healthmedicinet

A 59-year-old man with diabetes underwent uneventful phacoemulsification in 1990 in
the left eye with implantation of a one-piece polymethylmethacrylate IOL. Open-angle
glaucoma developed postoperatively and was treated with brimonidine (Alphagan, Allergan,
Irvine, CA), timolol maleate (Timoptic, Merck Co, West Point, PA), and latanoprost
ophthalmic solution (Xalatan, Pfizer Inc., New York). The right eye had phthisis bulbi
secondary to a surgery to repair a retinal detachment. The patient did not instill
sufficient medication and the optic disc damage increased. In 2006, iris rubeosis
with uveal ectropion developed secondary to diabetic retinopathy. Gonioscopy found
new vessels in the angle with synechiae in 360° of the angle. The intraocular pressure
(IOP) was 45 mmHg in the left eye. The best-corrected visual acuity (BCVA) was 1 logarithm
of the minimum angle of resolution (logMAR) unit in the left eye. Two intravitreous
injections of bevacizumab (Avastin, Genentech Inc., South San Francisco, CA) (1.25 mg/0.05 mL)
were administered in January and March 2007. Panretinal photocoagulation was applied
at the same time to permanently ablate the ischemic retina, and the new vessels resolved.
The IOP was 40 mmHg in the left eye after panretinal photocoagulation. In April 2007,
an Ahmed Glaucoma Valve model FP7 was implanted with the plate positioned superonasally.
Six months later, the bleb in the plate was encapsulated and the IOP was 14 mmHg.
Two years later in April 2009, the IOL-CB complex became dislocated (Fig. 1). The BCVA was 2 logMAR units and the IOP was 16 mmHg. The patient denied any ocular
or head trauma in the months before the examination. However, Valsalva maneuvers during
an episode of coughing may have occurred because the patient had chronic obstructive
lung disease. Transscleral 10/0 Prolene sutures were placed over and under both subluxated
haptics through the anterior and posterior capsules to capture the haptics. The Prolene
sutures were pulled to retract to the sclera and then were tied off. The IOL was centered,
but the superior CB was folded over the optic IOL (Fig. 2). The BCVA was 1 logMAR unit and the IOP was 15 mmHg. Two months later, the BCVA
decreased again after another episode of coughing, and the patient described intense
ocular pain. The IOP was 40 mmHg and the BCVA was 2 logMAR units. The tube was placed
behind the optic of the IOL; it was obstructed by the IOL, which increased the IOP
(Fig. 3). A 25-gauge pars plana vitrectomy was performed, and the tube was again moved in
front of the optic of the IOL using the tip of a forceps through one of the sutureless
sclerotomies. One year after vitrectomy, the IOP was 15 mmHg and the BCVA was 1 logMAR
unit. No other changes in the tube placement were seen (Fig. 4).

Fig. 1. Inferior dislocation of the IOL-CB complex. The tube is positioned in front of the
IOL-CB complex

Fig. 2. Suturing of the IOL-CB complex. The IOL-CB complex is sutured to the sulcus transsclerally
but the superior CB is folded onto the optic IOL (arrows)

Fig. 3. Subluxation of the IOL-CB complex. After an episode of coughing, the IOL-CB complex
is pushed forward and the tube is placed behind the IOL

Fig. 4. 1 year postoperatively. One year after posterior vitrectomy, there are no changes
or tube displacement behind the IOL