Occlusion of AquaPORT Flow in a Case of Toxic Anterior Segment Syndrome Following Implantable Collamer Lens Surgery Causing Severe Pupillary Block

PURPOSE: To present a case where following Implantable Collamer Lens (ICL) implantation the patient developed toxic anterior segment syndrome (TASS) with a subsequent pupillary block as a consequence of the occlusion of the AquaPORT (STAAR Surgical) flow hole. METHODS: Case report and literature review. RESULTS: A V4c toric ICL (STAAR Surgical) was implanted in the left eye of a 32-year-old woman. After 1 week, the lens was 15° off axis and uneventful lens alignment correction was performed. At postoperative day 1, an intraocular pressure (IOP) of 11 mm Hg and mild corneal edema were observed. At postoperative day 7, there was an uncorrected distance visual acuity of 20/800, an IOP of 44 mm Hg, diffuse corneal edema, and fibrin strands in the anterior chamber. TASS was diagnosed and topical steroids, cycloplegia, antiglaucoma drops, and oral acetazolamide were prescribed. At postoperative day 9, dispersed endothelial pigment with a fixed mid-dilated pupil were identified. Anterior segment optical coherence tomography showed strands of fibrin blocking the central ICL hole and angle closure. Pupillary block related to the fibrin occluding the AquaPORT hole consecutive to TASS was diagnosed. The patient underwent ICL removal, but had a persistent atonic, hyporeflexive pupil as a complication. CONCLUSIONS: This case demonstrates that an AquaPORT hole may not be enough to prevent pupillary block in cases with postoperative intraocular inflammation, causing severe postoperative complications such as Urrets-Zavalia syndrome. Clinicians should consider this diagnosis in cases with corneal edema in the early postoperative period following AquaPORT ICL insertion. [ J Refract Surg . 2020;36(12):856–859.]