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Calcium deposits on hydrophilic acrylic intraocular lenses
CORRESPONDENCE
Calcium deposits on hydrophilic acrylic intraocular lenses Bruna V. Ventura, MD, Marcelo Ventura, MD, Liliana Werner, MD, PhD, Marcony R. Santhiago, MD, PhD Different pathologic processes may lead to clinically significant opacification or discoloration of the optic component of intraocular lenses (IOLs) manufactured from various biomaterials and in various designs. Formation of deposits/precipitates on the IOL surface or within the IOL substance has been identified as a significant cause of visual impairment.1,2 We report histopathological analyses of 5 cases of postoperative IOL opacification. The cases occurred with the Mediphacos Ioflex, which is a foldable hydrophilic acrylic single-piece IOL. The patients reported decreased vision in a mean period of 31 months after uneventful phacoemulsification. The only effective treatment to restore vision was explantation of the calcified IOL with subsequent implantation of a new one. After extensive investigation, we could not determine a specific cause for the observed calcification except that 3 of the 5 patients had diabetes mellitus. All IOLs were explanted due to significant visual impairment and sent for pathological evaluation at the Intermountain Ocular Research Center, Salt Lake City, Utah, USA. Gross examination and light microscopy were performed on each IOL. It is critical to recognize the process involved in IOL opacification; otherwise, surgeons might perform unnecessary surgical procedures such as neodymium:YAG (Nd:YAG) posterior capsulotomies or vitrectomies in eyes in which the opacification is in the IOL itself and not in the posterior capsule or vitreous.3,4 LABORATORY FINDINGS Gross examination of the explanted IOLs showed a white discoloration of the specimens. Microscopic examination showed dense deposits forming an almost continuous crust, mostly on the anterior surface of the optic component. Deposits were arranged in a confluent pattern. In some cases, the deposits were most confluent along linear areas, probably corresponding to marks caused by forceps during the folding process. Small granular deposits were observed in areas outside the crust. Multiple small granular deposits were also generally observed within the optic and haptics of the IOLs, close to the surface. Some peripheral areas of the optic were relatively clear of surface and substance deposits/granules (Figures 1 and 2). Light microscopy analysis of the histopathological sections obtained from the IOL in 1 case 142
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
Figure 1. Explanted IOL of Case 1. A: Gross photograph showing IOL opacification on the optic and haptics. B: Light photomicrograph. Dense deposits can be observed mostly on the anterior surface of the optic component, highlighting the marks caused by forceps during the folding process. Pits corresponding to Nd:YAG laser application can also be seen in the center of the optic component (unstained, original magnification 40 and 100). C and D: Light photomicrographs showing confluent deposits arranged in a confluent pattern (unstained, original magnification 10). E: Light photomicrograph. Small granular deposits are observed in areas outside of the confluent deposits (unstained, original magnification 10). F: Light photomicrograph. Multiple small granular deposits are seen within the haptics of the IOL close to the surface (unstained, original magnification 100).
