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Opacification of a hydrophilic acrylic intraocular lens with exacerbation of Behçet’s uveitis1
Opacification of a hydrophilic acrylic intraocular lens with exacerbation of Behc¸et’s uveitis Chan Y. Kim, MD, Shin J. Kang, MD, Sung J. Lee, MD, Sung H. Park, MD, Hyoung J. Koh, MD Behc¸et’s disease is 1 of the most common causes of uveitis in the Eastern world. Its common ocular complications are uveitis, cataract, and obliteration of retinal vessels. Phacoemulsification with intraocular lens (IOL) implantation in patients with Behc¸et’s disease is known to be a safe procedure. We managed a patient with Behc¸et’s disease who had aggravated uveitis and opacification of a hydrophilic acrylic IOL (ACRL-C160, Ophthalmed) 4 months after cataract surgery. Recalcitrant uveitis despite maximum tolerable medication and IOL opacification with vitreous opacity necessitated an IOL exchange and trans pars plana vitrectomy. After the procedure, the eye became quiescent. However, the visual acuity was 20/200 because of the obliteration of retinal vessels. J Cataract Refract Surg 2002; 28:1276 –1278 © 2002 ASCRS and ESCRS
T
he ocular complications in Behc¸et’s disease consist of uveitis, cataract, and obliteration of retinal vessels. Because uveitis and steroid medication increase the incidence of cataract in Behc¸et’s disease, cataract is 1 of the most common complications that occurs in ocular Behc¸et’s disease.1 Phacoemulsification with intraocular lens (IOL) implantation is reported to be a safe procedure in patients with Behc¸et’s disease, although there could be an ocular inflammatory attack after the cataract surgery.2 Recently, foldable IOLs have been reported to be safe in uveitis patients.3 However, we report a patient with Behc¸et’s disease who had aggravated uveitis and opacification of an implanted hydrophilic acrylic IOL.
Ophthalmed) in May 2000. On examination, the visual acuity in the left eye was 5/200. Although the cornea was clear and the anterior chamber quiescent, the vitreous showed many cells behind a uniformly opacified IOL (Figure 1). Extensive vitreous opacity as well as opacification of the IOL hindered visualization of the fundus. Oral colchicine and steroid were prescribed; however, the vitreous reaction did not improve after 5 months of the maximum tolerable medication. A reaction began to occur in the anterior chamber. Because the patient wanted to stop the oral medication, IOL exchange and trans pars plana vitrectomy were planned.
Case Report A 62-year-old woman was referred because of uncontrolled inflammation after cataract surgery in September 2000. Behc¸et’s disease had been diagnosed in March 2000. The patient had uneventful cataract surgery in the left eye with implantation of a hydrophilic acrylic IOL (ACRL-C160, Accepted for publication March 12, 2002. Reprint requests to Hyoung J. Koh, MD, Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, 134 Shinchon-dong, Sodaemun-gu, Seoul, Korea, 120-752. E-mail: [email protected]. © 2002 ASCRS and ESCRS Published by Elsevier Science Inc.
Figure 1. (Kim) Photograph shows diffuse opacification of the ACRL-C160 IOL and a relatively quiescent anterior chamber. 0886-3350/02/$–see front matter PII S0886-3350(02)01356-1
CASE REPORTS: KIM
An infusion cannula was introduced into the inferotemporal sclera 3.5 mm from the limbus. After a corneoscleral incision was made, sodium hyaluronate (Healon威) was injected into the anterior chamber. A Vannas scissor was introduced into the anterior chamber, and the IOL was divided and removed. As the irrigating solution was introduced into the vitreous cavity, the vitreous opacity was removed. The vitreous opacity was dense, and there was a posterior vitreous detachment. After the vitreous opacity was removed, the inferior temporal retinal vessels were found to be occluded. A single-piece heparin-surface-modified poly(methyl methacrylate) (PMMA) IOL (CeeOn威, Pharmacia & Upjohn) was fixated in the ciliary sulcus. One week after surgery, the eye was quiescent. At 3 months, the visual acuity was 20/200. The explanted IOL, including the haptics, was diffusely opacified (Figure 2). Scanning electron microscopy of the cut section of the optic showed granular deposits in a region about 5.0 m beneath the anterior and posterior optic surfaces (Figure 3,A). Energy dispersive x-ray analysis was performed on the deposits in the same section and showed that calcium and phosphate peaks were present (Figure 3,B). However, there were no calcium or phosphate peaks in the surface and central area of the cut section (not shown).
