Indian Journal of Ophthalmology - Case Reports

CASE REPORT
Year
: 2022  |  Volume : 2  |  Issue : 1  |  Page : 116--118

Cosmetic iris prosthesis and severe visual loss


Ashutosh Dayal, Parivadhini Annadurai, Mona Khurana, Lingam Vijaya 
 Smt. Jadhavabai Nathmal Singhvee Glaucoma Services, Sankara Nethralaya, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. Lingam Vijaya
Smt Jadhavabai Nathmal Singhvee Glaucoma Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu
India

Abstract

We report a case of a 39-year-old male who presented with bilateral severe diminution of vision, raised intraocular pressures despite maximal therapy, and corneal edema with endothelial decompensation six years following cosmetic iris prosthesis implantation. Right eye had progressed to glaucomatous optic atrophy, while the left eye showed advanced glaucomatous damage. The patient underwent iris implant removal with Ahmed glaucoma valve implantation in the left eye to achieve adequate control of the intraocular pressures. This case report highlights the dangers and risk of serious vision-threatening complications associated with these implants. Patients must be made aware of the possible complications, and their use should be discouraged in normal eyes.



How to cite this article:
Dayal A, Annadurai P, Khurana M, Vijaya L. Cosmetic iris prosthesis and severe visual loss.Indian J Ophthalmol Case Rep 2022;2:116-118


How to cite this URL:
Dayal A, Annadurai P, Khurana M, Vijaya L. Cosmetic iris prosthesis and severe visual loss. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 17 ];2:116-118
Available from: https://www.ijoreports.in/text.asp?2022/2/1/116/334869


Full Text



Anterior chamber cosmetic iris prostheses were introduced by Kahn to treat oculocutaneous albinism and to improve the iris appearance in patients with congenital or traumatic iris defects such as coloboma or aniridia.[A] Currently, these implants are being marketed for cosmetic use in people willing to change their eye color, as an alternative to cosmetic contact lens. NewIrisColor® (Kahn Medical Devices, Panama City, Panama) and BrightOcular® (Stellar Devices, NY, USA) are the two models of cosmetic implants available. Both implants have been associated with significant vision-threatening complications.[1],[2],[3],[4] We describe a case with secondary glaucoma and endothelial decompensation following cosmetic iris prosthesis implantation and the challenges involved in the management.

 Case Report



A 39-year-old male, an actor by profession, presented with complaints of progressive diminution of vision in both eyes since past five years. He had a history of cosmetic iris prosthesis, BrightOcular® (Stellar Devices, NY, USA) implantation, done in both eyes 6 years back in India. He had undergone cosmetic implantation owing to his professional needs. The patient informed that he was noted to have raised intraocular pressures by a local practitioner 2 years after the surgery and started on topical intraocular pressure-lowering therapy but was not carrying interim medical reports. The pre-prosthesis surgery reports showed his uncorrected visual acuity to be 20/20 in both eyes with normal intraocular pressures, open angles on gonioscopy, and a healthy optic disc.

On presentation, his best-corrected visual acuity was no perception of light in the right eye and 20/40 in the left eye. Intraocular pressures measured using Goldman applanation tonometer (GAT) were 36 and 42 mm Hg in the right and the left eye, respectively, despite maximum topical medical therapy and oral acetazolamide. On slit-lamp examination, bilateral corneal edema was noted. Cosmetic iris prosthetic implants could be seen over the iris with pigments on the anterior lens capsule [Figure 1]. Gonioscopy revealed open angles (Schaffer grade 3) with dense pigmentary clumps over the trabecular meshwork. Glaucomatous optic atrophy was noted in the right eye while the left eye showed advanced glaucomatous cupping. Corresponding advanced visual field loss (tubular vision) in the left eye was noted on perimetry. On ultrasound biomicroscopy, partial aniridia was noted, with the iris implant rubbing against the iris stump. Corneal endothelial cell density was 542 and 576 per mm2 in the right and the left eye, respectively, suggestive of endothelial compromise. As the patient had bilateral intractable secondary glaucoma with severe corneal endothelial loss, iris prosthesis removal with Ahmed glaucoma valve (New World Medical, Inc., Rancho Cucamonga, CA) implantation was planned for the left eye. The surgical procedure was challenging and was performed ensuring no further damage to the corneal endothelium or crystalline lens. The iris prosthesis was explanted through a 2.7-mm clear corneal incision under a soft-shell technique, after performing two radial cuts to facilitate folding of the prosthesis. Ahmed glaucoma valve was implanted in the same sitting in the superotemporal quadrant. Postoperatively, the patient was started on topical steroids in a tapering dose. By the third postoperative day, corneal edema cleared, with visual acuity of 20/30 and intraocular pressure of 12 mm Hg [Figure 1]. The patient was explained about the risk of corneal decompensation and need for surgical intervention in the future owing to the low endothelial cell count.{Figure 1}

