Opacification of intraocular lenses (IOLs) in various forms has been reported in all 4 of the varieties of lens materials available. Herein we report total opacification (optic and haptic) of a single-piece acrylic hydrophilic IOL in 5 cases, where the AquaSense IOL (Ophthalmic Innovations, Inc, Ontario, Calif) was used. In 2 of the cases, the initial diagnosis was posterior capsular opacity, and in 1 patient who had diabetes it was also thought to be nonresolving vitreous hemorrhage.
Report of Cases.
Case 1. A 76-year-old man had uneventful left eye phacoemulsification with posterior chamber IOL implantation in November 2000. Best-corrected visual acuity (BCVA) preoperatively was 6/18 OS. Postoperative BCVA in January 2001 was 6/9 OS with a quiet eye. The patient was discharged.
This patient was referred again 16 months later in March 2002 with blurred vision of about 6 weeks' duration. The BCVA was 6/18. Anterior and posterior capsular opacification was diagnosed. The patient underwent Yag laser capsulotomy in July with little success. In August 2002, the patient's condition was reevaluated by the ophthalmic consultant with a view to repeating the Yag laser treatment when opacification of the IOL was suspected. The patient was scheduled for IOL exchange.
This patient underwent successful IOL exchange with anterior chamber IOL and anterior vitrectomy in October 2002. The IOL was fibrosed to the capsular bag and hence had to be removed en masse (Figure 1). On his last visit in late October, BCVA was 6/18 OS with a quiet eye. The patient was pleased with the results and discharged from our care.
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Figure 1. Total opacification of the intraocular lens in patient 1.
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Case 2. A 74-year-old woman had uneventful phacoemulsification of the right eye with posterior chamber IOL implantation in October 2000. She had noninsulin-dependent diabetes for 14 years and her preoperative BCVA was 6/24 OD. Postoperative BCVA on her follow-up visit in December 2000 was 6/24 OD. She had a quiet eye and early diabetic maculopathy. The patient was discharged to the opticians for further care.
The patient was seen again after 15 months in January 2002 complaining of blurred vision of 3 months' duration. Posterior capsular opacification was diagnosed and she underwent Yag laser capsulotomy 3 months later. On her follow-up visit 3 months after this procedure, her visual acuity was still hand motions and additional Yag laser treatment was proposed. The possibility that this patient had had a vitreous hemorrhage was also suggested. A B-scan showed vitreous opacities and the patient was scheduled to undergo right vitrectomy for nonresolving vitreous hemorrhage. The patient was seen by the ophthalmic consultant preoperatively and opacification of the IOL was diagnosed. The patient 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 diabetic maculopathy. However, she was happier with the quality of her vision and is being followed up in the diabetes clinic.
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Figure 2. Similar intraocular lens opacification in patient 2 as was seen in patient 1.
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Case 3. A 75-year-old woman underwent uncomplicated phacoemulsification of the left eye with posterior chamber IOL implantation in November 2000. Her preoperative BCVA was 6/12 OS. On her last postoperative clinic visit in December 2000 she could read 6/9 OS unaided and was very pleased with that result. She was discharged from our care.
She was seen again, nearly 2 years later, in November 2002 complaining of blurred vision. Her BCVA was 6/60 OS. This time her ocular condition was immediately diagnosed as opacification of the IOL and she is awaiting an IOL exchange.
Interestingly, of the 3 remaining patients in our study, 2 have subsequently been seen with total opacification of their IOLs. Their BCVA has deteriorated from 6/9 postoperatively to 6/60 and they are also awaiting IOL exchange. The third patient could not be reached.
Comment.
Silicone, hydrogel, and acrylic (hydrophilic and hydrophobic) are the principal materials used for manufacturing IOLs that can be folded to be inserted into the eye through a small self-sealing incision. There have been reports of varying degrees of opacification in all of these materials mentioned above.
The hydrophobic acrylic lenses (AcrySof; Alcon, Fort Worth, Tex) have been known to show glistening in the early postoperative period, resulting rarely in blurred vision. This has been attributed to the formation of small fluid-filled vacuoles within the optic of the IOL. In vitro studies have suggested that a change in the temperature of the surrounding environment may be the cause for this vacuolation.1-2
Some patients with hydrogel lenses (Hydroview model H60M;Bausch & Lomb Surgical, Rochester, NY) had significant reduction in visual acuity at 1 year postoperatively. This was attributed to late postoperative deposition of calcium on the surface of the lens. No definitive cause has been found for this.3
Silicone IOLs were the first foldable lenses and have been known to undergo brownish discoloration and central haze within the first 6 weeks postoperatively.4-5 This usually is not visually debilitating and has been attributed to light scatter from a layer of water vapor within the IOL that may have diffused into the silicone material.
Clinically significant postoperative opacification of hydrophilic acrylic IOL (model SC60B-OUV; Medical Developmental Research, Inc, Clearwater, Fla) has been reported. This has been reportedly due to the presence of granular deposits within the optic of the lens, which were naturally occurring calcium produced by the patient's body.6
In our department we performed 8 cases of routine uneventful phacoemulsification with implantation of the Aquasense IOL (Ophthalmic Innovations, Inc) by 3 different surgeons between October and November 2000. This was a single-piece foldable hydrophilic acrylic IOL (water content, 25%).
The patients in 5 of these cases had significant visual deterioration due to total opacification of the IOL more than a year after surgery. The whole lens had diffuse opacification within its substance and was uniformly distributed. All of them had a similar pattern of opacification with minimal variation.
No apparent cause for the opacification of the IOL could be found. The company's managing director in the United Kingdom was contacted (Ophthalmic Innovations, Inc, oral communication, November 2002). He explained that the opacification was due to an interaction between the silicone sleeve, used to hold the IOL in the vial, and the acrylic material of the IOL itself. This apparently imparted a negative charge to the IOL resulting in its opacification.
To our knowledge no other case has been reported in the literature where the whole IOL has opacified. The company refused to give out "proprietary" information on the exact number of IOLs that had been implanted, but an educated guess would be over 500. Apparently all these IOLs have been withdrawn and a modified version without the silicone sleeve has been introduced. Apparently no opacification has been reported so far with this new version. We have had no further experience with this IOL.
The authors have no relevant financial interest in this article.