ease had a hydrogel IOL. The patient’s visual acuity improved postoperatively. There are several reports of opacification of the Hydroview威 model H60M IOL (Bausch & Lomb)4 – 6 and the foldable hydrophilic acrylic lens SC60BOUV (MDR Inc.).7,8 We report opacification in a different type of hydrophilic acrylic IOL. Scanning electron microscopic findings and energy dispersive
Discussion Rauz and coauthors3 recently reported that implantation of foldable IOLs during phacoemulsification in eyes with uveitis was safe and comparable to previous reports of rigid surface-modified and unmodified PMMA IOLs. One panuveitis patient with Behc¸et’s dis-
Figure 2. (Kim) Clear (left) and explanted (right) ACRL-C160 IOL. During removal, the IOL was bisected. Both optic and haptic have diffuse opacification.
Figure 3. (Kim) A: Scanning electron microscopy of the cut section of the optic of an ACRL-C160 IOL. There are multiple granular deposits in a line beneath the external surface. B: Energy dispersive x-ray analysis shows calcium and phosphate peaks at the level of the granular deposits.
J CATARACT REFRACT SURG—VOL 28, JULY 2002
1277
CASE REPORTS: KIM
x-ray analysis suggest that the IOL opacification in our case was the result of granular deposits composed at least in part of calcium and phosphate within the IOL optic, similar to the opacification in the SC60BOUV IOL.8 It is not clear whether intraocular inflammation causes opacification of the hydrophilic acrylic IOL or the hydrophilic acrylic IOL causes an attack of intraocular inflammation in patients with Behc¸et’s disease. In our patient, the posterior uveitis was not relieved by colchicine and steroid medication; however, the eye became quiescent after an IOL exchange. Therefore, we think the responses may be associated with use of the hydrophilic acrylic IOL in Behc¸et’s disease. We do not know why the vitreous opacity with posterior reaction was so severe while the anterior segment was relatively quiescent. Behc¸et’s disease was diagnosed in our patient 2 months before cataract surgery. In this relatively short time, the retinal vessel occlusion is an unusual finding in Behc¸et’s disease. We think the vitreous reaction with resultant vessel occlusion of the inferior temporal retinal vessel occurred after cataract surgery. Although this case cannot be applied to all Behc¸et’s disease patients or all hydrophilic acrylic IOLs, we recommend caution in the use of this hydrophilic acrylic IOL in patients with Behc¸et’s disease. Patients with Behc¸et’s disease who have this IOL should be followed carefully.
1278
References 1. Ciftci OU, Ozdemir O. Cataract extraction in Behc¸et’s disease. Acta Ophthalmol Scand 1996; 74:74 –76 2. Matsuo T, Takahashi M, Inoue Y, et al. Ocular attacks after phacoemulsification and intraocular lens in patients with Behc¸et disease. Ophthalmologica 2001; 215:179–182 3. Rauz S, Stavrou P, Murray PI. Evaluation of foldable intraocular lenses in patients with uveitis. Ophthalmology 2000; 107:909 –919 4. Fernando GT, Crayford BB. Visually significant calcification of hydrogel intraocular lenses necessitating explantation. Clin Exp Ophthalmol 2000; 28:280 –286 5. Yu AKF, Shek TWH. Hydroxyapatite formation on implanted hydrogel intraocular lenses. Arch Ophthalmol 2001; 119:611– 614 6. Werner L, Apple DJ, Escobar-Gomez M, et al. Postoperative deposition of calcium on the surfaces of a hydrogel intraocular lens. Ophthalmology 2000; 107:2179–2185 7. Chang BYP, Davey KG, Gupta M, Hutchinson C. Late clouding of an acrylic intraocular lens following routine phacoemulsification. (letter) Eye 1999; 13:807– 808 8. 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 From the Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine (Kim, Koh), the Department of Ophthalmology, Inje University, Sanggye Paik Hospital (Kang), and the Department of Ophthalmology, Soonchunhyang University (Lee, Park), Seoul, Korea. None of the authors has a financial or proprietary interest in any product mentioned.
