Calcification of hydrophilic acrylic intraocular lens in eyes with silicone oil tamponade – an interventional case series report

Abstract

The authors have conducted an interventional case series study. The explants were examined by means of dual-beam FEI Quanta 3D EGF microscopy (FEI Company, Hillsboro, OR, USA), followed by scanning electron microscopy (SEM) and chemical analysis of the opacified area by energy-dispersive X-ray spectroscopy (EDS). The examinations were performed on both the transparent and opacified area of the explanted intraocular lens (IOLs). Case 1 A 29-year-old man with high myopia has been subjected to clear lens exchange surgery due to right eye dioptres decrease. A +10.00 dioptre hydrophilic Hydriol (PhysIOL) intra-ocular lens has been implanted into the capsular bag uneventfully. The best corrected visual acuity (BCVA) has been 20/20. Two years later, there was development in a secondary cataract. The Elschnig pearls were aspirated with a cannula leaving the posterior capsule intact. Six years later, rhegmatogenous retinal detachment appeared. We performed a pars plana vitrectomy with silicone oil tamponade. Postoperatively, the retina was attached and the BCVA reached 20/20. Three months later, the patient complained of reduced visual acuity; the BCVA was 20/40, and we encountered an opacification of the central part of the IOL. The retina remained attached (Fig. 1). Case 2 A 57-year-old woman complaining of decreased visual acuity, with a history of cataract and retinal detachment in the left eye, was referred to us. Phacoemulsification has been performed with implantation of a +4.00 dioptre Hydriol (PhysIOL) hydrophilic lens into the capsular bag. Zonular laxity was noticed, and a CTR 130 tension ring has been inserted. The retinal detachment has been treated through posterior pars plana vitrectomy and silicone oil tamponade. Ten months later, the silicone oil was removed. The retina remained attached with no posterior capsular tear. One month afterwards, BCVA was 20/25, and 11 months later, it decreased to 20/200. The retina remained still attached. However, a left eye pupillary area IOL opacification could be encountered (Fig. 2). Case 3 A 43-year-old woman with low visual acuity presented a history of cataract and rhegmatogenous retinal detachment surgery with silicone oil implantation. As the posterior capsula was intact, in spite of a iris coloboma, a Hydriol (PhysIOL) artificial IOL has been inserted into the capsular bag. After silicone oil extraction, BCVA showed to be 20/30, but 1 month later, the patient complained of blurred vision. Slit-lamp examination of the anterior pole revealed central IOL opacification. The retina remained attached (Fig. 3). In all three cases, artificial IOL opacification significantly reduced the visual acuity. The treatment consisted of explantation of the opacified implant and implantation of a transparent IOL. All interventions were uneventful. We performed a 2.2-mm main incision with two side ports at 11 and 2 o'clock. A viscoelastic substance (methylcellulose) was injected into the anterior chamber. We used a spatula to tear the adhesions between the lens implant and the anterior capsule and a hook to move the artificial lens off the bag into the anterior chamber. The main incision was enlarged to 4.5 mm to extract the opacified lens. No anterior vitrectomy was necessary. The transparent artificial lens was implanted into the bag. Two hydrophobic and one hydrophilic IOL were implanted due to financial reasons. The incisions were sealed by hydrosuture (Fig. 4). All vitrectomies, explanations, reimplantations and two of the phacoemulsifications were performed by the same surgeon. No posterior capsule rupture has been noticed. During explantation, traces of emulsified silicone oil could be noted on the implant surfaces. Our study reports opacifications of Hydriol (Physiol) hydrophilic acrylic implants by calcification. There are no such cases reported in the literature. We believe that the emulsified silicone oil that was present in the anterior chamber and on the surfaces of the implants might be the leading cause for calcification. Another interesting aspect might be the presence of three known major factors for calcification induction in all three cases: myopia, complex surgical procedures that probably have disturbed the blood–aqueous barrier and intraocular silicone oil in contact with the implant optical surface, respectively. Video S1. Central opacification of the posterior chamber hydrophilic acrylic Hydriol (PhysIOL) intraocular lens (IOL) can be noted. Two 1.2-mm side ports, at 10 and at 2 o'clock were performed followed by viscoelastic (methylcellulose) injection into the anterior chamber through the 10 o'clock side port. The adherences between the anterior capsule (margins of the capsulorhexis) and the anterior surface of the IOL were detached using a blunt spatula. After this step, a hook was introduced through the 10 o'clock side port. The instrument was used to mobilize the IOL in the bag and to pull it out into the anterior chamber. Then, the main incision was enlarged at 11 o'clock up to 4.5 mm through which with the aid of a blunt end forceps, the foldable single piece hydrophilic acrylic posterior chamber IOL could be explanted from the anterior chamber, without the need for a backfolding technique. The viscoelastics were removed using a bimanual irrigation/aspiration (I/A) probe. Thorough polishing of the anterior and posterior capsule was performed using the I/A probe and the polish programme of the phaco machine. A posterior chamber foldable single piece IOL was injected through the main incision using a Monarch® (Alcon) injector. The IOL was placed in the bag with the aid of a hook followed by removal of the viscoelastics with the bimanual I/A probe. The final step consisted in hydrosuture of the side ports and of the main incision. 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