Mechanically-Induced Pigment Dispersion despite Endocapsular Intraocular Lens Implantation

1
Mechanically-Induced Pigment Dispersion despite
Endocapsular Intraocular Lens Implantation

• Nathalie M. Guibord,MD
• Geisinger Medical Center

Author has no financial interest
2
Purpose

• To report a case of severe pigment dispersion
  that began on post-operative day one after
  cataract surgery with endocapsular implantation
  of a square-edge intraocular lens (IOL) .
• The cause of the pigment dispersion in this
  unique case is discussed.

3
Methods

• 70 year old Caucasian female
• Retinal detachment repaired by scleral buckle OD
  in 1995
• High myopia with lattice OU
• Pigment dispersion syndrome OU
• Krukenberg spindle, pigmentation on gonioscopy
  and q configuration to iris
• No iris trans-illumination defects (TIDs)
• Status-post uneventful phaco/IOL OS

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Methods

• Underwent phaco/IOL OD
• Two clock hours of weak zonules noted during
  chopping
• CTR model 14A (14.5 mm) inserted
• SA60AT 7.5 D in the bag
• Lens centered very well, in the bag

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Methods

• POD 1
• 4 pigmented cells in anterior chamber
• IOL well-centered and in the bag

6
Methods

• POD 3
• Still had 4 pigmented cells
• IOL confirmed to be endocapsular
• Vitreous was clear
• Laser peripheral iridectomy was performed due to
  q configuration of the iris

7
Methods

• Pigment-induced ocular hypertension occurred by
  POD 13
• Ta 31
• 4 pigmented cells
• 4 Iris TIDs in configuration of IOL, raising
  doubts that IOL was fully endocapsular
• IOL seemed very close to the iris
• Started on acetozolamide p.o.
• Schedule to return to O.R. the next day

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Results

• OR POD 14
• IOL found to be 100 endocapsular
• IOL explanted as pseudophacodonesis with
  square-edge iris chaffing suspected
• MA60AC 7.5 D was inserted in sulcus

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Results

• IOP controlled by POD 2 status-post IOL exchange
• patient gradually improved over the next few
  weeks
• 3 months post-op
• Va cc 20/20
• Ta 15 mmHg
• Trace flare
• Off all eye meds
• Has continued to do well since then

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Results

• Pseudophacodonesis occurred secondary to zonular
  dialysis (needing a CTR), large scleral buckle
  and vitreous pressure
• SA60AT should not be placed in the sulcus
• Zero angulation between optic and haptics
• Square edges anteriorly (optic and haptics)
• High risk for iris chaffing
• Not indicated in direction-for-use labeling

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Conclusion

• There are several reports of mechanically-induced
  pigment dispersion associated with the
  implantation of a SA60AT in the sulcus
• No reported cases of pigment dispersion from this
  IOL when positioned completely within the
  capsular bag

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Conclusion

• The primary cause of pigment dispersion in this
  case was pseudophacodonesis with an IOL with
  anterior square edges.
• This case demonstrates how it is prudent to
  insert a three-piece IOL with rounded anterior
  edges, in cases when the zonular integrity has
  been compromised and posterior vitreous pressure
  is present (as with a scleral buckle).