Written informed consent was provided by the patient for the publication of this case report.
The potential complications of ACIOL implantation include endothelial failure with cornea edema, chronic intraocular inflammation, secondary glaucoma, uveitis-glaucoma-hyphema syndrome, and CME.[5,6] The occurrence of spontaneous scleral perforation caused by ACIOL dislocation is relatively rare.
To our knowledge, Kumar et al reported the first case of subconjunctival dislocation of a Kelman Multiflex ACIOL after sustaining a blunt injury. In this case report, the ACIOL was located 4 mm from the superior limbus, causing chronic inflammation with CME and mild vitritis. In addition, Gungel et al reported a case of bilateral eyes with ACIOL tip spontaneous exposure causing open-globe injury. They suggested that the possible risk factors of ACIOL tip exposure may be chronic allergic conjunctivitis with frequent eye rubbing causing minor trauma and the long-term use of topical steroids causing scleral and corneal thinning. Rong and Lu reported a case of ocular rosacea, in which spontaneous ACIOL haptic tip exposure through the inferior limbus was detected 22 years after cataract extraction. Rong and Lu assumed that the ACIOL inferior protrusion may be the result of gravity on the ACIOL, chronic vigorous rubbing of the eye tissue, and oversize of the ACIOL. However, the main causes of ACIOL haptic tip exposure remained undetermined.
In the present case, the ACIOL upper haptic tip was exposed through the superior limbus. Notably, the previous ECCE scleral tunnel wound was found to be erosive and dehiscent. Therefore, the ACIOL was extracted without effort after conjunctival peritomy. We assumed that the vertically placed angle-supported ACIOL applied stress on the “angle,” which was near to the scleral tunnel wound. The stress pressed on the wound interfered with wound healing and facilitated ACIOL haptic tip exposure (Fig. 5B and C).
Scleral tunnel incision is the initial step of cataract surgery. Scleral tunnel incisions may occasionally be challenging for an inexperienced surgeon. A proper constructed wound is expected to be a water-tight tri-planar incision (Fig. 5A). A poorly constructed wound (ie, excessively deep or superficial, excessively wide or narrow) may lead to surgical consequences. Excessively deep penetration of the scalpel may result in direct injury to the anterior chamber (Fig. 5B), leading to globe perforation, injury to the ciliary body, and a poorly closed scleral incision. On the contrary, an overly superficial incision may result in a thin scleral flap and proneness to tearing. Inexperienced surgeons may consider performing a direct 1-plane scleral groove instead of a triplanar incision (Fig. 5C). Although, in the present case, we were unable to determine the record of the patient's initial surgical condition, it is thought that the scleral tunnel was poorly constructed, with premature entry or a 1-plane incision. Moreover, the initial orientation of the ACIOL was unknown. A properly oriented ACIOL is placed into the iridocorneal angle with the footplates of the lens in contact with the scleral spur, and the haptics distant from iridectomies and wounds. In this case, the initial scleral tunnel was made at 12 o’clock and was poorly constructed. The ACIOL haptic was expected to place away from the scleral tunnel. However, in a proportion of cases, it is possible that the ACIOL may rotate from a horizontal to a vertical position a few years after implantation due to long-term eye rubbing or disparity in the size of the ACIOL.
In patients with ACIOL implantation, the potential movement of the IOL may cause inflammation in localized tissue, leading to prolonged CME. We hypothesize that the CME and ERM were sequelae of the localized inflammation process initiated after protrusion of the ACIOL haptic tip. Injection of antivascular endothelial growth factor (anti-VEGF) drugs is unable to inhibit the origins of inflammatory process. Currently, the most effective treatment to cease intraocular inflammation is removal of the ACIOL. In this case, after ACIOL extraction, the CME was controlled and the thickness of the central retina was reduced compared with that observed preoperatively. In general, good vision may be restored after the resolution of the intraretinal fluid. However, in certain chronic or severe cases of CME, the resolution of the intraretinal fluid may not restore good vision if permanent damage to the macular cells has already occurred. In the present case, CME persisted for 6 months, despite the administration of injections with an anti-VEGF agent. It is thought that the retinal macular cells were already damaged, disrupting the integrity of the blood–retinal barrier.
In our opinion, poor construction of the scleral tunnel incision may cause wound dehiscence. The vertically aligned ACIOL haptic tip resting at the angle may exert stress toward the dehiscent wound, exacerbating tissue erosion and causing scleral perforation with haptic tip exposure. In such cases, IOL extraction and wound closure should be urgently managed to prevent wound infection and subsequent endophthalmitis. The early removal of the dislocated ACIOL may assist in controlling intraocular inflammation and improve CME. In contrast, delayed removal of an exposed ACIOL may cause prolonged CME, leading to permanent loss of vision.
We express our thanks to all colleagues and students who contributed to this study. Furthermore, we thank the editor, series editor, and reviewers for their constructive comments.
Conceptualization: Gow-Lieng Tseng.
Data curation: Hsinle Lin.
Investigation: Hsinle Lin.
Writing – original draft: Hsinle Lin.
Writing – review & editing: Hsinle Lin, Gow-Lieng Tseng.
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Keywords:Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
anterior chamber intraocular lens; cataract surgery; scleral perforation