- Email: [email protected]
Intraocular lens exchange with removal of the optic only
ARTICLE
Intraocular lens exchange with removal of the optic only Sung Jin Lee, MD, Hae Jung Sun, MD, Kyung Seek Choi, MD, Song Hee Park, MD
PURPOSE: To evaluate the clinical outcomes of intraocular lens (IOL) exchange in patients with an opacified ACRL-C160 intraocular lens (IOL) using an optic-only removal technique. SETTING: Department of Ophthalmology, Soonchunhyang University Hospital, Seoul, Korea. METHODS: The study comprised eyes with previous phacoemulsification and implantation of a single-piece hydrophilic acrylic IOL in the capsular bag and subsequent development of severe late opacification of the IOL. In all eyes, the IOL optic was explanted; any haptic with firm adhesions was left in the capsular bag. This was followed by placement of a new IOL. The perioperative complications were evaluated, and the best corrected visual acuity (BCVA) before surgery and after surgery was compared. RESULTS: Twenty-three eyes of 20 patients were evaluated. Uneventful IOL exchange and placement of a new IOL in the bag was achieved in 9 eyes (39.1%) and in the sulcus in 13 eyes (56.5%), with posterior capsule rupture in 2 eyes (8.7%). One eye (4.3%) developed zonular dehiscence, and scleral IOL fixation was performed. The mean BCVA was 0.64 G 0.35 logMAR before IOL exchange and 0.24 G 0.20 logMAR after IOL exchange. During 41 months of follow-up, 1 eye (4.3%) each was affected by recurrent anterior uveitis and delayed zonular dehiscence. The final mean BCVA was 0.38 G 0.40 logMAR. There was no corneal decompensation or infectious keratitis. CONCLUSION: The optic-only removal technique was a safe and helpful procedure that allowed recovery of visual acuity because it decreased the intraoperative complication of zonular dehiscence. J Cataract Refract Surg 2009; 35:514–518 Q 2009 ASCRS and ESCRS
Delayed opacification is seen in some hydrophilic acrylic intraocular lenses (IOLs) implanted during cataract surgery.1–5 The ACRL-C160 IOL (Ophthalmed) used in Korea is reported to develop opacification in 84.1% of cases approximately 2 years after implantation due to calcium precipitation.6,7 Exchange of the opacified IOL is required because of glare and a decline in visual acuity.
Submitted: October 4, 2008. Final revision submitted: November 22, 2008. Accepted: November 24, 2008. From the Department of Ophthalmology, College of Medicine, Soonchunhyang University, Seoul, Korea. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Sung Jin Lee, MD, #657 Hannam-dong Yongsan-gu, Seoul, 140-743, Korea. E-mail: [email protected].
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Q 2009 ASCRS and ESCRS Published by Elsevier Inc.
Zonular dehiscence is the most common intraoperative complication of IOL exchange surgery.5,8,9 Dagres et al.5 observed zonular dehiscence in 11 (44%) of 25 eyes having IOL exchange. This finding implies that separating the IOL from the firmly adherent lens capsule is technically challenging. When zonular dehiscence occurs, additional procedures are needed to remove the prolapsed vitreous. Also, complicated transscleral fixation of the IOL or unplanned anterior chamber IOL implantation is required. Thus, it is critical to avoid this complication to reduce operative time and tissue damage and to improve visual recovery after surgery. Yu and Ng8 report 3 instances (20%) of optic-only removal in 15 eyes having IOL exchange surgery. When tension of the lens capsule was identified during removal of the haptics, the haptics were left in the eye. Gashau et al.9 also left the haptics in the eye in some cases of IOL exchange. No complications related to the remnant haptics were reported in either study. 0886-3350/09/$dsee front matter doi:10.1016/j.jcrs.2008.11.045
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Figure 1. A: Slitlamp photography of an opaque ACRL-C160 IOL. B: Clear IOL (left) and opaque ACRLC160 IOL (right).
In the current study, we attempted to remove only the optic of the opacified ACRL-C160 (Figure 1) to reduce the incidence of zonular dehiscence and thus improve visual recovery. We also studied the visual outcomes and complications of the procedure. PATIENTS AND METHODS This retrospective study comprised patients who had IOL exchange surgery in which at least 1 haptic was left in the bag during removal of the optic of an ACRL-C160 IOL. All eyes were operated on by the same experienced surgeon (S.J.L.) between January 2001 and December 2005. The Institutional Review Board, Soonchunhyang University, Seoul, Korea, approved the study. The preoperative posterior capsulotomy state, preoperative and postoperative visual acuity, and intraoperative and postoperative complications were assessed. The removal of the opacified IOL was completed as follows: A clear corneal incision was created perpendicular to the haptic–optic junction, and an ophthalmic viscosurgical
device (OVD) was injected into the anterior chamber. A corneal puncture was made at least 90 degrees from the incision site with a Beaver blade. The optic was divided in the center with Vannas scissors through the corneal incision site, assisted with a lens hook through the corneal puncture site (Figure 2, A). The haptic was pulled using a lens hook to check the degree of adhesion between the haptic and lens capsule. The haptic was removed when adhesions were moderate or was amputated at the haptic–optic junction in cases of severe adhesions (Figure 2, B). The 2 divided optic pieces were removed through the corneal incision site with a toothed McPherson forceps. In cases of vitreous prolapse into the anterior chamber, a vitrectomy was performed using a 23-gauge vitreous cutter through the corneal entry site while an infusion cannula was used through the side puncture. If posterior capsule opacification (PCO) was present, a posterior capsulotomy was performed intraoperatively using a cystotome or a vitreous cutter (Figure 2, C). The anterior continuous curvilinear capsulorhexis (ACCC) size was adjusted with a vitreous cutter. A foldable IOL was inserted in the sulcus, where the haptics were oriented 90 degrees from the remnant haptics, and the optic was captured
Figure 2. A: Dividing the optic of an opaque ACRL-C160 IOL with Vannas scissors and a lens hook. B: Dividing the haptic–optic junction with Vannas scissors after fibrosis around the haptic was confirmed. C: Haptic remnants after removal of the optic. D: A new IOL in the sulcus with optic capture.
