Outcomes of a three-piece hydrophobic acrylic lens in opacified intraocular lens exchange

Objective: To analyze the cause of late postoperative opacification of hydrophilic acrylic intraocular lenses (IOLs) and the effect of IOL replacement surgery. Methods: This retrospective case series study comprised 15 eyes of 15 patients who were diagnosed as late postoperative opacification of hydrophilic acrylic IOLs from January 2019 to June 2020 at Qingdao Eye Hospital of Shandong First Medical University. The clinical data of patients were reviewed, and two IOLs were examined by scanning electron microscopy and energy dispersive X-ray spectroscopy. The intraoperative and postoperative complications of IOL replacement surgery were evaluated, and best corrected visual acuity was compared before and after surgery. Preoperative and postoperative data were compared using the paired t test. Results: The interval between the first IOL implantation and the detection of IOL opacification in 15 patients was (27.3±5.9) months. All the 15 patients had unilateral IOL opacification, and 9 patients had hypertension. Glycosylated hemoglobin A1c was significantly higher than the normal value in 4 of the 10 patients who underwent cataract surgery at our hospital. Confocal microscopy disclosed coralliform deposits on the superficial IOL optic. Scanning electron microscopy and energy dispersive X-ray spectroscopy showed the presence of calcium and phosphorus crystals in the opacification region of IOLs. Visual acuity in all 13 eyes receiving IOL exchange was significantly improved from 1.03±0.64 (logarithm of the minimum angle of resolution) to 0.39±0.21 (P<0.05). Posterior capsule rupture (4 eyes), new IOL implanted in the ciliary sulcus (3 eyes) and zonule breaking (1 eye) occurred during IOL replacement. Conclusions: IOL opacification is related with the IOL material and calcium ion concentration on the IOL surface. IOL replacement surgery can improve visual acuity safely and effectively. (Chin J Ophthalmol, 2021, 57: 512-518).

Clinical Features, Risk Factors, and Outcomes Following Surgery for Late Intraocular Lens Decentration in the Dead Bag Syndrome.

Possible Predisposing Factors for In-the-Bag and Out-of-the-Bag Intraocular Lens Dislocation and Outcomes of Intraocular Lens Exchange Surgery

Rationale:Opacification of monofocal intraocular lenses (IOLs) of various designs and materials has been reported. Hydrophilic acrylic IOLs are more prone to opacification than hydrophobic IOLs, but IOL surface modification by hydrophobic materials may improve biocompatibility, and few opacifications of such monofocal lenses have been reported to date. However, here we describe the characteristics of opacification of hydrophilic refractive multifocal IOLs with a hydrophobic surface modification in a cluster of patients who underwent uneventful cataract surgery.Patient Concerns:In this retrospective observational case series, the medical records of 7 patients in whom opacification of the IOL was identified after implantation of LS-313 MF30 (Lentis M plus, Oculentis), from November 2017 to May 2019, were reviewed.Diagnosis:All patients had undergone bilateral implantation of LS-313 MF30 IOLs. Ten eyes of 7 patients showed significant opacification at a mean 49.1 ± 10.2 months postoperatively.Interventions:The IOLs of 4 cases were explanted.Outcomes:All of the opacified cases had received LS-313 MF30 IOLs from February 2014 to August 2014 and experienced decreased visual acuity after 44.6 ± 10.5 months. The explanted IOLs of 4 cases were evaluated by scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), Alizarin-red, and von Kossa staining. These explanted IOLs showed fine and evenly distributed, whitish deposits on the entire IOL, particularly below the surface. Although the constituent of the deposits was identified as calcium by Alizarin-red and von Kossa stain, SEM, and EDX analysis showed no surface deposits of calcium. Paraffin-embedded sections of the IOLs were prepared, and calcium deposition was confirmed by EDX analysis at the subsurface region of the IOL.Lessens:Significant opacification of these hydrophilic refractive multifocal IOLs with hydrophobic surface modification was found to be due to abnormal calcification of the subsurface of the IOL. Clinicians must be aware of the opacification of this IOL design, despite surface modification. In particular, it should be noted that there is a high likelihood that the patient may experience vision-related symptoms even with moderate opacity and that opacification may lead to a burdensome IOL exchange.

