Several Attempts For The Management Of Residual Astigmatism After Implantable Contact Lens Implantation For Compound High Myopia And Astigmatism

To report a rare incidence of postoperative residual astigmatism caused by mislabelled implantable contact lens (ICL)

Case Report

Thirty-two years old male was asking for refractive surgery. CDVA was 1.0 (-6.50 -4.50 X 20  &  -6.5 -3.50 X 5 , OD and OS respectively). Schiempflug corneal tomography revealed bilateral thin corneas with regular bowties. Anterior chamber depth was more than 3.2mm in both eyes. He was scheduled for bilateral sequential ICL implantation. Based on STAAR online calculations, the desired lenses were 13.2mm ICL -11.0 +3.50 X 95 OD and  13.2mm ICL  -12.5 +4.5 X 110. Both surgeries went uneventfully. During postoperative follow-up, the refraction of the right eye was +3.0 -5.0 X 175. Slit-lamp examination and OPD III scan through a fully dilated pupil showed the lens was stable with no rotation. However, we took the patient back to the OR to rotate the lens 30 degrees anticlockwise based on the red-free pupil image on the OPD III scan. However, this could not solve the issue. We tried astigatismfix online calculator, OPD, and slit-lamp images but ended with more astigmatism and worsening postoperative refraction to  +4.0 -6.75 X 5. The patient was frustrated and did not come for a follow-up for several months. We recalled the patient, and with ray tracing technology (itrace), rotation of 70 degrees anticlockwise was suggested. A decision was made to follow this recommendation. 

On the first postoperative day, the refraction was 0.25-0.25 X 65, and UDVA was 1.0. the refraction remains stable during the following postoperative examinations for three weeks.

 

Residual astigmatism was neither due to miscalculation nor a transcription error. On the other hand, the lens was stable and did not rotate during the ongoing follow-up several months after the primary surgery. We believe it was due to a rare incidence of mislabelling of the ICL. Ray tracing technology may be advantageous over the other methods as it calculates the degree of rotation based on the actual postoperative refractive status of the eye, irrelevant to the power of the lens implanted.