Surgical management of acute angle-closure glaucoma after toric ICL implantation
Vetter et al.1 describe a case of acute angle-closure glaucoma (ACG) after implantation of a toric implantable contact lens (ICL) that was treated by extraction of the ICL, reversing the acute ACG. In our experience, cases of acute ACG following implantation of ICLs in patients who have had neodymium:YAG (Nd:YAG) laser iridotomies is best treated by a combination of miosis, oral or intravenous carbonic anhydrase inhibitors, and revision or creation of new Nd:YAG laser iridotomies using an Nd:YAG laser. This is a straightforward outpatient procedure that has resolved all our cases of acute ACG glaucoma in which pharmacologic agents have failed.
Performing a Nd:YAG laser iridotomy results in a puff of pigment into the anterior chamber, as opposed to a puff of pigment between the ICL and the crystalline lens, redirecting the aqueous into the anterior chamber and breaking the angle closure. If a pigment puff is seen between the ICL and the crystalline lens during the Nd:YAG laser iridotomy, the angle closure is unlikely to be broken. Immediate deepening of the anterior chamber and lowering of the intraocular pressure indicate a break of the angle closure.
In one of Apel's cases, laser iridotomies were performed in a layer of virgin iris. This appears to be a much less invasive procedure than that described by Schipper,2 and I recommend this treatment prior to taking patients to the operating room for ICL removal.
The mechanism of angle closure in cases of ICL implantation has not been fully explained but may be due to a combination of an ICL with a diameter that is too large and an ophthalmic viscosurgical device trapped between the ICL and the crystalline lens.
1. Vetter JM, Tehrani M, Dick HB. Surgical management of acute angle-closure glaucoma after toric implantable contact lens implantation. J Cataract Refract Surg. 2006;32:1065-1067.
© 2007 by Lippincott Williams & Wilkins, Inc.
2. Schipper I., 2007. Surgical management of acute angle-closure glaucoma after implantation of a toric ICL [letter], J Cataract Refract Surg, 33, 563-564.