Phakic intraocular lenses for correcting ametropia have always been controversial because of the potential risk to which a previously healthy eye is exposed. Although initially having promising results, severe complications can occur with phakic intraocular lenses. Newer versions of phakic lenses, such as the implantable collamer lens (ICL), have been effective, predictable, and safe. The posterior chamber ICL is one of two phakic lenses approved by the U.S. Food and Drug Administration for the treatment of high ametropia in the United States.1,2
However, there are reports of the potential risks associated with posterior chamber phakic intraocular lens, such as the development of cataracts, pupillary block associated with ocular hypertension, pigmentary dispersion syndrome, and endophthalmitis.3–7 There is scant evidence about the possibility of ICL luxation after trauma. We present a case with ICL dislocation after blunt ocular trauma with corneal decompensation that underwent Descemet stripping automated endothelial keratoplasty (DSAEK) to restore visual acuity.
A 39-year-old woman with a history of high myopia underwent ICL implantation in both eyes 6 years earlier. Preoperative examination manifested refraction of −9.75 −1.50 × 60 in the right eye and −12.00 −0.50 × 180 in the left eye. Postoperatively, both eyes achieved 20/20 visual acuity without complications and a clinical course was favorable in maintaining stable visual acuity, intraocular pressure (IOP) within normal ranges, and a suitable vault during follow-up.
Preoperatively, the white-to-white distance was 11.2 and 11.1 mm in the right and left eye, respectively, measured with Orbscan II (Bausch & Lomb, Rochester, NY), and anterior chamber depths of 3.28 and 3.32 mm in the right and left eye, respectively. Endothelial cell count was 2,873 cells/mm2 in the right eye and 2,652 cells/mm2 in the left eye. A fourth version ICL (ICLV4) of 11.5 mm length was chosen for both eyes. Surgery in both eyes was performed without any incidents or complications.
Six years later, the patient presented after blunt trauma in the right eye that caused eyelid ecchymosis and decreased vision. Visual acuity was 20/60 in the right eye and 20/20 in the left eye. IOP was 30 and 14 mm Hg in the right and left eye, respectively. Biomicroscopy evaluation showed hyposphagma with mild corneal edema in the lower periphery, a partially dislocated phakic ICL inside the anterior chamber with corneal touch, and no opacities (Fig. 1).
Figure 1. Clinical slit-lamp photograph of the right eye showing a partial dislocation of the implantable collamer lens in the anterior chamber with corneal touch and dyscoric pupil.
Initial treatment was with hypotensive ophthalmic solution of brimonidine tartrate and timolol maleate combination twice a day and prednisolone acetate 1% four times daily, decreasing IOP to 22 mm Hg within 3 days. The patient underwent surgery for repositioning of the ICL because no ocular structures had severe injuries and the lens remained clear. Relocation of the ICL was conducted uneventfully with topical anesthesia using a small amount of viscosurgical device (Fig. 2).
Figure 2. (A) Postoperative clinical slit-lamp photograph of the right eye with a clear cornea, a round pupil reactive to light, and the implantable collamer lens (ICL) in the posterior chamber with adequate vault. (B) Under pharmacological mydriasis, the ICL repositioned with adequate vault and no lens opacities.
The outcome was favorable. Best-corrected visual acuity was 20/40 and the specular microscopy showed an endothelial cell count of less than 800 cells/mm2, corneal thickness of 653 microns and a coefficient of variation of 55, and a hexagonality of 33% at 3 months postoperatively. Unfortunately, the uncorrected distance visual acuity decreased to hand motions and microbullae appeared in the corneal epithelium with unobtainable endothelial cell count (Figs. 3 and 4).
Figure 3. (A) Specular microscopy of the right eye with low endothelial cell count. (B) Notice the comparison versus the fellow eye showing a healthy corneal endothelium.
Figure 4. Progressive endothelial failure. Visual acuity decreased to hand motions and epithelial bullae formation under fluorescein staining.
