Opacification of hydrophilic intraocular lenses associated with vitrectomy and injection of intraocular gas

[Hydrophobic surface properties of hydrophilic acrylic lenses do not protect against calcification]

BACKGROUND

Opacification through calcification of hydrophilic acrylic intraocular lenses is a serious complication of cataract surgery, which usually results in explantation of the lens. In the process of calcification, the intraocular lens material plays a crucial role: calcification only occurs in hydrophilic acrylic lenses. Hydrophobic acrylic lenses show no crystal formation within the polymer. Hydrophilic acrylic lenses from some manufacturers have hydrophobic surface properties. The question arises as to what influence these surface properties have on the risk of calcification.

OBJECTIVE

The present study investigated whether the hydrophobic surface properties of hydrophilic acrylic lenses can prevent calcification.

MATERIAL AND METHODS

Using an electrophoretic in vitro model of calcification, two hydrophilic lenses with hydrophobic surface properties were compared to two hydrophilic lenses and a hydrophobic negative control to determine the risk of calcification. The lenses were then analyzed by optical microscopy, Alizarin Red and Von Kossa staining, scanning electron microscopy (SEM) and energy dispersive X‑ray spectroscopy (EDX).

RESULTS

All four hydrophilic lens models showed calcification within the polymer. No difference was found between the hydrophilic lenses and the hydrophilic lenses with hydrophobic surface properties in terms of crystal formation. The hydrophobic negative control showed no calcification.

CONCLUSION

The investigation conducted in this study under standardized conditions could show that hydrophobic surface properties of hydrophilic acrylic lenses do not protect against calcium phosphate crystal formation within the polymer. There also is a risk of calcification in these lens models.

FIL SSF intraocular lens opacification after pars plana vitrectomy with gas tamponade for traumatic lens luxation and retinal detachment: a case report and literature review

BACKGROUND

To report a case of sutureless scleral-fixated hydrophilic intraocular lens (FIL SSF IOL, Soleko, Italy) opacification following pars plana vitrectomy surgery using sulfur hexafluoride (SF6) for traumatic lens luxation associated with retinal detachment.

CASE PRESENTATION

A 77-year-old woman was referred to our emergency department after blunt trauma in her right eye. At the ophthalmic evaluation, visual acuity was hand movement, biomicroscopy showed pseudoexfoliation syndrome and a traumatic lens luxation in the vitreous chamber. The patient underwent pars plana vitrectomy, subluxated cataract explantation, and FIL SSF IOL implant. During surgery, an inferior retinal detachment was encountered, requiring 20% SF6 gas tamponade. No adverse events were encountered. One month postoperatively, visual acuity (BCVA) improved to 0,3 logMAR. At the 3-month follow-up, the patient presented with BCVA of 0,5 logMAR, and biomicroscopy showed a minimal IOL opacification. Six months postoperatively, BCVA decreased to 1.0 logMAR, and diffuse, IOL opacification was noted at slit lamp examination. The patient refused any other surgical intervention for IOL exchange.

CONCLUSIONS

Although hydrophilic IOL opacification gas related is known, to the best of our knowledge, this is the first case reported in the literature of FIL SSF IOL opacification after pars plana vitrectomy with gas tamponade for retinal detachment.

Opacification of Hydrophilic Acrylic Intraocular Lenses: Overview of Laboratory Methods for Histological Analysis and Replication of IOL Calcification

Opacification of intraocular lenses (IOLs) due to material changes is a serious complication that can compromise the good visual outcomes of uncomplicated cataract surgery. In hydrophobic acrylic IOLs, opacification can result from glistening formation, while in hydrophilic acrylic IOLs, there is a risk of calcification due to the formation of calcium phosphates within the polymer. Over time, various methods have been developed to investigate calcification in hydrophilic acrylic IOLs. The aim of this article is to provide an overview of standard histological staining and models used to simulate IOL calcification. Histological staining can be used to detect calcification and assess the extent of crystal formation. The development of in vivo and in vitro replication models has helped to identify the underlying pathomechanisms of calcification. In vivo models are suitable for assessing the biocompatibility of IOL materials. Bioreactors as an in vitro model can be used to investigate the kinetics of crystal formation within the polymer. The replication of IOL calcification under standardized conditions using electrophoresis allows for the comparison of different lens materials with respect to the risk of calcification. The combination of different analytical and replication methods can be used in the future to further investigate the pathomechanisms of calcium phosphate crystal formation and the influence of risk factors. This may help to prevent calcification of hydrophilic acrylic IOLs and associated explantation and complications.

Clinical Characteristics of Patients with Intraocular Lens Calcification after Pars Plana Vitrectomy

AIM

To determine the clinical risk factors that may increase the occurrence of intraocular lens (IOL) calcification in patients who had undergone pars plana vitrectomy (PPV).

