Editor, A 39-year-old man presented with blurred vision in his left eye (LE). He had a history of bilateral Artisan® phakic intraocular lens (PIOL) implantation for correction of − 6.00 D in the RE and − 7.50 D LE (axial length: 25.50 mm RE, 25.83 mm LE), carried out 2 months earlier. According to his records, preoperative fundus examination had been unremarkable and the procedure had been performed without complications. On examination, visual acuity (VA) was 20/25 RE and 20/20 LE. Anterior segment examination was unremarkable and intraocular pressure (IOP) was within normal limits. Fundoscopy revealed a superior macula-on retinal detachment (RD) arising from a giant retinal tear (GT) at 11–4 o’clock with an inverted posterior flap in the LE and a normal fundus with no posterior vitreous detachment in the RE. A 20-gauge pars plana vitrectomy was performed (Fig. 1), endophotocoagulation was applied to the edges of the GT and 5000 centistokes of silicone oil (SO) were used as tamponade. A macula-on, giant tear-associated retinal detachment seen during vitrectomy in the left eye. Note that the intraoperative view was relatively clear through the Artisan® phakic intraocular lens. Two weeks later, the patient complained of visual deterioration in the RE (Fig. 2) and fundoscopy showed a GT-associated, superior macula-on RD almost identical to that in the LE. A vitrectomy with endolaser and SO tamponade was performed in the RE. Right eye before surgery for retinal detachment. Silicone oil was removed 3 months after each surgery. Fundoscopy at the 6-month follow-up demonstrated an attached retina in both eyes. Visual acuity was 20/30 LE and 20/40 RE. Until recently, PIOL implantation has been considered to represent one of the few surgical options (along with clear-lens extraction) for correcting high myopic errors (> − 12 D). Interestingly, over the last decade the scientific pursuit of correction of moderate myopia using PIOLs in selected patients has gained increasing numbers of supporters. Since the US Food and Drug Administration (FDA) approval of the iris-claw Artisan®/Verisyse™ PIOL (OPHTEC BV (Netherlands) and Advanced Medical Optics, Inc. (AMO)) in 2004, its use has extended beyond the limits of multicentre trials to ‘routine’ refractive practice. Several studies regarding the safety and complication rates of the Artisan®/Verisyse™ PIOL have reported poor centration, glare or haloes, pupil ovalization, mild corneal oedema and RD as possible complications (Hernaez-Ortega & Soto-Pedre 2004; Tahzib et al. 2007; Guell et al. 2008). In eyes in which PIOLs are implanted to correct high myopia, the risk for RD would be, in the first instance, attributable to the myopia itself because a correlation between severe myopia and RD has been previously confirmed (Schepens & Marden 1966). In addition, the risk for RD in eyes implanted with phakic lenses for the correction of high myopia is reported to be higher in eyes with an axial length > 30.24 mm (Ruiz-Moreno et al. 2006). An earlier study (Ruiz-Moreno et al. 1999) reported an incident of RD of 4.8% in eyes implanted with anterior chamber PIOLs compared with 0.71–2.3% in patients with myopia and no previous intraocular surgery. The occurrence of a bilateral RD with GTs has been previously reported following LASIK (laser-assisted in situ keratomileusis) (Hernaez-Ortega & Soto-Pedre 2003), as well as after posterior chamber PIOL implantation (Navarro et al. 2005). Additionally, a case of unilateral GT-associated RD after Artisan® iris-claw PIOL implantation has been reported (Hernaez-Ortega & Soto-Pedre 2004). It was argued that the polymethylmethacrylate (PMMA)-induced inflammation in conjunction with an additional surgical trauma-associated inflammatory response may have led to tissue damage and subsequent giant retinal tear formation. In our case, the bilateral nature of the complication, the short period between the Artisan® PIOL implantation and occurrence of RD, the moderate myopia without significantly high axial length and the unremarkable preoperative fundus examination in a young healthy individual with a negative family history for both Marfan and Stikler syndromes comprise the main factors leading to high suspicion of an aetiological correlation between the Artisan® PIOL implantation and the observed complication. We believe that the combination of an inflammatory response, as previously mentioned, with perioperative IOP fluctuations may play a role in the underlying pathophysiological mechanism. It should also be noted that intraoperative vitrectomy manipulations were performed without difficulty through the Artisan® PIOL in both eyes (Fig. 1). To the best of our knowledge, this is the first report of a bilateral GT-associated RD following bilateral Artisan® PIOL implantation. Further studies are required to confirm this possible association. However, although the incidence is rare and the exact pathophysiology not fully elucidated, pretreatment counselling should include a discussion outlining the possible risk of RD in patients planning an Artisan® PIOL implantation for correction of myopia.
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Sep 2, 2011
Hiroshi Kunikata + 7
Open Access