612 CORRESPONDENCE

Pupil capture of intraocular lens in vitrectomized Two months later, the patient returned with temporal en-
trapment of the optic IOL by the pupil (Figure 1). There were
eye with primary pigment dispersion syndrome no changes in the intraocular pressure (IOP) or visual acuity
Javier Moreno-Monta~nes, MD, PhD, and no pseudophacodonesis or IOL tilting. The pupillary
capture was treated with pilocarpine and a face-up position
Angel Salinas-Alaman, MD, PhD, for 15 minutes. The distance between the cornea and IOL
Jes
us Barrio-Barrio, MD, PhD, Elvira Bonet-Farriol, MD was 5.21 mm. One week later, IOL entrapment recurred. Go-
nioscopy showed backward bowing of the iris bilaterally
Intermittent pupillary capture of an intraocular lens and trabecular meshwork pigmentation. Iris transillumina-
(IOL) is an early complication of sclera-fixated sutured tion showed spoke-like pattern defects in the mid-peripheral
posterior chamber IOL implantation. In the few iris (Figure 2). No Krukenberg spindle pigmentation was
found. The IOP was 16 mm Hg bilaterally. Laser peripheral
published cases of this complication, vitrectomy was iridotomy was performed in the right eye, and 1 year later,
performed with a scleral-fixated sutured IOL.1–5 The the iris was flat with no IOL recapture.
cases are related to Marfan syndrome,1,5 pseudoexfoli-
ation syndrome,1 lens subluxation,1,5 and unknown
causes.2,4 The proposed mechanism in cases with DISCUSSION
a well-positioned scleral-fixated sutured IOL is poste-
Primary PDS is usually a bilateral condition character-
rior iris bowing that pushes the IOL until pupillary
ized by iris pigment dispersion throughout the eye.6
capture occurs.1,2 To our knowledge, eyes with this
Iris transillumination defects are present in most
complication and primary pigment dispersion syn-
cases.6 Pigment dispersion syndrome is also associ-
drome (PDS) have not been reported. We describe
ated with more posterior iris insertion than normal,
a case of intermittent pupillary capture of an IOL
larger irides, long anterior zonules, and marked iris
secondary to primary PDS in which iris transillumina-
processes.6,7 Some authors suggest that hypoperfusion
tion of the contralateral eye clarified the cause of the
and hypoplasia of the iris are consistent with these fea-
IOL pupillary capture.
tures and can explain the relatively slow progression
of the primary PDS, presumably present from birth,
CASE REPORT
which will eventually subside as the effects of hypo-
Pars plana vitrectomy was performed in the right eye of a 48- perfusion diminish in later life.8 Histological studies
year-old man with a retinal detachment and previous cata-
ract surgery and a normal left eye. Four years later, the show hyperplasia of the iris dilator muscle, often asso-
IOL–capsular bag complex was dislocated; the IOL–capsular ciated with areas of loss of iris pigment epithelium.
bag was removed, and a C12 CZ70BD IOL (Alcon Laborato- Blinking, accommodation, or eye movements may
ries, Inc.) was sutured transsclerally at the 3 and 9 o’clock po- cause the concave iris configuration in eyes with previ-
sitions. This IOL is single-piece poly(methyl methacrylate) ous iris characteristics.6 Similar to previously reported
with a 7.0 mm diameter optic (total diameter 13.5 mm) and
smooth edges. It is commonly used for scleral fixation. The eyes,1,3 in the current case, the optic IOL capture oc-
eyelets in the haptics allow stable fixation, and the large optic curred temporally, despite 5.21 mm between the cornea
facilitates centration. and the IOL.

Figure 1. A: Optic IOL pupillary capture in the temporal area of the right eye. B: Laser peripheral iridotomies in the same eye. C: Slitlamp pho-
tograph after peripheral iridotomies shows that the IOL is not tilted and there is a normal distance between the IOL and iris.

