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Cataract Surgical Problem Edited by Rupert M. Menapace, MD

A 79-year-old woman had cataract surgery with intraocular lens (IOL) implantation in the left eye in 1990. A 3-piece IOL with a poly(methyl methacrylate) (PMMA) optic with positioning holes and polypropylene loops was fixated in the ciliary sulcus. In 1993, the right eye also had cataract surgery with implantation of a PMMA diffractive multifocal IOL. In 2013, 23 years after the first surgery, the patient started having repeated attacks of blurred vision and pain in the left eye, mostly after bowing her head. These symptoms subsided within several hours. When immediately consulting with the local ophthalmologist on 2 such occasions, a 3+ erythrocyte Tyndall phenomenon was found in the anterior chamber aqueous and trickle marks (traces) were found in the inferior sector of the cornea; the intraocular pressure (IOP) approached 60 mm Hg. The patient was treated with pressure-lowering eyedrops and acetazolamide tablets; by the following day, the condition of the eye had returned to normal. The attacks, however, recurred with increasing frequency. On 1 such occasion, 1 IOL loop was reported to be visible in the peripheral coloboma at 12 o’clock; however, this was not the case when the patient returned later. When these attacks persisted, the patient was finally referred to an anterior segment specialist. When the patient first presented, the pupil in the left eye was small, the IOL optic was at a distinct distance to the pupillary margin, and no IOL loop was visible in the slit-shaped peripheral coloboma. The refraction was 1.50 +1.25  175 in the right eye and 1.50 +0.50  5 in the left eye. The decimal corrected distance visual acuity (CDVA) was 0.8 and 0.9, respectively. Both central capsules where clear, the retina and macula were normal, and the optic nerve head was vital and centrally excavated with a cup-to-disc ratio of 0.4 in the right eye and 0.3 in the left eye. On full pupil dilation, a 3-piece IOL with a PMMA optic with positioning holes and polypropylene loops was exposed in the left eye (Figure 1). The loops were fixated in the ciliary sulcus, and the slightly tilted optic was decentered inferiorly. The aqueous was clear, and the IOP was 17 mm Hg. No change in haptic position or IOL rotation could be induced by gently massaging the limbus with a cotton swab under topical anesthesia. The patient was asked to immediately return if the symptoms recurred. Ten days later, she presented 2 hours after another attack. The biomicroscopic findings in the left eye were as described above, and the 844

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Figure 1. Mydriasis shows a sulcus-fixated IOL with 2-hole PMMA optic and polypropylene loops fixated in the sulcus. The iris exhibits a basal coloboma at 12 o'clock, giving visual access to the anterior capsule rim sealed to the posterior capsule. The IOL optic is decentered inferiorly and slightly tilted but definitely shows a positive distance to the pupillary margin with the pupil undilated.

IOP was 50 mm Hg. The IOL was in the same position as previously. When the patient was seen the next day after having received a single-shot medication of pressure-lowering drops, all finding were again normal. Considering the repeated occurrence of anterior chamber bleeding with blurry vision and IOP peaks in the presence of a sulcus-fixated open-loop IOL, what diagnostic and surgical options would you consider and what would be your preferred strategy to remedy this situation?

- This patient presents with late-onset recurrent hyphema associated with IOP spikes after cataract surgery. Possible causes related to the previous surgery include wound vascularization and IOL-related bleeding from iris touch or chafing and iris tucking. Other diagnoses to consider are neovascularization (related to diabetes, central retinal vein occlusion, ocular ischemia, and chronic uveitis), vascular anomalies (tufts, capillaries, microaneurysms, and hereditary telangiectasia), bleeding disorders (blood dyscrasias and anticoagulants), recent ocular surgery (peripheral iridotomy, trabeculectomy and microinvasive glaucoma surgery), and rare disorders (juvenile 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.03.009

