Spontaneous Late Subluxation of Polymethylmethacrylate Eye bag removal

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Spontaneous Late Subluxation of
Polymethylmethacrylate Intraocular Lens
                                   Abstract                                                                        patient declined further surgical intervention to remove the
                                   We report a case of spontaneous subluxation of poly-                            lens and insert an anterior chamber IOL. He was instead
                                   methylmethacrylate IOL within the capsular bag eight                            prescribed a contact lens that corrected his vision to 6/9 in
                                   years after cataract extraction and Nd:YAG capsulotomy. We                      the right eye and considerably relieved the double vision.
                                   discuss the possible mechanism of this complication and its
                                   implications.                                                                   Comment
                                                                                                                   Spontaneous lens subluxation is a rare complication that has
                                   Introduction                                                                    previously been reported after variable period of Nd:YAG
                                   Intraocular lens (IOL) displacement, subluxation and even                       capsulotomy following ECCE or phacoemulsification. Framme
                                   dislocation, have been reported before in cases with zonu-                      and co-authors reported two cases of IOL dislocation six
                                   lar weakness such as elderly patients and patients with                         months after Nd:YAG capsulotomy that were performed 19
                                   pseudoexfoliation (PEX) or uveitis.1-3 Also, it has been                        months and four years after ECCE.8 Also, Shigeeda et al
Mostafa Elgohary, FRCSI, FRCSEd,
                                   reported in patients who had plate-haptic silicone IOLs fol-                    reported four cases of complete posterior IOL dislocation four
is an Ophthalmologist with Essex   lowing Nd:YAG capsulotomy, in whom the IOL displace-                            to eight years after uneventful phacoemulsification.9
County Hospital, Colchester, UK.   ment occurred either in the immediate post-operative peri-                         Zonular damage is conceivably the underlying mecha-
                                   od or shortly after Nd:YAG capsulotomy.3-8                                      nism of this complication. Several factors seem to have
                                                                                                                   contributed to zonular damage and the subsequent lens
                                   Case Report                                                                     subluxation in our patient. The most important of these
                                   An 84-year-old male presented to the casualty department                        seem to be the excessive fibrosis and contraction of the
                                   complaining of sudden occurrence of vertical monocular                          capsular bag (Figure 1) that appears to have set in soon
                                   diplopia and blurring of vision in his right eye. He gave a                     post-operatively as evidenced by the need for Nd:YAG cap-
                                   history of bilateral Cataract Surgery and IOL implantation                      sulotomy repeatedly within four months of surgery.
                                   eight years before that was followed a few months later by                      Capsular contraction has been reported before to be asso-
                                   laser capsulotomy on the right eye. There was no history of                     ciated with late lens subluxation,10 predominantly in
                                   trauma or any ocular abnormality but he was on treatment                        patients with PEX syndrome1,2 and in those who had plate-
                                   for ischaemic heart disease.                                                    haptic silicone IOLs.3,7,11,12 Although the long time that
                                      His corrected visual acuity was 6/60 and 6/6 in the                          elapsed excludes a direct causal relationship to Nd:YAG
                                   right and the left eye, respectively, and intraocular pres-                     laser capsulotomy, it does not altogether discount a plausi-
N Ahmad, FRCSI, FRCS, FRCOphth,
                                   sure was normal. On slit lamp examination of the right                          ble zonular damage induced by the laser shock waves. The
is an Ophthalmologist with Essex
County Hospital, Colchester, UK.   eye the superior edge of the IOL was found in the pupil-                        in-the-bag fixation of a large diameter IOL, which was
                                   lary area (sunset appearance) (Figure 1). The IOL was                           meant mainly for sulcus fixation, is yet another factor that
Correspondence:                    enclosed within a fibrotic capsular bag with one haptic                         might have caused damage to the zonules by causing
Mr Mostafa A Elgohary,             bend in front of the optic. In his pre-operative assess-                        excessive stretching and distortion of the capsular bag as
Ophthalmology Department,
                                   ment, the patient did not have PEX but was found to be                          shown in the experimental study by Lim et al.13
Essex County Hospital,
Lexden Road,                       mildly myopic (-4) and his axial length was 22.09mm.                               The conclusion is that spontaneous subluxation of large
Colchester,                           The surgical notes showed that in April 1995 he had                          diameter PMMA IOLs can occur up to eight years after ECCE
CO4 5JL, UK.                       uneventful extracapsular cataract extraction (ECCE) on the                      and, Nd:YAG capsulotomy and can be managed conserva-
                                   right eye with in-the-bag implantation of a Storz poly-                         tively. The most likely cause is zonular dialysis induced
                                   methylmethacrylate (PMMA) single-piece IOL that had an                          mainly by capsular fibrosis and contraction and, perhaps to
                                   overall diameter of 13.75mm, an optic of 7mm and a hap-                         a lesser extent, by trauma from the laser and by capsular
                                   tic angulation of 10˚ that was followed in June by a similar                    bag distortion induced by the large IOL diameter. Early
                                   procedure on the left eye. Three months post-operatively,                       signs of excessive fibrosis of the capsular bag should
                                   Nd:YAG posterior capsulotomy was performed on the right                         prompt Nd:YAG anterior capsulotomy as suggested by
                                   eye for an opacified posterior capsule using 50 bursts and                      many authors1,2 especially in patients at an increased risk,
                                   a total energy of 229mJ and, a month later, 19 bursts and                       to minimise the chances of lens subluxation or even dislo-
                                   59mJ were used to enlarge the capsular opening.                                 cation and consequent future need for more invasive sur-
                                      Having understood the origin of his symptoms, the                            gical intervention.

