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Editors Selection IGR 9-4

Imaging: ASOCT

Robert Ritch

Comment by Robert Ritch on:

15105 Anterior segment imaging using optical coherence tomography and ultrasound biomicroscopy in secondary pigmentary glaucoma associated with in-the-bag intraocular lens, Detry-Morel ML; Van Acker E; Pourjavan S et al., Journal of Cataract and Refractive Surgery, 2006; 32: 1866-1869


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Detry-Morel et al . (1208) describe a nicely documented case of a 43-year-old man with high myopia and a history of retinal detachment OD, who developed unilateral iatrogenic pigment dispersion following uneventful phacoemulsification with capsular bag implantation of a posterior chamber intraocular lens followed by a neodymium:YAG laser capsulotomy OS. Close contact between the edge of the IOL and the posterior pigmented iris epithelium was documented by ultrasound biomicroscopy and anterior segment optical coherence tomography. The authors present a concise review of the literature.

Iatrogenic pigment dispersion has been described in a number of papers following posterior chamber lens implantation after cataract extraction, often in the ciliary sulcus, posterior chamber refractive lenses, and piggyback lens implantation. In addition to pigment dispersion, the findings can include elevated intraocular pressure (IOP), iris transillumination defects, the position of which can provide clues to the underlying mechanism, uveitis, and spontaneous hyphema. Secondary pigment dispersion has also been described after iris trauma at the time of lens implantation and from cysts of the iris pigment epithelium, iris nevus, and ciliary body melanocytoma. Mechanisms for iatrogenic pigment dispersion can include iris chafing from both haptics and optics. A complete bibliography is appended to this review for those who may find it useful. In this case, the patient presented with elevated IOP, spontaneous microhyphema and pigmented cells in the anterior chamber, along with bilateral radial transillumination defects, no Krukenberg spindles, and a large circular area of iris pigment loss at the pupillary border OS. There was moderate pigmentation of the trabecular meshwork OD and heavy pigmentation OS. The capsulorhexis was larger than the lens optic OS and the optic appeared shifted forward in relation to the plane of the capsulorhexis. Both OCT and UBM documented optic-iris contact.

However, I must question their conclusion that this patient did not have primary pigment dispersion, which they conclude by the lack of hyperpigmentation in the angular structures and posterior bowing of the iris plane in the fellow eye and the presence of atypical peripupillary topography of the posterior epithelial iris defects in the affected left eye. A history of retinal detachment should always instigate a search for signs of pigment dispersion syndrome. The typical iris concavity is eliminated after cataract extraction. A residual pigment reversal sign is unreliable after cataract extraction, which itself can lead to increased trabecular pigmentation. However, the radial transillumination defects and high myopia are suggestive. My guess is that this patient originally had bilateral pigment dispersion syndrome followed by secondary pigment dispersion syndrome OS on the basis of iris-optic chafing.

References

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  3. Bhorade AM, Edward DP, Goldstein DA. Ciliary body melanocytoma with anterior segment pigment dispersion and elevated intraocular pressure. J Glaucoma 1999; 8: 129-133.
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  5. Caplan MB, Brown RH, Love LL. Pseudophakic pigmentary glaucoma. Am J Ophthalmol 1988; 105: 320-321.
  6. Cykiert RC. Pigmentary glaucoma associated with posterior chamber intraocular lenses. Am J Ophthalmol 1986; 101: 500-501.
  7. Detry-Morel ML, Van Acker E, Pourjavan S, Levi N, De Potter P. Anterior segment imaging using optical coherence tomography and ultrasound biomicroscopy in secondary pigmentary glaucoma associated with in-the-bag intraocular lens. J Cataract Refract Surg 2006; 32: 1866-1869.
  8. Haberle H, Wirbelauer C, Aurich H, Pham DT. [Piggyback lens implantation for anisometropia in pseudophakic eyes]. Ophthalmologe 2003; 100: 129-132.
  9. Hoyos JE, Dementiev DD, Cigales M, et al. Phakic refractive lens experience in Spain. J Cataract Refract Surg 2002; 28: 1939-1946.
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    Micheli T, Cheung LM, Sharma S, et al. Acute haptic-induced pigmentary glaucoma with an AcrySof intraocular lens. J Cataract Refract Surg 2002; 28: 1869–1872.
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  18. Samples JR, van Buskirk EM. Pigmentary glaucoma associated with posterior chamber intraocular lenses. Am J Ophthalmol 1985, 100: 385-388.
  19. Siy Uy H, Chan PST. Pigment release and secondary glaucoma after implantation of single-piece acrylic intraocular lenses in the ciliary sulcus. Am J Ophthalmol 2006; 142: 330-332.
  20. Smith JP. Pigmentary open-angle glaucoma secondary to posterior chamber intraocular lens implantation and erosion of the iris pigment epithelium. J Am Intra-Ocular Implant Soc 1985, 11: 174-176.
  21. Sugiyama K, Kitazawa Y. Trabecular pigmentation following extracapsular cataract extraction and posterior chamber intraocular lens implantation. Ophthalmic Surg 1990, 21: 700-702.
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