J CATARACT REFRACT SURG—VOL 28, JULY 2002
T
he ocular complications in Behc¸et’s disease consist of uveitis, cataract, and obliteration of retinal vessels. Because uveitis and steroid medication increase the incidence of cataract in Behc¸et’s disease, cataract is 1 of the most common complications that occurs in ocular Behc¸et’s disease.1 Phacoemulsification with intraocular lens (IOL) implantation is reported to be a safe procedure in patients with Behc¸et’s disease, although there could be an ocular inflammatory attack after the cataract surgery.2 Recently, foldable IOLs have been reported to be safe in uveitis patients.3 However, we report a patient with Behc¸et’s disease who had aggravated uveitis and opacification of an implanted hydrophilic acrylic IOL.
Ophthalmed) in May 2000. On examination, the visual acuity in the left eye was 5/200. Although the cornea was clear and the anterior chamber quiescent, the vitreous showed many cells behind a uniformly opacified IOL (Figure 1). Extensive vitreous opacity as well as opacification of the IOL hindered visualization of the fundus. Oral colchicine and steroid were prescribed; however, the vitreous reaction did not improve after 5 months of the maximum tolerable medication. A reaction began to occur in the anterior chamber. Because the patient wanted to stop the oral medication, IOL exchange and trans pars plana vitrectomy were planned.
Case Report A 62-year-old woman was referred because of uncontrolled inflammation after cataract surgery in September 2000. Behc¸et’s disease had been diagnosed in March 2000. The patient had uneventful cataract surgery in the left eye with implantation of a hydrophilic acrylic IOL (ACRL-C160, Accepted for publication March 12, 2002. Reprint requests to Hyoung J. Koh, MD, Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, 134 Shinchon-dong, Sodaemun-gu, Seoul, Korea, 120-752. E-mail: [email protected]. © 2002 ASCRS and ESCRS Published by Elsevier Science Inc.
Figure 1. (Kim) Photograph shows diffuse opacification of the ACRL-C160 IOL and a relatively quiescent anterior chamber. 0886-3350/02/$–see front matter PII S0886-3350(02)01356-1
CASE REPORTS: KIM
An infusion cannula was introduced into the inferotemporal sclera 3.5 mm from the limbus. After a corneoscleral incision was made, sodium hyaluronate (Healon威) was injected into the anterior chamber. A Vannas scissor was introduced into the anterior chamber, and the IOL was divided and removed. As the irrigating solution was introduced into the vitreous cavity, the vitreous opacity was removed. The vitreous opacity was dense, and there was a posterior vitreous detachment. After the vitreous opacity was removed, the inferior temporal retinal vessels were found to be occluded. A single-piece heparin-surface-modified poly(methyl methacrylate) (PMMA) IOL (CeeOn威, Pharmacia & Upjohn) was fixated in the ciliary sulcus. One week after surgery, the eye was quiescent. At 3 months, the visual acuity was 20/200. The explanted IOL, including the haptics, was diffusely opacified (Figure 2). Scanning electron microscopy of the cut section of the optic showed granular deposits in a region about 5.0 m beneath the anterior and posterior optic surfaces (Figure 3,A). Energy dispersive x-ray analysis was performed on the deposits in the same section and showed that calcium and phosphate peaks were present (Figure 3,B). However, there were no calcium or phosphate peaks in the surface and central area of the cut section (not shown).