Intraocular lens exchange surgery at a tertiary referral center: Indications, complications, and visual outcomes

The purpose of this study was to compare the surgical outcomes of intraocular lens (IOL) refixation with intraocular lens exchange using perfluorocarbon liquid (PFCL) and fibrin glue-assisted sutureless scleral fixation surgery in patients with dislocation of the IOL. Twenty-five eyes of 25 patients who underwent surgery for dislocated IOLs with PFCL and fibrin glue-assisted scleral fixation were studied; 13 eyes experienced IOL refixation (in-the-bag and out-of-the-bag), and 12 eyes experienced IOL exchange. Preoperative and postoperative clinical features from patient charts and 25 eyes with >6 months' follow-up information were reviewed and analyzed. At postoperative 6 months, best-corrected visual acuity (BCVA) and spherical equivalent of IOL refixation and exchange were significantly improved (P=0.042, P=0.001), and endothelial cell density was significantly decreased in the two groups with no significant difference between them. Surgically induced astigmatism of IOL refixation improved from 0.90±0.47 to 0.61±0.37 (P=0.012), and IOL exchange improved from 1.17±0.64 to 0.73±0.37 (P=0.037) at postoperative 6 months, with no significant difference between the two groups. Complications occurred in four eyes in the IOL refixation group and in three eyes in the IOL exchange group. PFCL and fibrin glue-assisted IOL sutureless scleral refixation or exchanged fixation was an effective surgical treatment for IOL dislocation. Also, because postoperative BCVA, surgical outcomes, and complications did not differ significantly between IOL refixation and exchange surgery, if IOL exchange surgery is not indicated, IOL refixation surgical techniques should be considered.

To report the indications and outcomes of intraocular lens (IOL) exchange at a tertiary referral center in northern China over a period of 8 years. Setting: Ophthalmology departments of Hebei Eye Hospital, Hebei, China. Design: Retrospective cross-sectional study. In this retrospective study, the medical records of 233 patients with a history of IOL exchange were reviewed between 2016 and 2024. These cases were reviewed to determine surgical indications, the type of intraocular lens removed, the type of intraocular lens implanted, the time between operations, surgical complications, and visual outcomes. All postoperative data were analyzed at least six months after follow-up. The mean age of our participants was 50.05 ± 21.76 years (range 5–82 years), with a male percentage of 65.67%. The mean time between primary surgery and IOL exchange was 6.64 ± 6.16years (range 0.01–30 year). The main indications of IOL exchange were IOL dislocation (63.37%) and IOL opacification (21.81%). The most common ophthalmic comorbidity was high myopia. Procedures for secondary IOL implantation were scleral fixated IOL with sutures (34.16%), IOL in ciliary sulcus (26.75%), in-the-bag IOL (26.31%) and Iris fixation IOL (7.82%). The mean postoperative corrected distance visual acuity (CDVA) was significantly higher compared to the mean preoperative CDVA (p = 0.00). The mean preoperative and postoperative IOP were 16.23 ± 4.92 and 14.84 ± 3.05 mmHg, respectively (p = 0.00). No serious complications ware observed. IOL dislocation is the most common indication of intraocular lens implantation, followed by IOL opacification. Simultaneous scleral-sutured fixation after IOL replacement is the most common procedure in secondary IOL implantation.

Intraocular lens exchange surgery in dissatisfied patients with refractive intraocular lenses

To determine risk factors for intraocular lens (IOL) opacification (IOLop) after Descemet membrane endothelial keratoplasty (DMEK) and to analyze clinical outcomes after IOL exchange. Cross-Sectional Study : Analysis of all cases of IOL exchange because of post-DMEK IOLop with a minimum of 6-month postoperative follow-up observed in clinic between November 2021 and April 2022. Main outcomes analyzed at the study visit were change in logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity after IOL exchange, endothelial cell loss (ECL), and graft survival. An historical cohort of 232 pseudophakic DMEK eyes was retrospectively analyzed to determine risk factors for post-DMEK IOLop. Cross-Sectional Study : Four eyes were observed (median follow-up = 45 (35.5-86.8) months). IOL materials were hydrophilic acrylic IOLs in 2 eyes and hydrophobic-hydrophilic in the other 2. At the study visit, improvement in median best-corrected visual acuity after IOL exchange was statistically significant (0.25 (0.19-0.41) logMAR to 0.00 (0-0.10) logMAR; P = 0.041). ECL ranged between 57.7% and 85.3%, without cases of graft failure. In the historical cohort, 21 eyes (9.05%) had some IOLop. In multivariate logistic regression model (105 eyes where IOL material data was available), IOLs with high water content material (odds ratio = 65.5, P = 0.0005) and rebubbling (odds ratio = 9.51, P = 0.0138) were independent risk factors for post-DMEK IOLop. Post-DMEK IOLop is infrequent, but a non-neglectable proportion of cases may require IOL explantation. IOL exchange is safe and effective in these eyes but may pose a risk for increased ECL. This study confirms that IOL material and number of rebubblings are major risk factors for post-DMEK IOLop.

