In-the-bag multifocal intraocular lens causing pigment dispersion and refractory secondary ocular hypertension.

Pigment dispersion and elevated intraocular pressure (IOP) with sulcus placed hydrophobic acrylic intraocular lenses (IOLs) are described and are rare with in-the-bag IOLs. We report a case of a young lady with elevated IOP and pigment dispersion in one eye following an uneventful phacoemulsification and multifocal IOL implantation. The eye had eccentric capsulorrhexis and localized capsular fibrosis with anterior displacement of the IOL optic, resulting in pigment dispersion. The uncontrolled IOP and continued pigment dispersion were managed with IOL exchange (three-piece IOL) followed by filtration surgery, which helped to resolve the condition successfully.

Pseudophakic pigment dispersion with secondary glaucoma is commonly described following posterior chamber intraocular lens (PCIOL) implantation in the ciliary sulcus[1] and rarely with in-the-bag IOLs. Acrylic hydrophobic lenses are typically uniplanar with a smooth surface, square edge design (to decrease posterior capsular opacification), and unpolished lateral walls (minimize edge glare).[2] These lenses are designed for in-the-bag placement with adequately sized capsulorrhexis to ensure a 360° anterior capsular overlap of optic edge. Sulcus IOLs may cause pigment dispersion, iris chaffing, and elevated intraocular pressure (IOP). Delayed recognition or inappropriate management can result in irreversible vision loss due to secondary glaucoma.[2345] Challenges in diagnosis and management of this complication are discussed in our report.

Case Report

A 37-year-old lady underwent bilateral photorefractive keratectomy for myopic correction 15 years ago and cataract surgery with multifocal intraocular lens (MFIOL) implantation 3 months prior, elsewhere. The surgery was uneventful; however, patient had persistently elevated IOP in her left eye (LE) that was not responsive to medical treatment. Retained lens material and steroid responsiveness were suspected, and patient underwent anterior chamber (AC) wash and was switched to a low-dose steroid; despite these interventions, the IOP remained uncontrolled and hence she was referred to us.

At presentation, she was very symptomatic, with pain, decrease in vision, excess glare, and photic phenomenon in her LE and was on five antiglaucoma medications (AGMs) including oral acetazolamide. Her best-corrected distance visual acuity (BCVA) was 20/32 in the right eye (RE) and 20/80 in the LE. The IOP was 12 and 32 mmHg in the RE and LE, respectively. RE was quiet with MFIOL. The LE showed pigments on the corneal endothelium and deep AC with significant pigment dispersion. The pupil was mid-dilated, sluggishly reacting with sphincter atrophy from 2 to 7 o’clock position with iris atrophic patches and transillumination defects. An in-the-bag MFIOL was noted with pigment deposits on the surface [Fig. 1]. Examination under higher magnification revealed eccentric capsulorrhexis with focal capsular fibrosis from 3 to 5 o’clock position, with exposed and anteriorly displaced optic edge [Fig. 2]. Gonioscopy revealed open angles in both the eyes; dense trabecular meshwork pigmentation was noted in the LE [Fig. 3]. Optic discs were healthy in both the eyes. Ultrasound biomicroscopy revealed in-the-bag IOL with anteriorly displaced optic in the inferotemporal location. A diagnosis of pseudophakia with pigment dispersion and secondary ocular hypertension was made.

Figure 1

Multifocal intraocular lens in situ with pigments on the anterior lens surface

Figure 2

Uncovered optic edge due to fused anterior and posterior capsules from 3 to 5 o’clock position

Figure 3

Gonioscopy showing open angles with increased trabecular meshwork pigmentation in the left eye

In view of uncontrolled IOP and continued pigment dispersion, the LE IOL exchange with a three-piece MFIOL was planned. However, the patient refused an MFIOL due to severe glare and photic phenomenon and opted for a three-piece monofocal IOL. The IOL was explanted [Fig. 4]. The focal fibrosis of anterior and posterior capsule from 3 to 5 o’clock position was gently released by viscodissection and a three-piece acrylic hydrophobic IOL was inserted in the bag. Postoperatively, her BCVA improved to 20/20 in the LE with decrease in photopic phenomenon; however, she had sensitivity to light due to dilated pupil. The IOP was controlled for 1 week but increased over the next 6 weeks despite stopping steroids. The alternatives at this time were laser trabeculoplasty or trabeculectomy and LE trabeculectomy was performed. Adjunctive antimetabolites were not used due to scleral thinning noted intraoperatively. Her IOP was well controlled; however, 2 years later, she required one topical AGM to control the IOP. She maintains BCVA of 20/20 with a well-centered in-the-bag IOL [Fig. 5], no pigment dispersion, healthy disc, and normal visual field.

Figure 4

Clinical photograph of the explanted (multifocal intraocular lens)

Figure 5

Postoperative slit-lamp photograph showing a well-centered in-the-bag three-piece monofocal intraocular lens with a deep and quiet anterior chamber

Discussion

Masket in 1986 first described and coined the term pseudophakic posterior iris chafing syndrome, which is characterized by iris transillumination defects, pigment dispersion with or without elevation of IOP, intermittent microhyphemas, and uveitis–glaucoma–hyphema syndrome.[4] Most cases of pseudophakic pigmentary glaucoma are typically described with sulcus placement of hydrophobic IOLs. The overall risk of pigment dispersion after sulcus placement of the IOL has been reported in 16% and 30% of eyes,[1] with incidence increasing with time.[5]

IOL induced pigment dispersion and secondary glaucoma with in-the-bag IOLs is rare. However, this complication is reported in eyes with pseudoexfoliation and excessive zonular laxity resulting in excess uveal–IOL contact,[6] deformed or damaged in-the-bag IOL with uveal-IOL contact causing pigment dispersion with elevated IOP.[789]

In most cases, the elevated IOP related to pigment dispersion responds to medical treatment with ocular hypotensives. However, in refractory cases, IOL exchange/repositioning and/or glaucoma filtering surgery may be required to control the IOP. In our case, the cause of elevated IOP was probably multifactorial with pigment dispersion, inflammation, and possible predisposition to juvenile open-angle glaucoma. Heavily pigmented trabecular meshwork with decreased filtration possibly necessitated trabeculectomy despite IOL exchange. Posttrabeculectomy, there was a need for AGM to control IOP after 6 months, possibly due to bleb fibrosis. Multiple interventions, scarred conjunctiva, and no adjunctive antifibrotics could have contributed to early fibrosis.

Given the high volumes of cataract surgery and the use of premium monofocal and multifocal single-piece acrylic PCIOLs, it is important to recognize this rare postoperative complication. Excess pigment dispersion with high IOP after an uneventful cataract surgery should always raise suspicion of either an accidental sulcus placement or a displaced in-the-bag IOL apart from retained lens material.

Conclusion

Use of MFIOL in the presence of large/eccentric capsulorrhexis can predispose to serious complications such as anterior IOL displacement with pigment dispersion and secondary glaucoma. Caution should be exercised in such situation and using a 3-piece IOL would be safer in such situations.

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

This study was financially supported by Hyderabad Eye Research Institute.

Conflicts of interest

There are no conflicts of interest.