Eyeworld

EW NEWS & OPINION 11 T he complication presented herein has been described in only a few case reports. Given that the interest in the piggyback procedure has renewed in recent years second- ary to its utility in correcting resid- ual refractive errors, surgeons should be aware of the possibility of this postop complication. Case report A 66-year-old gentleman with macular degeneration presented with high myopia and cataract (case of Luther Fry, MD, Garden City, Kan.). 1 At that time, his spherical equivalent was approximately –20.0 D OU, and axial lengths were 28.83 mm OD and 28.52 mm OS. B-scan ultrasonography did not reveal posterior staphyloma, but corneal topography demonstrated keratoconus, particularly in OS. The patient underwent uneventful cataract surgery with in-the-bag implantation of a –4.0 D AcrySof MA60MA posterior chamber (PC) IOL (Alcon, Fort Worth, Texas) in OD, followed by in-the-bag implan- tation of a –9.0 D AR40M IOL (Advanced Medical Optics, Santa Ana, Calif.) in OS. On postop day 1, uncorrected visual acuity (UCVA) in OS was 20/400, 20/200 with pinhole. Residual refraction was +3.50 + 1.50 x 70 (20/100). An IOL exchange OS was attempted 12 days postop; however, the PC IOL was firmly attached to the capsular bag. Thus, a piggyback 3-piece AcrySof +5.0 D MA60MA IOL was placed in the ciliary sulcus without any com- plications. One day after the ex- change, UCVA was 20/200 without any improvement on pinhole. Resid- ual refraction of OS was –1.00 + 1.25 x 110, and IOP was 12 mmHg OS. Five weeks after the piggyback procedure, the patient complained of decreased vision OS. UCVA was 20/400 OS, without improvement on pinhole, and IOP was 42 mmHg OS. Gonioscopy revealed a heavily pigmented trabecular meshwork. Medical treatment with topical at- ropine 1%, dorzolamide 2%, timolol 0.5%, brimonidine 0.2%, and ke- torolac 0.5% was initiated. IOP in OS was stabilized pharmacologically to within normal limits by post- piggyback week 12, but iris atrophy persisted. The sulcus-placed IOL was successfully exchanged with a STAAR Surgical AQ5010V IOL (Monrovia, Calif.), with resultant clearing of anterior chamber pig- ment. However, the patient contin- ued to require aqueous suppressants for IOP control. Eventually, his medications were discontinued, and 2 weeks afterward, his IOP was 16 mmHg OD and 17 mmHg OS, while best corrected visual acuity was 20/125 OD and 20/200 OS. Lab analysis and results Gross examination, light mi- croscopy, and photography of the explanted lens were performed. The lens was then analyzed using an environmental scanning electron microscope (SEM) (FEI Quanta 2000 ESEM, Hillsboro, Ore.). Gross and microscopic analyses demonstrated significant amounts of pigment and iris-pigmented cells, located primarily on the optic pe- riphery and on the anterior surface and present in clusters for 360 de- grees around the optic. Of particular importance, SEM clearly showed the relatively thick and unpolished side walls of the IOL design, as well as the rough, square edge at the junc- tion between the lateral edge and the anterior optic surface of the patient's explanted ciliary sulcus- placed IOL. Comments One-piece and 3-piece AcrySof lenses have a square optic edge on the an- terior and posterior optic surfaces. The finishing of the square edges of these lenses was modified to give the side walls an unpolished or "tex- tured" appearance, which was found to improve postoperative glare phe- nomena. 2 This feature was extended along the length of the optic and haptics in the 1-piece lenses. The 1-piece AcrySof lens is not recom- mended for sulcus fixation. Differ- ent cases of pigmentary dispersion with such IOL designs have been described in the literature, which were generally managed with ex- plantation/exchange of the lens or by surgical repositioning within the capsular bag. 3-5 Similar complications have been reported with 3-piece AcrySof lenses, in a piggyback configuration 6,7 or standard sulcus fixation. 8 In piggy- back implantation, fixation of the anterior lens in the sulcus has been recommended to prevent interlen- ticular opacification. However, ac- cording to the manufacturer, the MA60MA AcrySof is the 3-piece design with low dioptric powers (ranging from –5.0 to +5.0 D), and its optic edge is 0.5 mm compared with 0.3 mm for the MA60AC. In addition to being thicker, the MA60MA IOL has a textured square- edged profile. We postulate that the thick textured square edges of this IOL, when placed within the ciliary sulcus of the patient's eye, predis- posed the patient to pigmentary dispersion syndrome and thus led to the complications described here. This case, as well as others, suggests that it is more appropriate to use IOLs with smooth, rounded edges when implanting an IOL within the ciliary sulcus, especially with a pig- gyback IOL. 3-8 In the patient described here, the STAAR AQ5010V IOL replaced the square-edged 3-piece AcrySof MA60MA. The STAAR IOL is a low power, 3-piece IOL with a cast- June 2014 by Joshua Ford, MD, Nick Mamalis, MD, and Liliana Werner, MD, PhD A case of pigmentary dispersion syndrome after piggyback IOL implantation Gross photograph (left) and light photomicrograph (right) of the anterior surface of the explanted IOL in this case. Clusters of pigment and pigmented epithelial cells can be seen. Source: Liliana Werner, MD, PhD molded silicone optic (6.3 mm in diameter), modified C-loop haptics, and a posterior optic-haptic angula- tion of 10 degrees (14.0 mm in over- all diameter). The optic edges are smooth and rounded. Other lenses have been specially designed for sul- cus fixation, as piggyback or supple- mentary IOLs. One example is the Sulcoflex lens (Rayner Intraocular Lenses, East Sussex, U.K.). 9 Design features of this lens include large optic and overall diameters, smooth and undulating haptics, and a convex-concave optic profile. Differential diagnosis 1. Cell deposits may be observed on the IOL surface after cataract surgery as part of a foreign-body reaction, and usually are com- posed of giant cells, macrophages, and fibroblast-like cells. They usu- ally degenerate and detach from the IOL surface in the postop period. If necessary, they can be "dusted off" the IOL surface by using a Nd:YAG laser. 2. Cellular deposits on the IOL surface may be related to previous episodes of uveitis; however, the patient in the case described here had no previous history of uveitis. EW References 1. Chang WH, Werner L, Fry LL, et al. Pigmen- tary dispersion syndrome with a secondary pig- gyback 3-piece hydrophobic acrylic lens. Case report with clinicopathological correlation. J Cataract Refract Surg 2007; 33:1106–1109. 2. Meacock WR, Spalton DJ, Khan S. The effect of texturing the intraocular lens edge on postoperative glare symptoms; a randomized, prospective, double-masked study. Arch Ophthalmol 2002; 120:1294–1298. 3. LeBoyer RM, Werner L, Snyder ME, et al. Acute haptic-induced ciliary sulcus irritation associated with single-piece AcrySof continued on page 13 Joshua Ford, MD Liliana Werner, MD, PhD Nick Mamalis, MD Cataract/IOL complications: Moran CPC reports 11-19 News_EW June 2014-DL_Layout 1 6/3/14 12:15 PM Page 11

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