Rhegmatogenous retinal detachment after intraocular lens implantation in high myopia:A case report and literature review

Shu-Yu Fu,Xiong-Gao Huang

The First Affiliated Hospital of Hainan Medical College,Haikou 570102,China

Keywords:Phakic intraocular lens implantation Rhegmatogenous retinal detachment Vitrectomy

ABSTRACT Objective:To observe the changes of diagnosis and treatment of a patient with rhegmatogenous retinal detachment (RRD) after phakic intraocular lens implantation in high myopia,and analyze its mechanism and treatment combined with the literature.Methods:To report a case of rhegmatogenous retinal detachment (RRD) after phakic intraocular lens implantation.Result:Two months after the patient underwent scleral cerclage+pad pressing+vitrectomy+silicone oil filling,the fundus color photos showed that the vitreous cavity was filled with silicone oil,the fundus retina was flat,the cerclage ridge was obvious,and a large number of old laser spots.After the silicone oil in the eye was removed,the eye examination:the naked visual acuity of the left eye was 0.12,the corrected visual acuity was -3.25ds/ -1.50dc* 180=0.4,the intraocular pressure was 19mmHg,the ring ridge was seen in the fundus after mydriasis,a large number of old laser spots and flat retina;The OCT showed that the macular structure of the left eye was complete and there was no subretinal fluid.Conclusion:Scleral cerclage+padding+vitrectomy+silicone oil filling is an effective treatment for retinal detachment (RD) after PIOL.

1.Introduction

High myopia is an eye disease.It is not only a simple ametropia,but also a disease threatening vision[1].In 2000,the prevalence of high myopia was about 2.7% (163 million) of the world population.Holden [2] predicted that myopia may affect half of the world population as the main cause of blindness by 2050.In the retrospective study of Kim [3],high myopia in East Asian population may be a factor in the high prevalence of RRD in young people.This paper reviews the treatment process of RRD in a patient with high myopia after PIOL,and observes the changes of his condition.Combined with literature analysis,this report is as follows.

2.Case Report

The patient was male,23 years old.He came to our outpatient clinic because of "black shadow in front of his left eye with vision loss for 10 days".The patient had high myopia in both eyes since childhood.He underwent bilateral PIOL in the external hospital in May 2019.The details are unknown.No previous special medical history.Admission eye examination:right eye visual acuity 0.05,-0.35ds/ -0.75dc * 5=0.05 (helpless correction),intraocular pressure:18mmhg;Left eye visual acuity 0.15 (helpless correction),intraocular pressure:14mmHg.The anterior segment examination showed that the intraocular lens of both eyes was located in front of the lens (Fig.1a and b),and there was no relevant abnormality.The a-ultrasound examination showed that the patient's ocular axis and corneal thickness were high myopia,with the right eye axis of 31.70mm,the left eye axis of 29.38mm and the right eye corneal thickness of 613 μ m.Corneal thickness of left eye 591 μ M (Figure 1D).

Figure 1 eye examination at first visit

Figure 2 follow up fundus examination after retinal reduction

Figure 3 follow up fundus examination after silicone oil removal

A.Posterior chamber intraocular lens can be seen by anterior segment photography.B.Under narrow light,the anterior chamber is normal,and the lens is transparent and entopic.C.The color photos of the fundus of the left eye showed that the retina showed leopard like changes,the lower retina was widely detached,multiple subretinal fixed folds,and two small holes were seen at 03:30 o'clock direction.D.Ocular a-ultrasound showed high myopia,ocular changes,elongated ocular axis and increased corneal thickness.

We gave the patient vitrectomy and silicone oil filling under local anesthesia.During the operation,one small hole under the nose and two small holes on the temporal side were observed.The temporal retina adhered closely to the proliferative membrane and the retina shrank in many places.After the proliferative membrane was completely stripped,heavy water was injected to flatten the retina,gas-liquid exchange was performed,and the liquid on the surface of the retina was sucked with a flute needle,then the retinal holes were photocoagulated and sealed,silicone oil was injected,and the retina was flat.Tobramycin dexamethasone eye drops and non steroidal anti-inflammatory eye drops were given to the eyes for 2 weeks.Follow up eye examination 2 months after operation:the naked visual acuity of the left eye was 0.12,which could be corrected to 0.3,and the intraocular pressure was 20mmhg;The anterior segment examination showed that the intraocular lens of the left eye was in the right position,the lens was transparent,and no abnormality was found in the other anterior segments (Fig.2a and b);The fundus examination after mydriasis showed that the vitreous cavity was filled with silicone oil,the retina was flat,the cerclage ridge existed,and the laser spot around the hole responded well (Fig.2C and D).

