressive hyperopia secondary to radial keratotomies. The bilateral radial keratotomies were performed 28 years before presentation. At presentation, her best-corrected visual acuity was 20/70−2 and 20/50−2 in the right and left eye, respectively. Intraocular pressure was 9 and 16 mm Hg in the right and left eye, respectively. Gonioscopic examination revealed grade 3 angles with 2+ pigment in the trabecular meshwork and mild peripheral anterior synechiae along the inferior quadrant in each eye. Anterior segment examination of the right and left eyes revealed 4 radial keratotomy incisions with an optical zone of 3.0 mm and a single arcuate keratotomy incision. Central corneal flattening and significant higher-order aberrations of the cornea were found in both eyes. The Artisan PIOL in each eye was well positioned with patent peripheral iridotomies. However, there was evidence of aggressive enclavation temporally and nasally of the iris stroma and the iris pigment epithelium (Fig. 1A, C). Bilateral pigment deposition was noted over the entire pupil, resulting in complete pupillary seclusion and occlusion (Fig. 1B, D). Preoperative biometric measurements of the right eye revealed an anterior chamber depth of 3.07 mm and an axial length of 25.48 mm. Biometric data of the left eye revealed an anterior chamber depth of 3.19 mm and an axial length of 25.51 mm.
      Fig 1
      Fig. 1(A) Preoperative anterior segment photograph of right eye demonstrating the Artisan lens with pupillary occlusion and seclusion. The picture was taken after 1 month of failed atropine 1% treatment. (B) Preoperative anterior segment photograph of right pupil demonstrating extent of pupillary occlusion and seclusion. The picture was taken after 1 month of failed atropine 1% treatment. (C) Preoperative anterior segment photograph of left eye demonstrating the Artisan lens with pupillary occlusion and seclusion. The picture was taken after 1 month of failed atropine 1% treatment. (D) Preoperative anterior segment photograph of left pupil demonstrating extent of pupillary occlusion and seclusion. The picture was taken after 1 month of failed atropine 1% treatment.
      Surgical management was conducted under general anaesthesia. Two paracentesis incisions were constructed at the 12 and 6 o'clock positions and the anterior chamber was filled with DisCoVisc (Alcon, Fort Worth, Tex). A 23-gauge microholding forcep from Microsurgical Technology (Redmond, Wash) was used to hold and stabilize the Artisan PIOL while a Kuglen hook was used to de-enclavate the iris at the 3 and 9-o'clock positions. A temporal conjunctival peritomy was made, followed by a scleral tunnel 1.5 mm from the surgical limbus. The Artisan PIOL was extracted uneventfully with the 23-gauge microholder. Extensive posterior synechiae was addressed manually with a Kuglen hook and with viscodilation. Five Grieshaber iris retractors (Alcon, Fort Worth, Tex) were used to dilate the iris to enhance visualization. The dense, thick iris pigment plaque on the central capsule was evacuated en-bloc with the anterior capsulotomy. A 2.4 mm clear cornea incision was made, uneventful phacoemulsification was performed, and an aspheric IOL was implanted into the capsular bag.
      The patient had an uneventful postoperative course with restoration of the pupillary margin in each eye (Fig. 2A, B). Her uncorrected visual acuity at the 3-month postoperative follow-up for the right and left eye was 20/20 and 20/20−2, respectively. Intraocular pressure remained normal postoperatively.
      Fig 2
      Fig. 2(A) Postoperative anterior segment photograph of right eye demonstrating restoration of the pupillary margin. (B) Postoperative anterior segment photograph of left eye demonstrating restoration of the pupillary margin.
      PIOL implantation is a valuable option for patients who do not meet the standard criteria for laser refractive surgery and for those who wish to maintain accommodation postoperatively.
      • Hassaballa MA
      • Macky TA
      Phakic intraocular lenses outcomes and complications: Artisan vs Visian ICL.
      ,
      • Tahzib NG
      • Nuijts RM
      • Wu WY
      • Budo CJ
      Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia; ten-year follow-up results.
      Although safe, they pose potential risks, including pigment dispersion, cataract formation, and progressive loss of endothelial cell count.
      • Hassaballa MA
      • Macky TA
      Phakic intraocular lenses outcomes and complications: Artisan vs Visian ICL.
      ,
      • Moshirfar M
      • Holz HA
      • Davis DK
      Two-year follow-up of the Artisan/Verisyse iris-supported phakic intraocular lens for the correction of high myopia.
      Studies of complete pupillary occlusion and seclusion have not been reported in the literature. This case report demonstrates a new possible complication with overaggressive iris enclavation. It is hypothesized that this aggressive enclavation caused extensive mechanical trauma to the iris pigment epithelium and led to profound iris pigment release, thereby generating complete pupillary seclusion and occlusion.
      The surgical technique described can be divided into 3 elements. First, the PIOL was de-enclaved and removed through a scleral tunnel. The iris pigment plaque was then removed en-bloc, and the iris was mechanically retracted. Finally, phacoemulsification and insertion of an IOL into the capsular bag was then completed. The removal of the PIOL was performed first in order to create more space for surgical manoeuvres and promote normal fluidics during phacoemulsification. A scleral tunnel is recommended in order to minimize surgically induced astigmatism. The mechanical release of iris pigment plaque allowed for en-bloc removal of the iris pigment plaque within the anterior capsulotomy.
      The described surgical technique enabled safe removal of the PIOL and iris pigment plaque and restored the pupil, thereby allowing for cataract surgery with minimal surgically induced astigmatism.

      CRediT Author Statement

      Rami Abo-Shasha: Writing – Original Draft, Writing – Review & Editing. Bo Li: Conceptualization, Methodology, Writing – Review & Editing, Supervision

      References

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        Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia; ten-year follow-up results.
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