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Case report

Visualization of the macula during elective pars plana vitrectomy in the presence of a dual-optic accommodating intraocular lens

Marques, Eduardo F. MD*; Ferreira, Tiago B. MD; Castanheira-Dinis, António MD, PhD

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Journal of Cataract & Refractive Surgery: May 2014 - Volume 40 - Issue 5 - p 836-839
doi: 10.1016/j.jcrs.2014.03.005
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Pars plana vitrectomy (PPV) was first described in 1975 by Machemer et al.1 Recently, small-incision sutureless PPV was introduced, leading to minimally invasive surgery with the current 23- and 25-gauge systems.2,3 Pars plana vitrectomy is used to treat a wide variety of pathologies, including complicated retinal breaks and rhegmatogenous retinal detachment, macular hole, epiretinal membrane (ERM), and diabetic eye disease.4

Presbyopia-correcting intraocular lenses (IOLs) are used to correct presbyopia after crystalline lens removal due to cataract or in patients having refractive lens exchange. Currently, 2 types of IOLs for presbyopia correction exist, multifocal and accommodating.5 It is known that multifocal IOLs affect visualization in macula surgery, a procedure that requires precise visualization for delicate surgical maneuvers.6–9 It is also known that the performance of multifocal IOLs is significantly affected in eyes with macular pathology.10 We report the case of a patient who had cataract surgery with implantation of a dual-optic accommodating IOL and, 18 months later, had a PPV for ERM removal. The accommodating IOL allowed perfect visualization of the macula without reflections or ghost images, enabling a safe PPV. Visual performance was excellent after surgery.

Case report

In March 2009, a 69-year-old woman had uneventful phacoemulsification in the left eye, with implantation of a Synchrony dual-optic accommodating IOL (Abbott Medical Optics, Inc.; +18.0 diopters [D]). Three months postoperatively, the uncorrected distance visual acuity (UDVA) was 20/20, the uncorrected intermediate visual acuity (UIVA) was 20/32, and the uncorrected near visual acuity (UNVA) was 20/40. Fundoscopy was normal in both eyes.

Fifteen months postoperatively, the patient presented with progressive loss of visual acuity and metamorphopsia in the left eye. The UDVA was 20/40, the UIVA 20/40, and the UNVA 20/50. The anterior segment revealed a well-centered IOL in the capsular bag with minor posterior capsule opacification. Fundoscopic examination showed an ERM in the left eye. Optical coherence tomography imaging confirmed the presence of an ERM with cystoid macular edema and a central macular thickness of 523 μm (Figure 1).

Figure 1
Figure 1:
Preoperative optical coherence tomography image showing ERM and cystoid macular edema.

After informed consent was provided, a 23-gauge PPV with posterior capsulotomy and ERM peeling was performed in October 2010. A binocular indirect ophthalmomicroscope (Biom 4, Oculus Surgical, Inc.) was used for visualization. Posterior capsule opacification was considered minimal before PPV, but during surgery it was noted that it interfered with fundus visualization and a small (3.0 mm), round, centered posterior capsulotomy was performed (as recommended in the manufacturer’s neodymium:YAG [Nd:YAG] laser protocol). During the PPV procedure, visualization was excellent; focusing on the macula was easy at all stages of the procedure, including ERM peeling and fluid–air exchange.

Twelve months after PPV, the UDVA was 20/20, the UIVA 20/20, and the UNVA 20/32. Optical coherence tomography showed the ERM had been removed and the macular edema was reduced (Figure 2).

Figure 2
Figure 2:
Postoperative optical coherence tomography image showing absence of ERM and reduction of macular edema.


There are currently 2 main options for surgical correction of presbyopia after removal of the crystalline lens: monovision or presbyopia-correcting (multifocal and accommodating) IOLs.5 Monovision has variable results and is not tolerated by some patients. Multifocal IOLs have different designs. In both refractive and diffractive multifocal IOLs, the lens design results in splitting the image into 2 or 3 foci; 15% to 17% of the light is lost due to random scatter.5 Furthermore, the multiple rings on the IOL often result in dysphotopsia such as halos, starbursts, or other visual aberrations. In addition, the multifocal optics can decrease low-contrast visual acuity in patients by an average of 1 Snellen line.5