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posterior to the ACCC (Figure 2, D). Then, the remaining OVD in the anterior chamber was removed and intraocular pressure (IOP) controlled. The corneal entry site was sutured as needed.
RESULTS Intraocular lens exchange was performed in 23 eyes of 20 patients. Seven patients (34.8%; 8 eyes) were men, and 13 patients (65.2%; 15 eyes) were women. The mean age of the patients was 64 years G 9 (SD) (range 35 to 77 years). The mean time between cataract surgery and IOL exchange was 28 G 16 months. Four eyes (17.4%) had diabetic retinopathy and 7 eyes (30.4%) had neodymium:YAG laser posterior capsulotomy before surgery. The mean postoperative follow-up was 41 G 14 months (range 14 to 72 months). The mean best corrected visual acuity (BCVA) was 0.64 G 0.35 logMAR preoperatively, improving to 0.24 G 0.20 logMAR 3 months after IOL exchange. The logMAR BCVA improved in all eyes (O0.2 in 18 eyes [78.3%]; !0.2 in 5 eyes [21.7%]). The final BCVA after 41 months of follow-up was 0.38 G 0.40 logMAR. There was an improvement in 0.40 logMAR BCVA 3 months postoperatively compared with preoperatively and a decrease of approximately 0.14 logMAR at the final evaluation at 41 months compared with 3 months postoperatively (Table 1). The decrease was probably due to the patients’ retinal functions because diabetic retinopathy was present in 4 eyes (17.4%), age-related macular degeneration in 3 eyes (13.0%), and myopic macular degeneration in 1 eye (4.3%). Six patients (26.1%) reported glare after surgery. The mean endothelial cell loss 3 months after surgery was 5.9% (98.2 G 142.7 cell/mm2). A single haptic was retained in 9 eyes (39.1%), and both haptics were left in 14 eyes (60.9%). A new IOL was implanted in the bag in 9 eyes (39.1%) and in the sulcus in 13 eyes (56.5%), and transscleral fixation was performed in 1 eye (4.3%). Of the 13 eyes with haptic implantation in the sulcus, the optic was captured posterior to the anterior CCC after circular extension of the fibrous anterior capsule with a vitreous cutter in 5 eyes. The newly implanted IOL was a foldable hydrophilic 1-piece acrylic IOL with a C-loop closed haptic (Centerflex or C-flex 570C, Rayner) in 16 eyes (69.6%) and a foldable hydrophobic 3-piece acrylic IOL (Sensar AR40, Advanced Medical Optics) in 7 eyes (30.4%). A posterior capsule rupture developed intraoperatively in 2 eyes (8.7%) when the optic was being divided, and zonular dehiscence occurred in 1 eye (4.3%). Anterior vitrectomy using a 23-gauge vitreous cutter was performed in 5 of the 7 eyes with a previous posterior capsulotomy, in 2 eyes with intraoperative
Table 1. Patient data and preoperative and postoperative visual acuity. Best Corrected Visual Acuity 3 Mo FU Age Case (Y) Sex Interval* Nd:YAG† Preop Postop Final (Mo)z 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
35 67 56 63 72 72 63 70 67 61 76 57 62 62 77 65 68 55 63 64 71 71 64
F F F M F F F F M F F F M M M F F M M M F F F
8 9 12 13 15 16 16 16 18 19 24 24 28 28 29 31 36 39 45 50 52 58 58
C C C C C C C
0.78 0.48 0.78 1.00 0.70 0.70 0.30 0.48 1.22 0.18 1.00 0.48 0.48 0.70 0.70 0.48 0.40 0.18 0.30 0.48 1.70 0.70 0.40
0.18 0.18 0.60 0.18 0.18 0.40 0.10 0.30 0.48 0.10 0.48 0.10 0.18 0.18 0.30 0.10 0.00 0.00 0.18 0.00 0.70 0.48 0.10
0.48 0.30 0.10 0.70 0.18 0.30 0.10 0.48 0.70 1.70 0.70 0.00 0.40 0.40 0.48 0.10 0.00 0.00 0.18 0.00 1.00 0.40 0.00
72 61 68 50 37 31 39 28 29 34 29 44 50 51 29 34 51 55 38 28 32 28 27
FU Z follow-up; Nd:YAG Z neodymium:YAG laser capsulotomy *Between first cataract surgery and IOL exchange † Nd:YAG laser capsulotomy before IOL exchange z After IOL exchange
posterior capsule rupture, in 1 eye with zonular dehiscence, and in 2 eyes that had intraoperative posterior capsulotomy due to severe PCO. Transscleral fixation was performed in 1 eye (4.3%) with zonular dehiscence (Table 2). Postoperatively, a transient increase in IOP occurred in 2 eyes (8.7%) and hyphema, cystoid macular edema, and recurrent anterior uveitis in 1 eye (4.3%) each. In 1 eye (4.3%), zonular dehiscence occurred 41 months after IOL exchange and ab externo transscleral fixation of 1 haptic was performed. There were no occurrences of bullous keratopathy or infectious keratitis. DISCUSSION As shown in the current study, the incidence of zonular dehiscence, the most common intraoperative complication of IOL exchange, can be reduced by removing the optic only, leaving the firmly adhered haptics in the bag. This is true even though the study
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Table 2. Combined procedures and complications. Complications Case
IOL Type
Insertion
Haptic*
Intraoperative
Combined Operative
Late
1 2 3 4 5 6 7 8 9 10 11
Centerflex Sensar Centerflex Sensar Centerflex Sensar Centerflex C-flex C-flex Sensar Sensar
Bag Bag Bag Bag Sulcus Sulcus Sulcus Bag Sulcus Bag Sulcus
