JUN 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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24 EW CATARACT June 2013 Cataract/IOL complications: Moran CPC reports A case of postoperative opacification of a hydrophilic acrylic IOL by Shannon Stallings, MD, Liliana Werner, MD, PhD, Nick Mamalis, MD Shannon Stallings, MD T he complication described in this article still leads to the explantation of a significant number of lenses analyzed in our laboratory. It is related to a particular class of intraocular lens (IOL) materials. Case report Seventeen months after uneventful cataract surgery with in-the-bag implantation of a Hydroview H60M (Bausch + Lomb, Rochester, N.Y.) hydrophilic acrylic IOL in 1998, a 70-year-old female patient with a history of Fuchs' corneal dystrophy presented with a progressive decrease in visual acuity, glare, and "cloudiness" in the right eye. She underwent Nd:YAG laser posterior capsulotomy, without significant improvement, and the lens was eventually explanted/exchanged in 2000 due to increasing optic haze observed at slit lamp examination (Figure 1). Although visual acuity only improved from 20/60 to 20/50 after IOL exchange, glare and "cloudiness" disappeared and the patient was satisfied with the results. Laboratorial analyses and results Gross examination showed a foldable posterior chamber hydrophilic Figure 1: Slit lamp photograph of the opacified hydrophilic acrylic lens (Hydroview) Case of Arne Öhrström, MD, Sweden Nick Mamalis, MD acrylic IOL, with grafted blue-colored PMMA haptics. Small deposits were seen on the optic corresponding to the IOL haze/opacification described clinically. Microscopic examination of the lens revealed a layer of irregular granular deposits almost completely covering both the anterior and posterior surfaces of the optic, but not the haptics. The deposits consisted of multiple fine, translucent spherical-ovoid granules. Additionally, small pits consistent with Nd:YAG laser treatment were observed on the posterior IOL surface. The lens was subsequently stained with 1% alizarin red, and a sagittal section of the optic was stained using the von Kossa method (histochemical stains for calcium). The granular deposits on the optic stained positive with alizarin red and dark brown using von Kossa's method confirming the presence of calcium. Liliana Werner, MD, PhD International, Ontario, Calif.). The first two designs were commercially available in the U.S. and the other two designs, while manufactured in the U.S, where not approved for use in the U.S. Although in many cases it was difficult to determine the time optic opacification was first observed, the lenses involved in the problem were on average explanted during the second year post-implantation. The opacification was not associated with an anterior segment inflammatory reaction, and Nd:YAG laser was ineffective in removing the calcified deposits from the lenses.1-3 Although it is now relatively rare to receive lenses from the four abovementioned designs in our laboratory, we still receive sporadic cases of hydrophilic acrylic lenses of other designs manufactured in the U.S. or abroad that were explanted because of optic calcification. Calcification of hydrophilic acrylic lenses appears to be a multifactorial problem, and factors related to IOL manufacture, IOL packaging (containing silicone components, which was the case with the explanted calcified Hydroview lenses), surgical techniques and adjuvants, as well as patient metabolic conditions, among others, may be implicated. As the exact combination of factors and sequence of events ulti- Comments Postoperative optic opacification of hydrophilic acrylic IOL designs has been a significant complication leading to IOL explantation since 1999.1 Different studies using histopathological, histochemical, electron microscopic, as well as elemental or molecular surface analytical techniques demonstrated that the opacification was related to calcium/ phosphate precipitation on the surface/subsurface and/or within the optic substance of the lenses (Figures 2 and 3).2,3 The four major designs manufactured in the U.S. involved in the problem were the Hydroview, the MemoryLens (Ciba Vision, Duluth, Ga.), the SC60B-OUV (Medical Developmental Research, Clearwater, Fla.), and the AquaSense (Ophthalmic Innovations Figure 2: Gross and light microscopic photographs of explanted calcified hydrophilic acrylic lenses (Hydroview). Many Nd:YAG laser pits can be seen in the light photomicrograph. Source: Mamalis/Werner laboratory, John A. Moran Eye Center

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