METHODS

The medical records of 14 patients who underwent IOL explantation due to clinically significant IOL opacification after PPV were reviewed. The date of primary cataract surgery, technique and implanted IOL characteristics; the time, cause and technique of PPV; tamponade used; additional surgeries; the time of IOL calcification and explantation; and IOL explantation technique were investigated.

RESULTS

PPV had been performed as a combined procedure with cataract surgery in eight eyes and solely in six pseudophakic eyes. The IOL material was hydrophilic in six eyes, hydrophilic with a hydrophobic surface in seven eyes and undetermined in one eye. The endotamponades used during primary PPV were C2F6 in eight eyes, C3F8 in one eye, air in two eyes and silicone oil in three eyes. Two of three eyes underwent subsequent silicone oil removal and gas tamponade exchange. Gas in the anterior chamber was detected in six eyes after PPV or silicone oil removal. The mean interval between PPV and IOL opacification was 20.5 ± 18.6 months. The mean BCVA in logMAR was 0.43 ± 0.42 after PPV, which significantly decreased to 0.67 ± 0.68 before IOL explantation for IOL opacification (p = 0.007) and increased to 0.48 ± 0.59 after the IOL exchange (p = 0.015).

CONCLUSIONS

PPV with endotamponades in pseudophakic eyes, particularly gas, seems to increase the risk for secondary IOL calcification, especially in hydrophilic IOLs. IOL exchange seems to solve this problem when clinically significant vision loss occurs.

Trans-Scleral Plugs Fixated FIL SSF IOL: A Review of the Literature and Comparison with Other Secondary IOL Implants

Purpose. To revise the current literature on FIL SSF (Carlevale) intraocular lens, previously known as Carlevale lens, and to compare their outcomes with those from other secondary IOL implants. Methods. We performed a peer review of the literature regarding FIL SSF IOLs until April 2021 and analyzed the results only of articles with a minimum of 25 cases and a follow-up of at least 6 months. The searches yielded 36 citations, 11 of which were abstracts of meeting presentations that were not included in the analysis because of their limited data. The authors reviewed 25 abstracts and selected six articles of possible clinical relevance to review in full text. Of these, four were considered to be sufficiently clinically relevant. Particularly, we extrapolated data regarding the pre- and postoperative best corrected visual acuities (BCVA) and the complications related to the procedure. The complication rates were then compared with those from a recently published Ophthalmic Technology Assessment by the American Academy of Ophthalmology (AAO) on secondary IOL implants. Results. Four studies with a total of 333 cases were included for results analysis. The BCVA improved in all cases after surgery, as expected. Cystoid macular edema (CME) and increased intraocular pressure were the most common complications, with an incidence of up to 7.4% and 16.5%, respectively. Other IOL types from the AAO report included anterior chamber IOLs, iris fixation IOLs, sutured iris fixation IOLs, sutured scleral fixation IOLs, and sutureless scleral fixation IOLs. There was no statistically significant difference in the rates of postoperative CME (p = 0.20), and vitreous hemorrhage (p = 0.89) between other secondary implants and the FIL SSF IOL, whereas the rate of retinal detachment was significantly less with FIL SSF IOLs (p = 0.04). Conclusion. The results of our study suggest the implantation of FIL SSF IOLs is an effective and safe surgical strategy in cases where there is a lack of capsular support. In fact, their outcomes seem to be comparable to those obtained with the other available secondary IOL implants. According to published literature, the FIL SSF (Carlevale) IOL provides favorable functional results with a low rate of postoperative complications.

Outcomes of Pars Plana Vitrectomy and 4-Point Sutured Scleral Fixation of Akreos AO60 Intraocular Lens in Clinical Settings: A Case Series

PURPOSE

To determine the long-term anatomic outcomes and surgical complications of pars plana vitrectomy (PPV) and 4-point Gore-Tex-sutured Akreos AO60 intraocular lens (IOL) scleral fixation.

DESIGN

Retrospective, multicenter, multisurgeon case series.

PARTICIPANTS

Ninety-seven patients in tertiary eye care centers.

METHODS

The patients underwent PPV and intraocular fixation of the Akreos AO60 IOL using Gore-Tex CV-8 sutures between January 2015 and April 2020. The inclusion criteria were aphakia, no capsular support, and a minimal 1 year of follow-up.

MAIN OUTCOME MEASURES

Uncorrected visual acuity (VA), complication rates or types, and refraction.

