MIGRATION OF HAPTIC INTO ANTERIOR CHAMBER POST CATARACT EXTRACTION, FOLLOWED BY DISPLACED PC-IOL Author Michelle Darnell, OD Candidate, Class of 2016 Pacific University College of Optometry, Forest Grove, Oregon ABSTRACT BACKGROUND & SYMPTOMS PACIFIC UNIVERSITY COLLEGE OF OPTOMETRY DIAGNOSIS & TREATMENT DISCUSSION ACKNOWLEDGEMENTS RC, a 53-year-old male presented with a history of cataract surgery with pc-IOL OD first, and OS one week later. Vision was good OU for about one week, when his vision suddenly clouded with “brown smog” and a large consistent shadow OD, with no pain or flashes. The patient was diagnosed with “Pigment Dispersion OD; source uncertain,” with a possibility of iris chafing from a haptic which was inadvertently placed in the ciliary sulcus. RC was scheduled for an Anterior Chamber washout and Reposition of IOL OD the next month. Six weeks later, the patient presented again with blurry vision OD. Two days previously he noted a dark constant blind spot in the superior temporal corner of his vision, and blurry vision since he noticed the dark spot, with no pain or flashes. Stable vision reported OS. Due to vitreal opacities, a B-scan was used to confirm a posterior vitreous detachment, as well as an early inferior detachment OD with a vitreal hemorrhage. The patient is a driver, and was told he would need to take two weeks off of work. The following day, RC underwent a pars plana vitrectomy with scleral banding, gas-fluid exchange, and laser treatment OD. He slept well until 3:30 am, when he awoke with pain OD. 3+ injection was noted OD, along with blood on the eye patch upon removal, a 1+ subconjunctival hemorrhage, hyphema, and vitreous hemorrhage. Two weeks post-RD repair, the patient reported reduced pain and irritation, but a new pressure sensation OD for the previous 3 days. VA was 20/50 OD. IOP was 15 mmHg OD, 11 mmHg OS. B-scan confirmed no retinal or choroidal detachment. The patient was started on Combigan and Pred Forte 1% BID OD and Atropine QD OD. Patient was not yet able to see well enough to return to work. RC continued to have pain and pressure OD for two weeks, when he also presented with double vision with the right image positioned nasally and superiorly. VA was 20/100 with an IOP of 20. The patient was told to continue Combigan, add Cosopt BID OD and Travatan QD OD. He was to discontinue the Atropine. As of 18 weeks post initial cataract surgery, the hyphema and vitreal hemorrhage were resolved. VA was 20/100 with an IOP of 22. In week 21, the patient presented to us for a second opinion on his treatment, along with new-onset monocular triplopia OD. There was no improvement on his binocular diplopia, red/irritated eye OD, and sensitivity to light OD. VA OD was 20/40, and -1.00D improved VA to 20/30. The OD pupil was fixed and non-reactive to light at 7mm. We noted with biomicroscopy that the temporal edge of the right IOL had moved into the anterior chamber, likely explaining the new-onset monocular triplopia. We confirmed IOL displacement with anterior segment OCT. (Fig 1) The medical treatment options available to this patient included:  IOL re-position  Cosmetic contact lens with artificial pupil  Exchanging the pc-IOL with an anterior chamber IOL  YAG capsulotomy OD  Monitor only After discussing the risks and benefits of additional surgery, the patient elected to first try a contact lens (CL) with artificial pupil to be prescribed by his primary care optometrist. It was our hope that the CL with artificial pupil would both correct the aesthetic appearance of the dilated pupil, as well as reduce or eliminate the triplopia. 10 days later, in Week 22, 1+ cells were noted in the anterior chamber OD, and the patient was diagnosed with an iridocyclitis secondary to possible chaffing of iris OD with IOL. Due to the intra-ocular inflammation, we discontinued his Travatan OD at that time, and had him continue prednisolone acetate TID OD and Combigan BID OD. The patient had a follow-up appointment with his primary care optometrist. At the time of that follow-up, the eye was red and irritated. The optometrist elected to wait until the eye had quieted before prescribing the contact lens, increased the prednisolone acetate to QID, and referred the patient back to us. At the subsequent appointment, VA OD was 20/80, and the IOP was 10 OU. The right pupil was non-reactive to light. Anterior chamber examination revealed 2+ cells. We increased prednisolone acetate to 6 times per day, put the patient back on Travatan QHS and had him continue Combigan BID. We discussed the potential referral to a retinal specialist for a steroid injection, a referral to a glaucoma specialist to control pressures, a cataract surgeon for potential re-positioning of the lens, and the possibility of a prescription CL as previously planned with the primary care optometrist. During his follow-up appointment in Week 25, the patient presented again for a follow-up exam and IOP check. VA’s were 20/25 with diplopia OD only. IOP via applanation was 19 mmHg OD. The anterior chamber still had 1+ cells, so we increased the patient’s prednisolone to 8 times per day. That same month (Week 28), the patient was seen by a retinal specialist for a complete retinal evaluation. OD VA was 20/60 and IOP was 20 mmHg OD, 11 OS. The right pupil was still dilated