A hypotheses to explain acute adjustment disorder after phakic intraocular lens implantation in a highly myopic patient: Potential causes and suggested remedies

Abstract

Phakic intraocular lenses (phakic IOLs) have expanded the options to correct high myopia surgically. However, we have noted that some very high myopes can have difficulty adjusting to the new uncorrected vision after Phakic IOLs. We hypothesize that in these cases, drastically increased optical magnification and altered spontaneous brain activity patterns can contribute to difficulty with delayed post operative recovery of visual function. We present empirical data from a case and calculate the magnification effect to support the hypotheses. This highly myopic patient, who had worn spectacles (and not contact lenses), underwent Visian Implantable Collamer Lens (ICL, Staar Surgical, Monrovia, CA USA) placement and subsequently developed an adjustment disorder post operatively. The patient’s preoperative refraction was −23.75 D Sph/+1.50 D Cyl @ 158 (spherical equivalent −23 D) in the right eye and −19.0 D Sph/+2.0 D Cyl @ 025 (spherical equivalent −18 D) in the left eye resulting into pre-operative spectacle related retinal image minification of 73.1% and 77.6% in size compared to emmetropic retinal image for the right and left eyes, respectively. Myopic patients who are habituated to glasses and adapt to this image minification. Therefore, the change in the image size after phakic IOL (intraocular lenses) placement can be difficult to adjust to immediately post operatively. Contact lenses can better simulate emmetropic sized retinal image and should preferably be trialed in preoperative evaluation.Secondly, several studies have highlighted neuronal activity alternations in high myopes, and also changes in neuronal activity after refractive surgery (Laser Assisted in Situ Keratomileusis (LASIK)) as demonstrated by functional magnetic resonance imaging (fMRI). It is hypothesized that neuronal connections are re-activated after refractive surgery as shown by alterations in amplitude of low frequency fluctuations (ALFF) in specific areas of the brain, including the primary visual cortex, lingual and medial occipital gyri, the left parahippocampal gyrus, cerebellar vermis and left posterior cingulate cortex, that can be linked with emotional and visuospatial processing.Therefore, we hypothesize that in some highly myopic patients, the combination of drastically altered retinal magnification and altered brain activity can result in acute adjustment disorder. Refractive surgeons should counsel these patients further regarding the adjustment period and additionally there should be a multi-disciplinary approach implemented to help patients cope with their resulting vision pre and post operatively.