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BRIEF COMMUNICATION
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 126-128

Delayed complete opacification of intraocular lens


Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India

Date of Submission30-Apr-2021
Date of Decision08-Aug-2021
Date of Acceptance25-Aug-2021
Date of Web Publication1-Dec-2022

Correspondence Address:
Rajesh Subhash Joshi
77, Panchatara Housing Society, Manish Nagar, Somalwada, Nagpur - 440 015, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_64_21

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  Abstract 


A 70-year-old male farmer underwent cataract surgery by the phacoemulsification technique 6 years ago. The patient has experienced diminished vision for the last 6 months. Slit-lamp biomicroscopy demonstrated significant opacification of the optic and haptic portion of the intraocular lens (IOL). The IOL was explanted followed by implantation of a polymethyl methacrylate IOL. The vision improved to 20/30 postoperatively. No IOL opacification was observed at follow-up visits. Histopathological evaluation of the explanted IOL exhibited calcium deposits in the optic and haptic portions of the IOL. We propose a new IOL opacification classification on the basis of etiology.

Keywords: Hydrophilic intraocular lens, intraocular lens opacification, polymethyl methacrylate


How to cite this article:
Joshi RS. Delayed complete opacification of intraocular lens. J Clin Ophthalmol Res 2022;10:126-8

How to cite this URL:
Joshi RS. Delayed complete opacification of intraocular lens. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Jan 31];10:126-8. Available from: https://www.jcor.in/text.asp?2022/10/3/126/362507



Intraocular lens (IOL) opacification is an early or delayed postoperative complication of cataract surgery.[1] This complication is common with almost all types of IOL material cataract surgery.[2] IOL opacification could be either localized to the optic of the IOL[1],[2],[3],[4],[5],[6],[7],[8],[9] or diffuse, involving the complete haptic and optic.[1],[9] IOL explantation is indicated in the case of central optic opacification or diffuse opacification of the IOL. Several materials, of which calcium and phosphate are common, have been implicated in opacification.[10],[11] Pseudoexfoliative materials have also been implicated in IOL opacification.[5] In this case report, we describe complete IOL opacification that required explantation and exchange and propose a new classification to encompass the new entity.


  Case Report Top


A 70-year-old male farmer presented with blurring of vision in his left eye for the last 6 months. The patient underwent cataract surgery with IOL implantation 6 years ago. No intraoperative and postoperative records of the procedure were available with the patient. The patient experienced no trauma or did not require any surgical intervention after the cataract surgery. The patient had no diabetes or any other systemic disease.

On examination, the visual acuity of the left eye was 20/80 not improving with pinhole. Slit-lamp examination of the left eye exhibited normal cornea, anterior chamber (AC), and iris. A single-piece dual haptic opaque hydrophilic IOL was observed in the opacified capsular bag [Figure 1]. The right eye exhibited a best-corrected visual acuity of 20/20 and an immature senile cataract. Intraocular pressure measured through applanation tonometry and dilated fundus examination through indirect ophthalmoscopy of both eyes was normal.
Figure 1: Photograph of a completely opacified intraocular lens after its explantation from the eye

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In view of diminished vision due to opaque IOL, a decision was taken to explant an IOL. Written informed consent was obtained from the patient. Under peribulbar anesthesia, the temporal clear corneal incision was taken and IOL was brought out of the capsular bag, it was bisected and removed [Figure 1]. The AC was filled with cohesive viscoelastic, and the capsular bag was opened using the iris repositor. The bag could not be opened on the nasal side, and a posterior capsular rent with no vitreous loss was observed. A scleral tunnel was constructed superiorly, and a 6-mm optic polymethyl methacrylate IOL was kept over the capsular bag. Viscoelastic was cleared from the AC, and the air bubble was injected to form the AC.

The vision of the patient improved to 20/30 in a 6-month postoperative visit. No IOL opacification was observed in the follow-up period.

The explanted IOL was sent for histopathological examination. The lens was dehydrated and embedded in the paraffin box. The cut section of the paraffin was made and was stained with von Kossa stain. Cross-section of the haptic and optic of the IOL exhibited calcium deposits in the intraoptic and haptic portion of the IOL which stained dark brown with this technique [Figure 2].
Figure 2: Microscopic cut section of the intraocular lens showing deposits of calcium (arrow)

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  Discussion Top


IOL opacification can be either localized, involving either the optic or haptic of the IOL, or diffuse, involving the complete optic and haptic. Opacification is typically ascribed to IOL defects and associated conditions of the patients.[2] The exchange of IOL due to opacification has been reported in most cases implanted with a hydrophilic IOL. Few reports on explantation of hydrophilic–hydrophobic acrylic IOL have also been described.[12] Although partial opacification of the IOL is commonly described in literature, few studies describe the complete opacification of the IOL.

The present study reports the complete opacification of a hydrophilic IOL. Izak et al. reported complete opacification of a hydrophilic acrylic IOL in a series of 87 explanted IOLs.[13] Yellowish diffuse opacification of a hydrophilic–hydrophobic IOL was noted by Bompastor-Ramos et al. in a series of 390 implanted IOLs.[12] Partial opacification of an IOL was reported by Al-Otaibi and Al-Qahtani as a centrally placed 2.5-mm snowflake-shaped opacity on the optic of the IOL.[6] A differential diagnosis of such opacity is the glistening of IOL, seen with a hydrophobic acrylic material. Glistenings are due to fluid-filled vacuoles. Jorge Pde et al. in their study on late opacification of a hydrophilic IOL reported partial opacification in all (6/84 eyes) eyes exhibiting IOL opacification.[9] Lee et al. reported opacification of the optical substance of a hydrophilic IOL, in which the peripheral part and the haptic of IOL were not opacified.[4] Spoke-like opacification of the anterior IOL surface was described by Milia et al. in patients with pseudoexfoliation.[5] Marcovich et al. reported opacification of a hydrophilic IOL in patients who underwent vitrectomy with injection of intraocular gas, mainly on the anterior surface of the IOL at the pupillary margin or the capsulorhexis opening.[1] Choudhry et al. reported intraoptic opacification of the hydrophilic IOL.[3] Localized opacification on the anterior surface of IOL was also reported in patients who underwent descemet-stripping endothelial keratoplasty.[8]

