LENS DISASTER

“Having the AcrySof Cachet angle-supported IOL implanted in an upside-down position is a disastrous situation that results in pupillary block, angle-closure glaucoma and endothelial decompensation,” said Thomas Kohnen MD, PhD, FEBO, Goethe-University, Frankfurt am Main, Germany at a Cornea Day session at the 18th ESCRS Winter Meeting in Ljubljana. He presented the case of a male patient 27 years of age who attended the emergency room at the University of Frankfurt because of a sudden onset of pain and loss of visual acuity in his right eye. The visual acuity was reduced to hand motions in the right eye but was 20/20 without correction in the left eye.

The patient said that eight weeks previously he had undergone bilateral implantation of the AcrySof® Cachet anglesupported phakic anterior chamber IOL (Alcon) to correct -7.5 D of myopia at another centre in another country. Inspection of the anterior segment revealed conjunctival injections, severe corneal oedema with a large 6.04mm pupil and an intraocular pressure (IOP) of 60 mmHg. The fellow eye had a normal appearance and IOP of 14.0 mmHg.

The resident on duty consulted with the faculty on duty and they decided to admit the patient to hospital. They immediately administered IOP reduction medication, including 500mg acetazolamide and 250mg mannitol intravenously combined with a topical 20mg timolol and 5.0mg dorzolamide eye drop combination (Cosopt®, Merck) and pilocarpine eye drops. Three hours later they attempted YAG-laser iridotomy but were unsuccessful and IOP remained at 60 mmHg.

ANTERIOR CONCAVITY
The following morning further examination with the Pentacam (Oculus) revealed that the central cornea had a thickness of 929.0 microns and an anterior chamber depth of 2.03mm, compared to 3.35mm in the fellow eye. Prof Kohnen brought the patient directly to the operating room and removed the phakic IOL from the patient’s left eye. Close inspection of the orientation markers on the haptic showed that the lens had been implanted upside down. Following removal of the IOL, the eye’s IOP rapidly returned to normal levels and there was a steady reduction in corneal oedema and a concomitant improvement in corrected distance visual acuity. By eight weeks' follow-up the eye had a corrected distance visual acuity of 20/20 and refraction in that eye was equivalent to the preoperative value of 7.5 D.

However, endothelial cell density was drastically reduced and appeared to fluctuate. One week after surgery it was 963 cells/mm2. At six weeks it was 1562 cells/mm2 and at eight weeks it was 1057 cells/mm2. Prof Kohnen noted that this is the first and only case reported so far of the Cachet phakic IOL being implanted upside down. He added that the markings on the IOL’s haptics make it a mistake that is very easy to avoid.

The complete case-report is in the May 2013 issue of JCRS.