DSAEK was performed to improve symptoms and visual acuity. Briefly, a donor endothelial lenticule was prepared using the Moria LSK (Moria, Antony, France) microkeratome with a 350-micron head. Immediately after, the cornea was trephined with an 8.5-mm punch. The recipient was prepared with a superior scleral 5-mm incision and anterior chamber maintainer placed nasally. Endothelial scraping and scoring were performed. The lenticule was inserted carefully using the Busin Glide (Moria) and forceps, so as to not collapse the anterior chamber and avoid contact with the ICL. The main wound was sutured tightly and the anterior chamber was completely filled with air for a period of 10 minutes, after which a small portion of the wound was released to leave a 50% residual air bubble.
At 1 day postoperatively, the lenticule was attached, the anterior chamber formed, and IOP was normal. An eye patch was placed and moxifloxacin 1% (Vigamox; Alcon Laboratories, Fort Worth, TX) and prednisolone acetate 1% (Prednefrin; Allergan, Los Angeles, CA) were instilled four times daily. Lubrication with unpreserved sodium hyaluronate (Lagricel Sophia Laboratories, Guadalajara, Mexico) was administered four times daily. The patient was treated in clinic every 72 hours for 1 week and then once every month. Four months after DSAEK, the uncorrected distance visual acuity was 20/40 with adequate endothelial cell count and excellent ICL vault (Figs. 5 and 6). IOP remained within normal limits. Subjectively, the patient was satisfied.
Figure 5. Clinical slit-lamp photograph after Descemet stripping automated endothelial keratoplasty. Notice the donor graft of approximately 250-microns thickness.
Figure 6. (A) High-resolution corneal optical coherence tomography (OCT) showing an adequate endothelial graft of 250 microns. (B) Anterior segment OCT showing Descemet stripping automated endothelial keratoplasty graft and implantable collamer lens with adequate vault of approximately 250 microns.
Of all of the phakic lenses currently available for the treatment of moderate to high ametropia, only two are approved by the U.S. Food and Drug Administration: the posterior chamber ICL and the Verisyse anterior chamber iris supported lens (Abbott Medical Optics, Santa Ana, CA).1,2
The associated complications reported with ICL include development of anterior subcapsular opacities (which in most cases are not visually significant),2,4–6 risk of ocular hypertension associated with pupillary block, endothelial cell loss, pigmentary dispersion syndrome, and endophthalmitis, the last being as low as 0.0167%.8 Nevertheless, little evidence regarding traumatic ICL dislocation is available.
In a study estimating the risk of visual loss associated with ICL, Sanders et al. calculated that adding the cases of visual loss greater than two lines of the U.S. Food and Drug Administration study and the risk of severe visual loss associated with retinal detachment as a complication of ICL-induced cataract surgery resulted in a total risk of 1.39%.4 This rate is lower than or comparable to other refractive procedures.1,2,9 Unfortunately, our patient presented with a visual loss of two lines of final best-corrected visual acuity.
There are many reports documenting the stability of the ICL,10 including a report by McCauley et al.11 of a soldier who was a victim of a grenade explosion 8 months after ICL implantation. He presented with vitreous hemorrhage and an intraorbital foreign body, but the ICL remained stable.
Reports of postoperative endothelial cell density show a cumulative endothelial cell loss at 3 years ranging between 6.57% and 9.7%.3 However, in our case, we observed greater endothelial cell loss probably associated with blunt trauma, endothelial touch by the dislocated ICL, ocular hypertension, and the two surgical procedures.
Surgeons need to be aware of every possible complication in refractive surgery. There are reports of traumatic flap dislocation after trauma.12 There are also several reports of iris-fixated phakic lens (Artisan/Verisyse) dislocation.13 To our knowledge, there is only one previous report, in which intraocular lens dislocation was present after occipital trauma.14 The authors hypothesized that the enlargement of the pupil may have been due to the patient being in a dark room. This is also the case of our patient, who received blunt trauma at night under scotopic conditions, and the adrenergic stimulus of the scenario could lead to an easier ICL dislocation.
Sikder et al. described cases that underwent DSAEK after implantation of anterior chamber (Artisan/Verisyse) phakic intraocular lens with good final outcomes and removal of the phakic intraocular lens in both cases.15 To our knowledge, there are no previous reports of DSAEK with posterior chamber phakic intraocular lens. Because of the age and adequate vault of our patient, we decided to perform DSAEK without removing the ICL and obtained an acceptable final uncorrected distance visual acuity.