RESULTS

Data from 101 eyes of the 97 patients were analyzed (mean follow-up duration, 33.4 months; range, 12-62 months). The mean ± standard deviation uncorrected logarithm of the minimum angle of resolution VA improved from 1.04 ± 0.73 (20/200 Snellen equivalent) before surgery to 0.66 ± 0.65 (20/80) at 6 months after surgery (P < 0.001). The most prevalent complications included hypotony (12.9%), ocular hypertension (12.9%), corneal edema (8.9%), cystoid macular edema (6.9%), and vitreous hemorrhage (5.9%). Refraction was measured between 3 and 6 months after surgery, and 61.8% of the patients had spherical equivalent of ± 2.0 diopters. Most complications occurred in the first postoperative month and resolved spontaneously or with medical treatment.

CONCLUSIONS

The results demonstrated that this surgical technique is well tolerated by the eyes, with a low complication rate in the long term. The rates of IOL opacification were infrequent for up to 62 months of follow-up.

Camellens FIL622-1 IOL Implantation in the Ciliary Sulcus: Refractive Outcomes and Optimization of A-constant

PURPOSE

To assess the refractive outcomes of patients who had sulcus implantation of the Camellens FIL622-1 intraocular lens (IOL) (Soleko) after posterior capsular rupture, and to optimize the A-constant suggested by the manufacturer.

METHODS

This study included patients who underwent secondary Camellens FIL622-1 IOL implantation in the ciliary sulcus after complicated cataract surgery with posterior capsular rupture. IOL power was calculated by the SRK/T formula, using the recommended A-constant (118.8) for ciliary sulcus implantation. A new optimized A-constant was obtained and used to evaluate the refractive outcomes. The main outcome measures were mean prediction error (PE), median absolute error (MedAE), mean absolute error (MAE), and percentage of eyes with a PE within ±0.50, ±1.00, and ±2.00 diopters (D).

RESULTS

Forty patients (40 eyes) were included in the study. The new optimized A-constant was 117.5, and the mean PE, MedAE, and MAE was -0.02 ± 0.73, 0.34, and 0.54, respectively. The percentage of eyes with a PE within ±0.50, ±1.00, and ±2.00 D was 65%, 87.5%, and 100%, respectively.

CONCLUSIONS

The Camellens FIL622-1 IOL represents a valid option as sulcus implantation after posterior capsular rupture and it would guarantee the surgeon an on-label option with a more accurate biometric calculation, at the time of surgical implantation, with the new optimized A-constant. [J Refract Surg. 2022;38(12):806-811.].

Development of a standardized in vitro model to reproduce hydrophilic acrylic intraocular lens calcification

Opacification through calcification of hydrophilic acrylic intraocular lenses (IOL) is a severe complication after cataract surgery. Causing symptoms that range from glare through to severe vision loss, the only effective therapy is explantation of the opacified IOL so far. Although IOL calcification is a well-described phenomenon, its pathogenesis is not fully understood yet. The purpose of the current study was to develop a laboratory model to replicate IOL calcification. Calcification could be reproduced using a horizontal electrophoresis and aqueous solutions of calcium chloride and disodium hydrogen phosphate. The analysis of the in vitro calcified IOLs was performed using light microscopy, Alizarin Red and Von Kossa staining, scanning electron microscopy, energy dispersive x-ray spectroscopy and electron crystallography using transmission electron microscopy and electron diffraction. The presented laboratory model could be used to identify hydrophilic IOLs that are at risk to develop calcification and to assess the influence of associated risk factors. In addition, it can serve as a research tool to further understand this pathology.

Should We Abandon Hydrophilic Intraocular Lenses?

PURPOSE

To characterize the features of hydrophilic intraocular lenses (IOLs) important in the clinical context of expected prolonged duration time of the IOL within the eye.

DESIGN

Perspective.

METHODS

Discussion includes possible factors and mechanisms associated with hydrophilic IOLs' susceptibility to calcification and posterior capsule opacification (PCO) formation.

RESULTS

Results of recently reported studies show that particular surgeries, such as pars plana vitrectomy, Descemet stripping (automated) endothelial keratoplasty, and Descemet membrane endothelial keratoplasty with intraocular gas or air injection, might predispose the calcification process of hydrophilic IOLs, leading to a significant decrease in visual quality and possibly explantation of the IOL. Hydrophilic IOLs are more susceptible than hydrophobic IOLs to PCO formation, which is the most common of late postoperative complications that are associated with significant side effects.

CONCLUSIONS

We believe that all patients should be informed about the higher risk of calcification and PCO associated with hydrophilic IOLs. We also recommend limiting the use of hydrophilic acrylic IOLs during cataract surgery, especially when it is combined with pars plana vitrectomy or endothelial keratoplasty, and in patients with endothelial diseases who will probably require operation on it in the future.