                                   References                                                                     7. Tuft SJ, Talks SJ. Delayed dislocation of foldable plate-haptic silicone
                                   1. Davison JA. Capsule contraction syndrome. J Cataract Refract Surg               lenses after Nd:YAG laser anterior capsulotomy. Am J Ophthalmol
                                       1993;19:582-9.                                                                 1998;126:586-8.
                                   2. Hayashi H, Hayashi K, Nakao F, Hayashi F. Anterior capsule contraction      8. Framme C, Hoerauf H, Roider J, Laqua H. Delayed intraocular lens dislo-
                                       and intraocular lens dislocation in eyes with pseudoexfoliation syn-           cation after neodymium:YAG capsulotomy. J Cataract Refract Surg
                                       drome. Br J Ophthalmol 1998;82:1429-32.                                        1998;24:1541-3.
                                   3. Shankar J, Halliwell M. Spontaneous posterior dislocation of an intraoc-    9. Shigeeda T et al. Spontaneous posterior dislocation of intraocular lenses
                                       ular lens presenting as pupillary block glaucoma. J Cataract Refract           fixated in the capsular bag. J Cataract Refract Surg 2002;28:1689-93.
                                       Surg 2003;29:410-1.                                                        10. Tappin MJ, Larkin DF. Factors leading to lens implant decentration and
                                   4. Petersen AM, Bluth LL, Campion M. Delayed posterior dislocation of sil-         exchange. Eye 2000;14(5):773-6.
                                       icone plate-haptic lenses after neodymium:yag capsulotomy. J Cataract      11. Dahlhauser KF, Wroblewski KJ, Mader TH. Anterior capsule contraction
                                       Refract Surg 2000;26:1827-9.                                                   with foldable silicone intraocular lenses. J Cataract Refract Surg
                                   5. Agustin AL, Miller KM. Posterior dislocation of a plate-haptic silicone         1998;24:1216-9.
                                       intraocular lens with large fixation holes. J Cataract Refract Surg        12. Reeves PD, Yung CW. Silicone intraocular lens encapsulation by shrink-
                                       2000;26:1428-9.                                                                age of the capsulorhexis opening. J Cataract Refract Surg
Figure 1: Subluxated IOL           6. Akerele T, Minasian M, Little B, Jagger J. Posterior dislocation of Staar       1998;24:1275-6.
within the capsular bag                plate haptic silicone lenses following Nd:YAG capsulotomy. Eye             13. Lim SJ, Kang SJ, Kim HB, Apple DJ. Ideal size of an intraocular lens for
(sunset appearance).                   1999;13(5):700-2.                                                              capsular bag fixation. J Cataract Refract Surg 1998;24:397-402.

22      REN • Dec/Jan 2005

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Description: Spontaneous Late Subluxation of Polymethylmethacrylate Eye bag removal