None of the etiological factors of IOL opacification were present in the case described here. As the patient was a farmer, he used insecticide and was also exposed to ultraviolet light in the field. We could not discern the exact role of both these factors in the IOL opacification. However, Jorge Pde et al. have shown in their study on late opacification of hydrophilic IOL, patients exposed to dry and hot weather round the year and exposed to the agricultural activity contribute to the IOL opacification.[9]

To simplify the understanding of IOL opacification, Neuhann et al. recommended a classification system that categorized IOL opacification into primary calcification associated with IOL or related to the manufacturing processes of the IOL, and secondary calcification caused by ocular environmental factors.[14] However, the various systemic and environmental factors have not being considered in this classification. Systemic factors include long-term intake of drugs such as amiodarone and rifabutin, and diabetes.[4] Environmental factors include thermal and solar damage to the optic. Local factors include pars plana vitrectomy with injection of intravitreal gases,[1] intracameral injection of air following endothelial keratoplasty,[8] asteroid hyalosis, viscoelastics, uveitis and pseudoexfoliation, and multiple intravitral injections of bevacizumab.


  Conclusion Top


The present case report highlights the complete opacification of IOL 6 years after cataract surgery. The exact etiology of the opacification could not be assessed from the histopathological evaluation of the explanted IOL, however, may be related to the ultraviolet exposure and insecticide exposure as the patient is engaged in the agricultural activity round the area and exposed to the ultraviolet light and insecticides.

Another crucial point was to streamline the classification of IOL opacification. We propose the classification of IOL opacification as follows:

  1. Local factors
  2. Systemic factors
  3. Environmental factors.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marcovich AL, Tandogan T, Bareket M, Eting E, Kaplan-Ashiri I, Bukelman A, et al. Opacification of hydrophilic intraocular lenses associated with vitrectomy and injection of intraocular gas. BMJ Open Ophthalmol 2018;3:e000157.  Back to cited text no. 1
    
2.
Mamalis N, Brubaker J, Davis D, Espandar L, Werner L. Complications of foldable intraocular lenses requiring explantation or secondary intervention – 2007 survey update. J Cataract Refract Surg 2008;34:1584-91.  Back to cited text no. 2
    
3.
Choudhry S, Goel N, Mehta A, Mahajan N. Anterior segment optical coherence tomography of intraocular lens opacification. Indian J Ophthalmol 2018;66:858-60.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Lee CE, Kim YC, Chang SD. Opacification of the optic of an Akreos Adapt intraocular lens. Korean J Ophthalmol 2010;24:371-3.  Back to cited text no. 4
    
5.
Milia M, Konstantopoulos A, Stavrakas P, Toufeeq A. Pseudoexfoliation and opacification of intraocular lenses. Case Rep Ophthalmol 2011;2:287-90.  Back to cited text no. 5
    
6.
Al-Otaibi AG, Al-Qahtani ES. Polymethyl methacrylate intraocular lens opacification 20 years after cataract surgery: A case report in a tertiary eye hospital in Saudi Arabia. Saudi J Ophthalmol 2012;26:105-7.  Back to cited text no. 6
    
7.
Ma ST, Yang CM, Hou YC. Postoperative intraocular lens opacification. Taiwan J Ophthalmol 2018;8:49-51.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Werner L, Wilbanks G, Nieuwendaal CP, Dhital A, Waite A, Schmidinger G, et al. Localized opacification of hydrophilic acrylic intraocular lenses after procedures using intracameral injection of air or gas. J Cataract Refract Surg 2015;41:199-207.  Back to cited text no. 8
    
9.
Jorge Pde A, Jorge D, Ventura CV, Ventura BV, Lira W, Ventura MC, et al. Late opacification in hydrophilic acrylic intraocular lenses: Analysis of 87 eyes in a random sample of 102 patients. J Cataract Refract Surg 2013;39:403-7.  Back to cited text no. 9
    
10.
Werner L, Kollarits CR, Mamalis N, Olson RJ. Surface calcification of a 3-piece silicone intraocular lens in a patient with asteroid hyalosis: A clinicopathologic case report. Ophthalmology 2005;112:447-52.  Back to cited text no. 10
    
11.
Stringham J, Werner L, Monson B, Theodosis R, Mamalis N. Calcification of different designs of silicone intraocular lenses in eyes with asteroid hyalosis. Ophthalmology 2010;117:1486-92.  Back to cited text no. 11
    
12.
Bompastor-Ramos P, Póvoa J, Lobo C, Rodriguez AE, Alió JL, Werner L, et al. Late postoperative opacification of a hydrophilic-hydrophobic acrylic intraocular lens. J Cataract Refract Surg 2016;42:1324-31.  Back to cited text no. 12
    
13.
Izak AM, Werner L, Pandey SK, Apple DJ. Calcification of modern foldable hydrogel intraocular lens designs. Eye (Lond) 2003;17:393-406.  Back to cited text no. 13
    
14.
Neuhann IM, Kleinmann G, Apple DJ. A new classification of calcification of intraocular lenses. Ophthalmology 2008;115:73-9.  Back to cited text no. 14
    


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