Laboratory and Clinical Experience With a Diffractive Trifocal Intraocular Lens Sutured to an Artificial Iris

PURPOSE

To determine in vitro, using a translational research approach before realizing the procedure in a patient with iatrogenic aphakia and partial aniridia, whether suturing a trifocal intraocular lens (IOL) to an artificial iris degrades the IOL's optical quality.

METHODS

Optical quality was analyzed by measuring the modulation transfer function (MTF) at a 3-mm aperture and at 50 and 100 lp/mm spatial frequencies. The FineVision Pod F GF IOL (PhysIOL) was assessed in two powers: two +20.00 diopters (D) (20A and 20B IOLs) and two +30.00 D (30A and 30B IOLs). The IOLs' decentration in relation to the artificial iris's center was evaluated. The laboratory results provided empirical evidence in the informed consent for surgical intervention in a patient with iatrogenic aphakia and iris defect in one eye. Clinical results were measured using the parameter of corrected distance visual acuity plus a patient self-assessment of the cosmetic appearance of the operated eye.

RESULTS

The 20A and 20B IOLs demonstrated a mean MTF reduction of up to 1.1%, whereas the 30A and 30B IOLs showed a decrease of up to 5.2% for both spatial frequencies. All lenses showed good centration levels. In the clinical case, the patient showed corrected distance visual acuity, distance-corrected near visual acuity, and distance-corrected intermediate visual acuity of 0.20, 0.20, and 0.22 logMAR, respectively. The patient was satisfied with the cosmetic outcome.

CONCLUSIONS

There was merely a slight reduction in trifocal IOL optical quality after it was sutured to an artificial iris. Clinically, the combined implantation of the artificial iris and FineVision IOL provided good functional and cosmetic outcomes. [J Refract Surg. 2022;38(1):61-68.].

Multifocal IOL explantation in patients with opaque lentis after refractive lens exchange

PURPOSE

We describe the outcomes of intraocular lens (IOL) explantation in a cluster of opaque multifocal Lentis LS-313 following refractive lens exchange (RLE).

METHODS

Single-centre, single-surgeon, retrospective case series.

RESULTS

The study enrolled 10 eyes of 10 patients, 6 male and 4 female. All patients had uneventful RLE with multifocal IOL implantation. The mean patient age at the time of RLE was 53 years ± 2.52 (SD). Two eyes had YAG laser capsulotomy prior to explantation. The mean interval between the initial RLE and IOL explantation was 5.4 years ± 1.4 (SD). IOL exchange was performed in all eyes in one procedure. Five eyes had in the bag hydrophobic acrylic IOL (3 multifocal and 2 monofocal), three eyes had 3-piece hydrophobic acrylic IOL in the ciliary sulcus and two had an anterior chamber IOL. Intraoperatively one patient had weak zonules and two patients had zonular dehiscence and required anterior vitrectomy. The mean preoperative CDVA was 0.25 ± 0.15 (SD) logMAR and at the final follow-up, improved to 0.00 ± 0.07 (SD) logMAR (p < 0.01). Light microscopy with von Kossa stain confirmed IOL calcification. No postoperative complications were recorded.

CONCLUSIONS

IOL exchange appears to be a feasible and safe surgical option for multifocal IOL opacification. However, patients must be warned of additional intraoperative risks including zonular dialysis, vitreous loss, retinal detachment and need for potential scleral or iris fixated IOL or anterior chamber IOL (ACIOL) with its associated sequel of complications. Moreover, YAG laser capsulotomy should be considered carefully as it increases the chances of intraoperative complications and restricts the surgical options of secondary IOL insertion such as in-the-bag IOL exchange with MFIOL.

Visualization of Forward Light Scatter in Opacified Intraocular Lenses and Straylight Assessment

Background: Qualitative visualization of forward light scatter and quantitative straylight measurement of intraocular lenses (IOLs). Methods: We analyzed two calcified IOL-explants, the Euromaxx ALI313Y (Argonoptics GmbH) and the LS-312 MF30 (Oculentis BV), one IOL with artificially induced glistenings (PC-60AD, Hoya), and one control (CT Asphina 409MP, Carl Zeiss Meditec AG) free of any opacification. Analysis included light microscopy, qualitative light scatter visualization using ray propagation imaging technique, and quantitative straylight measurement using C-Quant (Oculus). Results: More light scattering effect—visible as increased light intensity outside the IOL’s main focus—was evident in all opacified IOLs than the control. The highest straylight levels were observed in the Euromaxx (289.71 deg²/sr), which showed extensive granular deposits throughout its optic, followed by the MF30 (78.58 deg²/sr), which only showed opacification in its center. The glistenings-IOL demonstrated numerous microvacuoles within the optic and had straylight levels of 22.6 deg²/sr, while the control showed the lowest straylight levels (1.7 deg²/sr). Conclusions: Ray propagation imaging technique allowed qualitative assessment of off-axis veils of light that result from increased forward light scattering. Straylight was increased in all opacified lenses compared to the clear control lens. The IOL opacifications are significant sources of glare.

