Secondary Logo

Journal Logo

Consultation section

Refractive Surgical Problem

September consultation #1

Nuijts, Rudy M.M.A. MD, PhD

Journal of Cataract & Refractive Surgery: September 2013 - Volume 39 - Issue 9 - p 1445-1446
doi: 10.1016/j.jcrs.2013.07.006
  • Free

A 32-year-old man came for consultation in January 2013 because of decreased near vision and a suspected larger pupil in the left eye after refractive surgery elsewhere. He had implantation of an Implantable Collamer Lens phakic intraocular lens (pIOL) (Staar Surgical) in that eye in June 2012. Preoperatively, the refraction was approximately −7.5 diopters (D) in the left eye and −4.5 D in the right eye, which had previous femtosecond laser–assisted laser in situ keratomileusis (LASIK). After telephone consultation, the surgeon advised the patient to wear a plus contact lens in the left eye; however, this failed as a result of contact lens intolerance. In addition, the surgeon had advised taking constricting eyedrops (brimonidine tartrate [Alphagan]) because of halos.

On examination in January 2013, the uncorrected distance visual acuity was 20/20 in both eyes. The corrected distance visual acuity was 20/20 with +0.25 −0.50 × 85 in the right eye and 20/20 with plano −0.50 × 75 in the left eye. After cycloplegia, the refraction was +0.25 −0.50 × 95 in the right eye and +1.25 in the left eye. The uncorrected near visual acuity (UNVA) was Jaeger 1 (J1) in both eyes. The intraocular pressure (IOP) was 14 mm Hg in the right eye and 15 mm Hg in the left eye.

Slitlamp biomicroscopy of the left eye showed 2 peripheral iridectomies at 11 o’clock and 1 o’clock and some pigment deposits on the pIOL (Figure 1). There are no available details regarding the pIOL size. The vault between the back of the pIOL and the natural lens was approximately 2.5 times the central thickness of the pIOL. The iris had an anteriorly bowing configuration. Figure 2 shows anterior segment optical coherence tomography (AS-OCT) of the right eye and the left eye. Slitlamp biomicroscopy of the right eye showed an unremarkable LASIK flap and clear cornea. The central corneal thickness was 469 μm in the right eye and 548 μm in the left eye. Infrared pupillometry showed a mesopic pupil size of 4.64 mm and 4.66 mm, respectively.

Figure 1
Figure 1:
Slitlamp view of the left eye showing some pigment deposition (A) on the pIOL and the vault between the pIOL and the natural lens (B).
Figure 2
Figure 2:
Anterior segment OCT of the right eye (A) and the left eye (B) with a narrower chamber angle and a large vault between the pIOL and the natural lens.

The application of brimonidine tartrate was moderately successful in decreasing halos; however, the subjective complaints regarding reading vision have not changed.

Was the sizing of the posterior chamber (PC) pIOL correct? What would be your preferred treatment for the left eye: excimer laser enhancement or replacement of the pIOL? In the case of a replacement, how would you change the dimensions of the pIOL? Would you leave the patient on brimonidine tartrate for the rest of his life?

© 2013 by Lippincott Williams & Wilkins, Inc.