Eyeworld

EW CATARACT 23 April 2018 Removal challenge Implantation of such unapproved cosmetic devices will likely cause endothelial damage, as they rest against the angle, Dr. Raviv said. "They should be removed at the earliest sign of iritis, glaucoma, pupil ovalization, or endothelial compromise," Dr. Raviv said Such patients should have periodic endothelial cell counts, and psychological referral may be need- ed, Dr. Raviv said. One implant recipient Dr. Raviv is treating who has frank corneal edema in one eye and an 800 cell count in the other eye is still reluc- tant to have the implants removed. "He knows they must come out immediately, but he is so attached to his blue eye identity that he cannot fathom removing them," Dr. Raviv said. Dr. Miller said such patients don't usually come to him until they are well into the complication phase of the implants. He urges immediate removal. "If we could catch them early we could avoid a lot of this stuff," Dr. Miller said. "But they're happy early." The difference between such unapproved devices and legitimate devices includes the latter's implan- tation in the posterior chamber, where they are much more tolerat- ed. Unapproved devices end up in the anterior chamber where they are up against the trabecular meshwork, rubbing against the peripheral iris, and very close to the cornea. "It's the peripheral cornea contact that causes problems," Dr. Miller said. "It's almost like having an old-style closed loop anterior chamber lens in the eye, and those are known to be a disaster and came off the market years ago." EW Editors' note: Drs. Miller and Raviv have no financial interests related to their comments. Contact information Miller: kmiller@ucla.edu Raviv: tal.raviv.md@gmail.com 19, and the left eye implant was removed Jan. 23. As expected, the postop visual acuity sharply declined in the right eye. At the patient's Jan. 31 visit, his VA was 20/400 in the right eye and his IOP was 30 mm Hg, while the left eye was 20/20 –1 with 20 mm Hg while on drops. "He's now cleared phase one of the rehab process, but he has a long road in front of him," Dr. Miller said. Iris damage During removal, it became apparent the implant in the right eye im- pacted the iris underneath and left the pupil decentered. The implant, apparently injected through a superotemporal incision, engaged the iris and pulled it inferonasal- ly and caused a large iridectomy superotemporally where the implant caught the iris. The approach left a large tear and extensive posterior synechia inferonasally, which Dr. Miller was unable to break once the implant was removed. "The road in front of him for both eyes is going to be cataract sur- gery, an attempt in his right eye to fix the large iris defect, then some- how trying to get the pupil centered in the eye—although that is going to be a real challenge," Dr. Miller said. "Cataract surgery, iridoplasty, eventually DSEK or DMEK, and for the rest of his life he's going to have pressure management problems and will probably eventually get a tube shunt in both eyes." The outlook for the patient is similar to those with overseas im- plants treated by Tal Raviv, MD, as- sociate clinical professor of ophthal- mology, Icahn School of Medicine at Mount Sinai, New York Eye and Ear Infirmary of Mount Sinai, New York. "Once the implants are out, patients are typically still looking at multiple other surgeries; up to half of explants seem to need a combina- tion of cataract surgery, pupilloplas- ty, glaucoma surgery, and endothe- lial corneal transplantation," Dr. Raviv said. have had when told about the need to remove them. "They usually don't want to give them up until everything starts to hit the fan," Dr. Miller said. "This patient was already hitting the fan." The devices were removed by cutting them into multiple pieces and taking out the pieces. The right eye implant was removed Dec. than 600 cells per square millime- ter usually indicate the need for a corneal transplant. Despite the multiple problems, it was difficult to convince the pa- tient about the need to remove the implants. The reaction was similar to the reticence that Dr. Miller's previous patients with cosmetic implants and serious complications The cosmetic artificial iris is cut from the right eye with microscissors while being stabilized with micrograspers. A wedge-shaped piece of the artificial iris is removed from the eye. Source (all): Kevin M. Miller, MD

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