Explantation of iris-sutured intraocular lens

To report the prevalence of intraocular lens (IOL) opacification and related clinical features in patients implanted with Hydroview IOL. Gloucestershire Eye Unit, Gloucestershire, United Kingdom. A total of 1330 eyes of 1265 patients who had cataract surgery with Hydroview IOL implantation between September 2000 and April 2001 were reviewed between April and October 2004. The visual acuity, visual symptoms, IOL status, and associated ocular comorbidity were recorded. One hundred ninety-three (14.5%) of 1330 eyes had evidence of IOL opacification. A total of 56 (4.2%) had visually significant opacification and had IOL exchange. The prevalence of IOL opacification ranged from 1.1% in patients who had surgery in September 2000 to 36.3% in the December 2000 group. In eyes with IOL opacification, the visual symptoms were decreased vision (57%), glare (32%), and mistiness of vision (27%). One hundred forty-four eyes (75%) with IOL opacification had visual acuity of 6/12 or better; 21.5% of diabetic eyes had IOL opacification compared with 14.3% of nondiabetic eyes (P =.06); 20.5% of glaucomatous eyes had IOL opacification compared with 14.0% of nonglaucomatous eyes (P = .033). This is the first large sample recall of patients implanted with the Hydroview H60M IOL. The overall prevalence of IOL opacification was 14.5%, with peak prevalence in patients who had surgery in December 2000.

To report cases with intraocular lens (IOL) opacification following silicone oil (SO) endotamponade. Medical charts of 32 eyes with IOL opacification were evaluated retrospectively. All eyes had rhegmatogenous retinal detachment and had a history of previous hydrophilic acrylic IOL implantation. All patients underwent vitrectomy with SO endotamponade. Clinical features of all cases and the results of histochemical evaluation of explanted IOLs were reported. The mean duration of SO endotamponade was 4.6 ± 2.0 months. The mean follow-up was 67.0 ± 23.5 months. The interval between phacoemulsification surgery and IOL opacification was 27.4 ± 18.3 months. With the exception of two eyes, all IOL opacification was detected during the follow-up period after SO removal. IOL exchange was performed in 12 eyes (37.5%). Histochemical analysis revealed significant calcification mostly on the surface of explanted IOL optics. Vitreoretinal surgeons should be aware of that some hydrophilic IOLs may have the potential of opacification following SO endotamponade. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:37-43.].

