Transcript Case
Mechanically-Induced Pigment Dispersion despite Endocapsular Intraocular Lens Implantation Nathalie M. Guibord,MD Geisinger Medical Center Author has no financial interest Purpose • To report a case of severe pigment dispersion that began on post-operative day one after cataract surgery with endocapsular implantation of a squareedge intraocular lens (IOL) . • The cause of the pigment dispersion in this unique case is discussed. Methods • 70 year old Caucasian female – Retinal detachment repaired by scleral buckle OD in 1995 – High myopia with lattice OU – Pigment dispersion syndrome OU • Krukenberg spindle, pigmentation on gonioscopy and q configuration to iris • No iris trans-illumination defects (TID’s) • Status-post uneventful phaco/IOL OS Methods • Underwent phaco/IOL OD – Two clock hours of weak zonules noted during chopping • CTR model 14A (14.5 mm) inserted • SA60AT 7.5 D in the bag – Lens centered very well, in the bag Methods • POD #1 – 4+ pigmented cells in anterior chamber – IOL well-centered and in the bag Methods • POD #3 – Still had 4+ pigmented cells – IOL confirmed to be endocapsular – Vitreous was clear – Laser peripheral iridectomy was performed due to q configuration of the iris Methods • Pigment-induced ocular hypertension occurred by POD #13 – Ta 31 – 4+ pigmented cells – 4+ Iris TID’s in configuration of IOL, raising doubts that IOL was fully endocapsular • IOL seemed very close to the iris – Started on acetozolamide p.o. – Schedule to return to O.R. the next day Results • OR POD #14 – IOL found to be 100% endocapsular – IOL explanted as pseudophacodonesis with square-edge iris chaffing suspected – MA60AC 7.5 D was inserted in sulcus Results • IOP controlled by POD #2 status-post IOL exchange – patient gradually improved over the next few weeks • 3 months post-op – Va cc 20/20 – Ta 15 mmHg – Trace flare – Off all eye meds • Has continued to do well since then Results • Pseudophacodonesis occurred secondary to zonular dialysis (needing a CTR), large scleral buckle and vitreous pressure • SA60AT should not be placed in the sulcus – – – – Zero angulation between optic and haptics Square edges anteriorly (optic and haptics) High risk for iris chaffing Not indicated in direction-for-use labeling Conclusion • There are several reports of mechanically-induced pigment dispersion associated with the implantation of a SA60AT in the sulcus • No reported cases of pigment dispersion from this IOL when positioned completely within the capsular bag Conclusion • The primary cause of pigment dispersion in this case was pseudophacodonesis with an IOL with anterior square edges. • This case demonstrates how it is prudent to insert a three-piece IOL with rounded anterior edges, in cases when the zonular integrity has been compromised and posterior vitreous pressure is present (as with a scleral buckle).