A.Two months after the operation,the pupil of the left eye was not round according to the anterior segment after mydriasis.There was iris adhesion at 03:00,and the intraocular lens was located in the middle of the pupil.B.Under the narrow light,there are pigment particles in front of the intraocular lens.The lens is transparent and entopic.C.Fundus color photos 1 week after operation:silicone oil was filled in the vitreous cavity,the retina was restored,the cerclage ridge existed,and the laser spot reaction at the hole was good.D.Fundus color photos 2 months after operation:the vitreous cavity was filled with silicone oil,and the retina was flat.

The patient underwent intraocular silicone oil removal under local anesthesia in our hospital 2 months after retinal detachment reduction.Intraoperative fundus examination showed that the temporal retina became thin and pale.Retinal laser photocoagulation was performed here again.Follow up eye examination after silicone oil removal:the naked visual acuity of the left eye is 0.12,the corrected visual acuity is -3.25ds/ -1.50dc * 180=0.4,the intraocular pressure is 19mmhg,the anterior segment examination shows that the posterior chamber intraocular lens is in the right position,the pigmentation in front of the intraocular lens is more than before,and the pupil adhesion can not be dilated after mydriasis(Fig.3a and D).Fundus examination showed the presence of cerclage ridge,obvious laser spots and flat retina (Fig.3b,e).Fundus OCT showed that the inner layer structure of macular retina in the left eye was normal (Fig.3C and F)

A.Three months after taking out the intraocular silicone oil,the anterior segment of the left eye after mydriasis showed irregular pupil and extensive iris adhesion.B.Three days after silicone oil removal,the fundus color photo was slightly turbid,the cerclage ridge was found in the fundus,the retina on it was flat without proliferative membrane,and a large number of laser spots existed.D.Three months after the removal of intraocular silicone oil,the anterior pigment particles of intraocular lens were increased and the lens was transparent under narrow light.E.Three months after silicone oil removal,the fundus color photos were clearer than before,the retina was flat,and a large number of old laser spots existed.C、F.OCT of posterior pole showed intact retinal structure in macula.

3.Discussion

Since the patient's PIOL was performed in an external hospital,we did not have much data on the patient's pre intraocular lens implantation eye examination.Generally speaking,excimer laser treatment of high myopia has its scope of application.Laser in situ keratomileusis (LASIK) is limited by the patient's corneal thickness.The residual corneal stroma thickness after LASIK is greater than 250 μm can effectively reduce postoperative complications.Ikeda believe that when the myopia degree is >-14.00D,the postoperative effect of LASIK is poor,and the probability of degree regression will also increase significantly[4].Therefore,the degree of high myopia in LASIK operation is limited to -8.00d to -12.00d clinically,and transparent lens extraction+intraocular lens implantation or PIOL are considered for the surgical treatment of patients with ultra-high myopia of >-15.0d.But for young patients with high myopia to transparent lens removal has been controversial.One of the reasons is that after lens extraction,patients lose the ability of eye selfregulation of refraction.Second,studies show that compared with lens extraction for elderly cataract patients,the incidence of posterior segment complications in lens extraction for young patients will be greatly increased[5].Choosing PIOL can avoid the loss of eye selfregulation function and greatly reduce the changes of intraocular environment caused by lens extraction.Theoretically,keeping the lens in its normal position reduces the risk of posterior complications compared with transparent lens extraction.

