ACTA OPHTHALMOLOGICA 63 (1985) 380-382

Pro1 iferat ive vi t reoret i no pat hy after intraocular lens implantation

Leila Laatikainen and Ahti Tarkkanen

Department of Ophthalmology (Acting head: A. Tarkkanen), Helsinki University Central Hospital, Helsinki, Finland

Abstract. The first 3 patients with pseudophakic reti- nal detachment referred to the Helsinki University Eye Hospital are presented. All had undergone extracapsular cataract extraction with implantation of an iris-supported IOL in one case and a posterior chamber lens in two cases. All showed proliferative vitreoretinopathy (PVR) varying from Grade C, to D, when first examined for retinal detachment 6 to 16 weeks after cataract surgery. The retina was primarily re-attached in all cases, but re-detachment occurred in 2 of the 3 due to progressing PVR. Until now our incidence of pseudophakic retinal detachment is 0.3 %.

Key words: retinal detachment - intraocular lens - pseu- dophakos - proliferative vitreoretinopathy - intraocular lens implantation.

In aphakic retinal detachment, the retina is more often totally detached than in phakic retinal de- tachment (Norton 1963; Ashrafzadeh et al. 1973; Laatikainen & Tolppanen 1985), and aphakic eyes are more prone to have pre-operative proliferative vitreoretinopathy (PVR) (Ashrafzedeh et al. 1973) and more severe degrees of proliferative vitreo- retinopathy than are phakic eyes Ualkh et al. 1984). Our first 3 cases of pseudophakic retinal detach- ment surprisingly showed varying degrees of PVR (The Retina Society Terminology Committee 1983) when first examined.

Case Reports Case 1. A 70-year-old woman underwent extracapsular cataract extraction and insertion of an iris-supported Medallion type intraocular lens (IOL) in December 1982. Post-

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operatively, 0.06% phospholine iodide once a day had been prescribed because of some instability of the IOL. Two months after surgery the patient noticed 'hairs' in the visual field, and after another two months the vision blurred, at first temporarily but two weeks later perma- nently.

When first examined at this hospital 4 days after blurring of vision the visual acuity was counting fingers (CF) 2 m. The retina was totally detached with a large fixed star fold in the inferior temporal periphery and tight fixed folds around the optic disc (PVR grade C3) (Fig. 1). No retinal breaks were found.

An encircling silicone band was inserted with drainage of subretinal fluid and injection of 1 ml of sodium hyaluronate (Healon@) into the vitreous space. The re- tina was re-attached, but some folds nasal to the optic disc remained. The visual acuity improved to 0.1. Four weeks later the vision deteriorated again, and a funnel shaped detachment was diagnosed. A pars plana vitrectomy combined with injection of silicone oil was performed without success.

Case 2 A 77-year-old woman underwent extracapsular cataract extraction with implantation of a posterior chamber lens in May 1984. Two weeks later the implant surgeon diagnosed rupture of the posterior capsule and disloca- tion of the IOL. A contusion injury was suspected. The visual acuity was 0.3 with correction, there was some vitreous haze, but the retina was flat. Four weeks later the visual acuity was CF 30 cm. The retina was totally detached and showed large fixed star folds in the inferior quadrants corresponding PVR grade C2. A tear was found in the inferior nasal quadrant.

An encircling silicone band was inserted combined with a circular silastic sponge implant underneath the band in the inferior quadrants. Subretinal fluid was drained and 0.5 ml of Balanced Salt Solution (BSS)" was

Fig. 2. Case 3, pre-operative fundus chart of the right eye showing 2 retinal breaks (arrows) and fixed folds in the

macula and around the optic disc (PVR grade C3).

Fig. I , Case 1, pre-operative fundus chart showing a large star fold in the inferior temporal quadrant and multiple fixed

folds around the optic disc (PVR grade C3).

injected into the vitreous space to normalize the intra- ocular pressure. The retina was re-attached, and the visual acuity improved to CF 3 m. One month post- operatively the retina re-detached due to PVR. No fur- ther procedures were performed.

Case 3 A 68-year-old woman who had suffered from capsular glaucoma and cataract in her left eye underwent an uncomplicated extracapsular cataract extraction with im- plantation of a posterior chamber lens in August 1984. Three weeks post-operatively the visual acuity was 0.3, and the eye was quiet. One week later the patient noticed flashes of light, but she did not contact her doctor until the vision blurred 3 weeks later. The visual acuity was CF 1 m, there was some vitreous haze, and the retina was totally detached with multiple fixed folds arround the optic disc (PVR grade C3) (Fig. 2). There were 2 retinal breaks in the superior temporal quadrant.

A pars plana vitrectomy was performed combined with cryocoagulation of the retinal breaks, insertion of an encircling silicone band, drainage of subretinal fluid and fluid-gas (20 7% SF,) exchange. Five months post-operati- vely the retina was flat with macular pucker.

Discussion

These case reports confirm the findings of other authors that the interval between cataract extrac-

tion with IOL implantation and retinal detachment is often short (Snyder et at. 1979; Ross 1984). Because of this the patients may neglect the first symptoms of retinal detachment as they d o not know what is .normal<< post-operatively. Therefore the diagnosis of retinal detachment is protracted. T h e other reason for the late diagnosis may be the fear of the referring ophthalmologist to dilate the pupil for fundus examination.

The short interval from the implant surgery to the development of retinal detachment has been thought to suggest that trauma to the vitreous face during the surgery contributes to the development of later detachment (Ross 1984). In the present cases no intra-operative complications were repor- ted. I n one of them the post-operative period after cataract extraction had also been uncomplicated, the other two had had some difficulties with the lens - instability and dislocation. Two of the pre- sent cases had had their cataract surgery elsewhere. At o u r hospital, 2 pseudophakic detachments have been diagnosed after about 700 posterior chamber implantations giving an incidence of pseudophakic retinal detachmant of 0.3 %.

All 3 cases presented here showed signs of PVR when first examined for retinal detachment. In PVR there is a formation of membranes secondary

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to proliferation of cells along the detached vi- treous, inner retinal and outer retinal surfaces. The formation and contraction of the membranes may be very rapid following trauma or retinal detachment surgery. In pseudophakic detach- ments the incidence of PVR seems be higher than in aphakic detachments after routine cataract sur- gery (Wilkinson 1981; Boniuk et al. 1984). The increased ocular manipulation during IOL implan- tation may represent more trauma to the eye. Furthermore, one has to consider the role of the IOL haptics in the ciliary sulcus. Histopathological studies of successful autopsy cases have revealed deep embedding of the haptics into the ciliary body (Crawford 1981; McDonnell et al. 1983; Daicker 1984; Tarkkanen et al. 1985). Initially this may interfere with the uveal circulation. Also the foreign body type giant cell reaction around the polypropylene haptics may contribute towards the development of PVR.

The poor prognosis of PVR after surgical treat- ment is well demonstrated in the series of Meyer- Schwickerath et al. (1984). Intra-operatively 78% were attached whereas at 3 months only 34 9% were still in situ. In PVR Grade C, the success rate was 50%, in Grade C, through D, the rate was 30% whereas in Grade D, none remained attached. In order to avoid unneccessary delay in the treatment of pseudophakic retinal detachment, examination of the fundus through a dilated pupil is indicated after implant surgery, particularly if the patient complains of symptoms possibly related to a retinal break or detachment.

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Received on February 25th, 1985.

Author's address:

Leila Laatikainen, M. D., Department of Ophthalmology, Helsinki University Central Hospital, Haartmaninkatu 4 C, SF-00290 Helsinki, Finland.

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