ease had a hydrogel IOL. The patient’s visual acuity improved postoperatively. There are several reports of opacification of the Hydroview威 model H60M IOL (Bausch & Lomb)4 – 6 and the foldable hydrophilic acrylic lens SC60BOUV (MDR Inc.).7,8 We report opacification in a different type of hydrophilic acrylic IOL. Scanning electron microscopic findings and energy dispersive
Discussion Rauz and coauthors3 recently reported that implantation of foldable IOLs during phacoemulsification in eyes with uveitis was safe and comparable to previous reports of rigid surface-modified and unmodified PMMA IOLs. One panuveitis patient with Behc¸et’s dis-
Figure 2. (Kim) Clear (left) and explanted (right) ACRL-C160 IOL. During removal, the IOL was bisected. Both optic and haptic have diffuse opacification.
Figure 3. (Kim) A: Scanning electron microscopy of the cut section of the optic of an ACRL-C160 IOL. There are multiple granular deposits in a line beneath the external surface. B: Energy dispersive x-ray analysis shows calcium and phosphate peaks at the level of the granular deposits.
J CATARACT REFRACT SURG—VOL 28, JULY 2002
1277
CASE REPORTS: KIM
x-ray analysis suggest that the IOL opacification in our case was the result of granular deposits composed at least in part of calcium and phosphate within the IOL optic, similar to the opacification in the SC60BOUV IOL.8 It is not clear whether intraocular inflammation causes opacification of the hydrophilic acrylic IOL or the hydrophilic acrylic IOL causes an attack of intraocular inflammation in patients with Behc¸et’s disease. In our patient, the posterior uveitis was not relieved by colchicine and steroid medication; however, the eye became quiescent after an IOL exchange. Therefore, we think the responses may be associated with use of the hydrophilic acrylic IOL in Behc¸et’s disease. We do not know why the vitreous opacity with posterior reaction was so severe while the anterior segment was relatively quiescent. Behc¸et’s disease was diagnosed in our patient 2 months before cataract surgery. In this relatively short time, the retinal vessel occlusion is an unusual finding in Behc¸et’s disease. We think the vitreous reaction with resultant vessel occlusion of the inferior temporal retinal vessel occurred after cataract surgery. Although this case cannot be applied to all Behc¸et’s disease patients or all hydrophilic acrylic IOLs, we recommend caution in the use of this hydrophilic acrylic IOL in patients with Behc¸et’s disease. Patients with Behc¸et’s disease who have this IOL should be followed carefully.
1278
References 1. Ciftci OU, Ozdemir O. Cataract extraction in Behc¸et’s disease. Acta Ophthalmol Scand 1996; 74:74 –76 2. Matsuo T, Takahashi M, Inoue Y, et al. Ocular attacks after phacoemulsification and intraocular lens in patients with Behc¸et disease. Ophthalmologica 2001; 215:179–182 3. Rauz S, Stavrou P, Murray PI. Evaluation of foldable intraocular lenses in patients with uveitis. Ophthalmology 2000; 107:909 –919 4. Fernando GT, Crayford BB. Visually significant calcification of hydrogel intraocular lenses necessitating explantation. Clin Exp Ophthalmol 2000; 28:280 –286 5. Yu AKF, Shek TWH. Hydroxyapatite formation on implanted hydrogel intraocular lenses. Arch Ophthalmol 2001; 119:611– 614 6. Werner L, Apple DJ, Escobar-Gomez M, et al. Postoperative deposition of calcium on the surfaces of a hydrogel intraocular lens. Ophthalmology 2000; 107:2179–2185 7. Chang BYP, Davey KG, Gupta M, Hutchinson C. Late clouding of an acrylic intraocular lens following routine phacoemulsification. (letter) Eye 1999; 13:807– 808 8. 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 From the Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine (Kim, Koh), the Department of Ophthalmology, Inje University, Sanggye Paik Hospital (Kang), and the Department of Ophthalmology, Soonchunhyang University (Lee, Park), Seoul, Korea. None of the authors has a financial or proprietary interest in any product mentioned.
J CATARACT REFRACT SURG—VOL 28, JULY 2002