Article Date: 10/1/2009

Photic Maculopathy Following Exchange of Crystalens: Clinical and Spectral-domain OCT Features
CASE STUDY

Photic Maculopathy Following Exchange of Crystalens: Clinical and Spectral-domain OCT Features

FELIPE P. P. DE ALMEIDA, MD · KYLE J. ALLIMAN, MD · HARRY W. FLYNN, JR., MD

In 1983, McDonald and Irvine first described light-induced retinopathy following extracapsular cataract extraction and intraocular lens implantation.1 Intense illumination of operating microscopes used in ophthalmic surgery has been implicated in photic retinopathy.2-4 We report a case of macular phototoxic injury in a 38-year-old male patient who underwent a 12-minute multifocal intraocular lens (IOL) exchange procedure.

Felipe P.P. de Almeida, MD, is a visiting fellow at the Bascom Palmer Eye Institute in Miami. Kyle J. Alliman, MD, is a second-year vitreo-retinal fellow at Bascom Palmer. Harry W. Flynn, Jr., MD, is professor and J. Donald M. Gass Distinguished Chair of Ophthalmology at Bascom Palmer. This research was supported in part by Research to Prevent Blindness in New York. Otherwise, the authors have no financial disclosures to make. Dr. Flynn can be reached via e-mail at hflynn@med.miami.edu.

CASE REPORT

A 38-year-old man complained of a scotoma in the nasal visual field of his left eye three days after undergoing an uncomplicated multifocal intraocular lens exchange with a total operating time of 12 minutes. His corrected visual acuity was 20/25.

An oval, one-disc–diameter area of retinal atrophy and retinal pigment epithelium (RPE) attenuation was noted in the left eye superotemporally to the macula but without involvement of the fovea (Figure 1). Fluorescein angiography showed a well-circumscribed mottled hyperfluorescent pattern, consistent with phototoxic retinopathy (Figure 2). Spectral-domain optical coherence tomography (SD-OCT) scans of the lesion showed loss of the inner segment/outer segment junction with disruption of the underlying RPE (Figure 3). Central macular thickness was within normal limits, without photoreceptor disruption or edema. The fundus had been normal on preoperative examination. The patient had no history of diabetes or other systemic health problems and took no medications. The fellow eye's fundus was unremarkable other than a posterior vitreous detachment.

Figure 1. Fundus photography of the left eye affected with light-induced retinopathy. An oval, one-disc-diameter lesion is noted superotemporally to the left macula.

Figure 2. Fluorescein angiogram in light-induced retinopathy showing a mottled pattern of fluorescence without leakage in a well-circumscribed round lesion.

Figure 3. Spectral-domain OCT horizontal scan of light-induced retinopathy, showing loss of inner segment/outer segment junction with disruption of the underlying retinal pigment epithelium (arrows).

DISCUSSION

The patient's fundus appearance and fluorescein angiography were typical of those previously described as phototoxicity as caused by the light of operating microscopes.1-4 Optical coherence tomography findings in solar retinopathy were reported by Bechmann and associates using a first-generation OCT scanner.5 They described the main finding as a hyper-reflective area involving all retinal layers in two patients after watching a solar eclipse. In this patient, evaluation using a spectral-domain OCT demonstrated full-thickness fragmentation of photoreceptors and RPE.

Under experimental conditions, the threshold duration necessary to produce a clinically evident phototoxicity from coaxial light has been estimated to be as short as 7.5 minutes.6 In our patient, the surgery lasted 12 minutes. It was performed under general anesthesia, which may increase the possibility of stationary focusing of light on a fixed retinal area.7 This patient had a favorable outcome and good visual prognosis as the lesion spared the fovea. Preventive measures, such as use of minimum light intensity needed to perform the procedure, using oblique lighting angles, and preventing excess light from entering the pupil using an opaque barrier, should always be considered. Whether physical properties of the exchanged multifocal IOL increased the risk of retinal damage on account of its light-focusing effect on the retina is unknown.8

To the best of our knowledge, this case represents the first documented SD-OCT of a phototoxic lesion from the operating microscope. OCT is a useful tool for objective assessment of retinal pathology in clinical cases of acute phototoxicity. Ophthalmologists should be aware of the possibility of phototoxic retinopathy occurring during IOL exchange or other short ophthalmic procedures. RP

REFERENCES

  1. McDonald HR, Irvine AR. Light-Induced maculopathy from the operating microscope In extracapsular cataract extraction and intraocular lens Implantation, Ophthalmology. 1983;90:945–951.
  2. Michels M, Sternberg P Jr. Operating microscope-induced retinal phototoxicity: pathophysiology, clinical manifestations and prevention. Sun/Ophthalmol. 1990: 34:237–252.
  3. Khwarg SG, Llnstone FA, Daniels SA, Isenberg SJ, Hanscom TA, Geoghegan M, Straatsma BR. Incidence, risk factors, and morphology in operating microscope light retinopathy. Am J Ophthalmol. 1987;103:255–263.
  4. Byrnes GA, Antoszyk AN, Mazur DO, Kao TC, Miller SA Photic maculopathy after extracapsular cataract surgery. A prospective study. Ophthalmology. 1992;99: 731–737.
  5. Bechmann M, Ehrt 0, Thiel MJ, Kristin N, Ulbiq MW, Kampik A. Optical coherence tomography findings in early solar retinopathy. Br J Ophthalmol. 2000;84: 547–548.
  6. Irvine AR, Wood I, Morris BW. Retinal damage from the Illumination of the operating microscope. An experimental study in Pseudophakie monkeys. Arch Ophthalmol. 1984;102:1358–1365.
  7. Karp KO, Flood TP, Wilder AL, Epstein RJ. Photic maculopathy after pterygium excision. Am J Ophthalmol. 1999;128:248–250.
  8. Menezo JL, Peris-Martinez C, Taboada Esteve J. Macular phototrauma after cataract extraction and multifocal lens implantation: Case report. Eur J Ophthalmol. 2002;12:247–249.


Retinal Physician, Issue: October 2009