Hypotony After Rotation of an Intraocular Lens Haptic Into a Cyclodialysis Cleft
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736 AMERICAN JOURNAL OF OPHTHALMOLOGY June, 1986 Figure (Catalano and Kassoff). Comparison of the increased resting vault of the intraocular lens re- moved in Case 1 (right) with that of a similar unused lens (left). flexible as to touch the corneal endothelium when the globe is compressed (L. G. Leiske, unpublished data). This implies an inherent elasticity and "memory" of the lens haptic. Our two cases demonstrated that excessive posterior pressure may permanently deform a flexible anterior chamber intraocular lens, pro- ducing irreversible lens-corneal touch. For this reason consideration should be given to the early removal of a flexible anterior chamber lens that has vaulted enough to cause lens- corneal touch in association with pupillary- block glaucoma. References 1. Leiske, 1. G.: Anterior chamber implants. In Rosen, E. S., Haining, W. M., and Arnott, E. J. (eds): Intraocular Lens Implantation. St. Louis, C. V. Mosby, 1984, pp. 286-305. 2. Passo, M. S., and Van Buskirk, E. M.: Pupillary block with flexible anterior chamber intraocular lens- es. Am. J. Ophthalmol. 99:603, 1985. 3. Reidy, J. J., Apple, D. J., Googe, J. M., Richey, M. A., Mamalis, N., Olson, R. J., and Mackman, G.: An analysis of semiflexible, closed-loop anterior chamber intraocular lenses. Am. Intraocul. Implant Soc. J. 11:344, 1985. 4. Duffin, R. M., and Olson, R. J.: Vaulting char- acteristics of flexible loop anterior chamber intraocu- lar lenses. Arch. Ophthalmol. 101:1429, 1983. Hypotony After Rotation of an Intraocular Lens Haptic Into a Cyclodialysis Cleft William H. Davenport, M.D., Reay H. Brown, M.D., and Mary G. Lynch, M.D. Department of Ophthalmology, University of Texas Health Science Center at Dallas. Inquiries to Reay H. Brown, M.D., Department of Oph- thalmology, University of Texas Health Science Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75235. Inadvertent cyclodialysis clefts with associat- ed hypotony may occur after cataract extraction (with or without an intraocular lens), glaucoma filtering operations, other types of intraocular surgery, and trauma.!" Cyclodialysis clefts can be treated by a variety of techniques, including diathermy, suturing, and argon laser photoco- agulation.P" We treated a case of hypotony from an inadvertent cyclodialysis cleft that de- veloped after an extracapsular cataract extrac- tion, posterior chamber intraocular lens im- plantation, and trabeculectomy. The hypotony appeared four months after surgery and was associated with the rotation of the intraocular lens haptic into the cyclodialysis cleft. A 63-year-old man with advanced open-angle glaucoma developed dense cataracts in both eyes. His best corrected visual acuity was R.E.: counting fingers and L.E.: 20/200. The nuclear sclerotic changes in both eyes were compatible with the visual acuity. Despite two previous trabeculectomies, the average intraocular pres- sure in the right eye was 24 to 26 mm Hg with maximum medical therapy. Visual field exami- nation showed extensive defects that involved fixation in both eyes. The visual field defects in the right eye had shown progression, although it was difficult to differentiate between glauco- matous damage and increasing cataract. The patient underwent a combined extracap- sular cataract extraction, posterior chamber in- traocular lens implantation, and trabeculec- tomy in the right eye. To facilitate removal of the crystalline lens, a sector iridectomy was created at the 1 o'clock meridian, adjacent to the trabeculectomy site. The intraocular lens hap tics were positioned at the 10 and 4 o'clock meridians. There were no intraoperative com- plications. Postoperatively, visual acuity in the right eye improved to 20/80. The anterior cham- ber was deep. The horizontal cup-disk ratio was 0.95 with glaucomatous damage affecting central fixation. The macula was normal. Al- though adequate filtration through the trabecu- lectomy was initially present, a permanent fil- tering bleb did not develop. The intraocular pressure averaged 20 mm Hg with 0.5% timolol twice daily. Four months later, visual acuity in the pa- tient's right eye was 20/400. The anterior cham- ber was shallow. A bleb was not present. Seidel testing was negative. Intraocular pressure by applanation tonometry was 7 mm Hg. Gonios- copy disclosed that an intraocular lens haptic
Transcript of Hypotony After Rotation of an Intraocular Lens Haptic Into a Cyclodialysis Cleft
736 AMERICAN JOURNAL OF OPHTHALMOLOGY June, 1986
Figure (Catalano and Kassoff). Comparison of theincreased resting vault of the intraocular lens removed in Case 1 (right) with that of a similar unusedlens (left).
