CASE REPORT

Pigment dispersion syndrome induced by a

phakic lens. Monitoring by anterior segment
Optical Coherence Tomography
Pedro Rocha, MD, PhD1; Jos Augusto Abreu, MD, PhD2
Jos F. Alfonso, MD, PhD2; Candelaria Pinto Herrera, MD3; Jos Juan Aguilar, MD3

ABSTRACT: A 29-year-old man came to our department complaining of pain and

photophobia in the right eye (OD). He reported uneventful bilateral intraocular collamer
lens (ICL) implantation 5 years previously. In April 2012, he presented with anterior
uveitis with macular edema in the OD. Visual acuity (VA) was 0.5 in the OD, and 1.0 in
the left eye (OS). Pigment dispersion on the lens and nasal corectopia were observed in
the OD only. Anterior segment optical coherence tomography (OCT) revealed bilateral
iridolenticular contact, more marked in the OD. After bilateral explantation of the ICL, the
ocular symptoms disappeared and VA was recovered.
Serial anterior segment OCT following ICL implantation is extremely useful and can be
an effective method for monitoring the lens position, allowing early detection of long-term
complications.
J Emmetropia 2015; 1: 21-25

OCT is a simple-to-perform, non-invasive examination
that enables high resolution images of structures in the
anterior segment of the eye to be obtained. It has multiple
applications in both the anterior and posterior segment of
the eye, and is currently an essential tool for retina specialists
to assess the macular area, and for glaucoma specialists to
observe changes in the optic disc and nerve fiber layer1.
Knowledge of anterior chamber morphology, follow-
up of phakic intraocular lens (IOL) implants and their
relationship with the iris, crystalline lens and sulcus, have
allowed us to identify diseases and their pathophysiology
that we were unaware of prior to its introduction2-4. It
enables measurement and morphological evaluation of the
IOL vault, which is defined as the perpendicular distance
Submitted: 12/15/2014
Accepted: 2/23/2015
1
Ophthalmology Department, University Hospital of the Canary
Islands,Tenerife, Canary Islands, Spain.
2
Frnandez-Vega Ophthalmological Institute, Oviedo. Spain.
3
Ophthalmology Department, University Hospital of the Canary
Islands,Tenerife, Canary Islands, Spain.
Financial disclosure: The authors declare that they do not have any
commercial interest in any of the materials and methods mentioned
in this article, nor have they received any financial support.
Corresponding Author: Pedro Rocha Cabrera
Ophthalmology Department, University Hospital of the Canary
Islands.
Carretera La Cuesta-Taco, s/n, 38320 La Laguna (Tenerife), Spain
E-mail: procha975@yahoo.es
2015 SECOIR
Sociedad Espaola de Ciruga Ocular Implanto-Refractiva
between the anterior pole of the lens or crystalline lens and
the horizontal line joining two points on the scleral spur4,5.
IOL-induced pigment dispersion syndrome (PDS)
has been observed in IOLs positioned in sulcus or in-the-
bag6-12. The mechanism of PDS has been described and
well-established for years, triggered by mechanical friction
between the posterior part of the iris, the zonular fibers and
the IOL, producing pseudophakodonesis; other possible
causes are the IOL material, its thickness and inadequate
diameter13-16.
Phakic IOLs can alter structures directly related with
their location, increasing the risk of anterior subcapsular
cataract and elevated intraocular pressure (IOP)17-19.
One of the most widely used phakic IOL models is the
implantable collamer lens (ICL) (Staar, Inc. Monrovia,
CA, USA), composed of a hydrophilic collagen polymer,
with high compatibility to prevent the side effects of active
metabolism of the crystalline lens.
The aim of this paper is to present the case report of
a patient who had an ICL implanted in both eyes, and
which 5 years post-surgery, induced PDS with concomitant
anterior uveitis and macular edema. Clinical symptoms
resolved with extraction of the ICLs.
CASE REPORT
In July 2012, a 29-year-old man attended our clinic
with a one-week history of headache, and photophobia,
dysphotopsias, haloes, ocular pain and floaters in
both eyes, predominantly the right. His medical
ISSN: 2171-4703 21
22 OCT MONITORING OF POSTERIOR CHAMBER LENSES
history included allergic rhinitis. He had undergone
uneventful phakic IOL implantation with an ICL in
both eyes 5 years previously. According to the patient,
he was diagnosed with right acute anterior uveitis with
macular edema in April 2012, and did not recover his
former visual acuity (VA). He regularly practiced high
intensity sports.
On ophthalmological examination, VA in the right
eye (OD) was 0.5, and in the left eye (OS) was 1.0.
Biomicroscopy of the OD revealed an ICL IOL in
the posterior chamber, some pigment dispersion on
the IOL, and nasal corectopia (Figure 1), with no
reaction in the anterior chamber and disc hyperemia.
In the OS, the examination showed an ICL IOL in
the posterior chamber, with no inflammatory activity