1 2 1 2 1 2 1 2 2 1 1
d d d d Hyphema, increased IOP d d d CME d d
d d d d d d d d d d d
12 13 14 15 16 17 18 19
C-flex C-flex Sensar C-flex C-flex Centerflex Centerflex Sensar
Bag Sulcus Sulcus Sulcus Bag Sulcus Sulcus Bag
2 2 2 1 2 1 2 2
d Increased IOP d d d d PC rupture d
20 21
C-flex C-flex
Sulcus Sulcus
2 1
d d
22 23
C-flex C-flex
Scleral Fixation Sulcus
2 2
Zonular dehiscence PC rupture
d d d d d Anterior vitrectomy Anterior vitrectomy d d d PCO removal; anterior vitrectomy d Anterior vitrectomy Anterior vitrectomy Anterior vitrectomy d Anterior vitrectomy Anterior vitrectomy PCO removal; anterior vitrectomy Anterior vitrectomy PCO removal; anterior vitrectomy Anterior vitrectomy Anterior vitrectomy
d Zonular dehiscence d d d d d d d d d d
CME Z cystoid macular edema; IOP Z intraocular pressure; PC Z posterior capsule; PCO Z posterior capsule opacification; Pt Z patient *Number of remaining haptics
had no control group to compare the surgical outcomes. In our study, there were few complications associated with the remaining haptics during the mean follow-up of 41 months. Complications that can occur as a result of remnant haptics include dislocation of the haptic to the optic zone or into the vitreous cavity, interference with positioning of the newly implanted IOL, and iritis due to chafing of the iris when the haptics of the new IOL are located in the ciliary sulcus. During the follow-up of 41 months, no complications associated with haptic dislocation or interference with the positioning of a newly implanted IOL were observed. Six patients (26.1%) reported glare after surgery; however, the glare resolved by approximately 5 months after the surgery. The glare was thought to be due to the progression of capsule opacity, which covered the remnant haptics. The incidence of glare can be reduced by leaving a shorter haptic. It is difficult to conclude whether iris chafing or recurrent iritis has a relation to the shape of an IOL placed in the sulcus. One eye (case 11), which had 3piece IOL implantation in the ciliary sulcus, developed
intermittent recurrent anterior uveitis (4.3%) in our study. Using ultrasound biomicroscopy, Amino and Yamakawa10 confirmed that all optics with sulcusto-sulcus IOL fixation touched the iris in a study of out-of-the-bag IOL position. They report that rubbing between the IOL optic and iris contributed to the high flare counts in eyes with a sulcus-fixated IOL compared with the counts in the in-the-bag IOL group. However, because there were no statistical differences in corneal endothelial cell counts and visual outcomes, postoperative inflammation was affected more by the extent of the tissue damage during surgery and the length of surgery.10 We used the C-flex IOL in this study because scleral fixation using an IOL with broad, closed-loop haptics seems to be stable in cases of combined vitrectomy and intravitreal gas tamponade11; however, the possibility of iris chafing due to the IOL design should be considered. To avoid anterior shifting of the newly implanted IOL, the optic was captured posterior to the anterior CCC after the fibrous anterior CCC margin was extended with a vitreous cutter in 8 of the 13 eyes in which the IOL was implanted in the
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sulcus. The mean endothelial cell loss 3 months after surgery was 5.9% (98.2 G 142.7 cell/mm2).12 Many surgical methods have been used for IOL exchange5,13–15; all share the principle of dissection to avoid damage of the intraocular tissue, such as viscodissection and removal of anterior capsule adhesion. However, intraoperative complications, such as zonular dialysis, posterior capsule rupture, and iridodialysis, were encountered in approximately 30% of cases,8,9,13 reflecting the technical difficulty of IOL exchange. Most complications occurred during removal of adhered haptics. Yu and Ng8 report adhesions between the posterior capsule and the haptic in 5 (33.3%) of 15 eyes that had IOL exchange surgery; of the 5 eyes, 4 (80.0%) had posterior capsule rupture or disruption of the ciliary body. Gashau et al.9 removed the haptics in most cases; 13 (25.5%) of 51 eyes developed posterior capsule rupture of the zonular dehiscence. The haptics were left in 5 eyes due to severe adhesions; of these eyes, 4 had no complications associated with the remaining haptics. In our study, the overall incidence of intraoperative complications was 13.0%; complications comprised posterior capsule rupture in 2 eyes (8.7%) and zonular dehiscence in 1 eye (4.3%). The low incidence of zonular dehiscence emphasizes the effect of optic-only removal in reducing intraoperative complications. Attempts were made to remove the haptics in all cases of IOL exchange; only 1 haptic in 9 eyes (39.1%) was removed when adhesions were relatively mild. Dividing the optic into halves also made it easier to remove the haptics. The technique of removing the optic only is simple and easy to perform through a small corneal incision. Additional procedures are unnecessary because zonular dehiscence after the haptic removal can be avoided. Attention is required when cutting the haptic–optic junction with Vannas scissors to avoid damaging the intraocular structures. In conclusion, in cases of IOL opacity with capsule adhesions, removal of the optic only can reduce intraocular damage and make it easier to implant a new IOL, thereby improving the patient’s visual prognosis.
