Occlusive intraocular lenses (IOLs) are indicated for intractable diplopia,1 visual confusion, unsightly leucocoria, and a range of neuro-ophthalmic indications.2 We present a patient who experienced 18 years of enigmatic debilitating light perception and ghosting phenomenon through a black IOL implanted for intractable diplopia. We describe the mechanism underlying her light perception and demonstrate near infrared (IR)–blocking secondary black-on-black occlusive IOL implantation as an effective surgical approach in the management of this patient group.
A 61-year-old woman was referred to ophthalmology for the fifth occasion because of ghosting and perception of light in her right eye despite implantation of a Morcher 85F occlusive IOL 18 years previously. The symptoms were debilitating to the extent that she requested enucleation or optic nerve transection to abolish ongoing right-sided light perception degrading her binocular vision.
The patient had experienced intractable diplopia following orbital trauma sustained during a traffic accident when she was 31 years old. The corrected distance visual acuity was 6/12 in the right eye at first presentation. Strabismus surgery was unsuccessful, with consequent intractable diplopia. Occlusive scleral contact lenses were attempted to achieve visual suppression, but she was intolerant due to dry eye. Twelve years after the injury, phacoemulsification was performed with implantation of a black Morcher 85F occlusive IOL in the capsular bag (6.0 mm optic, 12.0 mm overall size) (Figure 1, A). Two months postoperatively, the visual acuity in the right eye was recorded as “perception of light.”
Over the following 18 years, the patient was referred on 5 occasions from primary care with intractable symptoms of ghosting and light perception from her occluded right eye. The mechanism underlying the right-sided light perception through the occlusive IOL could not be identified. Light leaking around the 6.0 mm occlusive optic or across the iris was considered the possible mechanism but symptoms persisted despite pilocarpine 2.0% 4 times a day to induce pupillary constriction and latanoprost 0.01% at night to deepen iris pigmentation.
Four further trials of occlusive scleral contact lenses were unsuccessful due to dry eye. The patient resorted to manual occlusion of her right eye to eliminate image degradation; binocular reading and working became difficult. Her visual quality of life on the VF-14 QOL questionnaire was 41 out of 100, contributing to depression.
When the patient was 61 years old, black-on-black occlusive IOL implantation was performed; a non-near IR–transmitting Artisan iris-claw occlusive IOL (Artisan 201, 5.4 mm optic, 8.5 total diameter, Ophtec BV) was implanted anterior to the Morcher occlusive IOL (Figure 1, B). At follow-up, the visual acuity was recorded as “no perception of light” in the right eye. Objective evaluation of the patient’s visual quality of life, using the VF-14 QOL, demonstrated dramatic postoperative improvement (increase to 81 out of 100). The patient was highly satisfied with the visual outcome, experiencing relief from optical distraction for the first time since the original ocular injury 30 years earlier.
Occlusive IOLs are indicated for intractable diplopia,1 visual confusion, unsightly leucocoria, and a range of neuro-ophthalmic indications.2 Black IOL implantation was first described in the literature by Choyce3 as early as 1964 in the management of a patient with intractable diplopia and further described for the treatment of leucocoria.4,5
Recent clinical observations2,6 and original research studies7,8 have advanced the understanding of occlusive IOLs in clinical use. A distinction has emerged between occlusive IOLs produced through tinting of poly(methyl methacrylate), which transmit near IR light (Morcher GmbH), and occlusive IOLs produced from silicone elastomer or polycarbonate, which provide broad-spectrum light occlusion (Dr. Schmidt Intraocularlinsen GmbH and Ophtec BV).6–8 Transmission of near IR light permits high-quality imaging using any scanning laser ophthalmoscopy or optical coherence tomography (OCT) imaging system in clinical use.6–9
Occlusive IOLs available for clinical use vary in occlusive optic diameter (5.4 to 10 mm), overall size (8.5 to 14 mm), and haptic angulation for posterior vaulting.2 Certain occlusive IOLs are limited to implantation within the capsular bag, the ciliary sulcus, or the anterior chamber.7,8 Consequently, the ophthalmologist must consider novel factors when selecting the optimal primary occlusive IOL for each patient, such as the importance of posterior segment monitoring with scanning laser ophthalmoscopy or OCT, status of the crystalline lens, presence or absence of capsule support, presence of ocular comorbidities, scotopic pupil diameter, clinical indication, and necessity of absolute light occlusion.2
Near IR–transmitting Morcher occlusive IOLs were emerging as the primary implants of choice due to the advantage of scanning laser ophthalmoscopy/OCT-based posterior segment imaging.6,8 We believe that this report is the first to identify the near IR window of transmission as a potential source of light perception and treatment failure. Morcher occlusive IOLs transmit light exponentially in the near-IR range (50% light transmission at 750 nm, 100% at 820 nm).8 Patients with near IR–transmitting occlusive IOLs may perceive light in the presence of light sources with strong near-IR components, such as environmental photopic light or incandescent illumination. The physiological basis of this phenomenon is the stimulation of photopigments in long-wavelength, red cone photoreceptors (peak spectral sensitivity 632 nm) by near-IR light.10 In the absence of binocular single vision, near-IR light perception may be sufficient to create ghosting phenomena with treatment failure and detriment to visual quality of life.
