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| CASE REPORT |
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| Year : 2023 | Volume
: 3
| Issue : 2 | Page : 311-313 |
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Implantable phakic contact lens exchange after seven years: A case report
Rajesh R Kapoor1, Snehal P Gade2, Suruchi R Kapoor3
1 Medical Director, Phaco and Refractive Eye Surgeon, Suruchi Eye Hospital and Lasik Centre, Navi-Mumbai, Maharashtra, India
2 Consultant, Comprehensive Eye Surgeon, Suruchi Eye Hospital and Lasik Centre, Airoli Navi-Mumbai, Maharashtra, India
3 K. J. Somaiya Medical College and Hospital, Mumbai, Maharashtra, India
| Date of Submission | 24-Nov-2022 |
| Date of Acceptance | 13-Jan-2023 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Rajesh R Kapoor
Medical Director, Phaco and Refractive Surgeon, Suruchi Eye Hospital and Lasik Centre, Airoli Navi-Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJO.IJO_3091_22
Implantable phakic contact lens (IPCL) exchange or removal is commonly done in case of wrong size implantation leading to either pupillary block glaucoma or cataract, residual refractive error, recurrent uveitis, and endothelial cell loss. Usual time for phakic lens exchange is within 3–6 months after the primary procedure. In this case report, we have shown that IPCL exchange can be considered as an option even after a long period of 7 years in young, high myopic patients, where clear lens extraction and corneal refractive procedure are not recommended.
Keywords: Exchange, IPCL, secondary angle-closure glaucoma, vault, WTW
How to cite this article:
Kapoor RR, Gade SP, Kapoor SR. Implantable phakic contact lens exchange after seven years: A case report. Indian J Ophthalmol Case Rep 2023;3:311-3 |
How to cite this URL:
Kapoor RR, Gade SP, Kapoor SR. Implantable phakic contact lens exchange after seven years: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 4];3:311-3. Available from: https://www.ijoreports.in/text.asp?2023/3/2/311/375020 |
Currently, the procedures to correct refractive errors include refractive corneal surgery, phakic intraocular lenses, and clear lens extraction with implantation of intraocular lens (IOL).[1],[2],[3],[4] The main goal of refractive surgery is to get rid of dependency on glasses and preserve vision quality with the same visual capacity. The current generation phakic IOLs are implanted in the posterior chamber. In addition to being simple and reproducible to insert, a phakic IOL also allows retention of accommodation and is reversible.[2],[3] It also has a central hole, which avoids rise in intraocular pressure (IOP) post-surgery.[2],[3]
Common causes for phakic IOL removal or exchange are high or low vault due to wrong size causing pupillary block glaucoma, cataract formation, residual refractive error, endothelial cell loss, and recurrent uveitis.[1],[2],[3],[4] The usual time for phakic IOL exchange is within 3–6 months after the primary procedure.
We are reporting a case of implantable phakic contact lens (IPCL) exchange done in the right eye (RE) of a young, 30-year-old female, 7 years later, due to high vault leading to glaucomatous changes.
| Case Report | |  |
A 30-year-old female came to our outpatient department (OPD) in 2014 with a desire to get rid of spectacles. Final diagnosis of bilateral high myopia was established after thorough evaluation. She was advised phakic IOL implantation in both eyes, as the corneal thickness was inadequate for corneal refractive surgery.
[Table 1] gives details of complete preoperative evaluation[2],[4] of both eyes. Phakic IOL power was calculated using an online calculator. She underwent IPCL implantation first in RE (April 2014) followed by LE (May 2014). At that time, the IPCLs were without central hole. | Table 1: Complete preoperative evaluation of both eyes for IPCL implantation surgery
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An IPCL of −11.0 D with a size of 13 mm was implanted in her RE. The surgical procedure was uneventful, but post-op day 1 showed rise in IOP (28 mmHg), which did not settle with medication. A Neodymium: Yttrium-Aluminum-Garnet (Nd–YAG) laser peripheral iridotomy was done on post-op day 3, following which the IOP settled to normal values. Vault size on optical coherence tomography (OCT) was 700 μm. As the RE showed no further signs of pressure rise in the subsequent follow-ups, LE IPCL implantation was planned. To avoid IOP rise post-surgery, remeasurement of White to White (WTW) was done, which gave an IPCL of smaller size. Thus, −9.50 D IPCL with 12.5 mm size was implanted in the LE. There was no IOP rise post-surgery, and the vault size was 550 μm. [Table 2] gives details of follow-up at 1 month. She was advised follow-up after 3 months to review the vault size and IOP, but post her marriage, she was lost for further follow-ups.
