Complications following implantation of posterior chamber phakic intraocular lens (pIOL)
- 1 Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
- 2 Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Dr RP Centre for Ophthalmic Sciences, New Delhi, Delhi, India
- Correspondence to Dr Prafulla Kumar Maharana; drpraful13@gmail.com
Abstract
A male patient in his 20s presented with right eye aphakic corneal decompensation and left eye intumescent cataract with phakic intraocular lens (pIOL) lenticular touch. He had a history of pIOL implantation in both eyes 6 months ago. On first postoperative day, uncorrected distance visual acuity was 20/400 and 20/20 in right and left eye, respectively. Postoperatively, a diagnosis of right eye toxic anterior segment syndrome (TASS) was made and pIOL was explanted. Subsequently, the patient developed intumescent cataract for which lens aspiration with posterior chamber intraocular lens (PCIOL) implantation was performed in the right eye. Ongoing uveitis with membrane formation warranted PCIOL explantation. The patient developed aphakic corneal decompensation in the right eye and underwent penetrating keratoplasty with intrascleral haptic fixation of an intraocular lens. Central pIOL-lenticular touch with intumescent cataract was diagnosed in the left eye for which pIOL explant with lens aspiration and PCIOL was done. TASS and post-pIOL cataract are rare but vision-threatening complications require judicious management for visual rehabilitation.
Background
Intraocular lens-based refractive procedures, including both phakic intraocular lens (pIOL) and refractive lens exchange (RLE), are used to correct higher degrees of refractive errors that cannot be effectively managed with kerato-refractive procedures alone.1 Although with the development of the new platforms of trifocal and toric intraocular lenses, the published visual results and patient satisfaction are very good, the pIOL technique is preferred over RLE, due to both its preservation of accommodation and its reversibility, but the greatest concern with performing an RLE in high myopia, particularly in those younger than 55 years, is the very significant increased risk of retinal detachment as a postoperative complication.2–6 Although angle-support pIOLs existed in the past, all of them have now been discontinued due to complications fundamentally related to the corneal endothelium, and therefore currently there are only two types of pIOLs in clinical use: iris-claw lenses with anterior fixation and those which are implanted in the posterior chamber. Some complications have been increasingly reported after anterior chamber iris-claw pIOLs, particularly chronic endothelial cell loss, which has been the cause of pIOL explantation, and even that has led to the need for corneal transplant. On another note, cataract was a concern with the original posterior chamber pIOLs, but its incidence has been significantly reduced, even to zero in some series, with newer models of the device. Other complications, such as postoperative pupillary block, toxic anterior segment syndrome (TASS) and Urrets-Zavalia syndrome, have been rarely reported following posterior chamber pIOL.7–15
Herein, we report a rare case of a high myope in his 20s who underwent pIOL implantation and suffered a series of complications associated with the procedure.
Case presentation
A male patient in his 20s presented with right eye aphakic corneal decompensation and left eye intumescent cataract related to low vault of a posterior chamber pIOL, as complications of a prior surgery performed 6 months earlier elsewhere. Corrected distance visual acuity (CDVA) was counting finger 50 cm and 20/1200 in right and left eye, respectively, with normal intraocular pressure. Slit-lamp examination revealed corneal oedema, pigment on endothelium, irregular anterior chamber with 360° peripheral anterior synechia and aphakia in the right eye (figure 1A) and intumescent cataract with pIOL lenticular touch in the left eye (figure 1B). His pupil was non-reacting and mid-dilated with fibrinous membrane at pupillary margin in the right eye. Ultrasonography of posterior segment was unremarkable in both eyes. He had a history of pIOL implantation in both eyes 6 months ago. On first postoperative day, uncorrected distance visual acuity was 20/400 and 20/20 in right and left eye, respectively. Severe uveitis was observed in the right eye and a diagnosis of TASS was made and pIOL was explanted. Severe ongoing postoperative uveitis with membrane formation warranted explantation of posterior chamber intraocular lens (PCIOL). Subsequently, the patient developed aphakic corneal decompensation in the right eye 1 month following surgery.
