History

• 44-year-old woman presents with mild blunt trauma to her eye
• Three days prior to presentation, patient was hit in the eye by her baby with a toy
• Night prior to presentation, she developed pain and blurry vision OS
• PMH: currently eight months pregnant
• POH: high myopia s/p phakic IOL OU years ago; retinal hole OS s/p laser retinopexy
• No past surgical history, family history or medications
• Denies alcohol and smoking

Exam Findings

• BCVA: 20/25 OD, HM OS (was unremarkable at ENT visit 05/2017)
• Pupils: round and reactive OD, irregular and fixed OS
• IOP: 17 OD, 49 OS
• EOMI
• Anterior exam: remarkable for left edematous eyelid, 1+ injection and edematous cornea. Within normal limits OD

Diagnosis

• Displaced Phakic Intraocular Lens

Phakic Intraocular Lenses

• Two types of phakic IOLs are FDA approved in the US
• Posterior chamber IOL
• Iris-fixated anterior chamber IOL
• Typically used for patients with severe degrees of refractive error
• Older than 21 years of age
• Stable refraction (<0.5D change over one year)
• Irido-corneal angle > 30 degrees
• Central endothelial count >2000
• Mesopic pupil <5-6mm
• Contraindications
• Active anterior segment disease (AC < 3-3.2mm; narrow angles, any angle abnormality)
• Glaucoma / IOP >21mmHg
• Anomalous irises / pupils
• Pre-existing macular pathology
• Retinal disease
• Recurrent or chronic uveitis
• Cataracts
• Systemic diseases a/w poor healing (e.g. DM, connective tissue disease, autoimmune disease etc)
• Outcomes at three years, as reported by Huang et al for the American Academy of Ophthalmology

• Complications
• Endothelial cell damage and decompensation
• Chronic inflammation
• Angle scarring
• Pigment dispersion (PCIOLs)
• Iris atrophy
• Pupillary block: ppx LPI 90 degrees apart
• Cataracts
• Endophthalmitis

Case Management

• Was unable to obtain HMO approval for in-clinic LPI in a timely manner
• Underwent same-day phakic IOL repositioning with surgical iridectomy OS

• Post-op week 1:
• BCVA 20/70 OS; IOP 15 OS
• Lens haptics found covering surgical iridectomy
• Considered LPI but iris was spastic and dilated post-op
• Post-op month 1, IOP elevated to 38
• Patient underwent phakic IOL extraction and given state of pregnancy, will defer further IOL placements to a later date

References

• Alio, Jorge et al. Follow-up Study of More than 15 years of an Angle-Supported Phakic Intraocular Lens Model (ZB5M) for High Myopia. Outcomes and Complications. JAMA Ophthalmology 131 (12), 2013.
• Allan, Barsam. Excimer Laser Refractive Surgery versus Phakic Intraocular Lenses for the Correction of Moderate to High Myopia (Review)”. Cochrane Database Syst Rev. Jan 18; 1:CD007679, 2012.
• Huang, D et al. Phakic Intraocular Lens Implantation for the Correction of Myopia. A report by the American Academy of Ophthalmology. Ophthalmology Nov; 116 (11): 2244-58, 2009.
• https://www.eyewiki.aao.org/Phakic_Intraocular_Lenses

Contact

• Sahar Bedrood, MD, PhD, saharbedrood@gmail.com
• Meghan Shan, MD, PhD, PGY-2 Ophthalmology resident, brandon.wong@med.usc.edu

Section Editors

• Vivek Patel, MD, Associate Professor of Clinical Ophthalmology, Program Director, vivek.patel@med.usc.edu
• Jesse Berry, MD, Assistant Professor of Clinical Ophthalmology, Associate Program Director, jesse.berry@med.usc.edu

 

Produced by: Monica Chavez, John Daniel, and Dr. Vivek Patel