Clinical reports document the refractory perception of light through Morcher near IR–transmitting occlusive IOLs despite complete occlusion of the pupillary aperture.2 A United Kingdom–based study of occlusive IOLs determined that 33% of patients remained symptomatic despite occlusive IOL implantation.11 It has been suggested that the mechanism of light entry in this patient group is across the intact sclerochoroidal tunic.2 This report suggests alternatively that transmission of near-IR light through near IR–transmitting occlusive IOLs is the primary mechanism of light perception.
Black-on-black secondary occlusive IOL implantation with the Artisan iris-claw IOL offers the advantages of producing near-IR light occlusion, removing the need for preoperative scotopic pupillometry and offering reversibility of occlusion with phakic implantation. To our knowledge, this report is the first to describe the efficacy of this surgical approach, with significant improvement in visual quality of life in the reported patient.
Patients having near IR–transmitting occlusive IOL implantation must be counseled preoperatively about the possibility of light perception in photopic conditions and not to expect absolute occlusion of light. This report highlights the need for ophthalmologists to balance the need for posterior segment monitoring against the patient’s requirement for absolute light occlusion when considering the near IR–transmitting properties of the primary occlusive IOL.
1. Wong SC, Islam N, Ficker L. Black occlusive IOLs [letter]. Ophthalmology
2. Lee RMH, Dubois VDJP, Mavrikakis I, Okera S, Ainsworth G, Vickers S, Liu CSC. Opaque intraocular lens implantation: a case series and lessons learnt. Clin Ophthalmol. 6, 2012, p. 545-549, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3334206/pdf/opth-6-545.pdf
. Accessed May 5, 2013.
3. Choyce DP. Black intraocular lens for leucocoria [letter]. J Cataract Refract Surg
4. Osher RH, Snyder ME. Phakic implantation of a black intraocular lens in a blind eye with leukocoria. J Cataract Refract Surg
5. White ST, McGinnity G. Black intraocular lens for leukocoria. J Cataract Refract Surg
6. Patel CK, Yusuf IH, Menezo V. Imaging the macula through a black occlusive intraocular lens. Arch Ophthalmol. 128, 2010, p. 1374-1376, Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/6969/elt1010_1374_1376.pdf
. Accessed May 5, 2013.
7. Yusuf IH, Peirson SN, Patel CK. Inability to perform posterior segment monitoring by scanning laser ophthalmoscopy or optical coherence tomography with some occlusive intraocular lenses in clinical use. J Cataract Refract Surg
8. Yusuf IH, Peirson SN, Patel CK. Occlusive IOLs for intractable diplopia demonstrate a novel near-infrared window of transmission for SLO/OCT imaging and clinical assessment. Invest Ophthalmol Vis Sci. 52, 2011, p. 3737-3743, Available at: http://www.iovs.org/content/52/6/3737.full.pdf
. Accessed may 5, 2013.
9. Yusuf IH, Peirson SN, Patel CK. Anterior segment optical coherence tomography in black-on-clear polypseudophakia [letter]. Acta Ophthalmol 2013 Feb 25. [Epub ahead of print].
10. Govardovskii VI, Fyhrquist N, Reuter T, Kuzmin DG, Donner K. In search of the visual pigment template. Vis Neurosci
11. Kwok T, Watts P. Opaque intraocular lens for intractable diplopia—UK survey. Strabismus