Pigmentary dispersion syndrome

Abstract

The article by Wintle and Austin1 describes a patient who developed transient intraocular pressure (IOP) elevation 1 month after cataract removal with placement of an AcrySof® intraocular lens (IOL) in the ciliary sulcus. I have the following observations/comments concerning this report: I have now placed more than 100 AcrySof MA60 BM IOLs in the ciliary sulcus, and there have been no instances of persistent IOP elevation or pigmentary dispersion syndrome (PDS). I do not know whether transient pigmentary dispersion occurred in any patient, but suspect that I could certainly find several cases in which it did. This is because many of the procedures involved iris-IOL contact during insertion or iris manipulation. If the IOL implantation described in this article were the cause of PDS, it would be most unlikely that the dispersion would be so brief. (After 6 months of stable IOP, the authors reported that the antiglaucoma therapy was discontinued and IOP remained normal for 18 months.) The authors described transillumination defects noted 1 month after the procedure. It is unlikely that the optic could cause extensive iris pigmentation loss in such a short time but it would be very easy for this to have occurred during intraocular manipulations. Furthermore, the location of the iris transillumination defects is not described. If they were possibly related to persistent iris-IOL contact, the defects would have been located in the paracentral region of the iris. It is, of course, possible that a haptic was in contact with the iris, but again one would not expect the course to have been self-limited and the iris transillumination defects would be expected to progress over time. It certainly appears that the authors are correct when they infer that their patient developed “iatrogenic pigmentary dispersion syndrome,” but based on my experience and their description of events, it appears unlikely that the AcrySof IOL was the cause. I obviously disagree with the their conclusion that AcrySof IOLs should only be placed in the capsular bag. Single-piece AcrySof IOLs are a different story, however. The haptics have sharp edges, and this IOL does not appear to be suitable for sulcus placement. In fact, while I have never seen an MA60 IOL that required removal because of pigmentary dispersion syndrome, I have seen a single-piece AcrySof IOL that needed removal because of PDS that occurred after inadvertent sulcus placement. In the latter patient, pigment release was sustained as was IOP elevation. Finally, with the recently released version of the MA60 (MA60 AT) the argument should now be moot. The square-edged design has been eliminated, and while I do not believe that this will change the landscape with regard to PDS (since I do not believe the previous MA60 was the cause of this), the new design has clear advantages as it eliminates both internal and external IOL reflections. Richard J Mackool MD aAstoria, New York, USA