confirmed the presence of calcium deposits on and within the IOL, which stained dark brown with the von Kossa method. Analysis of the optical cylinder of the IOL showed the calcium deposits stained in red by the alizarin red (Figure 2, F). DISCUSSION To our knowledge, calcium deposits have not been reported in this type of IOL. Packaging, as well as eventual changes in the polishing process, may be a reasonable explanation of this type of deposits.2 We hypothesize that any modified manufacturing method that uses a different buffer in the tumbling process could attract more protein.2 The process would then continue, with the deposition of minerals, most likely calcium, on top of the protein film. Three of the IOLs were from the same batch. 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.10.025
CORRESPONDENCE
143
REFERENCES 1. Werner L. Calcification of hydrophilic acrylic intraocular lenses [editorial]. Am J Ophthalmol 2008; 146:341–343 2. Werner L. Causes of intraocular lens opacification or discoloration. J Cataract Refract Surg 2007; 33:713–726 3. Haymore J, Zaidman G, Werner L, Mamalis N, Hamilton S, Cook J, Gillette T. Misdiagnosis of hydrophilic acrylic intraocular lens optic opacification; report of 8 cases with the MemoryLens. Ophthalmology 2007; 114:1689–1695 4. Walker NJ, Saldanha MJ, Sharp JAH, Porooshani H, McDonald BM, Ferguson DJP, Patel CK. Calcification of hydrophilic acrylic intraocular lenses in combined phacovitrectomy surgery. J Cataract Refract Surg 2010; 36:1427–1431 5. Gartaganis SP, Kanellopoulou DG, Mela EK, Panteli VS, Koutsoukos PG. Opacification of hydrophilic acrylic intraocular lens attributable to calcification: investigation on mechanism. Am J Ophthalmol 2008; 146:395–403 € € m A, 6. Werner L, Apple DJ, Escobar-Gomez M, Ohrstr o Crayford BB, Bianchi R, Pandey SK. Postoperative deposition of calcium on the surfaces of a hydrogel intraocular lens. Ophthalmology 2000; 107:2179–2185
Figure 2. Explanted IOL of Case 2. A: Gross photograph showing that the haptics of the IOL were cut and the IOL was divided in 2 parts to facilitate explantation. B, C, and D: Light photomicrographs. Dense deposits can be observed mostly on the anterior surface of the optic component, highlighting the marks caused by forceps during the folding process. Confluent deposits are arranged in a confluent pattern (unstained, original magnification 20, 40, 40, respectively). E: Light photomicrograph also showing confluent deposits on the haptic's anterior surface (unstained, original magnification 40). F: Calcium confluent deposits on the anterior surface (Alizarin red, original magnification 100).
Acute postoperative endophthalmitis with an unusual infective agent: Acinetobacter baumannii Gulfidan Bitirgen, MD, Ahmet Ozkagnici, MD, Hurkan Kerimoglu, MD, Umit Kamis, MD Acinetobacter baumannii has emerged as one of the most troublesome pathogens for health-care institutions globally. We report a case of acute postoperative endophthalmitis caused by A baumannii following uneventful cataract surgery. CASE REPORT
Calcification does seem more marked in the area of folding and holding by the insertion forceps. This finding led us to consider that a potential irregularity or sulcus created during the insertion may have played a role, facilitating the deposits that might otherwise have been naturally washed out. Theoretically, the formation of calcium deposits is related to either the material of the IOL or the local chemical microenvironment of the aqueous humor.5 In this regard, we recognize the potential significance of a metabolic disturbance such as diabetes,6 which was present in 3 of our cases. However, it should be noted that hydrophilic acrylic IOLs from the same manufacturer, but not from the same batch, were implanted in the fellow eyes of these patients. We therefore conclude that calcium deposits can occur with this type of IOL from a combination of factors, most likely a combination of a modified manufacturing method that meets a favorable scenario, such as metabolic changes in the aqueous humor or anatomic alterations on the IOL surface.
A nonimmunocompromised, previously healthy 76-year-old man was seen 2 days after the onset of blurred vision, eye redness, and pain. Symptoms had started 3 days after uneventful phacoemulsification with intraocular lens (IOL) implantation surgery for age-related cataract in the right eye. The examination revealed a visual acuity of counting fingers at 20 cm in the affected right eye. Slitlamp biomicroscopy showed conjunctival hyperemia, striate keratopathy, 1.0 mm hypopyon, pupillary membrane, and 4C cells in the anterior chamber. The intraocular pressure was 12 mm Hg measured by applanation tonometry. No fundus details were observed. On ocular ultrasonography, the retina appeared attached; moderate vitreous opacities were noted. Acute postoperative endophthalmitis was diagnosed in the right eye, and the patient was treated with a prompt vitreous tap for culture and injection of vancomycin (1.0 mg/ 0.1 mL) and ceftazidime (2.25 mg/0.1 mL) intravitreally. Postoperative medication included topical fortified vancomycin (50 mg/mL), fortified ceftazidime (100 mg/mL), and dexamethasone every hour, as well as oral moxifloxacin 400 mg once daily. Vitreous culture revealed the organism A baumannii. Because of the drug sensitivity of the organism, intravenous meropenem (1 g 3 times daily) was added to the existing treatment and moxifloxacin was stopped. On the fifth day, pain had ceased and hypopyon was no longer
