April 2018

CATARACT

Cataract editor’s corner of the world
Treating a cosmetic iris implant recipient


by Rich Daly EyeWorld Contributing Writer


 


The right eye of a patient with a cosmetic iris in situ. The natural iris is clearly disturbed as the pupil is dragged inferonasally. After cosmetic iris removal, a large superotemporal iris defect and extensive inferonasal synechiae were discovered.


The left eye with an anterior chamber cosmetic artificial iris in place. The pupil in the natural iris is displaced inferiorly. After cosmetic iris removal, a generous mid-peripheral temporal iris defect was discovered.

The cosmetic artificial iris is cut from the right eye with microscissors while being stabilized with micrograspers.

A wedge-shaped piece of the artificial iris is removed from the eye.
Source (all): Kevin M. Miller, MD

In today’s world we all face patients with high expectations. We try to manage and reset those expectations to what is available in our current armamentarium of technology. Most patients will be reasonable. However, we still have those patients who have unrealistic expectations and seek out cosmetic options that may produce more harm than good.
In this “Cataract editor’s corner of the world,” we hear of an interesting case presented by Kevin Miller, MD, of a patient who wanted to change the color of his eyes permanently and went abroad for artificial iris implants. It is an interesting adventure for both the surgeon and the patient, and we also get the perspective of Tal Raviv, MD, on how best to manage these situations.

Rosa Braga-Mele, MD,
Cataract editor

 

How surgeons are treating complications in patients who received artificial iris implants overseas

It was a gift that will keep on giving. Unfortunately, the overseas iris implant will keep on giving lifelong vision complications to one patient.
The 34-year-old male patient first presented in November 2017 at the practice of Kevin M. Miller, MD, professor of clinical ophthalmology, University of California, Los Angeles (UCLA).
It was a year and a half after the patient had received an artificial iris, which a friend paid for him to have implanted in Mexico.
The patient had dark irises, and those combined with the tattoo artist’s generous displays of ink made him feel self-conscious and looked at askance.
“He thought if he could change his eye color that might change behaviors,” Dr. Miller said. “And he said it did. After he got his new blue irises, people started treating him nicely. Maybe it was his psychology, but that’s what he reported.”
The patient said the February 2015 procedure implanting the irises was uneventful, and he had no recovery problems. About a year and a half after they were implanted, he suffered a trauma and then—not necessarily related to the trauma—started experiencing photophobia, light sensitivity, and redness in both eyes.
A local optometrist began treating him with prednisolone and cyclopentolate to dilate the pupils. Referred to a staff ophthalmologist at UCLA, the patient was continued on the prednisolone acetate every 2 hours while awake and referred to Dr. Miller.
At Dr. Miller’s first exam, the patient was less light sensitive with visual acuities of 20/30 +2 in the right eye and 20/15 –1 in the left eye. However, his IOP was 22 mm Hg in the right eye and 26 mm Hg in the left eye. Keratic precipitates were present in both corneas, which is a sign of chronic inflammation. Behind the cosmetic pupil in the right eye, the natural pupil was dragged inferonasally.
“Something was happening where the cosmetic iris was grabbing the peripheral iris,” Dr. Miller said. “The pupil in the left eye was decentered downward but not nearly as much as the right eye was pulled inferonasally.”
The worst finding was endothelial cell counts of 497 cells per square millimeter in the right
eye and 529 cells per square millimeter in the left eye. At his age, the patient should have had cell counts close to 2,500 or 3,000 cells per square millimeter. Counts of less than 600 cells per square millimeter usually indicate the need for a corneal transplant.
Despite the multiple problems, it was difficult to convince the patient about the need to remove the implants. The reaction was similar to the reticence that Dr. Miller’s previous patients with cosmetic implants and serious complications have had when told about the need to remove them.
“They usually don’t want to give them up until everything starts to hit the fan,” Dr. Miller said. “This patient was already hitting the fan.”
The devices were removed by cutting them into multiple pieces and taking out the pieces. The right eye implant was removed Dec. 19, and the left eye implant was removed Jan. 23.
As expected, the postop visual acuity sharply declined in the right eye. At the patient’s Jan. 31 visit, his VA was 20/400 in the right eye and his IOP was 30 mm Hg, while the left eye was 20/20 –1 with 20 mm Hg while on drops.
“He’s now cleared phase one of the rehab process, but he has a long road in front of him,” Dr. Miller said.

Iris damage

During removal, it became apparent the implant in the right eye impacted the iris underneath and left the pupil decentered. The implant, apparently injected through a superotemporal incision, engaged the iris and pulled it inferonasally and caused a large iridectomy superotemporally where the implant caught the iris. The approach left a large tear and extensive posterior synechia inferonasally, which Dr. Miller was unable to break once the implant was removed.
“The road in front of him for both eyes is going to be cataract surgery, an attempt in his right eye to fix the large iris defect, then somehow trying to get the pupil centered in the eye—although that is going to be a real challenge,” Dr. Miller said. “Cataract surgery, iridoplasty, eventually DSEK or DMEK, and for the rest of his life he’s going to have pressure management problems and will probably eventually get a tube shunt in both eyes.”
The outlook for the patient is similar to those with overseas implants treated by Tal Raviv, MD, associate clinical professor of ophthalmology, Icahn School of Medicine at Mount Sinai, New York Eye and Ear Infirmary of Mount Sinai, New York.
“Once the implants are out, patients are typically still looking at multiple other surgeries; up to half of explants seem to need a combination of cataract surgery, pupilloplasty, glaucoma surgery, and endothelial corneal transplantation,” Dr. Raviv said.

Removal challenge

Implantation of such unapproved cosmetic devices will likely cause endothelial damage, as they rest against the angle, Dr. Raviv said. 
“They should be removed at the earliest sign of iritis, glaucoma, pupil ovalization, or endothelial compromise,” Dr. Raviv said
Such patients should have periodic endothelial cell counts, and psychological referral may be needed, Dr. Raviv said.  
One implant recipient Dr. Raviv is treating who has frank corneal edema in one eye and an 800 cell count in the other eye is still reluctant to have the implants removed.
“He knows they must come out immediately, but he is so attached to his blue eye identity that he cannot fathom removing them,” Dr. Raviv said.
Dr. Miller said such patients don’t usually come to him until they are well into the complication phase of the implants. He urges immediate removal.
“If we could catch them early we could avoid a lot of this stuff,” Dr. Miller said. “But they’re happy early.”
The difference between such unapproved devices and legitimate devices includes the latter’s implantation in the posterior chamber, where they are much more tolerated. Unapproved devices end up in the anterior chamber where they are up against the trabecular meshwork, rubbing against the peripheral iris, and very close to the cornea.
“It’s the peripheral cornea contact that causes problems,” Dr. Miller said. “It’s almost like having an old-style closed loop anterior chamber lens in the eye, and those are known to be a disaster and came off the market years ago.”

Editors’ note: Drs. Miller and Raviv have no financial interests related to their comments.

Contact information

Miller
: kmiller@ucla.edu
Raviv: tal.raviv.md@gmail.com

Treating a cosmetic iris implant recipient Treating a cosmetic iris implant recipient
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