Late Dislocation of Iris-claw Phakic Intraocular Lens after Natural Childbirth: A Case Report.

Dear Editor,

Although, implantation of phakic intraocular lens (IOL) in the anterior chamber (AC) or posterior chamber correct high refractive errors, this modality has few complications that should be considered. This case report describes a female patient who had dislocation of iris-claw phakic after natural childbirth resulting in complications that require re-enclavating the lens.

A 35-year-old female patient presented to eye clinic with a 2-week history of red eye, pain, and blurred vision in the left eye after normal vaginal delivery. The patient did not receive epidural anesthesia during labor. The patient was in good health and had no previous medical history such as hypertension, diabetes mellitus, and trauma. She has a history of high myopia (−14.0 diopters [D] in the right eye and −13.5 D in the left eye) and underwent iris-claw phakic IOL implantation surgery 6 years ago. On ocular examination, her best-corrected visual acuity was 20 / 70 in the right eye and 20 / 400 in the left eye and increased by pinhole 20 / 100. Her refractive errors were +0.75 D / −0.25@ 10 D in right eye and unmeasurable in left eye. Slit-lamp assessment showed left acute anterior uveitis (AC cells and flare) and inferior dislocation of the iris-claw phakic IOL into the iridocorneal angle (Fig. 1) Her cornea was clear without pigmentary deposits, and the IOL had no contact with the corneal endothelium. Intraocular pressure (IOP) was recorded as 15 mmHg in the right eye and 20 mmHg in the left eye. Steroid drops (betamethasone 0.1%) and IOP-lowering drops (dorzolamde 2% and timolol 0.5%) was prescribed to control inflammation and IOP. Her conjunctival injection and AC reaction improved in subsequent examinations and IOP reached to 15 mmHg. She has been advised to a re-enclavation of iris-claw IOL. After 1 month, she had no symptoms and AC-IOL was clear and fixed horizontally (Fig. 1). In the follow-up examination, the patient had −0.75 D refractive error with 20 / 40 visual acuity postoperatively. This study was conducted after an approval by the Human Ethics Committee of Shahid Beheshti University of Medical Sciences (No. IR.SBMU.RETECH. REC.1399.1280).

Fig. 1

Dislocated the iris-claw phakic intraocular lens. (A) A slit-lamp image of inferior dislocation of the anteriorly iris-claw lens after natural childbirth. (B) One-month postoperative image of this eye, with the lens being re-enclavated. The patient provided written informed consent for the publication of the research details and clinical images.

In recent years, phakic IOLs in the AC or posterior chamber in patients with high refractive errors have provided excellent visual results and predictable refractive outcomes. One type of phakic IOLs is the iris-claw IOLs, which are fixated with haptics to the iris with clips. Irisclaw IOLs have demonstrated satisfactory results in insufficient capsule support, the surgical correction of an aphakic eye, phakic dislocation, or dislocation of an IOL [1]. A low rate of complications of these lenses have been reported in patients including slight pupil distortion, early post-operative raised IOP, hemorrhage in AC, chronic uveitis, cystoid macular edema, and endophthalmitis [2]. Traumatic or spontaneous dislocation of the iris-claw IOLs in AC is a rare event and has been reported in some studies [3]. The exact cause of iris-claw IOLs dislocation is not known, but factors such as the surgical factors (inadequate amounts of iris tissue for enclavation and excessive manipulation of the iris tissue during enclavation) and late iris atrophy predispose the patient to further problems [4]. Another possible reason for dislocation of IOL in this patient was the Valsalva maneuver during normal vaginal delivery. During the Valsalva maneuver, squeezing the eyelid and subsequently opening the eyelid can temporarily increase and then decrease IOP. These changes in IOP induce a pressure gradient across the pupil and can lead to iris-claw phakic IOL dislocation. [5] Therefore, it is recommended that pregnant women with phakic IOLs undergo ophthalmologic examination before birth delivery. Also, these patients may be an indication for an elective cesarean section.