2. Woodruff SA, Khan J, Dhingra N, Gashau I, Chawdhary S. [Late clouding of an acrylic intraocular lens following routine phacoemulsification] [letter]. Eye 2001; 15:361–362 3. Werner L, Apple DJ, Kaskaloglu M, Pandey SK. Dense opacification of the optical component of a hydrophilic acrylic intraocular lens; a clinicopathological analysis of 9 explanted lenses. J Cataract Refract Surg 2001; 27:1485–1492 4. Frohn A, Dick HB, Augustin AJ, Grus FH. Late opacification of the foldable hydrophilic acrylic lens SC60B-OUV. Ophthalmology 2001; 108:1999–2004 5. Dagres E, Khan MA, Kyle GM, Clark D. Perioperative complications of intraocular lens exchange in patients with opacified Aqua-Sense lenses. J Cataract Refract Surg 2004; 30:2569– 2573 6. Kim H-G, Lee S-H, Choi Y-J. [Late postoperative opacification of the foldable hydrophilic acrylic intraocular lens, ACRL-160]. [Korean] J Korean Ophthalmol Soc 2003; 44:315–320 7. Kim J-C, Kim C-S, Choi S-H, Lee S-B, Jo Y-J. [Clinical characteristics of patients with opacification of hydrophilic acrylic intraocular lens after cataract surgery]. [Korean] J Korean Ophthalmol Soc 2005; 46:1281–1290 8. Yu AKF, Ng ASY. Complications and clinical outcomes of intraocular lens exchange in patients with calcified hydrogel lenses. J Cataract Refract Surg 2002; 28:1217–1222 9. Gashau AG, Anand A, Chawdhary S. Hydrophilic acrylic intraocular lens exchange: five-year experience. J Cataract Refract Surg 2006; 32:1340–1344 10. Amino K, Yamakawa R. Long-term results of out-of-the-bag intraocular lens implantation. J Cataract Refract Surg 2000; 26:266–270 11. Kim SJ, Lee SJ, Park CH, Jung GY, Park SH. Long-term stability and visual outcomes of a single-piece, foldable, acrylic intraocular lens for scleral fixation. In press, Retina 2009 12. Storr-Paulsen A, Norregaard JC, Ahmed S, Storr-Paulsen T, Pedersen TH. Endothelial cell damage after cataract surgery: divide-and-conquer versus phaco-chop technique. J Cataract Refract Surg 2008; 34:996–1000 13. Voros GM, Strong NP. Exchange technique for opacified hydrophilic acrylic intraocular lenses. Eur J Ophthalmol 2005; 15:465– 467 14. Saeed MU, Jafree AJ, de Cock R. Intralenticular opacification of hydrophilic acrylic intraocular lenses. Eye 2005; 19:661– 664 15. Dahlmann AH, Dhingra N, Chawdhary S. Acrylic lens exchange for late opacification of the optic. J Cataract Refract Surg 2002; 28:1713–1714
REFERENCES 1. Chang BYP, Davey KG, Gupta M, Hutchinson C. Late clouding of an acrylic intraocular lens following routine phacoemulsification [letter]. Eye 1999; 13:807–808
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First author: Sung Jin Lee, MD Department of Ophthalmology, College of Medicine, Soonchunhyang University, Seoul, Korea
Intraocular lens exchange with removal of the optic only Sung Jin Lee, MD, Hae Jung Sun, MD, Kyung Seek Choi, MD, Song Hee Park, MD
PURPOSE: To evaluate the clinical outcomes of intraocular lens (IOL) exchange in patients with an opacified ACRL-C160 intraocular lens (IOL) using an optic-only removal technique. SETTING: Department of Ophthalmology, Soonchunhyang University Hospital, Seoul, Korea. METHODS: The study comprised eyes with previous phacoemulsification and implantation of a single-piece hydrophilic acrylic IOL in the capsular bag and subsequent development of severe late opacification of the IOL. In all eyes, the IOL optic was explanted; any haptic with firm adhesions was left in the capsular bag. This was followed by placement of a new IOL. The perioperative complications were evaluated, and the best corrected visual acuity (BCVA) before surgery and after surgery was compared. RESULTS: Twenty-three eyes of 20 patients were evaluated. Uneventful IOL exchange and placement of a new IOL in the bag was achieved in 9 eyes (39.1%) and in the sulcus in 13 eyes (56.5%), with posterior capsule rupture in 2 eyes (8.7%). One eye (4.3%) developed zonular dehiscence, and scleral IOL fixation was performed. The mean BCVA was 0.64 G 0.35 logMAR before IOL exchange and 0.24 G 0.20 logMAR after IOL exchange. During 41 months of follow-up, 1 eye (4.3%) each was affected by recurrent anterior uveitis and delayed zonular dehiscence. The final mean BCVA was 0.38 G 0.40 logMAR. There was no corneal decompensation or infectious keratitis. CONCLUSION: The optic-only removal technique was a safe and helpful procedure that allowed recovery of visual acuity because it decreased the intraoperative complication of zonular dehiscence. J Cataract Refract Surg 2009; 35:514–518 Q 2009 ASCRS and ESCRS
