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Consultation section: Cataract

Highly myopic vitrectomized eye develops delayed subluxation of 3-piece PMMA intraocular lens after complicated cataract surgery

Menapace, Rupert MD

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Journal of Cataract & Refractive Surgery: November 2019 - Volume 45 - Issue 11 - p 1686
doi: 10.1016/j.jcrs.2019.08.024
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A 50-year-old male patient had suffered a tennis ball contusion in his right eye in his youth. At the age of 29 years, he developed retinal detachment, which was successfully repaired by vitrectomy and gas tamponade. At the age of 35, the patient underwent laser in situ keratomileusis (LASIK) in both eyes. Three years Later, the right eye underwent cataract surgery with a 3-piece poly(methyl methacrylate) (PMMA) intraocular lens (IOL) implantation.

Upon presentation, the patient reported decreased visual acuity and monocular diplopia for 3 weeks. The corrected distance visual acuity was 0.4. The refraction was −3.75 +2.25 × 30. Corneal tomography showed a well-centered laser ablation zone with a total corneal cylinder of 1.7 diopters (D) at 45 degrees and a central corneal thickness of 483 μm. The axial length was 30.83 mm. Biomicroscopy revealed a subluxated 3-piece PMMA IOL with the optic massively decentered and tilted temporally with one haptic loop passing the pupil and located in the nasal chamber angle (Figure 1and Figure 2, A and B). The pupil dilated only scarcely on maximum topical medication. Retroillumination revealed iris pigment defects and transillumination, a very thin, translucent sclera with areas of shining through the uvea (Figure 2, C and D). Oblique capsule folds were visible nasally (Figure 2, C), whereas the temporal posterior capsule was obviously lacking. The intraocular pressure (IOP) was 11 mm Hg. Fundoscopy showed an attached myopic retina, and optical coherence tomography (OCT) showed a normal fovea.

Figure 1
Figure 1:
Loop of 3-piece poly(methyl methacrylate) intraocular lens displaced in front of nasal iris.
Figure 2
Figure 2:
A and B: IOL optic with undilated pupil. C and D: IOL optic with maximally dilated pupil. A and C: IOL optic with nasal capsule visualized with slightly oblique illumination. B and D: IOL optic visualized with retroillumination (IOL = intraocular lens).

Considering the context of a subluxated 3-piece PMMA IOL in a highly myopic eye with a very thin sclera and a poorly dilating pupil with a history of vitrectomy, what would be your options for a surgical repair?

© 2019 by Lippincott Williams & Wilkins, Inc.