Complications while removing the IOLAB 91Z lens for the UGH-UGH+ syndrome

Exchange of IOGEL hydrogel one-piece foldable intraocular lens for bag-fixated J-loop poly(methyl methacrylate) intraocular lens

In 1990, IOGEL lenses placed in the capsular bag were reported to displace into the vitreous after neodymium:YAG (Nd:YAG) laser capsulotomy. We exchanged a bag-placed IOGEL lens in one patient after erroneous biometry and capsular opacification. The technique and results of lens explantation, aspiration of Elschnig pearls, and in-the-bag implantation of a modified J-loop poly(methyl methacrylate) (PMMA) lens are demonstrated. Removal of the soft and nonadhesive IOGEL lens was easy. The capsule pockets held patent by the flanges of the taco-style IOGEL lens allowed for easy insertion and bag fixation of the J-style loops. Visual acuity improved from 20/60 to 20/20. Centration of the exchange IOL was satisfactory. In a series of 61 Nd:YAG laser posterior capsulotomies, we did not observe the reported tendency of IOGEL lenses to luxate posteriorly. Therefore, we recommend Nd:YAG discission of the posterior capsule as the preferred approach to posterior capsule opacification with IOGEL lenses. However, the technical ease of the technique makes the explantation and replacement of IOGEL lenses by a bag-fixated PMMA IOL a valid option to correct an erroneous biometry.

The Binkhorst Medal Lecture. Biologic relationship between poly(methyl methacrylate) intraocular lenses and uveal tissue

Implantation of a poly(methyl methacrylate) (PMMA) intraocular lens (IOL) after cataract surgery is associated with breakdown of the blood-ocular barrier and a foreign body inflammatory response. Although the material is biocompatible, it is not inert. The history of PMMA IOL implantation has reflected mechanical, chemical, and immunological interactions between the IOL and ocular tissues. The common link in these events is instability of the blood-ocular barrier. In this lecture, I discuss the nature of these interactions and present evidence that currently investigated methods of surface modification and capsular bag IOL implantation are effective in stabilizing the blood-ocular barrier.

An analysis of flexible anterior chamber lenses with special reference to the normalized rate of lens explantation

A survey of 1204 closed-loop anterior chamber intraocular lenses (AC-IOLs) and 310 open-loop AC-IOLs accessioned between November 1982 and January 1990 was conducted at the Center for Intraocular Lens Research. An analysis of complication rates was done after normalization of data with respect to market share totals. The results establish that an unacceptable complication rate is associated with the closed-loop design when compared with either the tripod or quadripod lens styles. Furthermore, the closed-loop designs, while comprising an estimated 45% of the total number of AC-IOLs estimated to be implanted in the United States (n = 674,000), were responsible for 80% of the AC-IOLs explanted after complications and accessioned at the authors' center. A rethinking of the extreme condemnation of all anterior chamber IOLs that has surfaced in recent years is warranted. This is particularly true with respect to indications for use of sutured posterior chamber (PC) IOLs as well as with regard to possible use of open-loop AC-IOLs in less-industrialized nations.

Complications of sulcus-supported intraocular lenses with iris sutures, implanted during penetrating keratoplasty after intracapsular cataract extraction

In a retrospective study, the authors analyzed visual results and postoperative complications in a series of 14 consecutive patients who had undergone penetrating keratoplasty and implantation of a posterior chamber intraocular lens (PC IOL) in the absence of the posterior capsule. Seven patients suffered from aphakic bullous keratopathy and seven from pseudophakic bullous keratopathy. Postoperative follow-up was 7.6 months on the average. Best-corrected postoperative visual acuity was 20/60 or better in four cases and 20/200 or better in eight. Glaucoma was present before surgery in four eyes, which persisted in all cases and developed in four new cases. Results of gonioscopic examination showed the postoperative development of goniosynechiae in four eyes. Pseudophakodonesis of various extent was present in ten eyes. Preoperatively, cystoid macular edema was diagnosed angiographically in one case. It did not improve after surgery and was seen in three additional eyes postoperatively. Causes for postoperative visual acuity lower than 20/200 were cystoid macular edema in three cases, graft rejection in one case, central retinal scar in one case, and optic nerve atrophy in one case. A distortion of the pupil was seen in three eyes in miosis and in four additional eyes in mydriasis. Corneal thickness as well as anterior chamber depth were within normal limits. Fluorophotometric evaluation of the blood-aqueous barrier showed values comparable with those obtained after intracapsular cataract extraction and implantation of an iris-fixated IOL. Despite the relatively good visual results, the high postoperative incidence of cystoid macular edema and/or glaucoma may discourage the use of this technique.