Delayed opacification is seen in some hydrophilic acrylic intraocular lenses (IOLs) implanted during cataract surgery.1–5 The ACRL-C160 IOL (Ophthalmed) used in Korea is reported to develop opacification in 84.1% of cases approximately 2 years after implantation due to calcium precipitation.6,7 Exchange of the opacified IOL is required because of glare and a decline in visual acuity.
Submitted: October 4, 2008. Final revision submitted: November 22, 2008. Accepted: November 24, 2008. From the Department of Ophthalmology, College of Medicine, Soonchunhyang University, Seoul, Korea. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Sung Jin Lee, MD, #657 Hannam-dong Yongsan-gu, Seoul, 140-743, Korea. E-mail: [email protected].
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Zonular dehiscence is the most common intraoperative complication of IOL exchange surgery.5,8,9 Dagres et al.5 observed zonular dehiscence in 11 (44%) of 25 eyes having IOL exchange. This finding implies that separating the IOL from the firmly adherent lens capsule is technically challenging. When zonular dehiscence occurs, additional procedures are needed to remove the prolapsed vitreous. Also, complicated transscleral fixation of the IOL or unplanned anterior chamber IOL implantation is required. Thus, it is critical to avoid this complication to reduce operative time and tissue damage and to improve visual recovery after surgery. Yu and Ng8 report 3 instances (20%) of optic-only removal in 15 eyes having IOL exchange surgery. When tension of the lens capsule was identified during removal of the haptics, the haptics were left in the eye. Gashau et al.9 also left the haptics in the eye in some cases of IOL exchange. No complications related to the remnant haptics were reported in either study. 0886-3350/09/$dsee front matter doi:10.1016/j.jcrs.2008.11.045
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Figure 1. A: Slitlamp photography of an opaque ACRL-C160 IOL. B: Clear IOL (left) and opaque ACRLC160 IOL (right).
In the current study, we attempted to remove only the optic of the opacified ACRL-C160 (Figure 1) to reduce the incidence of zonular dehiscence and thus improve visual recovery. We also studied the visual outcomes and complications of the procedure. PATIENTS AND METHODS This retrospective study comprised patients who had IOL exchange surgery in which at least 1 haptic was left in the bag during removal of the optic of an ACRL-C160 IOL. All eyes were operated on by the same experienced surgeon (S.J.L.) between January 2001 and December 2005. The Institutional Review Board, Soonchunhyang University, Seoul, Korea, approved the study. The preoperative posterior capsulotomy state, preoperative and postoperative visual acuity, and intraoperative and postoperative complications were assessed. The removal of the opacified IOL was completed as follows: A clear corneal incision was created perpendicular to the haptic–optic junction, and an ophthalmic viscosurgical
device (OVD) was injected into the anterior chamber. A corneal puncture was made at least 90 degrees from the incision site with a Beaver blade. The optic was divided in the center with Vannas scissors through the corneal incision site, assisted with a lens hook through the corneal puncture site (Figure 2, A). The haptic was pulled using a lens hook to check the degree of adhesion between the haptic and lens capsule. The haptic was removed when adhesions were moderate or was amputated at the haptic–optic junction in cases of severe adhesions (Figure 2, B). The 2 divided optic pieces were removed through the corneal incision site with a toothed McPherson forceps. In cases of vitreous prolapse into the anterior chamber, a vitrectomy was performed using a 23-gauge vitreous cutter through the corneal entry site while an infusion cannula was used through the side puncture. If posterior capsule opacification (PCO) was present, a posterior capsulotomy was performed intraoperatively using a cystotome or a vitreous cutter (Figure 2, C). The anterior continuous curvilinear capsulorhexis (ACCC) size was adjusted with a vitreous cutter. A foldable IOL was inserted in the sulcus, where the haptics were oriented 90 degrees from the remnant haptics, and the optic was captured
Figure 2. A: Dividing the optic of an opaque ACRL-C160 IOL with Vannas scissors and a lens hook. B: Dividing the haptic–optic junction with Vannas scissors after fibrosis around the haptic was confirmed. C: Haptic remnants after removal of the optic. D: A new IOL in the sulcus with optic capture.
