Ophthalmology DX: When an IOL Goes Footloose!

Slideshow

  • Figure 1. Five weeks after cataract surgery, the patient reported with a feeling that something had gone wrong. He was right. This image shows his anterior chamber intraocular lens had slightly rotated clockwise.

  • Figure 2. At the same 5-weeks postoperative visit, gonioscopy demonstrated how his IOL and footplate had rotated to totally cover the superior iridectomy.

  • Figure 3. Two weeks later after undergoing 2 laser procedures, this photo shows that the forward bowing of his iris was gone and that both edges of the IOL were visible, as were both iridotomies.

A 58-year-old patient presented to the office 1 month after having undergone cataract surgery on his right eye. During that operation, the posterior capsule was damaged and removed. At the time this case occurred, standard of care was to implant a single-piece anterior chamber lens. At the 1- and 3-week follow up visits, the patient appeared normal, with good vision, normal IOPs, and satisfactory lens positioning. However, 2 weeks later, the patient felt something was wrong in his right eye and returned to the clinic. The intraocular lens (IOL) had slightly rotated clockwise (Figure 1). As shown in (Figure 2), a gonioscopic evaluation revealed that the IOL and footplate had rotated to totally cover the superior iridectomy. The angle appeared open in the area between the footplates, but the right side of the implant was visibly covered by the forward bowing of the iris. The left side of the implant the iris was also bowed forward and his IOP had risen to 55 mm Hg OD. The patient was immediately sent to the surgeon the same day and underwent 2 laser in-office iridotomies. His postoperative pressure dropped back down to 15 mm Hg. On a later follow-up (Figure 3) the forward bowing of the iris was gone. Both edges of the IOL were visible, as were both iridotomies. 

Note how easily visible the reflection of the left edge of the IOL in Figure 3 when the forward movement of the iris is no longer present. This occurred because the pressure had returned to normal. The patient’s final vision was 20/20.

Newer AC IOLs are open style, thinner and have long angled footplates, flexible, and provide better long term outcomes. The earlier AC IOLs had a limited range of sizes available to the surgeon.1 Many older lenses were often a 1...

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Newer AC IOLs are open style, thinner and have long angled footplates, flexible, and provide better long term outcomes. The earlier AC IOLs had a limited range of sizes available to the surgeon.1 Many older lenses were often a 1 piece, nonflexible, PMMA material with 4 footplates, as seen in the above photos.2 

The AC IOL had rotated as seen in the left photo, to completely block the surgical iridectomy and cause the forward bowing of the iris and angle closure glaucoma. 

This patient experienced no optic nerve damage, thanks to the prompt referral to the surgeon. The problem of the lens movement was explained to the patient. The patient moved out of the area and follow ups were arranged by the surgeon.

References

1. Holt D, Young J, Stagg B, Ambati B. Anterior chamber intraocular lens, sutured posterior chamber intraocular lens, or glued intraocular lens: where do we stand? Curr Opin Ophthalmol. 2012;23(1):62-67. doi:10.1097/ICU.0b013e32834cd5e5 

2. Apple D,  Brems R, Park R, et al. Anterior chamber lenses. Part 1: Complications and pathology and a review of designs. J Cataract Refract Surg. 1987;13(2):157-74. doi:10.1016/s0886-3350(87)80131-1.

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