J CATARACT REFRACT SURG - VOL 37, MARCH 2011

Figure 2. A: Iris transillumination of the phakic contralateral eye (left eye) shows characteristic defects in the midperipheral iris of PDS in the
inferior iris. B: Iris transillumination of the affected eye (right) shows different types of iris defects: atrophy in the midperipheral iris characteristic
of primary PDS (arrows), defects secondary to laser iridotomies (arrowheads), and paracentral defects secondary to rubbing between the iris and
IOL.

The proposed treatments in these cases are laser iri- 2. Khng C, Snyder ME, Osher RH, Cionni RJ. Cataract surgical
dotomy (LI) and miotic therapy. Both treatments can problem. In: Masket S, ed, Consultation section. J Cataract
Refract Surg 2005; 31:264
restore the peripheral iris concavity to a planar config- 3. Masket S, ed, Consultation section. Cataract surgical problem.
uration, decreasing the posterior bowing of the iris.6 J Cataract Refract Surg 2005; 31:262
Long treatments using a miotic agent are not favored 4. Bading G, Hillenkamp J, Sachs HG, Gabel VP, Framme C. Long-
or are poorly tolerated. The reported cases of pupil term safety and functional outcome of combined pars plana vit-
capture were resolved using a peripheral LI because rectomy and scleral-fixated sutured posterior chamber lens
implantation. Am J Ophthalmol 2007; 144:371–377
it prevents or reduces the risk for IOL recapture.1,2 In 5. Johnston RL, Charteris DG, Horgan SE, Cooling RJ. Combined pars
these cases, I suggest using a low energy because the plana vitrectomy and sutured posterior chamber implant. Arch
mid-peripheral iris is atrophic and can easily be Ophthalmol 2000; 118:905–910. Available at: http://archopht.
perforated. ama-assn.org/cgi/reprint/118/7/905.pdf. Accessed December 2,
Higashide et al.1 report the usefulness of optical 2010
6. Niyadurupola N, Broadway DC. Pigment dispersion syndrome and
coherence tomography (OCT) for identifying the con- pigmentary glaucomada major review. Clin Exp Ophthalmol 2008;
cave iris configuration in 4 eyes with IOL pupillary 36:868–882. Available at: http://onlinelibrary.wiley.com/doi/
capture. Ultrasound biomicroscopy (UBM) has also 10.1111/j.1442-9071.2009.01920.x/pdf. Accessed December 2,
been proposed6; however, it is invasive and requires 2010
a water-gel bath and contact with the cornea early 7. Liu L, Ong EL, Crowston J. The concave iris in pigment dispersion
syndrome. Ophthalmology 2010 Aug 27; [Epub ahead of print]
postoperatively. No reports of unilateral cases men- 8. Gillies WE, Brooks AM. Clinical features at presentation of ante-
tion the contralateral eye. Although OCT and UBM rior segment pigment dispersion syndrome. Clin Experiment
technologies are useful, both eyes should be examined Ophthalmol 2001; 29:125–127
with a slitlamp. We believe that bilateral iris transillu-
mination is mandatory in cases of IOL pupillary
capture to identify unrecognized PDS. If transillumi-
nation is performed, we will likely identify more cases Prevalence of corneal astigmatism in cataract
of primary PDS in eyes with optic IOL capture. surgery candidates in Bangkok, Thailand
Kaevalin Lekhanont, MD, Wadakarn Wuthisiri, MD,
REFERENCES Porntip Chatchaipun, Anun Vongthongsri, MD
1. Higashide T, Shimizu F, Nishimura A, Sugiyama K. Anterior Cataract and intraocular lens surgery has advanced
segment optical coherence tomography findings of reverse pu-
pillary block after scleral-fixated sutured posterior chamber intra-
significantly in recent years. Therefore, the goal of
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35:1540–1547 providing optimal vision and minimizing

J CATARACT REFRACT SURG - VOL 37, MARCH 2011