ICLs

Is anyone else unfamiliar with an ICL? Maybe I was surfing the internet that day, but I can't remember ever learning about this from our faculty. Anyway, I comanaged one the other day.

ICL stands for Implantable Collamer Lens. It is literally a phakic IOL - it is inserted into the posterior chamber, in between the iris and the lens/anterior capsule. 

The biggest complication is iris bombe, with resulting pressure spikes, so the surgeons usually place TWO PIs in each eye just to be sure. Post-op management is pretty similar to cataract surgery, except the amount of pigment release from the iris is much more. Oh, and it is pretty trippy to see two additional surface reflections when you looking with a slit lamp.

ICLs are pretty neat - they are theoretically interchangeable, so if someone's Rx changes, they simply do an exchange. The success rates are excellent, with none of the LASIK downsides like irreversibility, haloes, glare, dryness, and aberrations. The only real downside is that the current technology doesn't correct for much astigmatism, but supposedly a solution to this is on the horizon.

Anyone else co-managed one of these yet?

You can learn more here: http://www.visianinfo.com/html/refractive_chart.html

Subluxed IOL removal

While observing at a local surgery center today, I watched the removal of a subluxated IOL today. The patient was in her 80s and had cataract surgery performed several years ago; over time, the IOL (and capsule) had been displaced dramatically - it looked exactly like the classic Marfan's photos. Apparently it is not uncommon for older cataract surgeries to result in zonule weakening down the road and IOL displacement. This lady had also undergone several YAG surgeries for PCOs, so the posterior capsule had large holes in it.

The surgeon was visibly nervous and had a real struggle to get the lens out - the patient's pupils were poorly dilated, and every time he tried to grab the IOL and move it anterior to the iris, the haptics would snap back and damage the iris. After practically destroying the woman's iris (I could clearly see retina through one segment), he finally resorted to cutting the IOL in half with scissors, then cutting the haptics off, and removing it piece by piece. By that time, he had made more than one large corneal incision of >4 mm. I estimated that over 1/3 of the corneal circumference had been cut open on one end, with smaller incisions on the other side as well - can you say "specialty contact lens fit?" That woman is bound to have gobs of post-op astigmatism.

After removing the IOL, the surgeon pulled some iris tissue through one of the incisions, snipped it to create a nice PI, then inserted an anterior chamber IOL. 

Holy crap

40 Year-old patient presents for routine examination at 8 AM.  Quick refraction, quick anterior segment.  Ask the patient about dilation- patient is quite hesitant (had a golfing match).  Patient remits and allows dilation; on the last view in the mid-periphery there was a horrible looking, elevated, choroidal nevus.  Something like this:

 Patient had a 4 year history at the clinic with 2 prior dilations, both of which did not mention the lesion. Took photos in office, referred out to ophthalmology for B-scan and fluorescine angiography the same day.  Angiography showed sentinel vessals and B-scan showed elevation.  6AM the next morning, patient is on a plane to the Moran Eye institute in Utah.  They run multiple cancer panels, and have 5 independent retinal specialists view the lesion.  Tests prove negative, and all give diagnosis of benign.  Patient comes home and goes to golf course.

Presumed Ocular Vaccinia

Saw a patient with nasty unilateral Herpes-looking disciform keratitis that recurs every 6 months or so. It started a few years back right after he got vaccinated for the H1N1 virus. His ulcer is unresponsive to any of the anti-viral agents available - viroptic, acyclovir, zirgan, etc. After consult with an ophthalmologist, we put him on steroids, and it made it a little better. He is 20/400 in the affected eye when the ulcer is active, and has residual vision loss even after it goes away on its own temporarily.

I did some reading, and found something on ocular vaccinia (you can even find it in Will's). Turns out that after receiving a viral vaccine, you can spread the virus to your eye for up to three weeks afterward if you touch the injection site, then rub your eye. Looks like that's what happened to this guy, but it never responds to medication. 

Thygesons Plus

Weird case.

Day 1: A 30-yr old male walks in with a nasty red, extremely painful eye. He has several subepithelial infiltrates, presumably from CL (AVO) overwear. We treated him with tobradex qid x 7d.

Day 7: No resolution from the tobradex. Pain is worse now, SEIs remain, now on both eyes. He says it started getting better, so he tried wearing his CLs again, and the pain returned with a vengeance. We gave him Pred Forte to use q1h x 1-2d, then qid x 1 week

Day 14: Eye is still red, still extremely painful. Patient is really frustrated. Turns out he used the whole bottle of Pred Forte in 2 days (ridiculous, I know). Eye felt better for a little while, then redness and pain returned worse than ever. Since SEIs can rebound from steroids, we gave him Pred again, with strict instructions to taper slowly over 1 week.

Day 21: Patient no-showed for 1-week FU.

2 weeks later: Decided to call the patient to make sure all was well. Patient reports no improvement; he has been living with his red, painful eye for over a month now, and can't get any relief. Says he didn't come in because he can't afford to. We offer to see him free of charge to see what is going on.

Patient shows up with classic Thygeson-looking SPK OU - no more subepithelial infiltrates now. Steroids obviously haven't worked for him, so we put him in a bandage CL (Focus N&D) - the doc I'm working with says this has worked for every case of Thygeson's he has ever seen.

1 week later: patient only wore the CL for 2 days, because he had pain when inserting it for 30 sec or so. After insertion though, it felt great. Classic Thygeson SPK is still there, but even more diffuse now OU. We educated him about the exacerbation-remission cycle of Thygeson's - there is nothing more to do after steroids and the bandage CL, unless we want to do chronic low-dose steroids, for which the patient has no money or desire. We sent him home and told him to wear the CL more frequently, as long as the eye isn't red or painful after the initial insertion - we'll see him back again in 3 mo.

I have no idea how he morphed from SEIs into Thygeson's. I wish I had taken photos. Weird.

A new viral presentation?

Since my time here in St. George, UT, we have seen dozens of odd presentations of what is presumably a viral infection.

Patient Presentation: 3-4+ conjunctival chemosis (looks like you can pop it with forceps), grade 2-3 limbal and tarsal conj papillae, diffuse redness, watery discharge, and mild-moderate discomfort. Looks like a nasty, nasty allergic response.

Treatment: Does not respond to steroid (even high-dose Pred Forte) and/or mast cell stabilizer/antihistamine treatment at all. Complete resolution in 2-3 weeks, with or without treatment. Faster resolution (1 week or less) with Betadine lavage. One practitioner has been treating simultaneously with Pataday and Bromday, but no improvement in resolution time.

Sounds viral, right? All of the other practitioners in this area have been seeing similar cases, with the same results. No one knows what it is, and I haven't been able to find anything like it in the literature. We've contemplated culturing and contacting the CDC to see if they know anything. Anyone else seen anything like it  or know what it is?