PHAKIC IOL EXPLANT WITH PHACOEMULSIFICATION

To describe a rare case of bilateral dense nuclear sclerosis in a young woman with Phakic IOL in situ and surgical challenges of cataract surgery in the same.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi

A 35-year-old woman with no known systemic illness presented to our centre with complaints of painless progressive diminution of vision in both eyes since the past 4 months. She also gave the history of having undergone phakic IOL – ICL implantation in both eyes 14 years ago elsewhere but had no documentation of the same.  The patient reported to have gained good visual acuity after ICL surgery. On examination patient had visual acuity finger counting at one meter in both eyes. Dense nuclear cataract was noted in both eyes with 3 clock hours of peripheral anterior synechia located supero-temporally in the left eye. The Phakic IOL did not have central aquaport with adequate vault height clinically. Ultrasound B scan was done and found to be anechoic in both eyes. ASOCT showed a vault height of 514 µm and 665 µm in right and left eyes respectively. On biometry axial length of right eye was 34.69mm in right eye and 34.36mm in left eye. Barrett’s universal II was used to calculate the IOL power. Specular count was found to be 2900 and 1082 cells per  square millimeter in right and left eye respectively. The patient underwent left eye ICL extraction with a 3.2mm clear corneal incision superiorly followed by phacoemusification. Few challenges were faced as superior incision had to be extended to 3.2mm for extraction of the ICL following which phacoemulsification was difficult due to wound leak. Phacoemusification had to be completed with a 2.8mm phaco probe sleeve and wound had to be closed with a single 10-0 nylon suture. Post operatively patient gained best corrected visual acuity of 6/18 in one week with left eye specular count of 1020. Swept-Source OCT of left eye shows a lamellar macular hole and is now on regular follow up.

In the evolving landscape of refractive surgery, it is important for physicians to explain to patients to store their documents well. In this rare case, early and dense nuclear sclerosis was possibly caused due to the absence of aquaport in the older generations of ICL. Intraoperatively one must be prepared for difficult anterior chamber fluid dynamics in the absence of appropriately sized phacoemusification probe sleeve.