The Icl Chaos – Boon Or Bane?

To highlight the importance of careful selection of patients for ICL and the management of secondary angle closure glaucoma in such patient with the help of a case report

University Hospital of Wales, Cardiff

A 59 year old gentleman of Polish origin presented with bilateral teary red eye with significant haloes in the evening worsening over 5 months duration. He was a known high myopic and had contact lens related keratitis in Right eye 10 years back and after successful treatment had Bilateral Implantable collamer lenses (ICL) in private sector 8 years back. As he had post operative haloes occasionally he was prescribed with Brimonidine to use when symptomatic.

On examination he had Visual acuity of 6/9 and 6/12, congested eyes with few pigments over the inferior endothelium and deep central anterior chamber. He had narrow angles (Shaffers grade 2) with moderate pigmentation and Intraocular pressure of 47 in both eyes. ICL was in place with clear lens and fundus revealed a bilateral tilted disc with prominent temporal crescent and cupping of 0.3. The secondary glaucoma was poorly controlled with medication and trial of laser Peripheral Iridotomies. He underwent Bilateral ICL explantation and clear lens extraction with IOL and Hydrus implant following which his IOP was controlled postoperatively and had a excellent visual outcome. Late onset secondary glaucoma following ICL is rarely reported in literature. 

This case highlights three key learning points: The need for careful patient selection for ICL to prevent haloes, the possible mechanisms of secondary late onset glaucoma in a patient with ICL and precautions to take when calculation of IOL power for refractive lens exchange due to underestimation of Anterior chamber depth measurements.