Neodymium:YAG laser cutting of intraocular lens haptics in vitro and in vivo

Various complications following intraocular lens (IOL) surgery result in explantation of the lenses. Haptic fibrosis may necessitate cutting the IOL haptics prior to removal. In this study we used the neodymium: YAG (Nd:YAG) laser to cut polypropylene and poly(methyl methacrylate) (PMMA) haptics in vitro and in rabbit eyes. In vitro we were able to cut 100% of both haptic types successfully (28 PMMA and 30 polypropylene haptics). In rabbit eyes we were able to cut 50% of the PMMA haptics and 43% of the polypropylene haptics. Poly(methyl methacrylate) haptics were easier to cut in vitro and in vivo than polypropylene haptics, requiring fewer shots for transection. Complications of Nd:YAG laser use frequently interfered with haptic transections in rabbit eyes. Haptic transection may be more easily accomplished in human eyes.

Intraocular lens removal for chronic cystoid macular edema

Intraocular lenses were removed from ten eyes with chronic cystoid macular edema demonstrated by fluorescein angiography. No corneal transplantation was done at the time of intraocular lens removal. Five eyes achieved a visual acuity of 20/50 or better. Exchange for a posterior chamber intraocular lens did not appear to have an adverse affect compared to simple intraocular lens removal.

Intraocular lens removal during penetrating keratoplasty for pseudophakic bullous keratopathy

Pseudophakic bullous keratopathy is now the most common reason for penetrating keratoplasty. In previous reports, the type of intraocular lens (IOL) most frequently encountered in these eyes was the iris plane IOL. The authors reviewed 27 cases of IOL removal during penetrating keratoplasty. Lenses were removed if they were dislocated or associated with iritis, recurrent hyphema, glaucoma, or persistent cystoid macular edema. The IOL encountered most often was the anterior chamber lens (in 22 eyes); closed thin loop, semiflexible or flexible anterior chamber lenses accounted for 19 of these. Iris plane lenses were removed from five eyes. No posterior chamber lenses were removed. Clear grafts were obtained in 24 of 27 cases (89%); visual acuity improved or remained the same in 24 cases, to 20/60 in 11 cases. The most common causes of poor postoperative vision were retinal disease (6/27 cases) and glaucoma (6/27 cases). The association between anterior chamber lenses and pseudophakic bullous keratopathy is probably the result of both the increase in use of these lenses and the documented propensity of the closed loop semiflexible anterior chamber lenses to cause complications.

A survey of intraocular lens explantations

A survey of intraocular lens (IOL) explantations performed during the 1984 calendar year requested dates of implantation and explantation, lens manufacturer, and lens style for anterior chamber, posterior chamber, and iris-supported lenses. The survey was distributed to 3,640 members of the American Society of Cataract and Refractive Surgery and was published in the September 15, 1985, issue of Ocular Surgery News. Information on 1,087 IOL explantations performed during 1984 by approximately 530 surgeons was received. Extrapolation of our survey's responses to the universe of ophthalmic surgeons suggests that the number of IOL explantations ranges from 7,000 to 11,000 each year. The actual numbers and percentages of explantations as well as reported complications vary with the relative percentage of any given manufacturer's lenses implanted and with the popularity of lens styles during the preceding years of implantation. For these reasons, the individual performance of various lenses should be read in the context of this report, considering the time of implantation and the practices that were then in vogue. This survey provides a general picture of IOL explantation but, more importantly, it provides a better structure for a report on 1985 explantations, which will follow.

