Pupil Ovalization After Phakic Intraocular Lens Implantation Is Associated with Sectorial Iris Hypoperfusion

CLINICAL SCIENCES Pupil Ovalization After Phakic Intraocular Lens Implantation Is Associated With Sectorial Iris Hypoperfusion

Peter Fellner, MD; Bertram Vidic, MD; Yashin Ramkissoon, MD; Arthur D. Fu, MD; Yosuf El-Shabrawi, MD; Navid Ardjomand, MD

Objective: To investigate iris perfusion in patients with Results: Iris perfusion defects were found in 5 of 6 pa- and without pupil ovalization after phakic intraocular lens tients with pupil ovalization. No perfusion deficits were implantation. noted in patients with round pupils.

Methods: Comparative retrospective randomized case Conclusion: Iris ovalization after phakic intraocular series of 6 participants, each with a regular pupil, and lens implantation may be associated with a lack of iris 6 participants with pupil ovalization after phakic intra- perfusion and with secondary ischemia. Patients with ocular lens implantation for high myopia were included these lenses and pupil ovalization should be followed in the study. Indocyanine green angiography was per- regularly. formed between 20 and 40 months (mean±SD, 26±6.1 months) after lens implantation. Arch Ophthalmol. 2005;123:1061-1065

REATMENT OF MYOPIA WITH chamber angle-supported phakic IOLs.7 ablative corneal refractive Since pupil ovalization may be a re- surgery is limited by the sult of iris ischemia,7,19 we investigated iris amount of tissue that can perfusion in 12 patients both with and be removed secondary to without pupil ovalization after phakic IOL risks of keratectasia resulting from cor- implantation according to indocyanine T 1-3 neal thinning. green (ICG) angiography findings. Implantation of phakic intraocular lenses (IOLs) is a method of correcting high refractive errors with preservation of accom- METHODS modation4 while avoiding ablation of corneal tissue. Since the introduction of phakic Twelve patients with various anterior cham- IOLs,5,6 IOL types have changed and are gen- ber angle-supported phakic IOLs (NuVita and erally safer.7,8 Three phakic intraocular ZSAL-4) underwent ICG angiography. Six pa- lenses are now available: angle-supported tients had developed varying degrees of pupil anterior chamber IOLs, iris-claw lenses, and ovalization within the phakic IOL axis, while posterior chamber IOLs.7,9,10 6 patients with phakic IOLs had no obvious iris Corneal endothelial cell loss, once a ma- ovalization on slitlamp examination. Institutional review board approval was not jor problem early in the development of 7,8,11-17 necessary, but explanation of the benefits and phakic IOLs, is less of a concern now. risks of ICG angiography were offered prior to However, there is still some concern about patient consent. the implantation of an IOL in a function- Phakic IOL implantation for high myopia ally healthy eye. treatment was performed in all cases. The Complications such as cataracts, post- demographic data of the patients are pre- Author Affiliations: operative uveitis, postoperative elevated in- sented in the Table. Department of Ophthalmology, The surgical technique has been previ- traocular pressure, decentration, symp- 16,20 Medical University Graz, Graz, tomatic halos, and pupil ovalization have ously described. Phakic IOL implantation Austria (Drs Fellner, Vidic, been reported.7,8,13,17,18 Pupil ovalization has was typically performed under retrobulbar an- El-Shabrawi, and Ardjomand); esthesia. Two hours prior to the procedure, the Moorfields Eye Hospital, been reported to occur in 40% of patients pupil was constricted with 2% pilocarpine eye London, England using the NuVita MA20 (Bausch & Lomb drops. A 7-mm corneal incision was made and 13 (Drs Ramkissoon, Fu, Surgical, San Dimas, Calif) phakic IOLs the phakic IOL was inserted into the anterior and Ardjomand). and in 18% of patients with the ZSAL-4 chamber after injection of viscoelastic mate- Financial Disclosure: None. (Morcher, Stuttgart, Germany) anterior rial (Amvisc; Bausch & Lomb). The lens length