Intraocular lens explantation following cataract surgery: Indications, techniques, and video demonstrations

As techniques for modern cataract surgery have expanded and premium intraocular lens (IOL) use is now widespread, patient expectations are high. The need for IOL explantation, whilst still low, remains an ongoing issue. Intraocular lens explantation can be challenging for a number of reasons and as such we have introduced an additional technique to add to the surgeon's repertoire. Bimanual haptic stripping of fibrosis at the specific area where the haptic is adherent to the capsular bag is an effective strategy to aid in dissection of haptics without compromising the capsule or zonules. Given the challenges associated with IOL explantation, newly designed IOLs need to avoid these "sticking points" at which the IOLs interact with the fibrosed capsule. Techniques we have evolved and which are described below should assist anterior segment surgeons to facilitate IOL removal in an efficient and safe way.

[Intraocular lens opacification after combined cataract and minimally invasive glaucoma surgery (MIGS)]

Drei Wochen nach komplikationsloser kombinierter minimal-invasiver Glaukom- und Kataraktoperation kam es zu einer Sehverschlechterung durch die Eintrübung der Intraokularlinse. Durch die Nichtanwendung der postoperativen antiinflammatorischen Lokaltherapie kam es zu einer homogenen Fibrinbildung auf der Linsenvorderfläche sowie einer beginnenden Vernarbung des Sickerkissens. Wir führten ein Needling mit 5‑Fluorouracil sowie eine Linsenpolitur mit dem Nd:YAG-Laser durch und erreichten so eine suffiziente Druckkontrolle und Sehverbesserung.

[Opacification of Intraocular Lenses]

The spectrum of complications in the use of intraocular lenses (IOL) is different today from at the time of their introduction. Opacities in the IOL material are increasingly described in the literature as a reason for IOL explantation. This paper provides an overview of the different forms of IOL material opacities. Currently relevant forms of IOL material opacities and their effects on optical quality are summarized. The main reason for opacification in hydrophilic IOLs is calcification, whereas in hydrophobic IOLs it is mainly the formation of so-called glistenings that is reported. Most material opacities affect various optical parameters and lead to increased intraocular straylight. In case of a disturbing material opacification, the only therapeutic option is to replace the opacified IOL.

Eintrübung von Intraokularlinsen

Das Spektrum an Komplikationen und die Explantationsgründe bei der Verwendung von Intraokularlinsen (IOL) haben sich durch die Weiterentwicklung der Kataraktchirurgie verändert. Eintrübungen des Materials beeinflussen dabei unterschiedlich stark die optische Qualität. Im Fall einer störenden Eintrübung des Materials ist auch heute noch – trotz aller Fortschritte auf dem Gebiet der IOL-Materialien – ein Austausch der IOL die einzige Behandlungsoption.

Incidence and Risk of Scleral-Fixated Akreos (AO60) Lens Opacification: A Case Series

Purpose:

Postoperative hydrophilic intraocular lens opacification can lead to decreased vision and may require intraocular lens exchange. This study aims to identify the incidence of scleral-fixated Akreos AO60’s (Bausch + Lomb) lens opacification and risk factors for this phenomenon.

Methods:

This is a retrospective case series of all patients who underwent scleral-fixated Akreos AO60 lens at our institution between January 1, 2015 and December 31, 2019. The following data were recorded: age, sex, medical history, indication for Akreos AO60 implantation, laterality, ocular history, previous ocular surgical procedures, subsequent intraocular surgical procedures after the Akreos implantation, lens opacification, visual significance of opacification, and Akreos explantation. Intraoperative and postoperative complications were recorded. Main outcome measures were the overall incidence of Akreos lens opacification as well as the incidence of these eyes undergoing subsequent intraocular surgery.

Results:

A total of 262 eyes of 257 patients underwent Akreos lens implantation. Overall, 2% (5 of 262) developed lens opacification. Two patients had Descemet stripping automated endothelial keratoplasty (DSAEK) concurrently with Akreos implantation. One patient underwent subsequent Baerveldt glaucoma implantation and DSAEK. The fourth patient had vitrectomy with sulfur hexafluoride gas followed by DSAEK. This represents a 25% (4 of 16) opacification rate among all patients who underwent DSAEK ( P ≤ .01, Fisher exact test). One patient developed opacification after undergoing 2 vitrectomies for retinal detachment in the absence of DSAEK.