J CATARACT REFRACT SURG - VOL 39, JANUARY 2013
Calcium deposits on hydrophilic acrylic intraocular lenses Bruna V. Ventura, MD, Marcelo Ventura, MD, Liliana Werner, MD, PhD, Marcony R. Santhiago, MD, PhD Different pathologic processes may lead to clinically significant opacification or discoloration of the optic component of intraocular lenses (IOLs) manufactured from various biomaterials and in various designs. Formation of deposits/precipitates on the IOL surface or within the IOL substance has been identified as a significant cause of visual impairment.1,2 We report histopathological analyses of 5 cases of postoperative IOL opacification. The cases occurred with the Mediphacos Ioflex, which is a foldable hydrophilic acrylic single-piece IOL. The patients reported decreased vision in a mean period of 31 months after uneventful phacoemulsification. The only effective treatment to restore vision was explantation of the calcified IOL with subsequent implantation of a new one. After extensive investigation, we could not determine a specific cause for the observed calcification except that 3 of the 5 patients had diabetes mellitus. All IOLs were explanted due to significant visual impairment and sent for pathological evaluation at the Intermountain Ocular Research Center, Salt Lake City, Utah, USA. Gross examination and light microscopy were performed on each IOL. It is critical to recognize the process involved in IOL opacification; otherwise, surgeons might perform unnecessary surgical procedures such as neodymium:YAG (Nd:YAG) posterior capsulotomies or vitrectomies in eyes in which the opacification is in the IOL itself and not in the posterior capsule or vitreous.3,4 LABORATORY FINDINGS Gross examination of the explanted IOLs showed a white discoloration of the specimens. Microscopic examination showed dense deposits forming an almost continuous crust, mostly on the anterior surface of the optic component. Deposits were arranged in a confluent pattern. In some cases, the deposits were most confluent along linear areas, probably corresponding to marks caused by forceps during the folding process. Small granular deposits were observed in areas outside the crust. Multiple small granular deposits were also generally observed within the optic and haptics of the IOLs, close to the surface. Some peripheral areas of the optic were relatively clear of surface and substance deposits/granules (Figures 1 and 2). Light microscopy analysis of the histopathological sections obtained from the IOL in 1 case 142
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
Figure 1. Explanted IOL of Case 1. A: Gross photograph showing IOL opacification on the optic and haptics. B: Light photomicrograph. Dense deposits can be observed mostly on the anterior surface of the optic component, highlighting the marks caused by forceps during the folding process. Pits corresponding to Nd:YAG laser application can also be seen in the center of the optic component (unstained, original magnification 40 and 100). C and D: Light photomicrographs showing confluent deposits arranged in a confluent pattern (unstained, original magnification 10). E: Light photomicrograph. Small granular deposits are observed in areas outside of the confluent deposits (unstained, original magnification 10). F: Light photomicrograph. Multiple small granular deposits are seen within the haptics of the IOL close to the surface (unstained, original magnification 100).
confirmed the presence of calcium deposits on and within the IOL, which stained dark brown with the von Kossa method. Analysis of the optical cylinder of the IOL showed the calcium deposits stained in red by the alizarin red (Figure 2, F). DISCUSSION To our knowledge, calcium deposits have not been reported in this type of IOL. Packaging, as well as eventual changes in the polishing process, may be a reasonable explanation of this type of deposits.2 We hypothesize that any modified manufacturing method that uses a different buffer in the tumbling process could attract more protein.2 The process would then continue, with the deposition of minerals, most likely calcium, on top of the protein film. Three of the IOLs were from the same batch. 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.10.025
