The Nightmare Of The Low Vault. When Nothing Works.

To describe a case of malposition of sulcus-supported phakic lenses as the cause of bilateral low vaults in a patient with no anatomical abnormalities of interest.

Refractive Surgery Department, Centro de Oftalmología Barraquer, Barcelona

A 26-year-old female patient came to our centre interested in refractive surgery. Her refraction was -3.75 in her right eye (RE) and 160º -0.50 -4.00 in her left eye (LE). Her best corrected visual acuity (BCVA) was 1.2 in both eyes (BE) and her near vision (NVA) was 1.0 in BE. An Eyecryl® lens was firstly implanted in the RE. As a low vault was observed, a larger size than recommended Eyecryl® lens was implanted in the LE. The LE presented a vault of zero. The BCVA after lens implantation was 1.2 and the NVA was 0.64 in BE.

Seeing that the sulcus-sulcus distance was greater in the horizontal meridian than in the vertical one, it was decided to rotate the lens in the LE to a vertical position. No significant improvement was achieved, so it was decided to replace the lens with one two sizes larger than recommended. The vault did not exceed 150 microns, the NV remained at 0.64, and anterior subcapsular opacities appeared in the LE.

It was decided to explant the sulcus-supported lenses and implant Artiflex® iris-fixated lenses in BE.

One month after the implantation, the patient presented with a BCVA of 1.3 and NVA of 1.0 in BE, the anterior subcapsular opacities in the LE have partially subsided, the patient reports no subjective symptoms of visual difficulties, and the endothelial cell count remains stable.

In all cases, BE ultrasounds were performed, showing malposition of the Eyecryl® lenses, with their haptics resting on a level posterior to the ciliary body. 

The main causes of low vault include a thick lens (≥ 4.0 mm), narrow ACD (< 3.1 mm), age > 30 years, and a small phakic lens size (< 12.0 mm); however, our patient did not present any of these conditions. 

This case describes the malposition of the phakic lens on the sulcus as the cause of low vaults despite the implantation of lenses with a larger diameter than that recommended by the manufacturer. Ultrasound is a tool that is becoming increasingly important as it allows us to accurately study the precise location of the lens in the intraocular space.