The design of multifocal IOLs was first reported to result in difficult visualization during PPV in the early days of refractive multifocal IOLs, such as the AMO Array (Allergan Surgical Products). In 1 case during the clinical trial of this IOL, the IOL had to be explanted because of poor visualization during vitrectomy to remove a macular ERM.A This IOL was reported to increase the difficulty of fine focusing during ERM dissection. In addition to the multiple rings of the IOL creating different focus zones on the anterior surface of the IOL, the reduced contrast sensitivity may make surgical maneuvers more difficult.7,9

With diffractive multifocal IOLs, similar increased difficulty was reported. In addition to decreased contrast sensitivity, multiple ghost images such as reflections of wave-shaped arches may interfere with the surgical view, especially in complicated cases.9 Furthermore, increased difficulty in visualization has been reported during fluid–air exchange and when intravitreal triamcinolone is used to assist visualization.6,8,9

Accommodating IOLs were developed with the objective of improving the near and intermediate visual acuities, without the unwanted dysphotopsia and reduced contrast sensitivity of multifocal IOLs. The Synchrony is a single-piece accommodating silicone IOL with a dual-optic system designed to mimic the natural lens accommodation. It has a 5.5 mm anterior optic with a fixed power of +32.0 D connected to a posterior 6.0 mm negatively powered optic by spring haptics. Under contraction of the ciliary muscle, the haptics produce forward movement of the positive anterior optic, which further separates the 2 optics, increasing paraxial optical power and allowing near vision.11 The performance of the dual-optic accommodating IOL for up to 4 years postoperatively has been documented with both dynamic high-resolution ultrasound biomicroscopy and with iTrace aberrometry (Tracey Technologies).B Clinically, the accommodation with the dual-optic accommodating IOL has been shown to be present several years after implantation, with patients maintaining long-term stable or even improved reading ability.12

A new generation of the dual-optic accommodating IOL, Synchrony Vu, has recently been developed. A central aspheric zone with negative spherical aberration was added to the anterior optic of the IOL, resulting in an increase of 1.00 D in depth of focus compared with the earlier generation. Modulation transfer function was also improved.C In a recent study of 31 patients (61 eyes) at 6 months postoperatively, 93% of patients achieved functional binocular UDVA of 20/25 or better for far and 20/32 or better for intermediate and near. Binocular UNVA and binocular corrected distance visual acuity of 20/40 or better was found in 97.7% of patients and 90.0% of patients, respectively. Mesopic contrast sensitivity, with and without glare, was reported to be within a normal range.D

The patient in our case was diagnosed with an ERM 15 months after cataract surgery with implantation of a dual-optic accommodating IOL. A PPV was performed without difficulty in visualization or focusing and without unwanted ghost images in any stage of PPV, including fluid–air exchange. Along with the presence of a single focusing zone on the anterior surface of the optic, better contrast sensitivity may contribute to better visualization. The existence of a dual-optic system did not seem to negatively affect visualization of the macula. Furthermore, the visual outcome after ERM removal was excellent.

In our experience, posterior capsulotomy performed with an Nd:YAG laser does not interfere with accommodation and that seems to be the case with this particular patient having capsulotomy during PPV.

The persistence of good UIVA and UNVA after vitrectomy in this case offers indirect evidence that the dual-optic accommodating IOL provides pseudophakic accommodation even after PPV. To our knowledge, this is the first report of an elective PPV in a patient previously implanted with a dual-optic accommodating IOL. The excellent visualization during PPV compared with the visualization with multifocal IOLs is a distinct advantage of accommodating IOLs that should be considered when choosing a presbyopia-correcting IOL.


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Other Cited Material

A. Allergan Clinical Research Department, personal communication, 1995
B. Marques E, Bohórquez V, Alarcon R, “Objective and Subjective Evidence of Accommodation 4 Years After Implantation of Dual-Optic Accommodating IOL,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, March 2011
C. Marques E, Kasthurirangan S, Evans S, “Development of an Optically Enhanced Dual-Optic Accommodating Intraocular Lens,” presented at the XXX Congress of the European Society of Cataract and Refractive Surgeons, Milan, Italy, September 2012. Abstract available at: Accessed February 13, 2014
D. Marques E, Peris-Martinez C, Buteyn A, “Early Clinical Outcomes of a Next-Generation Dual-Optic Accommodating Intraocular Lens,” presented at the XXX Congress of the European Society of Cataract and Refractive Surgery, Milan, Italy, September 2012. Abstract available at: Accessed February 13, 2014
© 2014 by Lippincott Williams & Wilkins, Inc.