CORRESPONDENCE
143
REFERENCES 1. Werner L. Calcification of hydrophilic acrylic intraocular lenses [editorial]. Am J Ophthalmol 2008; 146:341–343 2. Werner L. Causes of intraocular lens opacification or discoloration. J Cataract Refract Surg 2007; 33:713–726 3. Haymore J, Zaidman G, Werner L, Mamalis N, Hamilton S, Cook J, Gillette T. Misdiagnosis of hydrophilic acrylic intraocular lens optic opacification; report of 8 cases with the MemoryLens. Ophthalmology 2007; 114:1689–1695 4. Walker NJ, Saldanha MJ, Sharp JAH, Porooshani H, McDonald BM, Ferguson DJP, Patel CK. Calcification of hydrophilic acrylic intraocular lenses in combined phacovitrectomy surgery. J Cataract Refract Surg 2010; 36:1427–1431 5. Gartaganis SP, Kanellopoulou DG, Mela EK, Panteli VS, Koutsoukos PG. Opacification of hydrophilic acrylic intraocular lens attributable to calcification: investigation on mechanism. Am J Ophthalmol 2008; 146:395–403 € € m A, 6. Werner L, Apple DJ, Escobar-Gomez M, Ohrstr o Crayford BB, Bianchi R, Pandey SK. Postoperative deposition of calcium on the surfaces of a hydrogel intraocular lens. Ophthalmology 2000; 107:2179–2185
Figure 2. Explanted IOL of Case 2. A: Gross photograph showing that the haptics of the IOL were cut and the IOL was divided in 2 parts to facilitate explantation. B, C, and D: Light photomicrographs. Dense deposits can be observed mostly on the anterior surface of the optic component, highlighting the marks caused by forceps during the folding process. Confluent deposits are arranged in a confluent pattern (unstained, original magnification 20, 40, 40, respectively). E: Light photomicrograph also showing confluent deposits on the haptic's anterior surface (unstained, original magnification 40). F: Calcium confluent deposits on the anterior surface (Alizarin red, original magnification 100).
Acute postoperative endophthalmitis with an unusual infective agent: Acinetobacter baumannii Gulfidan Bitirgen, MD, Ahmet Ozkagnici, MD, Hurkan Kerimoglu, MD, Umit Kamis, MD Acinetobacter baumannii has emerged as one of the most troublesome pathogens for health-care institutions globally. We report a case of acute postoperative endophthalmitis caused by A baumannii following uneventful cataract surgery. CASE REPORT
Calcification does seem more marked in the area of folding and holding by the insertion forceps. This finding led us to consider that a potential irregularity or sulcus created during the insertion may have played a role, facilitating the deposits that might otherwise have been naturally washed out. Theoretically, the formation of calcium deposits is related to either the material of the IOL or the local chemical microenvironment of the aqueous humor.5 In this regard, we recognize the potential significance of a metabolic disturbance such as diabetes,6 which was present in 3 of our cases. However, it should be noted that hydrophilic acrylic IOLs from the same manufacturer, but not from the same batch, were implanted in the fellow eyes of these patients. We therefore conclude that calcium deposits can occur with this type of IOL from a combination of factors, most likely a combination of a modified manufacturing method that meets a favorable scenario, such as metabolic changes in the aqueous humor or anatomic alterations on the IOL surface.
A nonimmunocompromised, previously healthy 76-year-old man was seen 2 days after the onset of blurred vision, eye redness, and pain. Symptoms had started 3 days after uneventful phacoemulsification with intraocular lens (IOL) implantation surgery for age-related cataract in the right eye. The examination revealed a visual acuity of counting fingers at 20 cm in the affected right eye. Slitlamp biomicroscopy showed conjunctival hyperemia, striate keratopathy, 1.0 mm hypopyon, pupillary membrane, and 4C cells in the anterior chamber. The intraocular pressure was 12 mm Hg measured by applanation tonometry. No fundus details were observed. On ocular ultrasonography, the retina appeared attached; moderate vitreous opacities were noted. Acute postoperative endophthalmitis was diagnosed in the right eye, and the patient was treated with a prompt vitreous tap for culture and injection of vancomycin (1.0 mg/ 0.1 mL) and ceftazidime (2.25 mg/0.1 mL) intravitreally. Postoperative medication included topical fortified vancomycin (50 mg/mL), fortified ceftazidime (100 mg/mL), and dexamethasone every hour, as well as oral moxifloxacin 400 mg once daily. Vitreous culture revealed the organism A baumannii. Because of the drug sensitivity of the organism, intravenous meropenem (1 g 3 times daily) was added to the existing treatment and moxifloxacin was stopped. On the fifth day, pain had ceased and hypopyon was no longer
J CATARACT REFRACT SURG - VOL 39, JANUARY 2013