YO Challenging case: “Two IOLs luxated in vitreous chamber after blunt trauma”
Dr. Matteo Forlini MD,
Vitreoretinal Consultant, San Marino State Hospital, Republic of San Marino
A 60 years old female patient presented a long clinical history as:
– In 1998 she underwent excimer laser PRK operation to correct high myopia in both eyes
– After twenty years, in 2018, she developed cataract formation in the left eye, so she underwent Phacoemulsification with one-piece-foldable-IOL implantation in the capsular, bag, even if during the surgery a posterior capsule tear occurred (at that time the surgeon decided to implant the IOL in the bag even if a small posterior capsule tear was present)
– A year later, in 2019, the same surgeon decided to implant an ICL IOL in the sulcus, as a secondary piggyback add-on IOL over the one-piece-foldable-IOL already positioned in the capsular bag.
Then in February 2022 the patient came to our clinic presenting sudden vision loss in the left eye after blunt ocular trauma, with this ophthalmic scenario:
- BCVA: 4/10 sf +13.50
- SLIT LAMP: clear cornea, round centered pupil, ICL IOL positioned in the sulcus
- IOP: 28 mmHg
- FUNDUS: one-piece-foldable-IOL luxated in the vitreous chamber (no retinal detachment)
So we had to proceed with surgery in the left eye, performing pars plana vitrectomy in order to catch the luxated IOL in the vitreous chamber. (FIG 01)
So, after complete vitrectomy with peripheral vitreous base shaving, we remove the vitreous around the luxated IOL, in order to remove it avoiding the risk of retinal tractions all around it.
Also, capsular bag remnants were removed with pars plana approach using 25g crocodile-forceps, after we decided to choose the retropupillary enclavation of Iris-Claw IOL as secondary implantation solution for this patient.
Then I was attempting to remove the ICL IOL from the posterior chamber through the anterior chamber when suddenly it fell down in the vitreous chamber (since the capsular support was missing after I removed it).
(FIG 02, FIG 03)
So now two IOLs were present into the vitreous chamber! (The one-piece-foldable-IOL and the ICL-IOL).
(FIG 04)
I proceeded with the two IOLs removal from the vitreous chamber through the anterior chamber, using two 25g crocodile-forceps with bimanual manouvres, after opening the cornea in the superior sector (5.5 mm corneal opening)
(FIG 05, FIG 06)
Then, I implanted the Iris-Claw IOL with retropupillary enclavation, and sutured the cornea with three stitches (Nylon 10-0).
(FIG 07, FIG 08)
Finally I removed the three pars plana trocars (sutureless).
(FIG 09)
You can check the link of this surgery below:
One month post-operation, in April 2022, the patient presented a very good clinical scenario: (FIG 10, FIG 11, FIG 12, FIG 13, FIG 14, FIG 15)
- BCVA: 7/10 sf -0.50 cyl -2.00 at 160’
- SLIT LAMP: some Descemet Membrane folds
stable retropupillary Iris-Claw IOL
round centred pupil
(no pupillary distortion)
- IOP: 14 mmHg (brinzolomide + timolol x2)
- FUNDUS: normal (no macular edema)
Iris Claw IOL – Take Home Message
Advantages:
- Fast surgical procedure
- You can avoid conjunctival openining
- Fixated to the iris mid-periphery: minimal affect on the normal physiology of the iris or anterior chamber angle
- Lower incidence of corneal decompensation, secondary glaucoma and cystoid macular edema
Disadvantages:
- Complex surgical technique (?)
- Astigmatism (corneal opening 5.5 mm …)
- Risk of pupil distortion.