(A) Slit-lamp photograph reveals corneal oedema, fibrinous reaction in anterior chamber with 360° peripheral anterior synechia and aphakia in the right eye and (B) intumescent cataract with phakic intraocular lens lenticular touch in the left eye.
Two months later, intumescent cataract was observed in the left eye for which lens aspiration with PCIOL implantation was performed.
Treatment
At our centre, penetrating keratoplasty with intrascleral haptic fixation of intraocular lens was done in the right eye (figure 2A) and pIOL explant with lens aspiration and PCIOL implantation in the left eye (figure 2B).
(A) Clear corneal graft 6 months following penetrating keratoplasty and intrascleral haptic fixation of an intraocular lens in the right eye; and (B) pseudophakia with single-piece foldable hydrophobic acrylic intraocular lens in bag in the left eye.
Outcome and follow-up
Postoperative CDVA of 20/50 was noted at 6-month follow-up with a clear graft in the right eye, and 20/20 was noted at 3-month follow-up in the left eye. Specular microscopy revealed an endothelial cell count of 1164 and 1675 cells/mm² in right and left eye, respectively.
Discussion
Posterior chamber pIOL implantation has been described as a safe and effective surgery to correct higher levels of ametropia. It demonstrates numerous advantages over keratorefractive procedures for refractive correction of moderate and high myopia, such as lesser induction of postoperative aberrations, retinal image magnification and better contrast sensitivity.9 10 16
Implantable collamer lens (ICL) is the only Food and Drug Administration-approved posterior chamber pIOL and over the decade several alternatives of ICL have emerged. The safety and complications of these intraocular lenses have been reported rarely. Our patient developed TASS on postoperative day 1 of pIOL implantation, which is quite an infrequent complication pertaining to pIOLs. TASS can occur secondary to inadequate cleaning of surgical instruments, contamination of surgical instrument or IOLs, intracameral solutions, viscoelastics and adverse drug reactions; however, it is not always possible to trace and identify the actual causative agent. In our patient, the exact cause of TASS could not be ascertained. Although it has been frequently reported following cataract surgery, TASS following ICL-V4c has been reported in very few cases previously, and all cases were successfully managed with timely initiation of intense steroid therapy with none of them requiring pIOL explantation.11–13 17 It is important to identify and treat TASS with intensive steroid therapy as extensive anterior segment inflammation can result in grave sequelae such as toxic endothelial cell damage, corneal decompensation, secondary glaucoma, synechiae formation and cystoid macular oedema. These sequelae lead to visual disturbances and loss of visual function and may require surgical intervention such as in our case.
Cataract formation and raised intraocular pressure are the most recognised safety concerns associated with posterior chamber pIOL. In our patient, the intumescent nature of cataract suggested intraoperative iatrogenic trauma to the crystalline lens during pIOL implantation. Further chances of early lenticular opacification increase following intense inflammation. This is of relevance in patients undergoing ICL implantation surgery, where obtaining good unaided vision is of prime importance.
To conclude, refractive surgery in young patients provides excellent visual outcomes in terms of safety and efficacy. Lens-based procedures have proven to be safe but, as shown here, complications like TASS and iatrogenic cataract can occur following intraocular procedures, and patients must be well counselled preoperatively regarding such risks. Such complications are rare, but when they occur, they may have devastating long-term consequences on patients’ quality of life.
Learning points
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It is important to identify and treat toxic anterior segment syndrome with intensive steroid therapy as it can result in toxic endothelial cell damage, corneal decompensation and secondary glaucoma, which might lead to loss of visual functions and may require surgical intervention.
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Surgical trauma can lead to cataract. Hence, extreme caution must be taken during surgery.
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Surgical trauma-induced cataract may be intumescent and may not necessarily manifest in the immediate postoperative days; hence, a close follow-up is a must.
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Patients undergoing phakic intraocular lens implantation must be counselled about these possible complications preoperatively.
Ethics statements
Patient consent for publication
Footnotes
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Twitter @praful276
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Contributors SM—manuscript preparation. PS and MT—data collection. PKM—concept and design.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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