Additional long-term follow-up on the IOLAB Azar 91Z anterior chamber intraocular lens

A retrospective study of 98 91Z anterior chamber intraocular lenses used with intracapsular cataract extraction was performed. Minimum follow-up was 12 months and average follow-up was two years seven months. These patients were part of a group of 113 91Z patients previously reported with minimum six-months follow-up and an average of one year follow-up. Comparing the two groups showed the number of patients with 20/40 visual acuity declined from 84.1% to 67.4% and those with visual acuity less than 20/400 increased from 0.9% to 5.1%. The number of 91Zs explanted more than doubled from five (4.4%) to 11 (11.2%). Pseudophakic bullous keratopathy not present in the one-year follow-up group is occurring with longer follow-up. This study demonstrates an increasing incidence of inflammatory - hemorrhagic and corneal complications in 91Z patients.

Broken semiflexible intraocular lens implant

The haptic of a semiflexible anterior chamber intraocular lens (Kelman Quadraflex) broke inside the eye of a 70-year-old man. No history of major eye or head trauma could be elicited from the patient. Clinical manifestations included inferior corneal edema progressing toward the optical axis resulting from a free-floating haptic segment of the lens implant inside the anterior chamber. A significant decrease in endothelial density was documented over a short period of time. The surgical management of this case included removal of the free-floating haptic segment, removal of the lens implant, penetrating keratoplasty, and vitrectomy. Final visual acuity was 20/70.

Complications of intraocular lenses. A historical and histopathological review

Recent improvements in intraocular lens (IOL) design, manufacturing techniques, and surgical techniques have greatly reduced the incidence of complications following implantation, and many authors now consider IOL implantation to be among the most safe and effective major surgical procedures. However, adverse reactions are still seen--some as late sequelae of earlier IOL designs and implantation techniques and some as sequelae of more recent implantations using "state-of-the-art" lenses and surgical techniques. Complications may be due to various factors, including surgical technique, IOL design, or the inability of some eyes with preexisting disease to tolerate an implant. The authors trace the evolution of IOLs since Ridley's first implant, summarizing the modifications in lenses and surgical techniques that were made as complications were recognized. They then review the clinical and histopathological features of selected cases from more than 200 IOLs and/or globes removed due to IOL-related complications and studied in the University of Utah Ocular Pathology Laboratory. It is hoped that this review will provide insights into the pathogenesis of IOL complications, enhancing the current success of implant procedures and stimulating further basic and clinical research in this area.

A comparative study of the 91Z and other anterior chamber intraocular lenses

A retrospective study of 113 91Z anterior chamber intraocular lenses (IOLs) used with intracapsular cataract extraction (ICCE) was performed. The study compared operative complications, visual acuity at three and six or more months, and complications of the 91Z with other types of anterior chamber IOLs. The 91Z had a low incidence of operative complications, good short-term visual acuities, and few short-term complications. It had a high incidence of late, severe, inflammatory/hemorrhagic complications including uveitis-glaucoma-hyphema plus vitreous hemorrhage (UGH+ syndrome), cystoid macular edema, and iris chafing/bleeding. These complications necessitated removal of five lenses (4.5%). An additional 16 patients (14.2%) are under treatment for these late complications. This IOL was often difficult to remove without traumatizing the eye. I have not experienced these late complications with the other types of anterior chamber IOLs reported here; their long-term visual acuities were good and they were stable. None of them has been explanted.

Pathological and scanning electron microscopic evaluation of the 91Z intraocular lens

We analyzed 18 explanted 91Z anterior chamber lenses by light and scanning electron microscopy. Intermittent touch of the lens loops to the posterior corneal surface and the anterior chamber angle may have occurred. Erosion of the polypropylene loops into the anterior chamber angle recess and into the iris tissue was also observed. Fibrous tissue, uveal tissue, and inflammatory debris were noted on the loops, forming dense synechias at the points of contact with the angle recess. In some lenses the edges of the optics were sharp. Other significant manufacturing defects were rarely seen, and there was no evidence of degradation of polypropylene loops. The problems regarding surgical removal of this lens are discussed.