Acute fluid misdirection syndrome in intraocular collamer lens implantation: a case report and review of literature

We report a case of acute fluid misdirection syndrome during Intraocular Collamer Lens (ICL) implantation in a patient with high axial myopia. A 36-year-old woman was referred for high myopia correction through double incision viscoelastic-free ICL implantation. During surgery on the left eye, the anterior chamber (AC) shallowed abruptly upon initiation of standard balanced salt solution irrigation. Despite maneuvers, the AC reformation was inadequate, and progressive pupillary constriction was observed. Emergency management including par plana aspiration of retro capsular fluid and intraoperative atropine drops were performed. On postoperative day 1, the ICL tightly adhered to the iris. By postoperative day 7, the AC depth of left eye increased from 2.38 mm to 3.21 mm, and the iridocorneal angle widened from 19.4 to 30.6. The patient’s visual acuity improved. This case suggests an association between preoperative long axial length with anteriorly rotated ciliary processes and intraoperative fluid misdirection in refractive surgery. Pars plana aspiration and transient ciliary muscle paralysis may mitigate this complication.