Conclusions:

Akreos lens opacification can be visually significant and may occur after a retinal or corneal procedure that involves the use of intraocular gas or air.

Analysis of opacification patterns in intraocular lenses (IOL)

Objective

Intraocular lens (IOL) opacification may cause severe visual impairment. The pathogenesis remains unclear. The aim of this study was to analyse opacification patterns in different IOLs. Therefore, this multicentre, retrospective, observational study was conducted at Ludwig-Maximilians-University, Munich, Germany and University-Hospital Basel, Switzerland.

Methods and analysis

In this study, 75 opacified IOLs were identified and classified after extraction. Macroscopical photo documentation, light and electron microscopic analysis were done.

Results

68 acrylic-hydrophilic single-piece-IOLs, 1 acrylic-hydrophilic 3-piece-IOL, 6 acrylic-hydrophobic 3-piece-IOLs were extracted. The dataset comprised IOLs known for opacification and IOLs not having been reported yet. 67 IOLs showed a fine-granular and 8 IOLs a crust-like opacification pattern. According to literature, 62 of the fine-granular opacified IOLs were graded into type 1 (processing/packaging-induced primary opacification) and 13 into type 2 (secondary opacification of unknown aetiology). The anterior surface of the IOLs was affected in all 75 IOLs, the posterior surface only in 23 cases. Of all 67 fine-granular IOLs, 43 had a central defect and 21 had a zone without opacification (clear islet).

Conclusion

In our series, the morphology of IOL opacification did not follow the existing pathogenetic classification that strictly discriminates between primary and secondary causes. Fine-granular IOL opacification occurs with similar patterns in both type 1 and type 2 IOL opacification, while a crust-like pattern was only detected in type 2 IOL opacifications. Consequently, susceptibility of an IOL to opacification is caused by a multifactorial combination of material and processing properties as well as individual (pathological) conditions of the patient.

A rare intraocular lens surface foreign body during phacoemulsification surgery: A case report

RATIONALE

Only a few cases of intraocular lens (IOL) opacification during phacoemulsification surgery have been reported in the literature; intraoperative emergency due to IOL surface foreign body is even rarer.

PATIENT CONCERNS

A 76-year-old woman underwent uncomplicated cataract surgery in her right eye. A triangular transparent seemingly foreign body tightly attached to the posterior surface of the IOL was found during IOL implantation; the IOL surface foreign body prevented the patient from obtaining satisfactory visual acuity after surgery.

DIAGNOSIS

IOL surface foreign body.

INTERVENTIONS

After confirmation of the surface foreign body by swept-source optical coherence tomography (IOL Master 700), the surface foreign body was removed in a second surgery. After surgery, the IOL was still well centered.

OUTCOMES

Fortunately, the patient achieved distinctly improved vision without any visual disturbances in her right eye. To identify the material of the foreign body, it was examined by Fourier-transform infrared spectroscopy (FTIR).

LESSONS

This case suggests that surgeons should carefully observe IOLs before implantation. In addition, effective preoperative planning and skillful surgery can remove foreign bodies smoothly and improve patient vision.

A review of late intraocular lens opacifications

PURPOSE OF REVIEW

Phacoemulsification cataract surgery is one of the most commonly performed surgical procedure worldwide. In the majority of cases, intraocular lenses (IOLs) are implanted. Due to the increasing life expectancy and the fact that cataract surgery is performed in earlier stages, the anticipated IOL duration in the eye has increased over the last decades. The aim of this study was to review the types and describe the characteristics of late intraocular lens opacifications.

RECENT FINDINGS

Calcification was the most commonly reported type of opacification in hydrophilic IOLs; it usually negatively impacted the visual function and required IOL explantation. Glistening manifested in hydrophobic acrylic lenses and was frequent in some IOL models. In most cases glistening and subsurface nanoglistenigs do not lead to a decline in visual acuity or require IOL exchange. Current studies indicate that fluid-related phenomena may induce straylight, leading to a decrease of comfort and quality of vision.

SUMMARY

Several reports on late IOL opacifications have been published in recent years. In some cases, particularly in glistening, the development of the opacifications might be related to IOL aging. The influence of the fluid-related microvacuoles on the quality of vision requires further research.

[Opacification of intraocular lenses: laboratory and clinical findings]

Hintergrund

Das Spektrum der Komplikationen beim Einsatz von Intraokularlinsen (IOL) ist heute ein anderes als zur Zeit ihrer Einführung. Trübungen im IOL-Material werden vermehrt als Explantationsgrund in der Literatur beschrieben.

Ziel der Arbeit

Diese Arbeit soll einen Überblick über die verschiedenen Formen von IOL-Materialeintrübungen geben.

