We agree with Apel and Stephensen about first applying a conservative approach. However, there were aspects of this particular case that made the situation unlikely to be corrected by conservative and Nd:YAG laser treatment only.
Before the surgery, not 1 but 2 iridotomies were applied. The iridotomies were checked before surgery and judged to be patent, with excellent translucency. They were located 90 degrees apart, making simultaneous blockage by the ICL unlikely.
As soon as the blockage occurred, intravenous carbonic anhydase inhibitors at maximum dosage as well as topical intraocular pressure (IOP)-lowering treatment and miotic pharmacologic agents were applied, with no effect on IOP or pupil size. Moreover, the patient was close to collapse and felt seriously ill.
At the slitlamp examination in this acute phase, no signs of remaining ophthalmic viscosurgical device (OVD)-like tiny air bubbles, entrapped erythrocytes, or immobile cells were observed. Intraoperatively, no OVD efflux from behind the ICL was observed, making it unlikely that entrapped OVD was the reason for this specific problem.
The acute ACG was caused solely by excessive anterior vaulting of the oversized ICL. No OVD was detected behind the ICL intraoperatively. The patient's condition warranted the additional therapeutic alternative of explanting the ICL. Fortunately, the exchange for an iris-fixated phakic IOL corrected the situation and our patient is very satisfied.