There are three types of pIOL,the anterior chamber type,the intraocular lens covering the iris surface and the posterior chamber type.Compared with other PIols,posterior chamber pIOL has reduced the risk of anterior segment complications,such as corneal endothelial cell injury,anterior chamber Angle narrowing and anterior chamber inflammation [6],but there is still a risk of posterior segment complications.Jiang retrospectively analyzed that 8 of 530 patients with high myopia had retinal detachment.He believed that PIOL was not the factor leading to retinal detachment,but the progress process in the natural history of Rd.he also believed that early surgical intervention of high myopia could obtain better visual prognosis[7].Gabrielle et al.reported a case of retinal detachment with acute posterior vitreous detachment after posterior chamber IOL implantation in a 39 year old healthy woman[8].They also believe that the occurrence of retinal detachment in patients with high myopia after early posterior vitreous detachment (PVD) is a development process of the course of high myopia,which is due to premature vitreous liquefaction Posterior vitreous detachment and excessive eye axis are not iatrogenic changes caused by PIOL operation,and it is emphasized that preoperative and postoperative fundus examination is important to find PVD and retinal hole.However,Domènech did not agree with the above view in the report of retinal detachment 3 hours after PIOL in a 34 year old patient with high myopia[9].In their reported cases,the patients did not report any floating objects or optical examination symptoms before refractive surgery,and the interval between IOL implantation and retinal detachment was only 3 hours,Therefore,it is hypothesized that PIOL implantation may induce iatrogenic changes in the intraocular environment in patients with high myopia,which may increase the incidence of retinal detachment.It is well known that cataract surgery is a factor inducing retinal detachment.A retrospective analysis of 200000 patients undergoing phacoemulsification found that the risk of RD after cataract surgery will increase fourfold,and the younger the patients undergoing cataract surgery,the greater the risk of RD [10].The possible reasons are as follows:(1) it is related to the direct operation of the operating eye;(2) With the vitreous environment changes caused by surgery PVD and then RD;(3) It may be related to the combination of the above two factors.Most of the patients with pIOL implantation have high myopia and long eye axis.Although the transparent lens is retained and the operation site is not close to the vitreous body,it is inevitable that the lens,intraocular lens and iris move each other during the operation.This shift occurs during postoperative eye opening and closing,or during the operation of IOL implantation.It will lead to a sharp decrease in anterior chamber pressure,lead to acute posterior vitreous detachment and eventually form a horseshoe tear of the retina.In addition,several studies have shown that age and the length of eye axis are also related to the occurrence of RD after Piol[5][9][11].In patients with high myopia,the axial length of retinal detachment after anterior chamber intraocular lens implantation was 29.53 ±1.88mm,while that of posterior chamber intraocular lens implantation was 28.75-31.96mm,with an average axis length of 30.07mm[12],which was similar to that of this patient.At present,no research has confirmed that postoperative RD in patients with high myopia is caused by surgical factors or only the natural course of RD in high myopia.It is very important for surgeons to check the fundus of patients before and after surgery and to rule out fundus changes and preoperative intervention measures for susceptible lesions.

In this case,we chose external scleral encircling+external scleral cushion+vitrectomy+silicone oil tamponade and successfully reattached the detached retina.The postoperative best corrected visual acuity (BCVA) was significantly better than that before operation,and had a higher BCVA than that of the contralateral eyes.Clinically,there is no consensus on the treatment of RRD after pIOL.At present,there are three main surgical methods for rhegmatogenous retinal detachment:scleral buckling(scleralbuckle,SB),flat vitrectomy(parsplanavitrectomy,PPV),an d inflatable retinopexy (pneumaticretinopexy,PR).In the study of Ruiz-Moreno [13],it was found that for retinal detachment after Phakic anterior chamber intraocular lens implantation,scleral surgery was used to repair the retinal detachment,and the success rate of one operation was 87.5%.SB is often used to ensure the successful reduction of retinal detachment involving multiple holes or large areas without obvious holes.In addition,SB can prevent the growth of ocular axis and improve the recurrence rate of postoperative retinal detachment and the effectiveness of visual rehabilitation by strengthening the hardness of the posterior sclera.External scleral pressure can make the ridge caused by pressure be located at the back edge of the hole,thus effectively sealing the hole.PPV is the first choice for complex retinal detachment,such as posterior pole retinal hole,vitreous hemorrhage and proliferative vitreoretinopathy (Proliferative Vitreoretinopathy,PVR).In our case,this patient has multiple retina fixed folds and multiple holes and PVR.PPV can remove not only vitreous traction on the retina,but also opaque stroma,thus optimizing the treatment conditions.After vitrectomy,silicone oil is injected to restore retinal dissection.

To sum up,the occurrence of RRD after intraocular lens implantation in high myopia is not common.PPV combined with external scleral encirclement and cushion compression can not only improve the comfort of patients,but also give a more stable refractive state after operation,which is consistent with the literature report[14].In addition,the fundus of patients with high myopia should be carefully examined before pIOL,and fundus examination should be paid attention to during postoperative follow-up,and should be dealt with accordingly if necessary.