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Sulcus-fixated intraocular lens implantation for the management of negative dysphotopsia

Burke, Tomas R. MD, MRCPI, MRCOphth*; Benjamin, Larry FRCS, FRCOphth, DO

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Journal of Cataract & Refractive Surgery: September 2014 - Volume 40 - Issue 9 - p 1469-1472
doi: 10.1016/j.jcrs.2013.11.037
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Negative dysphotopsia refers to a patient’s perception of a dark brown or black crescent in the far temporal visual field in an eye that has had phacoemulsification with implantation of an in-the-bag posterior chamber intraocular lens (PC IOL).1 The term negative dysphotopsia was introduced in 2000.2 Worse under photopic conditions,3 there is an apparent reduction in the size of the perceived arc when the affected eye is abducted; that is, when the eye looks in the direction of the arc.3 The reported incidence varies from 0.2%2 to 15.2% on the first postoperative day, decreasing to 2.4% at 2 years.4

Factors that predispose to the development of the condition have been reported.5–8 However, a universally accepted theory on the causation of persistent negative dysphotopsia remains elusive. Holladay et al.5 recently presented an in-depth analysis, including ray-tracing simulations, of the possible etiology of the disorder and suggested that it is related to the perception of a shadow in the context of 1 of 3 optical settings. Of these, the shadows caused by “internal reflection” (type 1) and “anterior sharp IOL edge discontinuity” (type 2) were discounted as causing negative dysphotopsia. Instead, the symptom was related to a shadow caused by “posterior sharp/truncated lens discontinuity” (type 3). For the shadow occurring in this instance to be perceived, several conditions have to be satisfied. These include a small pupil, a distance of the IOL behind the pupil of 0.06 mm or more for silicone IOLs and of 1.23 mm or less for acrylic IOLs, a sharp-edged IOL design, and a functional nasal retina extending further anteriorly than where the shadow falls.5

Negative dysphotopsia occurs with many types of IOLs1 but has not been reported in the published literature with anterior chamber IOLs or when there has been IOL exchange with insertion of the replacement IOL in the ciliary sulcus.1 There have also been no reports after refractive corneal surgery. Spontaneous resolution of symptoms may occur in the months after phacoemulsification surgery with in-the-bag IOL insertion, and this has been related to the development of capsule opacification (translucency). The resulting scatter of light causes obliteration of the shadow that would otherwise give rise to negative dysphotopsia.5,9,10 In cases that do not resolve, several treatment mechanisms have been reported. These include orientating the IOL so that the haptics lie along the horizontal meridian,5 laser anterior capsulotomy,11,12 implantation of a secondary piggyback IOL in the ciliary sulcus,13–15 reverse optic capture,5 and IOL exchange with insertion of an IOL in the ciliary sulcus.3 Importantly, the prediction of at-risk eyes has not been possible; however, fellow eyes in patients with negative dysphotopsia are at higher risk for developing the condition.3

In this study, we set out to investigate the safety and efficacy of a standardized approach to managing patients with negative dysphotopsia using IOL exchange with implantation of a 3-piece IOL (Acrysof MA60AC, Alcon Eyecare Ltd.) replacement in the ciliary sulcus.

Patients and methods

This paper reports cases of negative dysphotopsia that were referred to the same surgeon (L.B.) for management at the Department of Ophthalmology, Stoke Mandeville Hospital, United Kingdom. These patients were recruited prospectively from the clinic at presentation or identified retrospectively from the ophthalmic surgery logs from a list of patients who had had IOL exchanges between 2009 and 2012. All patients were reviewed and negative dysphotopsia was diagnosed by L.B. before IOL exchange surgery was offered.

The specific details of the primary phacoemulsification surgery were not available in 1 case, which had been performed at another center. In the remaining cases, phacoemulsification was performed by 1 of 4 other surgeons using a 2.75 mm superior corneal incision along the steepest axis. All were performed under local anesthesia, 3 using sub-Tenon or peribulbar anesthesia and 1 using topical anesthesia. All IOLs were injected using a designated IOL injector.

Wavefront aberrometry was performed using the Zywave II aberrometer (Bausch & Lomb) in 3 cases. Anterior segment optical coherence tomography (OCT) was performed using an RS3000 (Nidek Corp.). The images were acquired using the dedicated anterior segment module with the corresponding adaptor attached over the objective lens.

After providing consent, all patients had exchange of the IOL under general anesthesia with removal of the PC IOL and replacement with a 3-piece IOL (Acrysof MA60AC) inserted in the ciliary sulcus.


The study evaluated 5 cases (5 eyes of 5 women). The median age at primary phacoemulsification with PC IOL implantation in the bag was 60 years (range 57 to 65 years). No complications were reported during any of the primary procedures. Table 1 shows the patients’ characteristics and procedures.

Table 1
Table 1:
Patient characteristics and procedures.

After the primary surgery, all patients described a dark brown or black arc/crescent in the temporal visual field in the operated eye that worsened under photopic conditions. There was a trend toward diminution of the symptoms when the eye looked in the direction of the temporal field in all eyes. This symptom was noted within the first 2 weeks postoperatively; 4 patients noted it began on the first postoperative day after removal of the eye pad. No patient reported other significant ocular histories. All eyes had quiet anterior chambers, and there was no evidence of corneal edema, including in the region of the main corneal wound. All PC IOLs were well centered, with the optics appropriately covered by the anterior capsulorhexis. There was no significant anterior or posterior capsule opacification, although 1 patient (patient 2) had a previous neodymium:YAG (Nd:YAG) posterior capsulotomy by another practitioner in an attempt to ameliorate the symptoms; however, the procedure had no effect.

