Fracture of an intraocular lens (IOL) haptic is a rare complication of cataract surgery. It can happen during insertion of the IOL or spontaneously after the procedure and occurs mostly with scleral-fixated IOLs or anterior chamber IOLs, leading to IOL decentration or more severe complications.1,2 The spontaneous breakage of a posterior chamber IOL (PC IOL) haptic is much more uncommon, with few cases reported.3–6 In all these cases, poly(methyl methacrylate) (PMMA) IOLs were involved and the haptic fragment was displaced into the anterior chamber.
In this report, we present management of an unusual case of a broken and entrapped fragment of a single-piece acrylic IOL haptic on the posterior capsule.
A 56-year-old woman attended our cataract clinic reporting blurred vision in the left eye. She had uneventful cataract extraction with IOL implantation in both eyes 5 years previously at another hospital. She also had neodymium:YAG (Nd:YAG) laser posterior capsulotomy in the right eye 1 year previously. The corrected distance visual acuity (CDVA) was 6/9 in the right eye and 6/36 in the left eye. Intraocular pressure was normal bilaterally.
On slitlamp examination, there was marked posterior capsule opacification (PCO) in the left eye, while a Nd:YAG laser central capsulotomy was evident in the right eye. However, foreign body resembling an IOL haptic fragment was trapped between the IOL and the posterior capsule in the left eye (Figure 1). Careful examination showed that the fragment was a broken IOL haptic entrapped between the IOL optic and the posterior capsule. Unfortunately, the patient's surgeon could not be contacted and thus her cataract surgery notes were unavailable.
The patient did not have visual or other complaints after her cataract surgery, and her vision had fully recovered. It was only over the 6 months before presentation that she began noticing a gradual loss of vision as the PCO in the left eye became prominent.
After discussion with the patient, an Nd:YAG posterior capsulotomy was performed in the left eye. On slitlamp examination 4 weeks after the procedure, a central Nd:YAG laser capsulotomy was seen in the left eye with normal anterior segment findings (Figure 2). Ultrasound examination showed the IOL haptic fragment in the vitreous cavity (Figure 3); the optic and remaining haptics appeared to be stable and well centered. The patient's CDVA was 6/9 in the left eye, and she said she was very happy with the final visual outcome.
The patient was reviewed for 6 months after Nd:YAG capsulotomy. During that period, there were no signs of inflammation, the IOL remained well centered, and the CDVA was stable at 6/9 in the left eye.
Spontaneous fracture of an IOL haptic is an extremely rare complication and mostly occurs with scleral-fixated IOLs.2,7,8 It has been suggested that the characteristic design and material of IOL haptics (eg, absence of an eyelet or bulb on which to affix the suture, instability of the optic–haptic junction, and softness of the jelly-like material) are the main factors predisposing to this complication.8
There have been few cases described of spontaneous fracture of an IOL haptic in PC IOLs.3–6 In all these cases, a PMMA IOL haptic had broken and migrated into the anterior chamber. Eleftheriadis et al.6 published an interesting case of PC IOL haptic fracture that resulted in corneal decompensation; the patient required corneal graft surgery. The broken haptic was removed from the anterior chamber and scanning electron microscopy performed. The findings were consistent with late fracture of the haptic in the capsular bag, which was presumably weakened by an improper implantation technique. Çaça et al.5 published a similar case of a PMMA IOL implanted in the sulcus in which spontaneous haptic breakage occurred with migration of the haptic into the anterior chamber.
In our case, the implanted IOL was acrylic and was implanted in the capsular bag. Although the reasons for postoperative breakage of the IOL haptic in our patient remain unclear, several factors could have been involved, including improper folding and implantation of the IOL. It is interesting that the haptic fragment was entrapped in the space between the IOL and the posterior capsule, causing no visual symptoms until PCO occurred. We thoroughly considered all the options regarding the management of this unusual condition. Finally, we decided to proceed with Nd:YAG laser capsulotomy, which restored the visual acuity and released the haptic fragment into the vitreous cavity. The patient had no complaints on follow-up 6 months after the capsulotomy.
This case report highlights the rare complication of a broken IOL segment entrapped in visually significant PCO. Neodymium:YAG laser capsulotomy was safe and effective in treating visually significant PCO and in releasing the broken haptic from the visual axis. There was no evidence of inflammation with migration of the acrylic haptic into the posterior segment, and IOL centration was not compromised.
None of the authors has a financial or proprietary interest in any material or method mentioned.
Kumar DA, Agarwal A, Jacob S, Agarwal A. Glued trans-scleral intraocular lens exchange for anterior chamber lenses in complicated eyes: analysis of indications and results. Am J Ophthalmol 2013; 156:1125-1133
Kumar DA, Agarwal A, Packiyalakshmi S, Jacob S, Agarwal A. Complications and visual outcomes after glued foldable intraocular lens implantation in eyes with inadequate capsules. J Cataract Refract Surg 2013; 39:1211-1218
Stallings S, Werner L, Chayet A, Masket S, Camacho F, Cutler Peck C, Mamalis N. Intraocular polyimide intraocular lens haptic breakage long-term postoperatively. J Cataract Refract Surg 2014; 40:323-326
Ainsworth JR, Spencer AF. Haptic breakage in one-piece poly(methyl methacrylate) intraocular lenses. J Cataract Refract Surg 1991; 17:863-864
Çaça I, Ünlü K, Ari Ş, Akşit İ. Spontaneous fracture of an implanted posterior chamber intraocular lens. Eur J Ophthalmol 2005; 15:507-509. Available at: http://medlib.yu.ac.kr/eur_j_oph/ejo_pdf/2005-15-507%20-%20509.pdf
. Accessed June 5, 2017
Eleftheriadis H, Sahu DN, Willekens B, Vrensen GFJM, Liu CSC. Corneal decompensation and graft failure secondary to a broken posterior chamber poly(methyl methacrylate) intraocular lens haptic. J Cataract Refract Surg 2001; 27:2047-2050
Tanaka H, Fujinami K, Watanabe K, Noda T, Akiyama K. Haptic breakage after transscleral fixation of a single-piece acrylic intraocular lens. Case Rep Ophthalmol 2014; 5:212-216. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4130822/pdf/cop-0005-0212.pdf
. Accessed June 5, 2017
Choi SK, Kim JH, Lee D, Lee JH. Breakage of the haptic of a single-piece acrylic intraocular lens after transscleral fixation [letter]. Acta Ophthalmol 2010; 88:e346-e347. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1755-3768.2009.01748.x/epdf
. Accessed June 5, 2017