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Patient No./Sex/Age, y IOL Type IOL Size Implanted, D Ovalization Grade Ischemia Grade Follow-up, mo 1/M/41 ZSAL-4* −11.5 1 1 24 2/F/46 NuVita† −10.5 2 1 27 3/M/55 ZSAL-4 −12.0 2 2 20 4/F/46 ZSAL-4 −8.5 1 1 20 5/F/30 ZSAL-4 −14.0 1 0 20 6/F/31 NuVita −14.0 2 2 26 7/F/22 NuVita −12.0 0 0 36 8/F/30 ZSAL-4 −13.0 0 0 26 9/F/26 ZSAL-4 −10.0 0 0 26 10/F/34 NuVita −14.0 0 0 29 11/F/29 NuVita −9.0 0 0 40 12/M/38 ZSAL-4 −10.5 0 0 25

Abbreviations: D, diopter; IOL, intraocular lens. *ZSAL-4 (Morcher, Stuttgart, Germany). †NuVita MA20 (Bausch & Lomb Surgical, San Dimas, Calif ).

was selected by adding 1 mm to the horizontal white-to- was within 10 seconds in normal eyes and myopic eyes white distance. The viscoelastic material was removed with a with phakic IOLs without iris ovalization. Three of 6 pa- Simcoe irrigation-aspiration cannula, iridotomy was per- tients demonstrated iris ovalization of grade 2 from 20 formed, and the corneal incision was closed with 3 inter- to 27 months after lens implantation (Figure 1). Of these rupted stitches (10-0 nylon; Ethicon Inc, Cornelia, Ga). The 3 patients, 1 patient had an iris perfusion defect of grade pupils were constricted and appeared round at the conclusion of the procedure. Dexamethasone ointment was applied 1 (sectorial delayed iris perfusion but normal iris vessel at the end of the operation and the eye was patched until pattern 22 seconds after intravenous ICG injection) and postoperative day 1. 2 patients had an iris perfusion defect of grade 2. Of 3 Postoperative treatment included the use of betamethasone/ patients with mild pupil ovalization (grade 1), 2 pa- neomycin drops 4 times per day, and the treatment tapered over tients demonstrated a delayed iris perfusion defect of grade a period of 5 weeks. All patients were seen on postoperative 1 (sectorial delayed iris perfusion but normal iris vessel day 1, after 1 week, 1 month, 3 months, 6 months, and then at pattern 20 seconds after intravenous ICG injection; 6-month intervals thereafter. Figure 2 and Figure 3) and 1 patient had a normal All procedures were performed by a single surgeon (B.V.) iris perfusion (grade 0). None of the aforementioned pa- in the Department of Ophthalmology at the Medical Univer- tients had obvious iris atrophy. sity Graz in Graz, Austria. The diagnosis and determination of the degree of pupil oval- All patients with phakic IOLs and round pupils also ization were done at the slitlamp. Three different degrees of pu- underwent ICG angiography and demonstrated nor- pil ovalization were recorded: grade 0 indicated no pupil oval- mal iris perfusion (grade 0; Figure 4). All iris vessels ization, grade 1 indicated mild pupil ovalization (pupil deviation were visible 10 seconds after intravenous ICG injec- not reaching the edge of the phakic IOL optic), and grade 2 tion (Table). indicated severe pupil ovalization (pupil deviation reaching the edge of the phakic IOL optic in at least 1 point).17 The patients underwent ICG angiography (Heidelberg Retina COMMENT Angiograph; Heidelberg Engineering, Heidelberg, Germany) of the iris. Patients received an intravenous bolus injection of Whereas refractive errors of low and moderate myopia 5 mL of 20% ICG (ICG-Pulsion; Pulsion Medical Systems, may often be treated by corneal refractive surgery, those München, Germany). The angiograms were recorded with a digi- of high myopia are often treated with phakic IOL im- tal camera (Sony Electronics Inc, Park Ridge, NJ) and ana- 4 lyzed in slow motion using Adobe Premiere Pro software (Adobe, plants or clear lens extraction. Vienna, Austria) by 3 of the investigators (P.F., B.V., N.A.). A Anterior chamber IOLs introduced in the 1950s and perfusion deficit was diagnosed if a sectorial absolute or early 1960s were associated with damage to the corneal en- iris hypofluorescence was noted. dothelium often resulting in corneal decompensation.5,6 Three different grades of iris hypofluorescence were re- Anterior chamber phakic IOLs experienced a renais- corded: grade 0 indicated normal iris perfusion within 10 sec- sance in the 1990s with the development of better and onds after intravenous ICG injection, grade 1 indicated secto- thinner designs.11,17 Concerns about rigid anterior cham- rial delay of filling iris vessels within the first 20 seconds after ber phakic IOLs still exist since complications, includ- intravenous bolus injection of ICG, and grade 2 indicated a per- ing uveitis, cataracts, pigment dispersion, elevated in- sistent lack of sectorial iris vessel perfusion. traocular pressure, and pupil ovalization, have been reported.7,8,17,19 Pupil ovalization after phakic IOL im- RESULTS plantation has been thought to be related to iris ischemia induced by haptic compression of the iris root ves- All patients had a round pupil at the end of the opera- sels since it is associated with iris retraction, iris atrophy, tion and at the follow-up at 6 months. Iris perfusion time and low-grade inflammation.7,17,19 This study shows, for