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posterior to the ACCC (Figure 2, D). Then, the remaining OVD in the anterior chamber was removed and intraocular pressure (IOP) controlled. The corneal entry site was sutured as needed.
RESULTS Intraocular lens exchange was performed in 23 eyes of 20 patients. Seven patients (34.8%; 8 eyes) were men, and 13 patients (65.2%; 15 eyes) were women. The mean age of the patients was 64 years G 9 (SD) (range 35 to 77 years). The mean time between cataract surgery and IOL exchange was 28 G 16 months. Four eyes (17.4%) had diabetic retinopathy and 7 eyes (30.4%) had neodymium:YAG laser posterior capsulotomy before surgery. The mean postoperative follow-up was 41 G 14 months (range 14 to 72 months). The mean best corrected visual acuity (BCVA) was 0.64 G 0.35 logMAR preoperatively, improving to 0.24 G 0.20 logMAR 3 months after IOL exchange. The logMAR BCVA improved in all eyes (O0.2 in 18 eyes [78.3%]; !0.2 in 5 eyes [21.7%]). The final BCVA after 41 months of follow-up was 0.38 G 0.40 logMAR. There was an improvement in 0.40 logMAR BCVA 3 months postoperatively compared with preoperatively and a decrease of approximately 0.14 logMAR at the final evaluation at 41 months compared with 3 months postoperatively (Table 1). The decrease was probably due to the patients’ retinal functions because diabetic retinopathy was present in 4 eyes (17.4%), age-related macular degeneration in 3 eyes (13.0%), and myopic macular degeneration in 1 eye (4.3%). Six patients (26.1%) reported glare after surgery. The mean endothelial cell loss 3 months after surgery was 5.9% (98.2 G 142.7 cell/mm2). A single haptic was retained in 9 eyes (39.1%), and both haptics were left in 14 eyes (60.9%). A new IOL was implanted in the bag in 9 eyes (39.1%) and in the sulcus in 13 eyes (56.5%), and transscleral fixation was performed in 1 eye (4.3%). Of the 13 eyes with haptic implantation in the sulcus, the optic was captured posterior to the anterior CCC after circular extension of the fibrous anterior capsule with a vitreous cutter in 5 eyes. The newly implanted IOL was a foldable hydrophilic 1-piece acrylic IOL with a C-loop closed haptic (Centerflex or C-flex 570C, Rayner) in 16 eyes (69.6%) and a foldable hydrophobic 3-piece acrylic IOL (Sensar AR40, Advanced Medical Optics) in 7 eyes (30.4%). A posterior capsule rupture developed intraoperatively in 2 eyes (8.7%) when the optic was being divided, and zonular dehiscence occurred in 1 eye (4.3%). Anterior vitrectomy using a 23-gauge vitreous cutter was performed in 5 of the 7 eyes with a previous posterior capsulotomy, in 2 eyes with intraoperative
Table 1. Patient data and preoperative and postoperative visual acuity. Best Corrected Visual Acuity 3 Mo FU Age Case (Y) Sex Interval* Nd:YAG† Preop Postop Final (Mo)z 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
35 67 56 63 72 72 63 70 67 61 76 57 62 62 77 65 68 55 63 64 71 71 64
F F F M F F F F M F F F M M M F F M M M F F F
8 9 12 13 15 16 16 16 18 19 24 24 28 28 29 31 36 39 45 50 52 58 58
C C C C C C C
0.78 0.48 0.78 1.00 0.70 0.70 0.30 0.48 1.22 0.18 1.00 0.48 0.48 0.70 0.70 0.48 0.40 0.18 0.30 0.48 1.70 0.70 0.40
0.18 0.18 0.60 0.18 0.18 0.40 0.10 0.30 0.48 0.10 0.48 0.10 0.18 0.18 0.30 0.10 0.00 0.00 0.18 0.00 0.70 0.48 0.10
0.48 0.30 0.10 0.70 0.18 0.30 0.10 0.48 0.70 1.70 0.70 0.00 0.40 0.40 0.48 0.10 0.00 0.00 0.18 0.00 1.00 0.40 0.00
72 61 68 50 37 31 39 28 29 34 29 44 50 51 29 34 51 55 38 28 32 28 27
FU Z follow-up; Nd:YAG Z neodymium:YAG laser capsulotomy *Between first cataract surgery and IOL exchange † Nd:YAG laser capsulotomy before IOL exchange z After IOL exchange
posterior capsule rupture, in 1 eye with zonular dehiscence, and in 2 eyes that had intraoperative posterior capsulotomy due to severe PCO. Transscleral fixation was performed in 1 eye (4.3%) with zonular dehiscence (Table 2). Postoperatively, a transient increase in IOP occurred in 2 eyes (8.7%) and hyphema, cystoid macular edema, and recurrent anterior uveitis in 1 eye (4.3%) each. In 1 eye (4.3%), zonular dehiscence occurred 41 months after IOL exchange and ab externo transscleral fixation of 1 haptic was performed. There were no occurrences of bullous keratopathy or infectious keratitis. DISCUSSION As shown in the current study, the incidence of zonular dehiscence, the most common intraoperative complication of IOL exchange, can be reduced by removing the optic only, leaving the firmly adhered haptics in the bag. This is true even though the study
