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| BRIEF REPORT |
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| Year : 2000 | Volume
: 48
| Issue : 3 | Page : 235-6 |
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Phakic-Pseudophakic bullous keratopathy following implantation of a posterior chamber IOL in the anterior chamber to correct hypermetropia
N Pushker, R Tandon, RB Vajpayee, JS Titiyal
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India
Correspondence Address:
N Pushker
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 11217259 
Keywords: Adult, Anterior Chamber, surgery, Cornea, pathology, ultrasonography, Corneal Diseases, etiology, pathology, ultrasonography, Humans, Hyperopia, surgery,
How to cite this article:
Pushker N, Tandon R, Vajpayee R B, Titiyal J S. Phakic-Pseudophakic bullous keratopathy following implantation of a posterior chamber IOL in the anterior chamber to correct hypermetropia. Indian J Ophthalmol 2000;48:235 |
There is an increasing demand for refractive surgery stemming from a heightened awareness among patients wearing spectacles or contact lenses. Cosmetic or occupational reasons prompt patients to seek the alternative option of refractive surgery.
Currently there is increased enthusiasm among ophthalmologists in extending refractive surgery to a greater number of patients. A review[1] of currently available options includes photorefractive keratectomy (PRK), laser assisted in-situ keratomilieusis (LASIK), intracorneal ring (ICR), clear lens extraction and phakic intraocular lenses (IOL) for myopia; and Holmium laser thermokeratoplasty (HO-TKP), LASIK, lens extraction and phakic IOL for hyperopia.
We report a case of bullous keratopathy associated with phakic IOL used to correct hyperopia.
| Case report | |  |
A 30-year-old man presented to us with complaints of progressive diminution of vision with intermittent pain, redness, watering and photophobia in his left eye since June 1997. He had poor vision with divergence of his right eye, and had been wearing glasses since early childhood. In 1988, he had sought the opinion of an ophthalmologist for surgical treatment of his refractive error. Previous records revealed retinoscopy values of + 8.5 DS in both eyes and best corrected visual acuity (BCVA) was counting fingers at one meter in right eye and 6/9 in left eye. Cornea and lens of both eyes were normal. He was diagnosed to have hypermetropia in both eyes with right divergent squint, amblyopia and eccentric fixation.
In August 1988 he had undergone refractive surgery: a posterior chamber intraocular lens (model PC 211, 3 piece Allergan ISP-14 mm overall diameter, + 13.5 D optical power as per IOL identification label on patient's old records) was implanted in the anterior chamber of his left eye to correct hypermetropia. Subsequently the BCVA was 6/36 in left eye with -3.00 Dsph; N12 unaided for near. In October, 1988, he also underwent refractive corneal surgery on his right eye. However, vision in the right eye did not improve after the surgery.
The patient presented to us with complaints of progressive diminution of vision in the left eye for past 2 years. On examination, his BCVA was finger counting at one metre in both eyes. Flashlight examination showed that the patient had a right divergent squint of 45° with limitation of the right eye on adduction. Slitlamp biomicroscopy examination revealed multiple corneal subepithelial circular nebular opacities in the midperiphery of his right eye. The rest of the anterior and posterior segment of the right eye was normal. The cornea of the left eye showed epithelial and stromal oedema and presence of bullae [Figure - 1] and a posterior chamber IOL implanted in the anterior chamber with haptics oriented horizontally [Figure - 2]. There was no visible peripheral iridotomy. Due to corneal oedema the fundus of the left eye was not visible.
The central corneal thickness measured by ultrasonic pachymetry was 0.56 mm in the right eye and 0.99 mm in the left eye. The endothelial cell count in the right eye was 3100 cells/mm2. In left eye the endothelial cells were not visible. Intraocular pressure (IOP) with Schiotz tonometer was 17.3 mmHg in the right eye and 23.1 mmHg in the left eye. On gonioscopy (Goldmann single mirror) the angle was open with narrow entry in right eye; left eye gonioscopy was not possible because of corneal oedema. Anterior chamber depth (A-Scan) was 2.30 mm in right eye. The axial length was 19.6 mm, in the right and 19.4 mm in the left eye. The patient was advised to undergo penetrating keratoplasty with IOL removal in the left eye with guarded visual prognosis.
| Discussion | | |
Currently applied surgical techniques include options for correction of almost all types of refractive errors. Surgical treatment choices recommended for correction of hyperopia are HO TKP for low, LASIK for low to moderate and clear lens extraction with posterior chamber IOL or phakic IOL for moderate to high hyperopia.[1-3] The latter has the advantage of retaining the power of accommodation. As opposed to phakic IOLs for myopia where both anterior chamber (AC) and posterior chamber (PC) lenses have been designed[1-[5], only PC IOLs have been advocated for surgical correction of hyperopia.[1-3] Hyperopes have a relatively small eye with shallow anterior chamber and are at greater risk for developing complications with AC lenses.
In this patient a conventional PC IOL designed for insertion in aphakic eyes was implanted in the AC to correct hyperopia in a practically one-eyed patient. Postoperatively the patient had -3.00 D refractive error and could comfortably pursue his occupation as an accountant without having to use any spectacles for a period of 10 years. However, by the age of 30 years his cornea decompensated resulting in bullous keratopathy and severe visual loss. The cause of endothelial decompen-sation in this case was implantation of a 14mm diameter PC IOL in a small hyperopic eye with a shallow chamber. This possibly led to intermittent IOL-endothelial touch.
The purpose of this report is to reiterate that there are specific IOLs specially designed for correction of specific refractive errors. PC IOLs only are advocated, and for correction of hyperopia not AC IOLs. At present, the Collamer Staar posterior chamber IOL, also dubbed as the implantable contact lens (ICL) is recommended.[1] It is folded and injected through a 2.5 mm incision. The ICL rests on the anterior surface of the crystalline lens, anchored peripherally at the sulcus. Clinical trials are being conducted in different countries. [2,[3]
Improper case selection and application of wrong choice of refractive IOL may result in blindness in patients undergoing refractive surgery. This report should instil a temperising influence on overenthusiasm in refractive surgery and emphasize the importance of proper selection of cases and surgical modalities.
| References | | |
| 1. | Zaldivar R, Roc G. The current status of phakic intraocular lenses. Int Ophthalmol Clin 1996;36:107-ll.  |
| 2. | Rosen E, Gore C. Staar Collamer posterior chamber IOL to correct myopia and hyperopia. J Cataract Refract Surg 1998;24:596-606. [ PUBMED] |
| 3. | Davidorf JM, Zaldivor R, Oscherow S. Posterior chamber phakic intraocular lens for hyperopia of +4 to +11D. J Refract Surg 1998;14:306-ll. |
| 4. | Alpar JJ, Fechner PU. The iris claw lens of Worst. In : Alpar JJ, Fechner PU, editors. Intraocular lenses. New York: Thieme Inc., 1986. pp 328-35. |
| 5. | Fechner PU, Van-der-Heijde-GL, Worst JG. Ntraouclar lens for the correctionof myopia of the phakic eye. Klin-Monatsble-Augen Leilkd 1988;193:29-34. |
[Figure - 1], [Figure - 2]
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