Surgical management of acute angle-closure glaucoma after toric ICL implantation

Reverse pupillary block with pigment dispersion and elevated intraocular pressure following bilateral phakic intraocular lens implantation

The authors describe a case of reverse pupillary block with pigment dispersion following sequential phakic intraocular lens (pIOL) implantation for high myopia, in a young female patient. The intraocular pressure (IOP) elevation began 3 weeks postoperatively, for which Nd-YAG laser peripheral iridotomies (PIs) were attempted elsewhere. Despite maximum medical therapy, the IOP was uncontrolled. She was referred to our institute for further management. Examination showed anteriorly displaced iris-pIOL diaphragm, iris pigment dispersion and raised IOP. The PIs were incomplete. Based on clinical evaluation and investigations, we concluded that the excess area of contact of the posterior iris over the pIOL caused a reverse pupillary block and pigment dispersion. The IOPs were controlled by repeating laser iridotomies and with medical therapy. Subsequently, the patient developed a low lens vault leading to bilateral cataract. Sequential explantation of the pIOL along with cataract extraction was performed and her vision was restored.

Clinical Prediction of Excessive Vault After Implantable Collamer Lens Implantation Using Ciliary Body Morphology

PURPOSE

To determine the factors related to the ciliary body that are predictive of outcomes of excessive vault (> 1,000 µm) after Implantable Collamer Lens (ICL V4c; STAAR Surgical) implantation.

METHODS

In this retrospective case-control study, 27 eyes of 27 patients who presented with excessive vault (> 1,000 µm) following implantation of an ICL V4c were matched in a 1:2 ratio with those who presented with a normal vault (250 to 1,000 µm) on white-to-white distance, anterior chamber depth, and ICL size. The preoperative biometric parameters and clinical outcomes were compared between the two groups. The relationship between the postoperative vault and various variables was assessed by multiple linear regression analysis. Conditional logistic regression models were used to estimate odds ratios (ORs) and 95% CIs for excessive vault.

RESULTS

The vault value 1 month postoperatively was associated with preoperative anterior chamber volume, iris-ciliary angle, and crystalline lens rise (P < .05). In the conditional regression logistic analysis, every 1° reduction in iris-ciliary angle was associated with 4% increased odds of vault greater than 1,000 µm (OR = 0.96; 95% CI = 0.93 to 0.99; P < .001) and the anteriorly positioned ciliary body was associated with an increased risk of excessive vault after ICL implantation (OR = 3.57; 95% CI = 1.67 to 7.63; P < .001). In the excessive vault group, 1 eye underwent the ICL extraction and 3 eyes had an ICL exchange for a smaller ICL. After the ICL exchange, the mean value of postoperative vault decreased from 1,525.67 ± 468.22 to 810.33 ± 254.92 µm.

CONCLUSIONS

Eyes with an anteriorly positioned ciliary body were associated with a higher rate of excessive vault after ICL implantation, so the size of the ICL may need to be adjusted in these patients. Assessment of ciliary body characteristics adds significant information to the prediction of excessive vault after surgery. [J Refract Surg. 2020;36(6):380-387.].

Causes of elevated intraocular pressure following implantation of phakic intraocular lenses for myopia

The purpose of this study is to present the causes and visual acuity outcomes in patients with elevated intraocular pressure (IOP) following implantable collamer lens (ICL) implantation. A chart review identified patients who developed high IOP at any postoperative examination and a minimum follow-up period of 3 months after ICL implantation. Data are reported out to 6 months postoperatively. Outcome measures included causes of elevated IOP, best-corrected visual acuity (BCVA) at last visit, number of glaucoma medications, other interventions, and glaucomatous damage. Elevated IOP occurred in 58 (10.8 %) of 534 eyes that received ICL. The mean age was 28 ± 7.2 years. The preoperative IOP was 16.3 ± 1.2 mmHg. Elevated IOP most commonly occurred on the first postoperative day (23/58 (39.7 %) eyes) due to retained viscoelastic. This was followed by steroid response in 22/58 (37.9 %) eyes at 2-4 weeks postoperatively. IOP elevation in 6 (10.3 %) eyes was related to high ICL vault and pupillary block, and in 4 (6.9 %) eyes due to synechial angle closure. At last visit, BCVA was 20/40 or better in 56/58 (96.6 %) eyes, and 5/58 (8.6 %) eyes remained on glaucoma medications due to persistent steroid response (2 eyes), synechial angle closure glaucoma (1 eye), and other causes (2 eyes). One eye showed glaucomatous damage. Two eyes with high vault and elevated IOP underwent ICL explantation. There is a moderate risk of transiently developing elevated IOP after ICL implantation. Thorough removal of viscoelastic and use of anti-glaucoma medications during steroid use will reduce the majority of cases with postoperative IOP elevation.