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Figure 1. A, Iris perfusion in an eye with phakic intraocular lens and pupil ovalization (grade 2), 10 seconds after intravenous indocyanine green injection. Sectorial iris perfusion defects can be seen at the iris periphery (asterisk) and at the pupil margin (arrow). B, The same eye at 22 seconds after injection shows normal perfusion in the periphery (asterisk) but lacks sectorial iris vessel–filling at the pupil margin (arrow).

A B

Figure 2. A, Sectorial iris perfusion defect (asterisk), 11 seconds after intravenous indocyanine green injection in an eye with pupil ovalization (grade 1). Arrow indicates pupil margin. B, Iris perfusion is normal 20 seconds after injection.

the first time, iris perfusion defects in patients with pha- rescein or ICG to assess perfusion of anterior ocular struc- kic IOLs. tures has been previously described.21,22 The ICG was used We described all cases of slitlamp-evident ovaliza- rather than sodium fluorescein for angiography because tion of the pupil as pupil ovalization, whereas Alio et al17 fluorescein may be difficult to visualize in patients with classified pupil ovalization as pupil deviation in the me- heavily pigmented iris tissue.23 ridian of the placement of the phakic IOL haptic that The ICG angiograms showed mild to severe iris per- reaches the edge of the phakic IOL optic in at least 1 point. fusion defects in 5 of 6 eyes with pupil ovalization. In 3 No quantitative grading for pupil ovalization has been eyes, iris perfusion in some segments was delayed for sev- published yet, and our grading has been adapted to dis- eral seconds after intravenous injection of ICG but was tinguish between mild and severe pupil ovalization. normal at the 22- to 25-second time period. In 2 other In this study, we used ICG angiography to investi- eyes, we found permanent iris perfusion defects, espe- gate iris perfusion in eyes with phakic IOLs with and with- cially at the pupil margin. Though the ovalization was out pupil ovalization approximately 2 years after IOL im- in the axis of the IOL, perfusion defects were not only plantation. Indocyanine green angiography is an infrared- seen at the axis of the larger diameter of the ovalization based dye imaging technique introduced for retinal and but also elsewhere in the iris. choroidal disorders. Further advances in videoangiog- The ICG angiography results were normal in 1 eye with raphy have allowed for precise assessment of degree and mild ovalization 20 months after implantation and in eyes timing of perfusion in ocular vasculature. The use of fluo- without pupil ovalization.