Material und Methoden

Die heute relevanten Formen von IOL-Materialeintrübungen und deren Auswirkungen auf die optische Abbildungsqualität wurden zusammengestellt.

Ergebnisse und Diskussion

Als Grund für eine Eintrübung steht bei hydrophilen IOL die Kalzifikation im Vordergrund, während bei hydrophoben IOL v. a. über die Entstehung sog. „Glistenings“ berichtet wird. Die meisten Materialeintrübungen beeinflussen verschiedene optische Parameter und führen zu einem erhöhten intraokularen Streulicht. Im Falle einer störenden Materialeintrübung besteht die einzige Therapieoption in einem Austausch der eingetrübten IOL.

A narrative review of intraocular lens opacifications: update 2020

The opacifications of intraocular lenses (IOLs) can significantly impact patients visual quality. Despite the identification of specific risk factors, manufacturing changes, opacifications are not eliminated. Likewise, more attention in recent studies was paid to possible new risk factors, however one of the most important purposes of the studies remains opacifications effect on visual performance, which could be disturbed in different aspects. The aim of this review is to discuss the main risk factors of IOLs opacification in particular IOL types, and its impact on vision quality. Different risk factors were discussed in the study, including the material of IOLs, the impact of the breakdown of blood-aqueous barrier (BAB), and certain surgeries that can be associated with opacification formation. Glistenings occur more often in a hydrophobic material, however, the changes in water content of the IOLs can significantly reduce the formation of glistenings. The studies showed a significant effect of intraocular injection of exogenous air or gas during Descemet-stripping endothelial keratoplasty, Descemet-stripping automated endothelial keratoplasty, Descemet membrane endothelial keratoplasty, and pars plana vitrectomy on calcification formation. It raises a concern, as the incidence of these surgeries is increasing. Visual acuity decreases significantly after the calcification in IOLs occurs, and it usually causes IOLs exchange. However, disability glare seems to be more affected in patients with IOLs, which were affected by glistenings than visual acuity. Disability glare is associated with increased levels of straylight, which was widely evaluated in recent studies and it was reported to be a susceptible measurement to detect the presence of IOLs pathology. For future researches, it should be noticed that disability glare and straylight are more appropriate in evaluating IOLs opacification effect on visual quality than visual acuity. While reviewing the main risk factors of IOLs opacifications particular attention must be paid on calcification occurrence in hydrophilic acrylic IOLs after surgeries with intraocular injection of exogenous air or gas.

Physicochemical Analysis of Sediments Formed on the Surface of Hydrophilic Intraocular Lens after Descemet's Stripping Endothelial Keratoplasty

An intraocular lens (IOL) is a synthetic, artificial lens placed inside the eye that replaces a natural lens that is surgically removed, usually as part of cataract surgery. The opacification of the artificial lens can be related to the formation of the sediments on its surface and could seriously impair vision. The physicochemical analysis was performed on an explanted hydrophilic IOL and compared to the unused one, considered as a reference IOL. The studies were carried out using surface sensitive techniques, which can contribute to a better understanding of the sedimentation process on hydrophilic IOLs’ surfaces. The microscopic studies allowed us to determine the morphology of sediments observed on explanted IOL. The photoelectron spectroscopy measurements revealed the presence of organic and inorganic compounds at the lens surface. Mass spectroscopy measurements confirmed the chemical composition of deposits and allowed for chemical imaging of the IOL surface. Applied techniques allowed to obtain a new set of information approximating the origin of the sediments’ formation on the surface of the hydrophilic IOLs after Descemet’s stripping endothelial keratoplasty.

Variation in intraocular lens calcification under different environmental conditions in eyes with supplementary sulcus-supported lenses

Purpose

Analysis of explanted intraocular lenses (IOLs) from pseudophakic eyes with supplementary sulcus-supported IOLs.

Methods

In this laboratory investigation, ten supplementary and capsular bag IOLs were analyzed. All lenses were received between January 2012 and March 2018. Explants were examined morphologically with histological and electron microscopic techniques and patients’ medical history was evaluated. Additionally, we used a technique new to this field: Transmission Electron Microscopy and electron diffraction pattern analysis was performed to investigate the structure of the opacifying crystals in detail.

Results

Eleven lenses were explanted due to IOL opacification from seven polypseudophakic eyes: In three cases the supplementary lens calcified, in three cases the capsular bag IOL (both lenses analyzed) and in one case both IOLs (only the supplementary was received). Additional surgical procedures and comorbidities included pars plana vitrectomy or Descemet stripping endothelial keratoplasty and diabetes mellitus. For each opacified lens, a varying layer of a Calcium phosphate beneath the optic surface was apparent. Crystal characterization revealed its composition to be Hydroxyapatite.

