Case report

Calcification of hydrophilic intraocular lenses: Laboratory analysis and surgical technique for intraocular lens exchange

Phogat, Jitender MS; Rathi, Manisha MS; Verma, Ritesh MB BS*; Marwah, Nisha MD; Sachdeva, Sumit MS; Dhull, Chand Singh MS

Author Information
Journal of Cataract and Refractive Surgery Online Case Reports: October 2017 - Volume 5 - Issue 4 - p 64-66
doi: 10.1016/j.jcro.2017.09.003
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Abstract

The cataract surgery technique has evolved into a safe and successful procedure for visual rehabilitation of those who are blind from cataracts.1 Even after an uneventful cataract surgery, complications can reduce the visual outcome. Intraocular lens (IOL) calcification is an uncommon complication following cataract surgery.2 This phenomenon has also been observed in silicone IOLs in association with asteroid hyalosis.3,4 Calcification of ophthalmic devices is considered rare but has been observed in silicone scleral buckles, the intracameral portion of Molteno implants, and IOLs.5 Multiple factors, including IOL material, host environment, packaging, and surgical instruments such as forceps-related impressions, are involved in the pathogenesis of this phenomenon.2,6 In a 1-year study of the incidence of posterior chamber IOL (PC IOL) opacification at our institute, 2 patients required an IOL exchange because of decreased visual acuity from IOL opacification. The IOL opacity was due to calcification, which was confirmed by von Kossa stain.

CASE REPORTS

The study was conducted at the Regional Institute of Ophthalmology, PGIMS, Rohtak, Haryana. All patients who presented to the outpatient department from June 2016 to June 2017 were checked for PC IOL opacification. No PC IOL calcification was seen in the patients who had surgery at our institute; however, 2 patients who had surgery at another institute in the same state presented with decreased vision due to PC IOL calcification.

Case 1

A 46-year-old woman presented to the eye outpatient department with decrease of vision in the left eye 1.5 years after phacoemulsification with implantation of a hydrophilic PC IOL of +20.5 diopters (D) under local anesthesia. The postoperative period was uneventful. There was no history of systemic illness or long-term medication. At the time of presentation, the corrected distance visual acuity (CDVA) in the left eye was 5/60. Slitlamp examination revealed an opacified well-centered IOL in the bag (Figure 1).

Figure 1.
Figure 1.:
Preoperative photograph showing opacified IOL.

Intraocular lens exchange was performed under local anesthesia after the patient provided written informed consent. The opacified IOL was explanted via a sclerocorneal tunnel made superiorly, and a +20.5 D hydrophobic IOL was implanted in the bag. The explanted IOL was preserved in formalin and sent for histopathology and culture.

Topical antibiotics and steroids were started. At 1 week, the UDVA was 6/9. The histopathology report showed a positive von Kossa stain for calcium, which was deposited on the surface of the IOL; the culture was negative (Figures 2 and 3).

Figure 2.
Figure 2.:
Intraoperative photograph showing explanted IOL.
Figure 3.
Figure 3.:
Positive von Kossa stain showing calcium deposits on the IOL surface.

Case 2

A 60-year-old woman presented to the eye outpatient department with decrease of vision in the right eye 6 months after phacoemulsification with implantation of a +20.0 D hydrophilic PC IOL. The postoperative period was uneventful, and the CDVA in the right eye was 6/9. There was no significant medical or family history. At the time of presentation, the CDVA in the right eye was 6/60. Slitlamp examination showed an opacified IOL with a clear cornea, a quiet anterior chamber, and an intact posterior capsule (Figures 4 and 5).

Figure 4.
Figure 4.:
Slitlamp photograph showing opacified IOL.
Figure 5.
Figure 5.:
Intraoperative photograph showing explanted opacified IOL.

Intraocular lens exchange was performed after the patient provided written informed consent. The opacified IOL was explanted via a sclerocorneal tunnel, and a +20.0 D hydrophobic IOL was implanted in the bag. An antibiotic steroid combination was started, and the opacified IOL was sent for histopathology (Figure 6).

Figure 6.
Figure 6.:
Postoperative slitlamp photograph.

The histopathology showed a positive von Kossa stain. At 1 week, the CDVA was 6/9.

Surgical Technique

Before surgery, the pupil was dilated with topical tropicamide and phenylephrine. The conjunctival flap was raised, and wet-field cautery was done. A sclerocorneal tunnel was created, and entry into the anterior chamber was made with a keratome. Methylcellulose was injected into the anterior chamber.

With the use of a blunt hook and a 26-gauge cannula, an ophthalmic viscosurgical device (OVD) was injected between the IOL and the posterior capsule. Using an IOL dialer, the IOL optic edge was gently lifted to assess the degree and extent of adherence between the IOL and the capsular bag. All IOL–capsular adhesions should be released before IOL rotation to prevent zonular damage and/or a capsule tear.

After the IOL had been freed from the anterior capsule attachments, the edge of the IOL optic was gently lifted and methylcellulose was injected posterior to the IOL into the capsular bag. Using an IOL dialer, the IOL haptics were released from the posterior lens capsule and the IOL was brought gently into the anterior chamber without damaging the corneal endothelium or the capsular bag. The IOL was then removed with a McPherson forceps. Methylcellulose was injected to inflate the capsular bag, and a new hydrophobic IOL was implanted in the bag.

DISCUSSION

Intraocular lens calcification became a significant issue in the late 1990s when primary calcifications developed in several popular hydrophilic acrylic IOLs (Hydroview [Bausch & Lomb, Inc.], Memorylens [CIBA Vision], SC60B-OUV [Medical Development Research, Inc.], and Aqua-Sense [Ophthalmic Innovations International, Inc.]).A Delayed calcification of an IOL is a rare multifactorial phenomenon that occurs secondary to IOL material and host environment factors. It starts at the surface, progressing into the IOL matrix over time.7 Many cases of early or late opacification with varying presentations and in IOLs of different materials have been reported. Neuhann et al.8 thus proposed a classification based on the 3 main types of calcification: (1) primary calcification, which is inherent to the IOL itself and related to its manufacture and/or storage; (2) secondary calcification, which is due to environmental conditions and factors related to the patient; and (3) false-positive calcification or pseudocalcification, in which other diseases are misdiagnosed as calcification.9 Calcification has not been reported in hydrophobic acrylic or poly(methyl methacrylate) IOLs.B

Calcification of an IOL is an uncommon indication for IOL exchange, and few cases have been reported.10,11 Because of fibrosis and synechiae formation between the IOL and posterior capsule, posterior capsule rupture can occur during explantation. It is important to separate the IOL completely from the posterior capsule by injecting an OVD.

Disclosure:

None of the authors has a financial or proprietary interest in any material or method mentioned.

REFERENCES

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OTHER CITED MATERIAL

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© 2017 by Lippincott Williams & Wilkins, Inc.
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