Viscocannula-assisted reinversion of implantable collamer lens: comparison of postoperative outcomes with the fellow eyes

PURPOSE

To analyze and compare the postoperative outcomes of eyes with accidental intraoperative inversion of implantable collamer lens (ICL) and viscocannula-assisted reinversion in high myopia.

DESIGN

Retrospective observational case comparison.

METHODS

SETTING

Institutional practice.

PATIENTS

Consecutive eyes with accidental intraoperative inversion of ICL and viscocannula-assisted reinversion from January 2007 to September 2010 were analyzed retrospectively. They were compared with the fellow eyes with normal ICL implantation at 1 month, 6 months, and 2 years.

MAIN OUTCOME MEASURES

Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), corneal pachymetry, endothelial cell loss, intraocular pressure, lens transparency, anterior chamber depth, and postoperative uveitis.

RESULTS

A total of 206 myopic eyes had ICL implantation. Eight eyes (3.8%) of 8 patients had accidental intraoperative reinversion. Their fellow eyes had normal ICL implantation. There was no significant change (P = .611) in UCVA (reinverted and fellow eyes) at 2 years. There was no significant difference in postoperative UCVA (P = .611) and BCVA (P = .854) between the reinverted and the fellow eyes. The mean endothelial loss at 1 month, 6 months, and 2 years was 0.96% ± 0.5%, 0.92% ± 0.63%, and 0.89% ± 0.52% respectively in the reinverted eyes. There was no significant difference in the endothelial loss between the 2 groups at 1 month (P = .753), 6 months (P = .834), and 2 years (P = .916). One out of 8 eyes with reinversion had postoperative corneal edema, which resolved at 48 hours. None of the eyes reported uveitis or glaucoma. There was no loss of lens transparency.

CONCLUSION

Intraoperative inversion can occur during insertion of ICL and viscocannula-assisted reinversion can be performed without significant complications.

Implantable collamer posterior chamber intraocular lenses: a review of potential complications

PURPOSE

To review the peer-reviewed literature reporting postoperative complications of the most recent models of Visian Implantable Collamer posterior chamber intraocular lenses (ICL, STAAR Surgical Co).

METHODS

A literature search of the PubMed database was performed to identify all articles related to ICL complications. Articles were obtained and reviewed to identify those that reported complications using the latest ICL designs.

RESULTS

Cataract was the major postoperative complication reported: 136 (5.2%) in 2592 eyes. Of those, 43.4% (n=59) were reported within 1 year, 15.4% (n=21) between 1 and 3 years, and 35.3% (n=48) ≥ 3 years after ICL implantation. Twenty-one (15.4%) cataracts were reported as surgically induced, 46 (33.8%) eyes had poor vault (<200 μm), and cataract surgery was carried out in 27.9% (n=38) of eyes. Early acute intraocular pressure increase was also reported to be relatively frequent, whereas acute pupillary block was less frequent and mostly resolved with additional iridotomies. A total of 42 ICLs were explanted due to cataract and IOP. Reported endothelial cell loss varied from 9.9% at 2 years to 3.7% 4 years postoperatively. This loss was reported to be more pronounced within the first 1 to 2 years, with stability or lower progression after that time.

CONCLUSIONS

The majority of reported complications after ICL implantation are cataract formation. The improvements in lens geometry and more accurate nomograms applied to the selection of the lens to be implanted, in addition to the surgeon's learning curve, might be factors in the decreased occurrence of postoperative complications reported currently.