Author reply

There is an expression “all that glitters is not gold.” Disturbing glittering sensations of light following cataract surgery may actually originate from the intraocular lens (IOL). Visual complaints of “glittering” following cataract surgery have been the subject of numerous reports linking the cause to optic edge design, material and shape of the IOL. Glittering (or shimmering) sensations and disturbing secondary images of light, producing rings, arcs, and central flashes, are commonly referred to as positive dysphotopsia as incoming light is internally reflected by the squared edges of the implant and projected onto the retinal surface. Off axis light striking the temporal cornea projects onto the nasal edge of the IOL and can create secondary images and disabling glare under scotopic conditions (1,2). Distinguishing the etiology of abnormal visual sensations derived from complex optical aberrations induced by the edge of the IOL from those visual symptoms produced by neurological pathology creates an interesting intersection of commonality between the anterior segment ophthalmic surgeon and the neuro-ophthalmologist. CASE 1 A 57-year-old man had cataract surgery on the left eye. Immediately postoperatively, he complained of seeing a double broken circle with dots around it and a secondary image. Light projected from the temporal field produced a secondary image nasally (Fig. 1A). Symptoms were worse at night when viewing a light source (Fig. 1B). The patient refused surgery in the fellow eye until the problem glare and secondary images was resolved in the left eye. A dilated examination was performed and appeared unremarkable. The patient was offered a second opinion with neuro-ophthalmology. Multiple tests were performed, including automated visual fields, macular optical coherence tomography, and multifocal electroretinography. All testing was normal. The patient was referred to another anterior segment specialist and an IOL exchange was performed with the insertion of an IOL with a round edge optic. Immediately following the IOL exchange, the quality of the symptoms improved slightly but his complaints have not totally resolved.FIG. 1: Positive dysphotopsia. A. Patient drawing depicts a ring and secondary image (image of light) generated by a light source located at approximately 35° in the temporal visual field at a distance of 33 cm. The ring is probably produced from the edges of the intraocular lens. B. A glare source viewed by a pseudophakic eye will produce refracted and reflected images if light rays are able to reflect internally from the edge of the lens. The reflected glare imaged will appear as a thin crescent or partial ring on the side of the retina opposite the glare source [modified from Ref. (1)].Visual dysfunction following implantation of an IOL after cataract surgery may also be manifested as a negative dysphotopsia. First described over 10 years ago (3), negative dysphotopsia appears as a temporal, dark, crescent-shaped shadow following in-the-bag posterior chamber IOL implantation (Fig. 2). Negative dysphotopsias have been linked to the square edge design of the IOL optic, shape of the IOL, high index of refraction, and the anterior capsule extending over the edge of the optic (1,2,4–7). Square truncated edges on many IOLs, originally designed to reduce posterior capsule opacification, may be the source of both positive and negative dysphotopsias. Negative pseudophakic dysphotopsias are caused by the absence of light in the extreme temporal field from the edge of the IOL causing a crescent shadow on the nasal retina where light would normally be transmitted by the crystalline lens of a phakic eye. Although articles demonstrating the crescent-shaped shadow with ray tracing studies are available and the clinical appearance of these symptoms has corresponded to the introduction of square edges, the topic is still debated (4,7). The circular IOL optic accounts for the crescent shape seen in positive and negative dysphotopsias.FIG. 2: Patient drawings of a variety of negative dysphotopsias and the model of intraocular lens implanted in each patient [modified from Ref. (1)].Pseudophakic dysphotopsias are generally considered to be an annoyance of little functional significance. However, many patients become functionally or psychologically disabled from their symptoms. These symptoms have a clear impact on daily visual function and generate the “unhappy 20/20 patient.” It is not uncommon that many of these patients seek second opinions from other ophthalmologists and, in fact, may be referred to a neuro-ophthalmologist for extensive evaluation to rule out neurologic causes of their complaints. The differential diagnosis of pseudophakic dysphotopsias includes a host of neurological conditions with symptoms such as visual field loss, halos, flashes, and entoptic phenomenon such as visual auras, scintillations, and visual hallucinations. Krista et al (8) reported in a study of pseudophakic patients without confounding ophthalmic diseases and with excellent visual acuity, that a visual function questionnaire correlated strongly with patient dissatisfaction from pseudophakic dysphotopsia. This study revealed that subjective visual function may indeed be compromised because of pseudophakic dysphotopsias in otherwise normal 20/20 pseudophakic eyes. Not only is vision of 20/20 considered normal but also the entire ophthalmic examination of the eye is unremarkable. This places an increased burden on the ophthalmologist when examining symptomatic patients to correctly diagnose the symptoms because there are no objective tests to measure the severity of pseudophakic dysphotopsias. Despite bitter complaints about their vision, it is not uncommon for patients who easily read the 20/20 line on a Snellen acuity chart following cataract surgery to be told there is nothing wrong with their eye or their vision. Ophthalmologists may advise patients that their symptoms will disappear over time, suggesting neural adaption may suppress the severity of their awareness of their symptoms. Osher (9) reported negative dysphotopsias in 15.2% on the first postoperative day, 3.2% at 1 year, and 2.4% at 2–3 years. In contrast, after being told there is nothing wrong with their eyes, some patients may go years living with their symptoms without complaining. An IOL exchange from a truncated edge design to a rounded edge design may relieve symptoms of patients with positive dysphotopsias. Several reports have demonstrated relief of symptoms from negative dysphotopsias following YAG laser of the anterior capsule (10,11), IOL exchange with a sulcus fixated IOL (12,13) or prolapsing the optic through the capsulorhexis into the anterior capsule (reverse optic capture), and piggyback IOL implantation into the ciliary sulcus (14). CASE 2 A 71-year-old woman underwent uneventful phacoemulsification with IOLs in both eyes. Since surgery, she described a temporal “dark ring around both eyes” producing a sensation that she could not see and that she was going to step into a hole when she walked. She described “blinders and a dark spot” on the side of her vision as if she was looking through binoculars all of the time. Her symptoms were dismissed by 2 ophthalmologists and she was re-evaluated 8 months later. Visual acuity was 20/20 and J1 in each eye. On examination, there was extensive fibrosis of the anterior (not posterior) capsule extending over the anterior optic of the IOL by several millimeters. Bilateral YAG laser was performed to the anterior capsule allowing light to pass through the periphery of the lens optic, relieving the patient of her symptoms (Fig. 3).FIG. 3: Patient with negative dysphotopsia. A. There is fibrosis and opacification of the anterior capsule around the intraocular lens in the left eye. B. Following YAG laser anterior capsulotomy, the patient's symptoms resolved.In addition to the positive and negative dysphotopsias discussed above, there is another visual dysfunction commonly seen after cataract surgery following implantation of a multifocal IOL. Multifocal IOL intolerance not uncommonly results in patient dissatisfaction with the quality of vision despite having 20/20 eye in each eye. Referred to as “waxy” or “vaseline” vision, these patients may bitterly complain that they are unable to see clearly despite being able to read 20/20 high-contrast Snellen acuity. Concentric diffractive rings in multifocal IOLs create 2 simultaneous focal points and increase light scatter, resulting in reduced retinal image contrast. If the cornea has significant aberrations (>0.5 μm over a 6-mm zone) and is combined with the reduced retinal image contrast from the multifocal IOL, the result is poor quality of vision. Excessive corneal higher order aberrations of the Zernikie third-order and fourth-order (Z3 + Z4) terms have been statistically and clinically linked to multifocal lens intolerance and visual dysfunction (15). Light sources may also produce the presence of a halo (the simultaneously defocused image). Treatment options include refractive surgery to eliminate corneal higher order aberrations with limited success or an IOL exchange with a monofocal IOL. The critical issue in arriving at the correct diagnosis of visual dysphotopsia is the temporal relationship of symptomatic onset after cataract surgery. Many patients complaining of undesired visual disturbances following cataract surgery may seek secondary and tertiary referrals for relief of their symptoms. 20/20 vision and a normal eye examination may pose a conundrum to the clinician to resolve these visual symptoms. All that glittering may not be gold, but it may be pseudophakic dysphotopsias.

