Introduction: Opaque bubble layer (OBL) disappearance during keratorefractive lenticule extraction eliminates bubble-dependent established visual cues such as the white ring and meniscus sign, complicating anterior-posterior plane identification. We describe 2 cases demonstrating the usefulness of previously described ridge sign as a real-time visual indicator to facilitate accurate plane confirmation and lenticule dissection with OBL loss. Patient and Clinical Findings: Case 1 involved a 28-year-old man with myopic astigmatism and normal tomography. Case 2 involved a 30-year-old woman with low myopia and an adequate corneal thickness. In both cases, the initially formed OBL dissipated after an unplanned intraoperative pause. No interface bubbles were present when dissection was resumed. Diagnosis, Intervention, and Outcomes: In both cases, the absence of OBL rendered the conventional visual signs unhelpful. A small anterior pocket was created on one side, followed by a posterior pocket on the other side. The previously described ridge sign, which is a sloping ridge bridging the cap and stromal bed, was visualized, confirming the correct plane entries. The lenticules were extracted smoothly. The postoperative uncorrected distance visual acuity was 20/20 in both cases. Conclusions: The previously described ridge sign seemed useful for anterior posterior plane differentiation despite complete OBL loss in these 2 cases, suggesting potential clinical utility when conventional OBL-dependent signs were no longer visible.
Introduction: Subretinal lens material is a rare condition with only 10 reported cases: 2 after blunt trauma and 8 after various surgical procedures including phacoemulsification and pars plana lensectomy. This article reviews the current literature and reports 2 unusual cases of subretinal migration of lens material. Patients and Clinical Findings: To the authors' knowledge, case 1 is the second reported case of a subretinal intraocular lens (IOL) and the first to describe its removal. This occurred in a 27-year-old man after femtosecond laser-assisted cataract surgery in the setting of a dislocated IOL and a giant retinal tear. Case 2 describes subretinal migration of a cataractous lens nucleus in a 74-year-old man after phacoemulsification complicated by posterior capsular tear and a giant retinal tear. Diagnosis, Intervention, and Outcomes: In both cases, the subretinal lens material was removed by pars plana vitrectomy using intraocular forceps to maneuver the material through the giant retinal tear. Conclusions: This case report reviews the current literature and highlights the risk of attempting to retrieve a posteriorly dislocated nucleus from an anterior approach, the importance of a thorough preoperative dilated fundus examination, and the potential role of conservative management in selected cases.
Inverted implantation of the Sulcoflex piggyback intraocular lens (IOL) is a rare clinical scenario. These cases demonstrate a previously unreported mechanism of acute angle-closure glaucoma caused by pupillary block in pseudophakic patients without optic capture. 2 women presented with acute ocular pain, blurred vision, and markedly elevated intraocular pressure (IOP) after Sulcoflex piggyback IOL implantation to correct postoperative refractive surprise. Clinical examination revealed shallow anterior chambers, corneal edema, and unexpected concavity of the piggyback IOL anterior surface. Anterior segment optical coherence tomography confirmed inverted piggyback IOL orientation in both cases. Pupillary block due to inverted IOL positioning was diagnosed in both patients. Acute management included systemic and topical antiglaucoma therapy and Nd:YAG laser peripheral iridotomy. Subsequent lens removal with viscogoniosynechiolysis was performed in one case, while IOL repositioning was performed in the other. Clinical outcomes differed–delayed recognition in one case led to advanced secondary glaucoma and corneal decompensation, while early recognition in the other allowed restoration of vision with normal IOP. Inverted Sulcoflex piggyback IOL implantation can lead to acute angle closure in the absence of optic capture. Early recognition and intervention are essential to prevent irreversible complications.
This report describes a case of irregular astigmatism induced by presumed premature photopolymerization of a light-adjustable lens (LAL) with ActivShield exposed to ambient light over a 2-year period without postoperative light treatments. A 74-year-old woman with blurry vision was referred for evaluation of distorted optics in an ActivShield LAL 2 years after cataract surgery complicated by a posterior capsule tear and vitreous prolapse requiring anterior vitrectomy and sulcus placement of the IOL. She had not received any postoperative light treatments to adjust or lock-in the IOL, which resulted in apparent premature photopolymerization of the optic material in the area of her pupil due to ambient light exposure. The distorted LAL was exchanged for a conventional monofocal IOL with excellent visual results. After IOL exchange, the patient's visual distortion resolved. Her uncorrected distance visual acuity was 20/25, which improved to 20/20 with correction. ActivShield UV protector cannot indefinitely protect the LAL 2.0 from premature photopolymerization because of accidental exposure to ambient light. To achieve optimal visual outcomes, preoperative and postoperative counseling is critical to ensure compliance with UV protection until all light treatments have been completed.
A 44-year-old man, head of human resources in an office setting and a dedicated recreational cyclist, presented seeking visual rehabilitation. He was diagnosed with keratoconus at the age of 16. The left eye underwent deep anterior lamellar keratoplasty (DALK) in 2012, followed by implantation of an anterior chamber phakic intraocular lens (pIOL) (Artisan) 3 years later to correct residual ametropia. The right eye was treated with intracorneal ring segments (ICRS) in 2019 to address irregular astigmatism. The patient reported an inability to tolerate rigid gas-permeable (RGP) contact lenses (CL) and described being functionally monocular because anisometropia prevented comfortable spectacle wear. More recently, he began experiencing increasing difficulty with near vision tasks. On examination, manifest refraction in the right eye was −5.75 −2.25 × 45, achieving a corrected distance visual acuity (CDVA) of 20/40. The left eye had a refraction of +1.25 −1.25 × 180, with 20/20 visual acuity. Slitlamp evaluation showed a clear cornea in the right eye with well-centered ICRS (Figure 1 JOURNAL/jcrsoc/04.03/02158035-202501000-00047/figure1/v/2025-10-28T185800Z/r/image-tiff ). The left eye had a clear lamellar graft, with a well-positioned pIOL and a patent peripheral iridectomy. Intraocular pressure was measured at 11 mm Hg in the right eye and 12 mm Hg in the left. Fundus examination was unremarkable in both eyes. Tomographic analysis revealed simulated keratometry values in the right eye of 47.21 diopters (D) at 56 degrees and 49.06 D at 146 degrees, with a thinnest corneal thickness of 426 μm (Figure 2 JOURNAL/jcrsoc/04.03/02158035-202501000-00047/figure2/v/2025-10-28T185800Z/r/image-tiff ). In the left eye, K1 was 42.44 D at 174 degrees and K2 was 44.49 D at 84 degrees, with the thinnest pachymetry measuring 540 μm. Specular microscopy showed endothelial cell density of 2245 cells/mm 2 in the right eye and 2167 cells/mm 2 in the left (Figure 3 JOURNAL/jcrsoc/04.03/02158035-202501000-00047/figure3/v/2025-10-28T185800Z/r/image-tiff ). The patient now seeks options to improve distance vision and reduce spectacle dependence in the right eye. In a keratoconic eye that has undergone ICRS implantation and presents with residual myopic astigmatism and a thinnest pachymetry of 426 μm, what is your preferred strategy to achieve spectacle-free distance vision? Would you consider a pIOL, customized topography-guided photorefractive keratectomy (PRK), or another approach? Do you believe there is potential to gain lines of corrected vision in this eye?