After 7 years, in August 2021, she came with complaints of blurring of vision in RE along with mild pain and redness. [Table 3] shows details of examination which led to diagnosis of RE secondary angle-closure glaucoma, following which antiglaucoma medications were started. As gonioscopy showed closed angles due to high vault, a decision for second refractive procedure was made. | Table 3: Detailed examination of both eyes with RE showing closed angles with advanced field defects
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After discussion with the patient, she underwent IPCL exchange in September 2021 (within 1 month). We repeated the RE WTW measurements by IOL Master 700 and manually by digital caliper.[4] An average of three readings of both the methods, optical 11.8 mm and manual 11.3 mm, was used to calculate the IPCL to be exchanged.[4] The newly calculated IPCL had the same power (−11.0 D) but a smaller size (12.5 mm). New-generation IPCL with a central hole was implanted.
Surgical Procedure
Under topical anesthesia, previous side ports (1 mm) and temporal main incision (2.8 mm) were reopened. IPCL haptics near the main incision were lifted partially in Anterior Chamber (AC) under dispersive viscoelastic cover. Once both haptics near the main incision were freely tilted in AC, one of the haptics was firmly held by forceps and pulled out through the main incision, pulling the whole IPCL out.[5] Then, new IPCL was implanted in the routine manner. The surgery went uneventful. Postoperatively, she was put on antibiotic steroid, anti-inflammatory and anti-glaucoma eyedrops along with tear substitutes.
[Table 4] shows details of vault size, IOP, and angles over 1 year. There was no evidence of any anterior or posterior synechiae formation at any follow-ups. Postoperative day 1 visual acuity was 6/9p, which settled to 6/9 at 1 month. The IOP settled to 17 mmHg at 2 months. At the end of 1 year, final visual acuity and IOP were 6/9 and 15 mmHg, respectively, with a vault size of 604 μm. | Table 4: Postoperative follow-up showing vault size, IOP, and angles in RE till 1 year
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| Discussion | | |
We could not get any references for IPCL exchange done after such a long period. In an ideal scenario, the IPCL exchange should have been done within 6 months of the primary procedure, but the patient was lost to follow-up for seven long years. Other options in the above case would have been IPCL removal with clear lens extraction with Posterior Chamber Intraocular Lens (PCIOL) implantation or IPCL removal followed by corneal refractive surgery.
But instead, we chose a third option of IPCL exchange, as clear lens extraction and PCIOL implantation are not recommended in a young, high myopic patient due to increased relative risk of retinal detachment.[1] Corneal refractive surgery was not an option due to thin cornea with high myopia.
Precise calculations and appropriate sizing of phakic IOL are extremely important.[3] WTW is the most important parameter to determine the sizing of phakic IOL.[4] Larger phakic IOL leads to high vault causing pupillary block glaucoma (as happened in our case), and smaller phakic IOL leads to low vault causing cataract formation.[4]
We followed her for 1 year to see the development of cataract and glaucoma progression. It was stable after 1 year [Figure 1]a and [Figure 1]b and [Figure 2]a and [Figure 2]b. | Figure 1: (a) RE pre-op closed angles; (b) RE post-op open angles at 1 year. RE = right eye
Click here to view |
 | Figure 2: (a) RE pre-op high vault 1040 μm; (b) RE post-op vault 604 μm at 1 year. RE = right eye
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| Conclusion | | |
A successful outcome in such a case shows that phakic lens exchange is possible even after a long period of time with due consideration of pros and cons of the procedure and WTW measurement is of utmost importance for calculating the right-sized phakic lenses.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Sachdev GS, Singh S, Ramamurthy S, Rajpal N, Dandapani R. Comparative analysis of clinical outcomes between two types of posterior chamber phakic intraocular lenses for correction of myopia and myopic astigmatism. Indian J Ophthalmol 2019;67:1061-5. [ PUBMED] [Full text] |
| 3. | Pandey SK, Sharma V. Commentary: Expanding indications of newer and economically viable phakic posterior chamber intraocular lens designs. Indian J Ophthalmol 2019;67:1066-7. [ PUBMED] [Full text] |
| 4. | Deshpande K, Shroff R, Biswas P, Kapur K, Shetty N, Koshy AS, et al. Phakic intraocular lens: Getting the right size. Indian J Ophthalmol 2020;68:2880-7. [Full text] |
| 5. | Coskunseven E, Kayhan B, Jankov II. Tuck-and-pull technique for posterior chamber phakic intraocular lens explantation. Indian J Ophthalmol 2021;69:3740-2. [ PUBMED] [Full text] |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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