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Figure 3. A, Mild pupil ovalization (grade 1) in an eye with anterior chamber phakic intraocular lens before indocyanine green angiography. B, Sectorial iris perfusion delay is seen 10 seconds after indocyanine green injection (asterisk), especially at the pupil margin (arrow). C, Iris perfusion looks normal 20 seconds after indocyanine green injection.

for the IOL length is the largest corneal diameter plus 1mm17,26; however, this is an estimation and may not re- flect the proper anterior chamber diameter. Anterior chamber depth measurement using ultrasound biomicroscopy, optical coherence tomography, or Scheimp- flug photography could be useful for phakic IOL size measurement and may reduce the pressure on the iris roots through better IOL intraocular fit. New foldable phakic IOLs are commercially available now, and these lenses have the additional advantage of reducing the haptic pressure in the chamber angle.27-31 The long-term relevance and associations of iris perfusion defects, which are demonstrated on ICG videoangiography, and subsequent development of iris ischemia are still unclear. However, these patients may require regular follow-up, and IOL explantation may be considered in patients with extensive pupil ovalization associated with symptoms of chronic anterior uveitis. Figure 4. Iris perfusion in an eye with phakic intraocular lens, 11 seconds after indocyanine green injection. Normal iris perfusion (grade 0) is seen in Submitted for Publication: June 11, 2004; final revi- the peripheral iris tissue and at the pupil margin. sion received November 16, 2004; accepted November 16, 2004. All patients with pupil ovalization and 2 patients Correspondence: Navid Ardjomand, MD, Department of with round pupils showed cell deposits on the IOLs. Ophthalmology, Medical University Graz, Auenbrugger- This may be related to breakdown of the blood-aqueous platz 4, A-8036 Graz, Austria (navid.ardjomand barrier, as previously described in anterior segment @meduni-graz.at). ischemia.22 However, uveitis was not observed and no Previous Presentation: Presented at the annual meeting patient was receiving topical medication at the time of of the European Society of Cataract & Refractive Sur- angiography. gery, Munich, Germany, September 9, 2003. Anterior segment ischemia has been described as oc- curring after different ocular surgery procedures such as REFERENCES strabismus or retinal detachment surgery.21,22 Iris atrophy, uveitis, and even phthisis bulbi have been de- 1. Seitz B, Torres F, Langenbucher A, Behrens A, Suarez E. Posterior corneal cur- scribed with anterior segment ischemia.22 Experimen- vature changes after myopic laser in situ keratomileusis. Ophthalmology. 2001; tally induced anterior segment ischemia results in rubeosis 108:666-673. iridis in a rabbit model. Histopathologic examination of 2. Comaish IF, Lawless MA. Progressive post-LASIK keratectasia: biomechanical instability or chronic disease process? J Cataract Refract Surg. 2002;28:2206- eyes with anterior chamber IOLs has revealed iris ghost 2213. 24,25 vessels. Iris atrophy was not noticed in any of our pa- 3. Ou RJ, Shaw EL, Glasgow BJ. Keratectasia after laser in situ keratomileusis (LASIK): tients, particularly not in those with sectorial iris vessel– evaluation of the calculated residual stromal bed thickness. Am J Ophthalmol. filling defects. 2002;134:771-773. 4. O’Brien TP, Awwad ST. Phakic intraocular lenses and refractory lensectomy for One difficulty with the phakic anterior chamber IOL myopia. Curr Opin Ophthalmol. 2002;13:264-270. implantation surgical technique is the accurate measure- 5. Strampelli B. Sopportabilia di lenti acriliche in camera anteriore nella afachio o ment of phakic IOL size. The general recommendation nei vizi di refrazione. Ann Ottalmol Clin Ocul. 1954;80:75-82.

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