Purpose. To report 7 cases of intraocular lens (IOL) opacification following treatment of postoperative anterior chamber fibrin with recombinant tissue plasminogen activator (rtPA) after cataract surgery. Methods. Retrospective case series of 7 eyes in 7 patients who developed IOL opacification after receiving rtPA for anterior chamber inflammatory membrane formation resulting from phacoemulsification cataract surgery. Three explanted IOLs were investigated with light microscopy, histochemical analysis, scanning electron microscopy, and X-ray spectrometry. Results. All patients underwent uncomplicated cataract surgery and posterior chamber hydrophilic IOL implantation. Anterior chamber inflammatory membranes developed between 1 and 4 weeks of surgery and were treated with intracameral rtPA. IOL opacification was noted between 4 weeks and 6 years after rtPA treatment with reduced visual acuity, and IOL exchange was carried out in 3 patients. Light microscopy evaluation revealed diffuse fine granular deposits on the anterior surface/subsurface of IOL optic that stained positive for calcium salts. Scanning electron microscopy (SEM) and energy-dispersive X-ray spectrometry (EDS) confirmed the presence of calcium and phosphate on the IOL. Conclusions. Intracameral rtPA, though rapidly effective in the treatment of anterior chamber inflammatory membranes following cataract surgery, may be associated with IOL opacification.