From the Department of Ophthalmology (YO, TY, DS, RK, KT, KN), Keio University School of Medicine; J&J Ocular Surface and Visual Optics Department (DM), Keio University School of Medicine; the Department of Ophthalmology (TY), Tokyo Dental College; and Minamiaoyama Eye Clinic (IT), Tokyo, Japan.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Takefumi Yamaguchi, MD, Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
Recently, the implantation of iris-fixated phakic intraocular lens (IF pIOL) has been proved to be a very effective and predictable refractive technique for treatment of high myopia, especially to correct high myopia in patients who are not candidates for refractive corneal surgery using an excimer laser.1–3 Although the IF pIOL procedure has become standard to correct high myopia, severe postoperative complications have been reported including retinal detachment, traumatic aniridia, IOL dislocation, pigment dispersion syndrome, and endothelial cell loss.4 However, to our knowledge postoperative pupillary block glaucoma has not been previously reported in eyes with IF pIOL. Herein, we present a patient who developed pupillary block glaucoma after implantation of IF pIOL (Artisan/Verisyse, Ophtec BV, Groningen, The Netherlands).
A 43-year-old man underwent implantation of IF pIOL at a local eye clinic. His preoperative best-corrected visual acuity was 20/20 with −11.5 dioptor (D) −1.75 D × 175 in the right eye and 20/20 with −13.75 D −1.50D × 10 in the left eye. The anterior chamber depth was 3.73 mm in the right eye and 3.90 mm in the left eye before the implantation of pIOL measured by Orbscan (Bausch & Lomb, Rochster, NY). Slit-scanning Scheimpflug image of anterior segment revealed no abnormal shape of the iris in both eyes.
He underwent peripheral laser iridotomy (LI) at 10-o’clock bilaterally 1 month before the uneventful implantation of IF pIOL at the local clinic. He noticed sudden-onset ocular pain and nausea in the right eye 15 hours after IF pIOL implantation at night. At first he went to the local clinic and referred to our hospital, then he was diagnosed pupillary block glaucoma.
Slit-lamp examination revealed extremely shallow anterior chamber, the arcade-shaped pigment dispersion on the posterior surface of pIOL, pupillary block along the peripheral margin of pIOL without presentation of iris-bombe, and closure of peripheral iridotomy (Fig. 1). The iris moved forward with the IF pIOL and the lens remained in the physiologic position, which made the distance between the lens and the iris wide. The intraocular pressure (IOP) by Goldmann applanation tonometry was 62 mm Hg in the right eye and 22 mm Hg in the left eye. Despite the intravenous infusion of mannitol 20% 300 mL (Nikken, Nagoya, Japan) and the application of 4% topical pilocarpine (Sanpilo, Santen, Osaka, Japan) every 5 min, the pupillary block did not relieved. Because laser iridotomy seemed difficult to perform due to the corneal edema caused by the high IOP and extremely shallow anterior chamber, peripheral surgical iridectomy was performed at 11-o’clock position. Two days after surgery, his visual acuity improved to 20/25. The IOP was 6 mm Hg in the right eye. The anterior chamber became deep and the angle was open in the right eye. The endothelial cell density was 3,105 cells/mm.2 The visual acuity improved to 20/20 with +0.50 D −1.00 D × 170 6 months after the peripheral iridectomy.
Figure 1. Slit-Lamp Examination Revealed Extremely Shallow Anterior Chamber, the Arcade-Shaped Pigment Dispersion on the Posterior Surface of pIOL, Pupillary Block Along the Peripheral Margin of pIOL Without Presentation of Iris-Bombe, and Closure of Peripheral Iridotomy. The Distance Between the Lens (yellow Arrow) and the Iris (white Arrow) Was Wide Because the Lens Remained in the Physiologic Position.
Artisan/Verisyse IF pIOL has been used successfully for treatment of high myopia, especially to correct high myopia.1–3 Postoperative vision-threatening complications, which have been very uncommon, include cataract, endothelial cell decompensation, and retinal detachment.4 Pupillary block glaucoma is reported in patients with iris-fixated IOL for aphakic eye,5 angle-supported pIOLs6 and posterior chamber pIOLs.7–10 Bylsma et al. reported a case of bilateral pupillary block after implantation of posterior chamber pIOL.9 Zaldivar et al. reported 6 patients with pupillary block glaucoma after implantation of posterior chamber pIOL.10 In their reports, 4 of 6 patients had not received preoperative peripheral iridotomies and in the other 2 patients, iridotomies closed, which induced pupillary block. However, as for IF pIOL for high myopia, pupillary block is an uncommon postoperative complication. A previous systemic literature review by Chen et al.. did not disclose early pupillary block glaucoma as a postoperative complication in patients after implantation of IF pIOL.4 PubMed and Medline search using keywords “pupillary block” and “Artisan/Verisyse, iris-fixated phakic intraocular lens” revealed no case reports in the literature.