flexible as to touch the corneal endotheliumwhen the globe is compressed (L. G. Leiske,unpublished data). This implies an inherentelasticity and "memory" of the lens haptic.Our two cases demonstrated that excessiveposterior pressure may permanently deform aflexible anterior chamber intraocular lens, producing irreversible lens-corneal touch. For thisreason consideration should be given to theearly removal of a flexible anterior chamberlens that has vaulted enough to cause lenscorneal touch in association with pupillaryblock glaucoma.
References
1. Leiske, 1. G.: Anterior chamber implants. InRosen, E. S., Haining, W. M., and Arnott, E. J. (eds):Intraocular Lens Implantation. St. Louis, C. V.Mosby, 1984, pp. 286-305.
2. Passo, M. S., and Van Buskirk, E. M.: Pupillaryblock with flexible anterior chamber intraocular lenses. Am. J. Ophthalmol. 99:603, 1985.
3. Reidy, J. J., Apple, D. J., Googe, J. M., Richey,M. A., Mamalis, N., Olson, R. J., and Mackman, G.:An analysis of semiflexible, closed-loop anteriorchamber intraocular lenses. Am. Intraocul. ImplantSoc. J. 11:344, 1985.
4. Duffin, R. M., and Olson, R. J.: Vaulting characteristics of flexible loop anterior chamber intraocular lenses. Arch. Ophthalmol. 101:1429, 1983.
Hypotony After Rotation of anIntraocular Lens Haptic Into aCyclodialysis Cleft
William H. Davenport, M.D.,Reay H. Brown, M.D.,and Mary G. Lynch, M.D.Department of Ophthalmology, University of TexasHealth Science Center at Dallas.
Inquiries to Reay H. Brown, M.D., Department of Ophthalmology, University of Texas Health Science Center atDallas, 5323 Harry Hines Blvd., Dallas, TX 75235.
Inadvertent cyclodialysis clefts with associated hypotony may occur after cataract extraction(with or without an intraocular lens), glaucomafiltering operations, other types of intraocularsurgery, and trauma.!" Cyclodialysis clefts canbe treated by a variety of techniques, includingdiathermy, suturing, and argon laser photocoagulation.P" We treated a case of hypotonyfrom an inadvertent cyclodialysis cleft that developed after an extracapsular cataract extraction, posterior chamber intraocular lens implantation, and trabeculectomy. The hypotonyappeared four months after surgery and wasassociated with the rotation of the intraocularlens haptic into the cyclodialysis cleft.
A 63-year-old man with advanced open-angleglaucoma developed dense cataracts in botheyes. His best corrected visual acuity was R.E.:counting fingers and L.E.: 20/200. The nuclearsclerotic changes in both eyes were compatiblewith the visual acuity. Despite two previoustrabeculectomies, the average intraocular pressure in the right eye was 24 to 26 mm Hg withmaximum medical therapy. Visual field examination showed extensive defects that involvedfixation in both eyes. The visual field defects inthe right eye had shown progression, althoughit was difficult to differentiate between glaucomatous damage and increasing cataract.
The patient underwent a combined extracapsular cataract extraction, posterior chamber intraocular lens implantation, and trabeculectomy in the right eye. To facilitate removal ofthe crystalline lens, a sector iridectomy wascreated at the 1 o'clock meridian, adjacent tothe trabeculectomy site. The intraocular lenshaptics were positioned at the 10 and 4 o'clockmeridians. There were no intraoperative complications. Postoperatively, visual acuity in theright eye improved to 20/80. The anterior chamber was deep. The horizontal cup-disk ratiowas 0.95 with glaucomatous damage affectingcentral fixation. The macula was normal. Although adequate filtration through the trabeculectomy was initially present, a permanent filtering bleb did not develop. The intraocularpressure averaged 20 mm Hg with 0.5% timololtwice daily.
