Intraocular lens, anterior segment photographs, and posterior segment photograph. A, The sulcus-fixed black occlusive 85F polymethyl methacrylate intraocular lens (Morcher GmbH, Stuttgart, Germany). This lens is CE (Conformité Européene) marked and is used across the European Union but does not have US Food and Drug Administration approval in the United States, where its use is authorized on a compassionate basis. Anterior segment photographs of the right eye (B) and left eye (C) demonstrating the difference in pupil color attributed to the black occlusive intraocular lens in the left eye. D, Posterior segment photograph of the left eye demonstrating that fundus photography with visible light is not possible with the Morcher 85F intraocular lens in situ. The circular orange reflex is a corneal artifact.
Confocal scanning laser ophthalmoscopic image of the macula and horizontal optical coherence tomographic scan through the fovea obtained through the black occlusive intraocular lens, confirming macular hole closure in the left eye (A), and the phakic right eye showing normal macular anatomy (B).
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Patel CK, Yusuf IH, Menezo V. Imaging the Macula Through a Black Occlusive Intraocular Lens. Arch Ophthalmol. 2010;128(10):1374–1376. doi:10.1001/archophthalmol.2010.239
Black occlusive intraocular lens (IOL) insertion has been shown to be an effective treatment for intractable diplopia,1,2 visual confusion, and poor cosmesis resulting from leukokoria.3-5 A significant disadvantage of occlusive IOL insertion is that conventional funduscopy is not possible, preventing the detection of posterior pole disease. Here we describe a patient in whom we made the novel discovery of successful macular imaging through an occlusive IOL using an infrared light–based scanning laser ophthalmoscope/optical coherence tomography (OCT) scanner. We suggest that this report is likely to fundamentally change the current thinking on occlusive IOLs and to promote their use in the management of these patients.
A 74-year-old woman had a stage 3 idiopathic full-thickness macular hole in the left eye with corrected Snellen visual acuity of 6/6 OD and 6/60 OS. She underwent pars plana vitrectomy, and revision surgery was required 3 months later for a persistent macular hole.
The patient then noted visual confusion. Best-corrected visual acuity had deteriorated to 1/60 OS. Occlusion of the left eye with a patch was the only treatment that alleviated symptoms. The patient preferred implantation with a black occlusive IOL over the options of an occlusive contact lens, corneal tattooing, or tarsorrhaphy. Phacoemulsification was performed with implantation of an 85F black occlusive IOL (Figure 1A). There was successful resolution of symptoms and the visual acuity was 6/6 OD.
The patient returned 9 months later with blurred vision in the right eye down to an uncorrected visual acuity of 6/18. We confirmed a difference in pupil color between the right and left eyes (Figure 1B and C) and that fundus visualization was not possible through the black IOL (Figure 1D). An irregular macular reflex was identified in the right eye and an OCT scan was requested. The photographer was unaware of the ophthalmic history of the left eye and proceeded with OCT scanning of both eyes using a Heidelberg Spectralis OCT scanner (Heidelberg Engineering, Inc, Vista, California). Macular images of the left and right eyes (Figure 2) were successfully acquired with simultaneous use of scanning laser ophthalmoscopy and OCT.
To our knowledge, this is the first report of fundus visualization using an infrared-based scanning laser ophthalmoscope/OCT scanner (operational at 820/870 nm) in an eye implanted with a black occlusive IOL. This observation suggests that the black polymethyl methacrylate IOL transmits sufficient infrared light to permit macular imaging. We have subsequently confirmed in a laboratory study high levels of transmission of infrared light through an occlusive IOL (I.H.Y., Stuart N. Peirson, PhD, C.K.P., unpublished data, June 2010).
Black occlusive IOLs have been implanted across a range of indications, including intractable diplopia, visual confusion, and unsightly leukokoria,3,4 and have been demonstrated to produce high levels of postoperative satisfaction in patients.1,2 However, the clinical decision to implant an occlusive IOL has, to this point, been troubled by the dogma that preventing medical and ophthalmic practitioners from visualizing posterior pole structures carries significant risk, limiting the selection of this effective treatment.
The identification of a means of visualizing the retina eliminates this risk and could allow more patients to benefit from occlusive IOL insertion. The nature of consent for patients in whom occlusive IOL is a therapeutic option needs to fundamentally change to reflect this finding.
This novel observation has significant implications for diagnosis and monitoring of medical and ophthalmic disease in current and future patients with occlusive IOLs in situ where disc and retinal assessments are essential and for preoperative evaluation if therapeutic IOL exchange to transparent media is considered.
Moreover, the observed ability of occlusive IOLs to transmit infrared light suggests the potential for development of infrared light–based assessment tools such as Snellen charts for this patient group.
Correspondence: Dr Patel, Oxford Eye Hospital, Oxford Radcliffe Hospitals National Health Service Trust, West Wing, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DY, England (firstname.lastname@example.org).
Financial Disclosure: None reported.