Introduction: 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. Patient and Clinical Findings: 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. Diagnosis, Intervention, and Outcomes: 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. Conclusions: 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.
Griffin et al. (2025) studied this question.