Wavefront aberrometry in 3 cases showed no significant aberrations were detected.

During the IOL exchange procedure, patient 2 required anterior vitrectomy (in the presence of the previously performed Nd:YAG capsulotomy). The power of the implanted IOLs ranged between +14.0 D and +24.0 D. The time to IOL exchange ranged between 4 months and 36 months. All patients had uncorrected distance visual acuity of at least 6/9 at follow-up.

In all cases, the negative dysphotopsia resolved immediately after IOL exchange surgery. There were no intraoperative or postoperative complications. Patient 1 subsequently had fellow-eye cataract extraction with primary insertion of the same type of IOL in the ciliary sulcus. She did not develop dysphotopsia symptoms postoperatively in this eye.

Figure 1 shows the anterior segment OCT images before and after IOL exchange in patient 5.

Figure 1
Figure 1:
Anterior segment OCT of the left eye of patient 5. The images in the right column and left column are through the 3 o’clock and 9 o’clock hour positions of the iris and IOL optic, respectively. The images in the upper panels were obtained after primary phacoemulsification with in-the-bag PC IOL insertion. The images in the lower panels were taken at similar locations after IOL exchange with the IOL insertion in the ciliary sulcus. Note the marked reduction in the iris–IOL distance after IOL exchange; the anterior surface of the sulcus IOL is essentially in contact with the posterior surface of the iris at the pupillary border (IOL = intraocular lens).


Intraocular lens exchange with implantation of an Acrysof MA60AC IOL in the ciliary sulcus was a successful and safe surgical technique for the management of negative dysphotopsia in our series of 5 eyes. Furthermore, it appears that primary insertion of an IOL in the ciliary sulcus may be effective in preventing the development of negative dysphotopsia in fellow eyes at risk for developing the condition.

Our study supports the findings from a smaller cohort reported by Vámosi et al.3 In that study, 2 patients (2 eyes) with negative dysphotopsia were successfully treated with IOL exchange with implantation of a sulcus IOL. One eye each received angulated IOLs that were poly(methyl methacrylate) or acrylic. In a third case in that study, 1 patient had IOL exchange with in-the-bag insertion of the Acrysof MA60AC IOL (ie, the IOL that was implanted in the ciliary sulcus in our series) after removal of the primary IOL. Despite the procedure, the symptoms of negative dysphotopsia persisted. That patient subsequently had phacoemulsification in the fellow eye with in-the-bag insertion of an Acrysof MA60AC IOL and again developed negative dysphotopsia. This highlights that the development of negative dysphotopsia and its management are related to the positioning of the IOL rather than the type of IOL that is used.

The mechanism for resolution of negative dysphotopsia after IOL exchange with insertion of the IOL in the ciliary sulcus is most likely related to the anteriorization of the IOL. This moves the shadow causing the negative dysphotopsia more anteriorly and away from functional nasal retina; that is, the negative dysphotopsia shadow is still present but is no longer perceived. Hence, the patient’s symptoms resolve.

Masket et al.1 described a method for the management of negative dysphotopsia that involved leaving the IOL–capsular bag complex undisturbed and placing a piggyback 3-piece IOL in the ciliary sulcus in 7 cases. The negative dysphotopsia symptom was reduced or resolved in all cases. This may have been due to the type 3 shadow being moved slightly more anteriorly but still being perceived by the nasal retina. An additional patient had iris suture fixation of the IOL–capsular bag complex. This patient did not have improvement in symptoms. Although it is clear from the ultrasound biomicroscopy images presented in that study that there was some anteriorization of the IOL, it is probable that this movement was not sufficient to prevent continued perception of the type 3 shadow because the iris is a delicate structure.

Although there have been no reported cases of negative dysphotopsia after IOL exchange with insertion of an IOL in the ciliary sulcus in the published literature, there is still a theoretical risk that negative dysphotopsia will occur. The only IOL position that can definitely prevent the occurrence or reoccurrence of negative dysphotopsia is implantation of an anterior chamber IOL. Of course, this is undesirable because it may lead to, among other complications, corneal decompensation and secondary glaucoma.

Identification of patients who are at risk for developing negative dysphotopsia is not possible.1 Furthermore, it was reported that there was no significant difference in the distance between the iris and the IOL (in the bag) of patients with negative dysphotopsia and those without the symptoms.3 Therefore, we advocate that all clinicians who have responsibility to review patients after cataract surgery specifically ask whether the patients have symptoms of negative dysphotopsia because some may not report the symptom unless specifically questioned about it. Although certain patients may be happy to live with the symptoms, for many the symptoms are distracting and unacceptable. Recognition of the condition will mean that patients do not have ineffective treatments, such as Nd:YAG posterior capsulotomy, that can make subsequent IOL exchange more complex. However, we advocate that patients wait at least 3 months before being listed for IOL exchange to ensure that the condition has ample time to self-resolve.

From reviewing the literature, this report is the largest series describing IOL exchange with insertion of a sulcus IOL for the management of negative dysphotopsia. Given that this condition has never been reported with IOLs implanted in the ciliary sulcus and in our series all patients had a complete resolution of their symptoms, we believe that our proposed treatment strategy is effective and should be advocated.

What Was Known

  • Several management options have been suggested for the treatment of pseudophakic negative dysphotopsia, although there is little consensus on which is the most effective at consistently leading to the resolution of symptoms.

What This Paper Adds

  • Intraocular lens exchange with sulcus-fixated IOL implantation led to a complete resolution of negative dysphotopsia symptoms and appeared to be safe.


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