 Discussion



Anterior chamber iris implants have gained popularity as a cosmetic method for changing iris color. These implants, though not approved by the United States Food and Drug Administration (US FDA), are still used in countries such as Panama, Turkey, and India.[1],[3],[4],[5]. Previously documented postoperative complications due to iris implants include secondary glaucoma (46%–50%), endothelial decompensation (33%–78%), chronic uveitis (30%–38%), cataract formation (10%–15%), hyphema (7.8%), severe iris tissue damage, iridocorneal synechiae, and corectopia.[5],[6] A systematic review by Galvis et al.[5] reported glaucoma to be the most common complication, with 70% of the eyes requiring explantation of the implants due to complications.

Despite well-reported high incidence of serious vision-threatening adverse events, cosmetic implants continue to be widely advertised, sometimes with celebrity testimonials.[7] Eye care providers, while respecting the patient's wish to have this essentially cosmetic procedure, should remain vigilant about these vision-threatening complications and counsel appropriately. Our patient deteriorated from an uncorrected visual acuity of 20/20 to blindness within a matter of few years. Many times, patients are reluctant to undergo implant removal as they are apprehensive about the sudden cosmetic change. In our case, because the patient was a professional actor and had incomplete film shoots lined up, he was initially unwilling for explantation of the prosthesis. This may have led to unnecessary delay in the surgical intervention in the early stages of the disease. Our case may be indicative of the patient profile opting for these iris implants who may be hesitant in opting for explantation owing to their professional needs. Moreover, their inability to publicly acknowledge the presence of the iris implant may hinder awareness regarding its complications. We feel that the problem may be under-reported due to this reason.

Surgical management in such eyes is challenging due to structural damage to the eye, raised intraocular pressure, and risk of corneal decompensation.[1],[2],[5],[6] Thus, a meticulous preoperative and intraoperative planning is required. These patients should be followed up closely and the need for further interventions must be clearly discussed.

We are reporting this case to highlight that the anterior chamber iris prostheses carry a risk of vision-threatening complications that may progress rather rapidly. Although the newer BrightOcular® iris prosthesis model was marketed as a safer alternative to the earlier models, the risk of associated complications remains high. Unfortunately, despite few case reports highlighting the risks, these implants are still offered by ophthalmologists to the patients. A lot more needs to be done to sensitize and create awareness among ophthalmic community.

We feel that both the patients and ophthalmologists need to be aware of the potential risks, need for close follow-up, and chance of explantation prior to implanting these prostheses. Moreover, we also suggest that the patients must be encouraged by their ophthalmologist to undergo explantation once the signs of pigment dispersion (i.e., increased IOP and endothelial changes) are noted. Manufacturers and regulatory agencies of countries should take responsibility and document all possible complications preferably in a public domain. Colored contact lenses could be a safer alternative for those requiring eye color change due to therapeutic or professional needs as the use of cosmetic iris implants comes with a significant risk of visual loss.

 Conclusion



Cosmetic iris implants can have serious sight threatening complications and hence their use should be strongly discouraged in normal healthy eyes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Other Cited Material

A. Kahn DA, “Iris Diaphragm Implant (Newiris) in Oculocutaneous Albinism,” poster presented at the annual meeting of the American Academy of Ophthalmology, Las Vegas, Nevada, USA, November 2006.

References

1Bore M, Choudhari N, Chaurasia S. Management of complications of cosmetic iris implants in a phakic eye: A case report and literature review. Int Ophthalmol 2019;39:1141-6.
2Arthur SN, Wright MM, Kramarevsky N, Kaufman SC, Grajewski AL. Uveitis-Glaucoma-Hyphema syndrome and corneal decompensation in association with cosmetic Iris implants. Am J Ophthalmol 2009;148:790-3.
3Mansour AM, Ahmed IIK, Eadie B, Chelala E, Saade JS, Slade SG, et al. Iritis, glaucoma and corneal decompensation associated with BrightOcular cosmetic iris implant. Br J Ophthalmol 2016;100:1098-101.
4Chaurasia S. Devastating complication of cosmetic iris implants. Indian J Ophthalmol 2017;65:771-2.
5Galvis V, Tello A, Corrales MI. Postoperative results of cosmetic iris implants. J Cataract Refract Surg 2016;42:1518-26.
6Hoguet A, Ritterband D, Koplin R, Wu E, Raviv T, Aljian J, et al. Serious ocular complications of cosmetic iris implants in 14 eyes. J Cataract Refract Surg 2012;38:387-93.
7BrightOcular change eye color permanently, eye color surgery. [Last accessed on 2021 Mar 21]. Available from: https://brightocular.com/.