and unreactive to light. Retina confirmed no new detachments, and previous RD OD was treated with a scleral buckle and laser. During Week 30, we located a cataract surgeon in Utah who specializes in high-risk cataract surgeries in patients with zonular problems, such as those with Marfan Syndrome. He agreed to see the patient, and in week 34, the patient had his IOL exchanged, and iris repaired. At the 1 day post-op, RC’s VA’s were 20/100 OD, pinhole to 20/20. Trace corneal edema was noted, as well as trace cells in the anterior chamber. The three iris sutures were holding, the pc-IOL was correctly centered, and his IOP was 13mmHg. Overall, the patient is doing well. He has a fixed, non-functioning pupil of 5mm, and will likely need a fixed pupil contact in the future to balance the aesthetic component of his anisocoria. He still has multiple images in his right eye, but can see up close without correction, which makes him very happy. His eye is no longer red and irritated. We are continuing to monitor his IOP for fluctuations. Symptoms: A 53 YOM presents for a second opinion for cloudy vision post-cataract extraction for the past 3 months, and an interior pressure sensation OD for two months. Signs: The patient had a history of cataract extraction (CE) with pc-IOL OD and OS, followed two weeks later by repositioning of a haptic that had migrated into the anterior chamber OD. Three weeks later, the patient experienced a PVD OD, followed by a retinal detachment in the same eye after seven weeks. One day post RD repair, the patient presented with a pain and pressure sensation OD, a hyphema, dilated pupil, and an intraocular pressure of 34 mm Hg. The patient also had monocular triplopia OD. OD pupil is fixed with no correctopia. Patient has difficulty driving at night, frequent injection OD and sensitivity to light OD. Biomicroscopy reveals malpositioned IOL with the temporal portion prolapsed into the anterior chamber OD, confirmed with anterior segment OCT. Diagnosis: The patient was diagnosed with: Dislocated anterior IOL OD (379.33, H27.129), Acute Iridocyclitis OD (364.02, H20.011), and previous Retinal Detachment OD (361.01, H33.011). Treatment: The retinal detachment was treated with a vitrectomy, scleral buckle and nitrogen gas bubble injection. The patient was prescribed topical prednisolone acetate 1% OD for the inflammation and light sensitivity, as well as Combigan BID OD and Travatan QD OD to lower the IOP. At this time, the patient is working with a cataract surgeon/corneal specialist to re-position the pc-IOL and hoping there will be no residual damage to the iris. Figure 1: [Left] Anterior segment OCT showing the temporal aspect of the pc-IOL shifted into the anterior chamber temporally OD. Note that the angles are open. [Right] Anterior segment OCT showing a properly placed and centered pc-IOL OS with open angles and a flat iris. Thomas Cruse, OD, Vandi Rimer, OD, and Howard Amiel, MD Spivack Vision Center 6881 S Yosemite St., Centennial, CO REFERENCES 1.Wu, Lihteh, MD, Rafael Alberto Garcia, MD, and Robert H. Graham, MD. "Intraocular Lens Dislocation Treatment & Management." Medscape. N.p., 18 Dec Web. 1 Aug Schwartz, Stephen G., MD, Harry W. Flynn, JR MD, and William E. Smiddy, MD. "Intraocular Lens Dislocation: A Vitreoretinal Perspective." Ophthalmology Management. Ophthalmology Management EUpdate, 1 May Web. 1 Aug Bhardwaj V, Rajeshbhai GP. Axial Length, Anterior Chamber Depth-A Study in Different Age Groups and Refractive Errors. Journal of Clinical and Diagnostic Research: JCDR. 2013;7(10): doi: /JCDR/2013/ "Cases of Displaced IOL Hapics." Personal interview, Howard Amiel, MD. 30 July Table 1 [2] lists the major causes of intraocular lens dislocation. The average axial length of the adult eye is 23.3 mm [3]. Surgical records show RC’s right axial length is mm. This increased axial length puts the patient at a higher risk for haptic displacement and IOL dislocation because eyes with a larger axial length tend to also be taller and wider than average, leading to a larger than average capsular bag. With one exception, all of the pc-IOL lenses commonly used at Spivack Vision Center have a 13mm diameter, which are designed to fit snugly in an average-diameter capsular bag. IOLs placed within a larger capsular bag are more likely to shift for the first month or so, until the capsular bag shrinks around the IOL. [4] This is the likely reason, assuming no surgical complications, that one haptic moved into the anterior chamber less than 3 weeks after the original surgery. The dislocated IOL noted in Week 18 could have been a result of the large capsular bag, as discussed above, or secondary to prior vitreoretinal surgery when the patient had his retinal detachment repaired in Week 11 or the uveitis and/or hyphema noted throughout the patient’s treatment, per Table 1. Unfortunately, there is no way to determine the cause with 100% certainty. Currently, we are working to quiet the patient’s eye so he can be fit with a cosmetic contact lens with an artificial pupil to match the left eye’s pupil. Once the eye has quieted, we will also work in conjunction with corneal specialist Howard Amiel, MD to investigate the possibility of surgically repositioning the misplaced IOL. Table 2 source: See Reference [2] Table 1 source: See Reference [2]