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xanthogranuloma, retinoblastoma, leukemia, uveal melanoma, iris metastases, and Lowe syndrome). Evaluations should include a complete blood count, coagulation workup, blood sugar, hemoglobin A1c, electrolytes, and liver-function tests. Carotid dopplers would be helpful in determining the risk for ocular ischemia. A chest x-ray and abdominal ultrasound (US) should be considered if there is a suspicion of malignancy and metastases. An ophthalmic US, fluorescein angiography of the iris and retina, and US biomicroscopy (UBM) of the anterior segment should be performed to look for local causes. We are told that the recurrent hyphema may be posture related and that there was an observation suggestive of pseudophacodonesis (ie, the haptics were observed in the coloboma on 1 occasion and then not on another occasion); thus, the cause seems to be related to the IOL. Although there is no mention of iris transillumination defects or IOL–iris touch, the decentered sulcus-placed IOL is still highly suspect as the cause. The UBM should confirm this by showing IOL–iris touch or iris tuck, even in the absence of clinical findings.1 Treatment would depend on the diagnosis. In addition to treating the underlying condition, ocular management may include panretinal photocoagulation for ocular ischemia, photocoagulation of vascular anomalies, and topical management of uveitis or glaucoma. Because the likely cause is the pseudophacodonesis, stabilization of the IOL should be performed. In this case, the IOL is a 3-piece model with flexible haptics. My preferred management would be externalization of the haptics and scleral tunnel fixation of the externalized haptics as originally described by Gabor and Pavilidis2 and popularized by Agarwal et al.3

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capsulorhexis was not performed during surgery. The IOL is placed in the sulcus; however, it is not stable. While it rotates, 1 loop has occasionally been seen in the iridectomy. The IOL is also decentered inferiorly and is slightly tilted. The IOL is probably too small for the sulcus, and thus the problem. Stabilization of the existing IOL or an exchange would probably solve the problems. There are several options from which to choose. Fixating the existing IOL to the iris with sutures is an option. However, in some cases this procedure can result in chronic uveitis or cystoid macular edema postoperatively. A more complicated solution is to glue the haptics to the sclera. This technique is described by Agarwal et al.1 Two scleral flaps are made 180 degrees apart, the haptics are externalized and placed under the flaps, and the haptics are glued to the scleral bed with biological glue. If this maneuver were successful, there would likely be fewer postoperative problems. An IOL exchange is another option. Unfortunately, the incision has to be rather large for an exchange of an IOL with a hard PMMA optic. With the clear, untouched posterior capsule, a posterior capsulorhexis could be performed and a 3-piece acrylic IOL implanted with the loops again placed in the sulcus and the optic captured in the posterior capsulorhexis. With this maneuver, the IOL would remain stable. The patient has a diffractive multifocal IOL in the other eye; however, the history does not say whether the patient uses glasses for near or far. With an IOL exchange, I would aim for emmetropia after having ensured that the patient can tolerate anisometropia. Charlotta Zetterstr€ om, MD, PhD Stockholm, Sweden

George Beiko, BM, BCh, FRCSC St. Catharines, Ontario, Canada REFERENCE REFERENCES 1. Pavlin CJ, Harasiewicz K, Foster FS. Ultrasound biomicroscopic analysis of haptic position in late-onset, recurrent hyphema after posterior chamber lens implantation. J Cataract Refract Surg 1994; 20:182–185 2. Gabor SGB, Pavilidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007; 33:1851–1854 3. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg 2008; 34:1433–1438

- This 79-year-old patient had cataract surgery many years ago, and the problem in the left eye appeared 23 years after surgery. The IOL implanted was an older rigid model, and it is likely that a complete anterior

1. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg 2008; 34:1433–1438

- In this case of repeated occurrence of anterior chamber bleeding causing transient IOP spikes and blurry vision in the presence of a subluxated sulcus-fixated open-loop IOL, my diagnosis is uveitis–glaucoma–hyphema (UGH) syndrome. The lower haptic of the inferiorly decentered posterior chamber IOL (PC IOL) seems to have eroded some of the supporting zonular fibers, and this haptic is fixated somewhere behind the plane of the zonular ring. This could be verified by high-resolution UBM. When the patient bends and bows her head, the upper haptic is encouraged to freely move, like a loose

J CATARACT REFRACT SURG - VOL 40, MAY 2014

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