Four months later, visual acuity in the patient's right eye was 20/400. The anterior chamber was shallow. A bleb was not present. Seideltesting was negative. Intraocular pressure byapplanation tonometry was 7 mm Hg. Gonioscopy disclosed that an intraocular lens haptic
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Figure (Davenport, Brown, and Lynch). A gonioscopic view of the sector iridectomy. The intraocularlens haptic emerges from behind the iris (whitearrow) and is lodged within a cyclodialysis cleft(black arrow). The tip of the haptic is visible anteriorto the iris (asterisk).
had rotated into the sector iridectomy and thatthe curved portion of the haptic was lodgedwithin a cyclodialysis cleft (Figure). Large choroidal detachments were present. The maculashowed edema with pigment mottling. Thepatient was treated with 1% atropine twicedaily. Timolol was discontinued.
One week later, the findings were unchangedand a surgical closure of the cleft was planned.The intraocular lens haptic was rotated out ofthe cyclodialysis cleft. The patency of the cleftwas tested by the method described by Chandler and Maumenee! and Maumenee andStark." Dilute fluorescein was injected into theanterior chamber. A scleral incision was madein the inferotemporal quadrant and clear suprachoroidal fluid was drained. Despite repeatedinjection of fluorescein, choroidal drainage,and the use of a cobalt blue light, fluoresceinwas not recovered from the suprachoroidalfluid. The failure to recover fluorescein fromthe suprachoroidal space suggested that thecleft had closed after the intraocular lens wasrepositioned. Postoperatively, treatment wasbegun with 1% atropine twice daily.
On the first postoperative day the intraocularpressure was 15 mm Hg. The anterior chamberwas deep. However, on the second day, theintraocular pressure was 4 mm Hg and a choroidal detachment was present. At three days,the cleft was treated with an argon laser (spotsize, 200 J.Lm; duration, 0.1 second; power, 1.5to 2.0 W). Thirty applications were placed at
the margins of the cleft. The intraocular pressure remained low. Laser therapy was repeatedone week later with 100 applications of 2.5 W.By the following week, the intraocular pressurehad increased to 15 mm Hg and the visualacuity had improved to 20/100. At a threemonth follow-up examination, the intraocularpressure and visual acuity were stable.
It is not certain whether the cyclodialysisoccurred at the time of the sector iridectomy orwith some other intraocular maneuver. However, hypotony did not occur until four monthsafter surgery and was associated with rotationof the intraocular lens haptic into the iridectomy. Thus, it is conceivable that rotation of theintraocular lens haptic opened a cleft thatwould otherwise have remained closed. Latehypotony has been described after cataract surgery with and without intraocular lens implantation.!"
The intraocular pressure of 15 mm Hg and adeep chamber on the first postoperative daysuggest that the cleft may have been closedtemporarily after the intraocular lens was repositioned. Thus, the fluorescein test for cleftpatency may have been misleading because of atemporary closure of the cleft.
As demonstrated by this case, posteriorchamber intraocular lenses are capable of rotating intraocularly. When cataract extraction andintraocular lens implantation are combinedwith sector iridectomy, placement of the haptics perpendicular to the iridectomy may noteliminate complications from the haptics.
References
1. Meislik, J., and Herschler, J.: Hypotony due toinadvertent cyclodialysis after intraocular lens implantation. Arch. Ophthalmol. 97:1297, 1979.
2. Chandler, P. A., and Maumenee, A. E.: Amajor cause of hypotony. Am. J. Ophthalmol.52:609, 1961.
3. Maumenee, A., and Stark, W. J.: Managementof persistent hypotony after planned or inadvertentcyclodialysis. Am. J. Ophthalmol. 71:320, 1971.
4. Joondeph, H. c.: Management of postoperative and post-traumatic cyclodialysis cleftswith argon laser photocoagulation. OphthalmicSurg. 11:186, 1980.
5. Partamian, L. G.: Treatment of a cyclodialysiscleft with argon laser photocoagulation in a patientwith a shallow anterior chamber. Am. J. Ophthalmol. 99:5, 1985.