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Table 2. Combined procedures and complications. Complications Case
IOL Type
Insertion
Haptic*
Intraoperative
Combined Operative
Late
1 2 3 4 5 6 7 8 9 10 11
Centerflex Sensar Centerflex Sensar Centerflex Sensar Centerflex C-flex C-flex Sensar Sensar
Bag Bag Bag Bag Sulcus Sulcus Sulcus Bag Sulcus Bag Sulcus
1 2 1 2 1 2 1 2 2 1 1
d d d d Hyphema, increased IOP d d d CME d d
d d d d d d d d d d d
12 13 14 15 16 17 18 19
C-flex C-flex Sensar C-flex C-flex Centerflex Centerflex Sensar
Bag Sulcus Sulcus Sulcus Bag Sulcus Sulcus Bag
2 2 2 1 2 1 2 2
d Increased IOP d d d d PC rupture d
20 21
C-flex C-flex
Sulcus Sulcus
2 1
d d
22 23
C-flex C-flex
Scleral Fixation Sulcus
2 2
Zonular dehiscence PC rupture
d d d d d Anterior vitrectomy Anterior vitrectomy d d d PCO removal; anterior vitrectomy d Anterior vitrectomy Anterior vitrectomy Anterior vitrectomy d Anterior vitrectomy Anterior vitrectomy PCO removal; anterior vitrectomy Anterior vitrectomy PCO removal; anterior vitrectomy Anterior vitrectomy Anterior vitrectomy
d Zonular dehiscence d d d d d d d d d d
CME Z cystoid macular edema; IOP Z intraocular pressure; PC Z posterior capsule; PCO Z posterior capsule opacification; Pt Z patient *Number of remaining haptics
had no control group to compare the surgical outcomes. In our study, there were few complications associated with the remaining haptics during the mean follow-up of 41 months. Complications that can occur as a result of remnant haptics include dislocation of the haptic to the optic zone or into the vitreous cavity, interference with positioning of the newly implanted IOL, and iritis due to chafing of the iris when the haptics of the new IOL are located in the ciliary sulcus. During the follow-up of 41 months, no complications associated with haptic dislocation or interference with the positioning of a newly implanted IOL were observed. Six patients (26.1%) reported glare after surgery; however, the glare resolved by approximately 5 months after the surgery. The glare was thought to be due to the progression of capsule opacity, which covered the remnant haptics. The incidence of glare can be reduced by leaving a shorter haptic. It is difficult to conclude whether iris chafing or recurrent iritis has a relation to the shape of an IOL placed in the sulcus. One eye (case 11), which had 3piece IOL implantation in the ciliary sulcus, developed
intermittent recurrent anterior uveitis (4.3%) in our study. Using ultrasound biomicroscopy, Amino and Yamakawa10 confirmed that all optics with sulcusto-sulcus IOL fixation touched the iris in a study of out-of-the-bag IOL position. They report that rubbing between the IOL optic and iris contributed to the high flare counts in eyes with a sulcus-fixated IOL compared with the counts in the in-the-bag IOL group. However, because there were no statistical differences in corneal endothelial cell counts and visual outcomes, postoperative inflammation was affected more by the extent of the tissue damage during surgery and the length of surgery.10 We used the C-flex IOL in this study because scleral fixation using an IOL with broad, closed-loop haptics seems to be stable in cases of combined vitrectomy and intravitreal gas tamponade11; however, the possibility of iris chafing due to the IOL design should be considered. To avoid anterior shifting of the newly implanted IOL, the optic was captured posterior to the anterior CCC after the fibrous anterior CCC margin was extended with a vitreous cutter in 8 of the 13 eyes in which the IOL was implanted in the
