Total Opacification of Intraocular Lens Implant After UncomplicatedCataract Surgery: A Case Series

Opacification of intraocular lenses (IOLs) in various forms has beenreported in all 4 of the varieties of lens materials available. Herein wereport total opacification (optic and haptic) of a single-piece acrylic hydrophilicIOL in 5 cases, where the AquaSense IOL (Ophthalmic Innovations, Inc, Ontario,Calif) was used. In 2 of the cases, the initial diagnosis was posterior capsularopacity, and in 1 patient who had diabetes it was also thought to be nonresolvingvitreous hemorrhage.

Case 1. A 76-year-old man had uneventful left eye phacoemulsification with posteriorchamber IOL implantation in November 2000. Best-corrected visual acuity (BCVA)preoperatively was 6/18 OS. Postoperative BCVA in January 2001 was 6/9 OSwith a quiet eye. The patient was discharged.

This patient was referred again 16 months later in March 2002 with blurredvision of about 6 weeks' duration. The BCVA was 6/18. Anterior and posteriorcapsular opacification was diagnosed. The patient underwent Yag laser capsulotomyin July with little success. In August 2002, the patient's condition was reevaluatedby the ophthalmic consultant with a view to repeating the Yag laser treatmentwhen opacification of the IOL was suspected. The patient was scheduled forIOL exchange.

This patient underwent successful IOL exchange with anterior chamberIOL and anterior vitrectomy in October 2002. The IOL was fibrosed to the capsularbag and hence had to be removed en masse (Figure 1). On his last visit in late October, BCVA was 6/18 OS witha quiet eye. The patient was pleased with the results and discharged fromour care.

Case 2. A 74-year-old woman had uneventful phacoemulsification of the righteye with posterior chamber IOL implantation in October 2000. She had noninsulin-dependentdiabetes for 14 years and her preoperative BCVA was 6/24 OD. PostoperativeBCVA on her follow-up visit in December 2000 was 6/24 OD. She had a quieteye and early diabetic maculopathy. The patient was discharged to the opticiansfor further care.

The patient was seen again after 15 months in January 2002 complainingof blurred vision of 3 months' duration. Posterior capsular opacificationwas diagnosed and she underwent Yag laser capsulotomy 3 months later. On herfollow-up visit 3 months after this procedure, her visual acuity was stillhand motions and additional Yag laser treatment was proposed. The possibilitythat this patient had had a vitreous hemorrhage was also suggested. A B-scanshowed vitreous opacities and the patient was scheduled to undergo right vitrectomyfor nonresolving vitreous hemorrhage. The patient was seen by the ophthalmicconsultant preoperatively and opacification of the IOL was diagnosed. Thepatient had an IOL exchange with posterior chamber IOL in October 2002 (Figure 2). At her last visit in January 2003,BCVA was hand motions. She was noted to have advanced untreatable diabeticmaculopathy. However, she was happier with the quality of her vision and isbeing followed up in the diabetes clinic.

Case 3. A 75-year-old woman underwent uncomplicated phacoemulsification of theleft eye with posterior chamber IOL implantation in November 2000. Her preoperativeBCVA was 6/12 OS. On her last postoperative clinic visit in December 2000she could read 6/9 OS unaided and was very pleased with that result. She wasdischarged from our care.

She was seen again, nearly 2 years later, in November 2002 complainingof blurred vision. Her BCVA was 6/60 OS. This time her ocular condition wasimmediately diagnosed as opacification of the IOL and she is awaiting an IOLexchange.

Interestingly, of the 3 remaining patients in our study, 2 have subsequentlybeen seen with total opacification of their IOLs. Their BCVA has deterioratedfrom 6/9 postoperatively to 6/60 and they are also awaiting IOL exchange.The third patient could not be reached.

Silicone, hydrogel, and acrylic (hydrophilic and hydrophobic) are theprincipal materials used for manufacturing IOLs that can be folded to be insertedinto the eye through a small self-sealing incision. There have been reportsof varying degrees of opacification in all of these materials mentioned above.

The hydrophobic acrylic lenses (AcrySof; Alcon, Fort Worth, Tex) havebeen known to show glistening in the early postoperative period, resultingrarely in blurred vision. This has been attributed to the formation of smallfluid-filled vacuoles within the optic of the IOL. In vitro studies have suggestedthat a change in the temperature of the surrounding environment may be thecause for this vacuolation.^1,2

Some patients with hydrogel lenses (Hydroview model H60M;Bausch &Lomb Surgical, Rochester, NY) had significant reduction in visual acuity at1 year postoperatively. This was attributed to late postoperative depositionof calcium on the surface of the lens. No definitive cause has been foundfor this.³

Silicone IOLs were the first foldable lenses and have been known toundergo brownish discoloration and central haze within the first 6 weeks postoperatively.^4,5 This usually is not visuallydebilitating and has been attributed to light scatter from a layer of watervapor within the IOL that may have diffused into the silicone material.

Clinically significant postoperative opacification of hydrophilic acrylicIOL (model SC60B-OUV; Medical Developmental Research, Inc, Clearwater, Fla)has been reported. This has been reportedly due to the presence of granulardeposits within the optic of the lens, which were naturally occurring calciumproduced by the patient's body.⁶

In our department we performed 8 cases of routine uneventful phacoemulsificationwith implantation of the Aquasense IOL (Ophthalmic Innovations, Inc) by 3different surgeons between October and November 2000. This was a single-piecefoldable hydrophilic acrylic IOL (water content, 25%).

The patients in 5 of these cases had significant visual deteriorationdue to total opacification of the IOL more than a year after surgery. Thewhole lens had diffuse opacification within its substance and was uniformlydistributed. All of them had a similar pattern of opacification with minimalvariation.

No apparent cause for the opacification of the IOL could be found. Thecompany's managing director in the United Kingdom was contacted (OphthalmicInnovations, Inc, oral communication, November 2002). He explained that theopacification was due to an interaction between the silicone sleeve, usedto hold the IOL in the vial, and the acrylic material of the IOL itself. Thisapparently imparted a negative charge to the IOL resulting in its opacification.

To our knowledge no other case has been reported in the literature wherethe whole IOL has opacified. The company refused to give out "proprietary"information on the exact number of IOLs that had been implanted, but an educatedguess would be over 500. Apparently all these IOLs have been withdrawn anda modified version without the silicone sleeve has been introduced. Apparentlyno opacification has been reported so far with this new version. We have hadno further experience with this IOL.

The authors have no relevant financial interest in this article.

Corresponding author: Yajati Kumar Ghosh, FRCSEd, Department of Opthalmololgy,Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom (e-mail: yajati_ghosh@hotmail.com).