in the anterior chamber. Intrinsic motility was within
the reference range. IOP was 9 mmHg in both eyes.
Bilateral disc edema was noted in the fundus, more
intense in the OD, with normal macula in both
eyes. The visual field showed superior arciform
scotoma in the OD and generalized loss of global
mean sensitivity in the OS. Macular and disc OCT
showed bilateral disc edema, more intense in the OD,
so the patient was referred to hospital to rule out an
acute neurological event. Fluorescein angiography
(FAG) found early hyperfluorescence consistent with
papillitis in the OD, with normal findings in the
OS. Computed tomography and lumbar puncture
were also normal. Laboratory test results were
unremarkable: complete blood count and routine
biochemistry results were within reference ranges, and
C-reactive protein (CRP), rheumatoid factor (RF),
VDRL, angiotensin-converting enzyme (ACE), anti-
neutrophil cytoplasmic antibodies (ANCA) and HLA
A29, B2, B7 and DR2 tests were negative; serology
tests were positive for cytomegalovirus (CMV) IgG
Figure 1. Biomicroscopy of the OD: nasal corectopia can be seen, with
more significant fraying and iris atrophy in this sector.
JOURNAL OF EMMETROPIA - VOL 6, JANUARY-MARCH
only. There were no abnormal findings on brain and
orbital nuclear magnetic resonance imaging (MRI),
except for a single hyperintense focal lesion in the right
parasagittal region of the corpus callosum. Auditory
neurophysiologic examination was normal. Topical
and oral corticosteroid treatment was prescribed, and
a watchful attitude was adopted. Following anterior
segment OCT using the Topcon 3D OCT-2000
Spectral Domain system, a low vault of 167 microns
was observed between the IOL and crystalline lens, as
well as probable peripheral iridolenticular contact in
the OD and OS (Figures 2 and 3). After the prescribed
treatment, a gradual improvement was noted in the
papillitis symptoms, which eventually disappeared
completely. The VA did not improve however, and the
patient continued to report persistent dysphotopsias
and haloes. The IOLs were then explanted from both
eyes, with recovery of the VA, which returned to 1.0
with disappearance of the haloes and dysphotopsias
(Figure 4). An endothelial count performed post-
explantation showed cell density 2268 cells/mm2
and hexagonality 69% in the OD, and cell density
2233cells/mm2 and hexagonality 59% in the OS.
DISCUSSION
As we know, the crystalline lens continues to grow
concentrically throughout life20. This will cause
progressive intraocular changes, and the space between
the iris and crystalline lens will therefore decrease
steadily over the years.
OCT is a crucial diagnostic procedure in
understanding the natural growth of the crystalline lens21.
Posterior chamber phakic lenses (ICL and phakic
refractive lenses [PRL]) have been a therapeutic option
in the correction of ametropia in patients who cannot
benefit from corneal refractive treatment.
Numerous complications have been described with
ICL phakic lenses, including haloes, glare, chronic
anterior uveitis, pupil ovalization22-25, anterior sub-
capsular cataract26-31, increased IOP32, endothelial
loss33, pigment dispersion34 (as in our case), pupillary
block35,36 and glaucoma.
The use of anterior segment OCT allowed us to
determine the etiology of the patients condition:
iridolenticular friction which caused pigment dispersion
from the posterior part of the iris, altering the blood-
aqueous barrier and thereby inducing the production
of inflammatory factors responsible for the macular
edema observed. The patients sporting activities
aggravated pigment dispersion by iridolenticular
friction, accentuated by a grade 1 vault. We have not
found papillitis described as a complication of ICL
implantation, and it may have had another etiology, e.g.
viral. In our case, we believe it was a casual finding37-41.
 OCT MONITORING OF POSTERIOR CHAMBER LENSES 23

Figure 2. Anterior segment OCT of the OD, in which iridolenticular contact and a low grade 1 vault between the IOL and crystalline lens
can be seen.

Figure 3. Anterior segment OCT of the OS; a low grade 1 vault can be seen.

Figure 4. Anterior segment OCT of the OD after IOL explantation.

We conclude that in the insertion of phakic ICLs, the accommodation42-45. The vault should also be accurately
possibility of growth of the crystalline lens (which occurs evaluated prior to surgery. OCT monitoring of ICL
naturally in humans over time) should be assessed, as implants could aid in the early diagnosis of any changes
should changes in the shape and position of the lens with in relation to structures in the anterior segment.

JOURNAL OF EMMETROPIA - VOL 6, JANUARY-MARCH

24 OCT MONITORING OF POSTERIOR CHAMBER LENSES
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First author:
Pedro Rocha, MD, PhD
University Hospital of the Canary Islands.
Canary Islands, Spain

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