Late In-the-Bag IOL Dislocation in Patients With Uveitis
Late In-the-Bag IOL Dislocation in Patients With Uveitis
A total of 1056 patients with uveitis underwent cataract extraction with IOL implantation. From these, six patients (6 eyes) experienced IOL dislocation. All had previously undergone uneventful elective cataract extraction by phakoemulsification, with complete capsulorhexis and endocapsular IOL implantation between 1997 and 2008. The mean age at cataract surgery was 53 years (range 22–75 years). Dense nuclear sclerosis was reported in one case. No patient had pseudoexfoliation, high myopia or earlier vitreoretinal surgery. There were no documented intraoperative complications, and no reported zonular dehiscence. Foldable acrylic IOLs were used in all cases. Acrysof series lenses (Alcon Laboratories, Fort Worth, Texas, USA), were used in five cases with hydrophobic acrylic MA series three-piece IOLs used in four patients and an acrylic hydrophobic one-piece IOL in one patient. SofTec I (Lenstec, St Petersburg, Florida, USA), one-piece hydrophilic acrylic was used in the sixth case. No capsule dehiscence was observed intraoperatively, and all lenses were postoperatively well centred. No patient suffered preoperative or postoperative trauma. The patients' diagnoses, clinical presentation and outcomes are summarised in Table 1. All patients had chronic uveitis and have been under the care of MUC since their cataract surgery.
The mean time elapsed between surgery and spontaneous IOL dislocation was 10.3 years (range 5–13 years), and the mean age at diagnosis with IOL dislocation was 65 years (range 35–84 years). Uveitis was well controlled in all six patients at the time of diagnosis. One patient had chronic hypotonous maculopathy.
Reduced vision was reported by all patients, and one had monocular diplopia. Two reported oscillopsia, describing a 'wobble' in vision. In Case 4 (figure 1C), this worsened after gently rubbing her eye, and she presented with the inferior IOL dislocation. In all six eyes, the IOL dislocation was in-the-bag. Five eyes exhibited partial, inferior dislocation with a mobile IOL, and in four of these, the IOL/capsule complex was substantially displaced, bringing peripheral capsule with any associated fibrosis or opacification into the visual axis (figures 1A–E). Case 6 presented with partial dislocation of the IOL capsule complex into the anterior chamber (figure 1F).
(Enlarge Image)
Figure 1.
(from left to right): Anterior segment images. (A and B) Patient 3. A one-piece acrylic intraocular lens (IOL) partially dislocated within the capsular bag before spontaneous total dislocation. Note fibrosis and contracture of the capsular bag. (C) Patient 4. A three-piece acrylic IOL significantly dislocated inferiorly and crossing the centre of the pupil. Proliferative cortical material is seen superiorly within the capsular bag forming a complete Sommering's ring. (D) Patient 5. A one-piece acrylic IOL dislocated inferiorly. (E) Patient 2. A three-piece IOL dislocated inferiorly. (F) Patient 6. One haptic of three-piece acrylic IOL dislocated within the capsular bag into the anterior chamber. The rest of the capsular bag, containing the optic and other haptic were positioned behind the iris.
Cases 2 and 5 were managed conservatively: Case 2 had tolerable vision (0.4 logarithm of the minimum angle of resolution (LogMAR)), and her uveitis remained quiescent; Case 5 had chronic idiopathic panuveitis with IOL dislocation in her only functioning, prephthisical eye, and surgery was considered an unacceptable risk.
In Case 3, 1 month after diagnosis, and while awaiting scleral fixation of the dislocated IOL, he presented as an emergency with severe pain and profound visual loss, with the IOL-bag complex dislocated into the anterior chamber causing pupil block glaucoma, corneal decompensation and vitreous prolapse into the anterior chamber. In this patient, and in Case 6, the IOL-bag complex was removed via a clear corneal incision. Both patients have been left aphakic: Case 3 achieves 0.1 LogMAR VA with a contact lens, uveitis is well controlled, and no further surgery is planned. Case 6 achieves 0.4 LogMAR with aphakic spectacles, but she is one-eyed, and no further surgery is being considered.
Cases 1 and 4 underwent 23-gauge pars plana vitrectomy and scleral fixation of IOL. In case 1, the IOL was replaced with a 1-piece CZ70BD polymethylmethacrylate posterior chamber lens (Alcon Laboratories, Fort Worth, Texas) with scleral sutures passed through the haptic eyelets. In case 4, sutureless fixation of the existing IOL was achieved by incarceration of the haptics in scleral tunnels. There were no operative or postoperative complications, no macular oedema, and no significant worsening of uveitis. The IOLs have remained stable after 25 and 5 months, respectively.
Dislocation caused reduced VA in all six cases; in those four undergoing surgery, it subsequently improved. In both cases with sclera-fixated IOL, the final VA was 0.1 LogMAR. For the two patients managed conservatively, VA has remained stable after 19 and 54 months. Comparing pre-IOL dislocation and final VA for all patients, two patients have improved, but four patients lost VA with an average deterioration of 0.2 LogMAR (range 0.1–0.2). In those with deterioration of 0.2 LogMAR or more, contributing factors are posterior capsular opacification and hypotonous maculopathy in Cases 2 and 5, respectively.
Capsular fibrosis was observed in all cases, and in Cases 3 and 4, substantial amounts of fibrotic, or lens epithelial proliferative material, were seen within the peripheral capsular bag, forming partial or complete Soemmering's rings. In Case 4, this was removed during vitrectomy before refixation of the IOL. Histopathology of the explanted lens-capsule complex in Case 6 showed the IOL and haptics enclosed within the capsular bag, with evidence of fibrous metaplasia of the anterior lens capsule epithelium, predominantly around the central opening. No zonular fibres were visible on light microscopy.