The importance of this report is to make the ophthalmologist aware of the potential risk of ICL dislocation with trauma years after ICL implantation and subsequent corneal decompensation after such an event, and to report DSAEK as an adequate technique to resolve endothelial failure with posterior chamber phakic intraocular lenses.
- Sanders DR, Vukich JA, Doney K, Gaston MImplantable Contact Lens in Treatment of Myopia Study Group. U.S. Food and Drug Administration clinical trial of the Implantable Contact Lens for moderate to high myopia. Ophthalmology. 2003;110:255–266. doi:10.1016/S0161-6420(02)01771-2 [CrossRef]
- Sanders DR, Doney K, Poco MImplantable Contact Lens in Treatment of Myopia Study Group. U.S. Food and Drug Administration clinical trial of the implantable collamer lens (ICL) for moderate to high myopia: three-year follow-up. Ophthalmology. 2004;111:1683–1692. doi:10.1016/j.ophtha.2004.03.026 [CrossRef]
- Dejaco-Ruhswurm I, Scholz U, Pieh S, et al. Long term endothelial changes in phakic eyes with posterior chamber intraocular lenses. J Cataract Refract Surg. 2002;28:1589–1593. doi:10.1016/S0886-3350(02)01210-5 [CrossRef]
- Sanders DR. Actual and theoretical risks for visual loss following use of the implantable contact lens for moderate to high myopia. J Cataract Refract Surg. 2003;29:1323–1332. doi:10.1016/S0886-3350(02)02040-0 [CrossRef]
- Khalifa YM, Moshirfar M, Mifflin MD, Kamae K, Mamalis N, Werner L. Cataract development associated with collagen copolymer posterior chamber phakic intraocular lenses: clinicopathological correlation. J Cataract Refract Surg. 2010;36:1768–1774. doi:10.1016/j.jcrs.2010.04.039 [CrossRef]
- Gonvers M, Bornet C, Othenin-Girard P. Implantable collamer lens for moderate to high myopia: relationship of vaulting to cataract formation. J Cataract Refract Surg. 2003;29:918–924. doi:10.1016/S0886-3350(03)00065-8 [CrossRef]
- Schmidinger G, Lackner B, Pieh S, Skorpik C. Long-term changes in posterior chamber phakic intraocular collamer lens vaulting in myopic patients. Ophthalmology. 2010;117:1506–1511. doi:10.1016/j.ophtha.2009.12.013 [CrossRef]
- Allan BD, Argeles-Sabate I, Mamalis N. Endophthalmitis rates after implantation of the intraocular collamer lens: survey of the users between 1998 and 2006. J Cataract Refract Surg. 2009;35:766–769. doi:10.1016/j.jcrs.2008.12.027 [CrossRef]
- Sanders DR, Vukich JA. Comparison of implantable contact lens and laser assisted in situ keratomileusis for moderate to high myopia. Cornea. 2003;22:324–331. doi:10.1097/00003226-200305000-00009 [CrossRef]
- Hashem A, El Danasoury A, Anwar H. Axis alignment and rotational stability after implantation of the toric implantable collamer lens for myopic astigmatism. J Refract Surg. 2009;25:S939–S943. doi:10.3928/1081597X-20090915-08 [CrossRef]
- McCauley MB, Anderson DM, Johnson AJ. Posterior chamber Visian implantable collamer lens: stability and evaluation following traumatic grenade explosion. J Refract Surg. 2008;24:648–651.
- Ramírez M, Quiroz-Mercado H, Hernandez-Quintela E, Naranjo-Tackman R. Traumatic flap dislocation 4 years after LASIK due to air bag injury. J Refract Surg. 2007;23:729–730.
- Güell 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]
- Kong J, Quin XJ, Li XY, Zhang JS, Qu B. Implantable collamer lens dislocation. Ophthalmology. 2010;117:399. doi:10.1016/j.ophtha.2009.09.010 [CrossRef]
- Sikder S, Patel V, Holz HA, Mifflin MD, Davis S, Moshirfar M. Management of corneal endothelial decompesation caused by iris-fixated phakic intraocular lenses with Descemet stripping automated endothelial keratoplasty. Cornea. 2011;30:1045–1047. doi:10.1097/ICO.0b013e3182035dd0 [CrossRef]