Clinical characteristic features of this case was as follows; early sudden night-onset IOP increase, extremely shallow anterior chamber, the arcade-shaped pigment dispersion on the posterior surface of pIOL, pupillary block along the peripheral margin of pIOL without presentation of iris-bombe, wide distance between the lens and the iris, and closure of peripheral iridotomy.
Our case involved early pupillary block glaucoma secondary to IF pIOL implantation due to the lack of patent iridotomy. IF pIOL reported to cause postoperative anterior segment structural alterations like crystalline lens rise,11 angle alterations,12 and pupil ovalization.4 In our case, contact of iris with posterior surface of the pIOL optics might be induced by postoperative anterior structural alterations and/or iris-ciliary body anterior rotation followed by night mydriasis. Together with the closure of peripheral iridotomy, the iris-pIOL diaphragm caused “pupillary block”, obstruction of aqueous flow, and narrowed the angle, which resulted in the sudden increase in IOP.
To our knowledge, this is the first case report of pupillary block glaucoma after implantation of IF pIOL. Our case may provide important insight on the unique mechanism of pupillary block after implantation of pIOL for refractive surgeons and glaucoma specialists. Although pupillary block glaucoma may be one of the rare complications of IF pIOL, closure of peripheral iridotomies can cause pupillary block glaucoma. Recurrent spontaneous closure of laser peripheral iridotomy can occur after implantation of pIOL.13 It is imperative that patients with IF pIOL must be carefully observed after surgery.
- Guell JL, Morral M, Gris O, Gaytan J, Sisquella M, Manero F: Five-year follow-up of 399 phakic Artisan-Verisyse implantation for myopia, hyperopia, and/or astigmatism, Ophthalmology. 2008;115:1002–1012. doi:10.1016/j.ophtha.2007.08.022 [CrossRef]
- Stulting RD, John ME, Maloney RK, Assil KK, Arrowsmith PN, Thompson VM: Three-year results of Artisan/Verisyse phakic intraocular lens implantation. Results of the United States Food And Drug Administration clinical trial, Ophthalmology. 2008;115:464–472 e461. doi:10.1016/j.ophtha.2007.08.039 [CrossRef]
- Yamaguchi T, Negishi K, Kato N, Arai H, Toda I, Tsubota K: Factors affecting contrast sensitivity with the Artisan phakic intraocular lens for high myopia, J Refract Surg. 2009;25:25–32.
- Chen LJ, Chang YJ, Kuo JC, Rajagopal R, Azar DT: Metaanalysis of cataract development after phakic intraocular lens surgery, J Cataract Refract Surg. 2008;34:1181–1200. doi:10.1016/j.jcrs.2008.03.029 [CrossRef]
- Hogewind BF, Theelen T: Slit-lamp-adapted optical coherence tomography of pupillary block after Artisan lens implantation for aphakia, Int Ophthalmol. 2007;27:337–338. doi:10.1007/s10792-007-9075-4 [CrossRef]
- Ardjomand N, Kolli H, Vidic B, El-Shabrawi Y, Faulborn J: Pupillary block after phakic anterior chamber intraocular lens implantation, J Cataract Refract Surg. 2002;28:1080–1081. doi:10.1016/S0886-3350(01)01114-2 [CrossRef]
- Smallman DS, Probst L, Rafuse PE: Pupillary block glaucoma secondary to posterior chamber phakic intraocular lens implantation for high myopia, J Cataract Refract Surg. 2004;30:905–907. doi:10.1016/j.jcrs.2003.09.019 [CrossRef]
- Kodjikian L, Gain P, Donate D, Rouberol F, Burillon C: Malignant glaucoma induced by a phakic posterior chamber intraocular lens for myopia, J Cataract Refract Surg. 2002;28:2217–2221. doi:10.1016/S0886-3350(02)01213-0 [CrossRef]
- Bylsma SS, Zalta AH, Foley E, Osher RH: Phakic posterior chamber intraocular lens pupillary block, J Cataract Refract Surg. 2002; 28:2222–2228. doi:10.1016/S0886-3350(02)01303-2 [CrossRef]
- Zaldivar R, Davidorf JM, Oscherow S: Posterior chamber phakic intraocular lens for myopia of −8 to −19 diopters, J Refract Surg. 1998; 14:294–305.
- Baikoff G, Bourgeon G, Jodai HJ, Fontaine A, Lellis FV, Trinquet L: Pigment dispersion and Artisan phakic intraocular lenses: crystalline lens rise as a safety criterion, J Cataract Refract Surg. 2005;31: 674–680. doi:10.1016/j.jcrs.2004.09.034 [CrossRef]
- Yamaguchi T, Negishi K, Yuki K, Saiki M, Nishimura R, Kawaguchi N, Tsubota K: Alterations in the anterior chamber angle after implantation of iris-fixated phakic intraocular lenses, J Cataract Refract Surg. 2008;34:1300–1305. doi:10.1016/j.jcrs.2008.04.033 [CrossRef]
- Park IK, Lee JM, Chun YS: Recurrent occlusion of laser iridotomy sites after posterior chamber phakic IOL implantation, KoreanJ Ophthalmol. 2008;22:130–132.