Transcript Severe Z Syndrome - ASCRS/ASOA 2010

Severe
Z Syndrome
with the Plate-Haptic Silicone
Hinged Accommodating IOL
Leonard H Yuen, MD MPH MRCOphth
Shu-Yen Lee, MD FAMS
Wei-Han Chua, MD FAMS
SINGAPORE NATIONAL EYE CENTRE (SNEC)
The authors have no financial interest
in the subject matter of this poster
Background
• The Crystalens (Bausch & Lomb,
USA) accommodating IOLs are
gaining popularity for patients
hoping to obtain functional
distance and mid-range vision
following crystalline lens removal
• Recently case reports of
accommodating lens tilting
described as “Z Syndrome” have
been published following
uneventful cataract surgery 1,2,3,4
particularly with the Crystalens
AT45.5,6
(Bottom picture courtesy: J Cazal, MD, and C. Verges, MD)
• In a previous case series of
Z syndrome, the use of
Nd:YAG capsulotomy was
successful in treating the
lens tilt even after 9 weeks
postoperatively.1
However, we believe that
this treatment is effective
only in mild cases.
• To our knowledge this is the
first reported case of Severe
Z Syndrome with the
Crystalens AT52SE, which
warranted intraocular
repositioning of the lens to
restore anatomical
positioning and achieve
optimal visual outcome.
Case Report
A 45-year old female high myope with a manifest refraction of OS -11.00 -0.25 x
090 (DBCVA 20/20) underwent uneventful cataract surgery.
Intraoperatively, a clear corneal incision was made and Amvisc viscoelastic was
used. A 5.5mm complete circular capsulorrhexis was done and a +10.0 dioptre (D)
Crystalens AT52SE was implanted in the bag. No complications, specifically capsular
bag rupture or zonulysis, were observed.
POD 1: UCVA 20/80 and slit lamp examination was unremarkable
POW 3: DBCVA 20/20 with a manifest refraction of OS -1.00 -1.00 x 005
POW 4: Pt noticed a decrease in UCVA. Manifest refraction OS -1.50 -2.00 x 175
POW 12: Immigrated abroad and presented to the Singapore National Eye Centre
UCVA at this point was 20/400, with a manifest refraction
of OS +1.50 -4.00 x 100 (DBCVA 20/50). A near addition of
+2.00 could only achieve N18, equivalent to Snellen
20/120
Slit lamp examination
showed a dramatic
forward protrusion of
the inferior optichaptic junction that
encroached into the
anterior chamber
beyond the plane of
the dilated pupil
Superior anterior capsular phimosis with optic
capture was noted, with encapsulation of the
superior haptic within the bag. The inferior
portion of the optic was squeezed forward.
Retro-illumination revealed capsular wrinkling.
Treatment with neodymium:YAG laser capsulotomy was considered,
but the severity of the tilting deterred the decision of doing so
and subsequent intraocular manipulation was performed.
Intraoperatively the inferior lens haptic was freed from the capsular fibrosis and
iris hooks were used to immobilize the iris and to immobilize the pupil maximally.
The superior haptic was enveloped firmly by the fibrosed capsule and thus left
unmanipulated. The optic was pressed backwards and the haptic hinges vaulted
posteriorly to its anatomical position.
First day postoperatively, UCVA was 20/25 OS;
At one month, UCVA was 20/20, with a manifest
refraction of plano -0.75 x 15. A +2.00D near add lens
allowed her to read N5, equivalent to Snellen 20/20.
There was obvious flattening of the inferior iris:
Preop: +1.50 -4.00 x 100
Postop: Plano -0.75 x 15
Pre-operative
Post-operative
ASOCT confirmed a
posteriorly vaulted IOL
Discussion
The Crystalens AT52SE is a biconvex silicone plate IOL with an enlarged 5.0
mm optic. Its hinges are designed to move anteriorly during accommodation
to achieve near focus.
INTRINSIC DESIGN
The lens’ square edge design reduces posterior capsule opacity however its
effectiveness is unknown in patients under 50 years of age7 as in this patient.
The hinged accommodative mechanism of the Crystalens is believed to
be capsule dependent. Capsular fibrosis can however impede the axial
movement, and in cases of asymmetric capsular fibrosis the IOL can
decentrate.6 Its makeup of silicone material has not been shown to
increase lens decentration or tilting.3,4
Pointers suggested to reduce the incidence of Z-Syndrome:
1. Appropriately sized capsulorrhexis (5.5 to 6.0mm, as in this case)
2. Round CCC with the anterior capsule covering the plate haptics7
3. Cortical removal7
4. Capsular polishing5
5. Ophthalmic viscoelastic devices (OVD) should also be entirely removed
from behind the lens and the IOL gently nudged backwards at the final
stages of cataract surgery.
We are unaware of reports of asymmetric tilting with other types of IOLs.
Mild Z-Syndrome with the Crystalens were remedied by Nd:YAG capsulotomy.1
In this severe case, which resembles more like the letter “N”, surgical
repositioning is more appropriate. Previous reports have suggested IOL
exchange6 as an option however in this case IOL exchange would have been
difficult as the haptic was entrenched within the superior capsule adhesions.
References
The authors believe that
there is no uniform
treatment to treat this
syndrome, however the
severity of the
configuration of the IOL
and its relation to the
capsule will help guide
the surgeon to the
appropriate management
option.
1.
2.
3.
4.
5.
6.
Yuen L, Trattler W, Boxer Wachler B. Two Cases
of Z syndrome with the Crystalens after
uneventful cataract surgery. J Cataract Refract
Surg. 2008 Nov;34(11):1986-9.
Arkin C, Ozler SA, Mentes J. Tilt and
decentration of bag-fixated intraocular lenses:
a comparative study between capsulorhexis
and envelope techniques. Doc Ophthalmol.
1994;87(3):199-209.
Hayashi K, Harada M, Hayashi H, Nakao F,
Hayashi F. Decentration and tilt of polymethyl
methacrylate, silicone, and acrylic soft
intraocular lens. Ophthalmology. 1997
May;104(5):793-8.
Jung CK, Chung SK, Baek NH. Decentration and
tilt: silicone multifocal versus acrylic soft
intraocular lenses. J Cataract Refract Surg. 2000
Apr;26(4):582-5.
Jardim D, Soloway B, Starr C. Asymmetric vault
of an accommodating intraocular lens. J
Cataract Refract Surg. 2006;32:347-350.
Cazal J, Lavin-Dapena C, Marin J, Verges C.
Accommodative Intraocular Lens Tilting. Am J
Ophthalmol. 2005 Aug;140(2):341-4.