Conclusions and Importance

We report on a series of secondary calcification in lenses explanted from polypseudophakic eyes. In some cases, calcification occurred in the capsular bag lens, in other cases in the supplementary lens, or in both. The severity of the morphological change could be related to the comorbidities and the presence of surgery subsequent to the lens implantations. Detailed morphology of the opacifying crystals was revealed.

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Intraocular lenses exhibited calcification in a series of polypseudophakic eyes.

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Pathology occurred in the capsular bag lens, the supplementary lens, or in both.

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Calcification was associated with different environmental factors.

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Depending on the factor, morphology and pattern of the opacity differed.

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Transmission Electron Microscopy revealed the opacifying crystals' ultrastructure.

Toric Lentis Mplus intraocular lens opacification: A case report

Purpose

To present the case of a patient with Toric Lentis Mplus intraocular lens (IOL) (Oculentis, Berlin, Germany) opacification after vitrectomy and his follow-up.

Observations

A 44-year-old man with high myopia and right optic neuritis history complained of visual impairment due to cataract in the right eye. We performed uneventful phacoemulsification and implanted a Toric Lentis Mplus IOL in his right eye. Six months later, he came to us with a retinal detachment in the nasal area of the right eye. We performed a 25-gauge vitrectomy with gas tamponade and endolaser treatment. Ten months after the vitrectomy, he complained of blurred vision in the right eye again. On slit-lamp examination, we observed a wide opacification localized to the anterior surface of the IOL. We explanted the IOL from the right eye and replaced it with a Clareon IOL (Alcon, Fort Worth, TX). The explanted IOL was examined under light microscopy and scanning electron microscopy.

Conclusions and importance

We described a case of postoperative opacification of Toric Lentis Mplus IOL after vitrectomy. We found calcium aggregate deposits on the anterior surface of the IOL. Given the higher frequency of fundus disease observed in patients with high myopia, hydrophilic acrylic IOLs should be used with caution in patients with high myopia and in young patients. To our knowledge, this is the first report of Toric Lentis Mplus IOL opacification after the 2017 Field Safety Notice by Oculentis in response to the Food and Drug Administration's recall.

Subsurface calcification of hydrophilic refractive multifocal intraocular lenses with a hydrophobic surface: A case series

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.

Clinical and material degradations of intraocular lenses: A review

PURPOSE

To review the published scientific literature concerning clinical and material degradations of intraocular lenses after implantation in cataract surgery.

METHODS

A search was undertaken using the following databases: CENTRAL (including Cochrane Eyes and Vision Trials Register; The Cochrane Library: Issue 2 of 12 February 2019), Ovid MEDLINE (R) without Revisions (1996 to February week 2, 2019), Ovid MEDLINE (R) (1946 to February week 2, 2019), Ovid MEDLINE (R) Daily Update 19 February 2019, MEDLINE and MEDLINE non-indexed items, Embase (1980-2019, week 7), Embase (1974-2019, 19 February), Ovid MEDLINE (R) and Epub Ahead of Print, in-Process & Other Non-Indexed Citations and Daily (1946 to 19 February 2019), Web of Science (all years), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Only published articles in English were selected. Search terms/keywords included 'IOL' or 'intraocular lens', combined with 'opacification', degradation, glistenings, nanoglistenings, whitening, transmittance, light scatter, discolouration/discoloration, performance, quality, material, biocompatibility, calcification, explantation and ultraviolet/UV radiation. Relevant in-article references not returned in our searches were also considered.

RESULTS

After review of the available articles, the authors included 122 publications in this review, based on the quality of their methodology and their originality. The studies included in this review were randomized controlled trials, cohort studies, case-controlled studies, case series, case reports, laboratory studies and review papers. Differing material degradations of intraocular lenses have been described and their associated pathophysiology studied. Reported anomalies include photochemical alterations, water vacuoles, internal and surface calcific deposits, surface coatings and discolouration. The nature of such changes has been shown to depend on the type of intraocular lenses material used and/or manufacturing processes and storage conditions employed. Changes in the intraocular lens can also be influenced by surgical technique, coexisting ocular pathologies and topical and systemic medications. The clinical significance of these degradations is variable, with some resulting in significant visual disturbance and the need for intraocular lens explantation and others producing only minimal visual impairments. Failure to recognize the precise nature of the problem may lead to unnecessary laser capsulotomy procedures.

CONCLUSION

Clinical degradations of intraocular lenses are uncommon but have been reported following the implantation of intraocular lenses made of differing biomaterials. Their correct identification and thorough investigation to determine the underlying cause is necessary for optimal patient management and the prevention of such problems. Choosing a lens made of a particular material may be important in patients with certain ocular conditions.