Results
A total of 1056 patients with uveitis underwent cataract extraction with IOL implantation. From these, six patients (6 eyes) experienced IOL dislocation. All had previously undergone uneventful elective cataract extraction by phakoemulsification, with complete capsulorhexis and endocapsular IOL implantation between 1997 and 2008. The mean age at cataract surgery was 53 years (range 22–75 years). Dense nuclear sclerosis was reported in one case. No patient had pseudoexfoliation, high myopia or earlier vitreoretinal surgery. There were no documented intraoperative complications, and no reported zonular dehiscence. Foldable acrylic IOLs were used in all cases. Acrysof series lenses (Alcon Laboratories, Fort Worth, Texas, USA), were used in five cases with hydrophobic acrylic MA series three-piece IOLs used in four patients and an acrylic hydrophobic one-piece IOL in one patient. SofTec I (Lenstec, St Petersburg, Florida, USA), one-piece hydrophilic acrylic was used in the sixth case. No capsule dehiscence was observed intraoperatively, and all lenses were postoperatively well centred. No patient suffered preoperative or postoperative trauma. The patients' diagnoses, clinical presentation and outcomes are summarised in Table 1. All patients had chronic uveitis and have been under the care of MUC since their cataract surgery.
The mean time elapsed between surgery and spontaneous IOL dislocation was 10.3 years (range 5–13 years), and the mean age at diagnosis with IOL dislocation was 65 years (range 35–84 years). Uveitis was well controlled in all six patients at the time of diagnosis. One patient had chronic hypotonous maculopathy.
Reduced vision was reported by all patients, and one had monocular diplopia. Two reported oscillopsia, describing a 'wobble' in vision. In Case 4 (figure 1C), this worsened after gently rubbing her eye, and she presented with the inferior IOL dislocation. In all six eyes, the IOL dislocation was in-the-bag. Five eyes exhibited partial, inferior dislocation with a mobile IOL, and in four of these, the IOL/capsule complex was substantially displaced, bringing peripheral capsule with any associated fibrosis or opacification into the visual axis (figures 1A–E). Case 6 presented with partial dislocation of the IOL capsule complex into the anterior chamber (figure 1F).
(Enlarge Image)
Figure 1.
(from left to right): Anterior segment images. (A and B) Patient 3. A one-piece acrylic intraocular lens (IOL) partially dislocated within the capsular bag before spontaneous total dislocation. Note fibrosis and contracture of the capsular bag. (C) Patient 4. A three-piece acrylic IOL significantly dislocated inferiorly and crossing the centre of the pupil. Proliferative cortical material is seen superiorly within the capsular bag forming a complete Sommering's ring. (D) Patient 5. A one-piece acrylic IOL dislocated inferiorly. (E) Patient 2. A three-piece IOL dislocated inferiorly. (F) Patient 6. One haptic of three-piece acrylic IOL dislocated within the capsular bag into the anterior chamber. The rest of the capsular bag, containing the optic and other haptic were positioned behind the iris.
Cases 2 and 5 were managed conservatively: Case 2 had tolerable vision (0.4 logarithm of the minimum angle of resolution (LogMAR)), and her uveitis remained quiescent; Case 5 had chronic idiopathic panuveitis with IOL dislocation in her only functioning, prephthisical eye, and surgery was considered an unacceptable risk.
In Case 3, 1 month after diagnosis, and while awaiting scleral fixation of the dislocated IOL, he presented as an emergency with severe pain and profound visual loss, with the IOL-bag complex dislocated into the anterior chamber causing pupil block glaucoma, corneal decompensation and vitreous prolapse into the anterior chamber. In this patient, and in Case 6, the IOL-bag complex was removed via a clear corneal incision. Both patients have been left aphakic: Case 3 achieves 0.1 LogMAR VA with a contact lens, uveitis is well controlled, and no further surgery is planned. Case 6 achieves 0.4 LogMAR with aphakic spectacles, but she is one-eyed, and no further surgery is being considered.
Cases 1 and 4 underwent 23-gauge pars plana vitrectomy and scleral fixation of IOL. In case 1, the IOL was replaced with a 1-piece CZ70BD polymethylmethacrylate posterior chamber lens (Alcon Laboratories, Fort Worth, Texas) with scleral sutures passed through the haptic eyelets. In case 4, sutureless fixation of the existing IOL was achieved by incarceration of the haptics in scleral tunnels. There were no operative or postoperative complications, no macular oedema, and no significant worsening of uveitis. The IOLs have remained stable after 25 and 5 months, respectively.
Dislocation caused reduced VA in all six cases; in those four undergoing surgery, it subsequently improved. In both cases with sclera-fixated IOL, the final VA was 0.1 LogMAR. For the two patients managed conservatively, VA has remained stable after 19 and 54 months. Comparing pre-IOL dislocation and final VA for all patients, two patients have improved, but four patients lost VA with an average deterioration of 0.2 LogMAR (range 0.1–0.2). In those with deterioration of 0.2 LogMAR or more, contributing factors are posterior capsular opacification and hypotonous maculopathy in Cases 2 and 5, respectively.
Capsular fibrosis was observed in all cases, and in Cases 3 and 4, substantial amounts of fibrotic, or lens epithelial proliferative material, were seen within the peripheral capsular bag, forming partial or complete Soemmering's rings. In Case 4, this was removed during vitrectomy before refixation of the IOL. Histopathology of the explanted lens-capsule complex in Case 6 showed the IOL and haptics enclosed within the capsular bag, with evidence of fibrous metaplasia of the anterior lens capsule epithelium, predominantly around the central opening. No zonular fibres were visible on light microscopy.
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