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sulcus. The mean endothelial cell loss 3 months after surgery was 5.9% (98.2 G 142.7 cell/mm2).12 Many surgical methods have been used for IOL exchange5,13–15; all share the principle of dissection to avoid damage of the intraocular tissue, such as viscodissection and removal of anterior capsule adhesion. However, intraoperative complications, such as zonular dialysis, posterior capsule rupture, and iridodialysis, were encountered in approximately 30% of cases,8,9,13 reflecting the technical difficulty of IOL exchange. Most complications occurred during removal of adhered haptics. Yu and Ng8 report adhesions between the posterior capsule and the haptic in 5 (33.3%) of 15 eyes that had IOL exchange surgery; of the 5 eyes, 4 (80.0%) had posterior capsule rupture or disruption of the ciliary body. Gashau et al.9 removed the haptics in most cases; 13 (25.5%) of 51 eyes developed posterior capsule rupture of the zonular dehiscence. The haptics were left in 5 eyes due to severe adhesions; of these eyes, 4 had no complications associated with the remaining haptics. In our study, the overall incidence of intraoperative complications was 13.0%; complications comprised posterior capsule rupture in 2 eyes (8.7%) and zonular dehiscence in 1 eye (4.3%). The low incidence of zonular dehiscence emphasizes the effect of optic-only removal in reducing intraoperative complications. Attempts were made to remove the haptics in all cases of IOL exchange; only 1 haptic in 9 eyes (39.1%) was removed when adhesions were relatively mild. Dividing the optic into halves also made it easier to remove the haptics. The technique of removing the optic only is simple and easy to perform through a small corneal incision. Additional procedures are unnecessary because zonular dehiscence after the haptic removal can be avoided. Attention is required when cutting the haptic–optic junction with Vannas scissors to avoid damaging the intraocular structures. In conclusion, in cases of IOL opacity with capsule adhesions, removal of the optic only can reduce intraocular damage and make it easier to implant a new IOL, thereby improving the patient’s visual prognosis.
2. Woodruff SA, Khan J, Dhingra N, Gashau I, Chawdhary S. [Late clouding of an acrylic intraocular lens following routine phacoemulsification] [letter]. Eye 2001; 15:361–362 3. Werner L, Apple DJ, Kaskaloglu M, Pandey SK. Dense opacification of the optical component of a hydrophilic acrylic intraocular lens; a clinicopathological analysis of 9 explanted lenses. J Cataract Refract Surg 2001; 27:1485–1492 4. Frohn A, Dick HB, Augustin AJ, Grus FH. Late opacification of the foldable hydrophilic acrylic lens SC60B-OUV. Ophthalmology 2001; 108:1999–2004 5. Dagres E, Khan MA, Kyle GM, Clark D. Perioperative complications of intraocular lens exchange in patients with opacified Aqua-Sense lenses. J Cataract Refract Surg 2004; 30:2569– 2573 6. Kim H-G, Lee S-H, Choi Y-J. [Late postoperative opacification of the foldable hydrophilic acrylic intraocular lens, ACRL-160]. [Korean] J Korean Ophthalmol Soc 2003; 44:315–320 7. Kim J-C, Kim C-S, Choi S-H, Lee S-B, Jo Y-J. [Clinical characteristics of patients with opacification of hydrophilic acrylic intraocular lens after cataract surgery]. [Korean] J Korean Ophthalmol Soc 2005; 46:1281–1290 8. Yu AKF, Ng ASY. Complications and clinical outcomes of intraocular lens exchange in patients with calcified hydrogel lenses. J Cataract Refract Surg 2002; 28:1217–1222 9. Gashau AG, Anand A, Chawdhary S. Hydrophilic acrylic intraocular lens exchange: five-year experience. J Cataract Refract Surg 2006; 32:1340–1344 10. Amino K, Yamakawa R. Long-term results of out-of-the-bag intraocular lens implantation. J Cataract Refract Surg 2000; 26:266–270 11. Kim SJ, Lee SJ, Park CH, Jung GY, Park SH. Long-term stability and visual outcomes of a single-piece, foldable, acrylic intraocular lens for scleral fixation. In press, Retina 2009 12. Storr-Paulsen A, Norregaard JC, Ahmed S, Storr-Paulsen T, Pedersen TH. Endothelial cell damage after cataract surgery: divide-and-conquer versus phaco-chop technique. J Cataract Refract Surg 2008; 34:996–1000 13. Voros GM, Strong NP. Exchange technique for opacified hydrophilic acrylic intraocular lenses. Eur J Ophthalmol 2005; 15:465– 467 14. Saeed MU, Jafree AJ, de Cock R. Intralenticular opacification of hydrophilic acrylic intraocular lenses. Eye 2005; 19:661– 664 15. Dahlmann AH, Dhingra N, Chawdhary S. Acrylic lens exchange for late opacification of the optic. J Cataract Refract Surg 2002; 28:1713–1714
REFERENCES 1. Chang BYP, Davey KG, Gupta M, Hutchinson C. Late clouding of an acrylic intraocular lens following routine phacoemulsification [letter]. Eye 1999; 13:807–808
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First author: Sung Jin Lee, MD Department of Ophthalmology, College of Medicine, Soonchunhyang University, Seoul, Korea