Reversible opacification of hydrophobic acrylic intraocular lens- two cases report
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The opacification of the intraocular lens (IOL) can cause significant visual deterioration. It is known that opacity of hydrophobic acrylic IOLs is rare. We report 2 cases of reversible optic opacification of hydrophobic acrylic intraocular lenses (Tecnis ZCB00, Abbott), observed within 2 months after uneventful cataract surgery.
Case 1: Uneventful cataract surgery was performed on the left eye of an 86-year-old diabetic man with chronic open-angle glaucoma. A hydrophobic acrylic intraocular lens (IOL; Tecnis ZCB00, Abbott, Lake Bluff, IL) was implanted in the bag. Eye drops containing 0.5% levofloxacin and 1.0% prednisolone were used after surgery along with topical anti-glaucoma medications. At 7 weeks postoperative, cloudy, concentric IOL opacification developed, accompanied by decreased visual acuity and increased intraocular pressure. However, the opacification completely disappeared after 9 weeks.
Case 2: Uneventful cataract surgery was performed on the left eye of a 72-year-old woman. A hydrophobic acrylic IOL (Tecnis ZCB00) was implanted in the bag. At 2 weeks postoperative, cloudy, concentric IOL opacification developed, accompanied by ocular discomfort. After 4 weeks, opacification and discomfort completely disappeared.
We observed two cases of completely reversible opacification of hydrophobic acrylic IOLs. The exact nature of the transient opacity remains unclear, but an inflammatory origin cannot be completely ruled out.
KeywordsCataract Intraocular lens Hydrophobic Acrylic Reversible TASS
corrected distance visual acuity
posterior capsule opacification
Although millions of cataract surgeries using posterior chamber lens implantation are performed worldwide each year, intraocular lens (IOL) opacification remains a serious complication that can affect visual acuity. The causes of IOL opacification are various and usually unclear. For this reason, the materials and design of IOLs have continuously improved. It is known that hydrophobic acrylic IOLs have a low incidence rate of posterior capsule opacification (PCO), discoloration and calcification compared to IOLs of different composition [1, 2]. One previous study reported that opacification of hydrophobic acrylic IOLs occurred when the IOLs were inserted in a piggyback manner . The attachment of lens epithelial cells on IOL surface contributes to piggyback IOL opacification. Acrysof IOL (SA60AT, Alcon, TX, USA) showed more lens epithelial cell attachment compared to Tecnis IOLs (ZCB00, Abbott, Lake Bluff, IL) in an animal study . Most IOL opacities are generally irreversible and eventually require clinical intervention for clearance.
Recently, we encountered two cases of IOL opacification that developed within 2 months after hydrophobic acrylic IOL implantation (Tecnis ZCB00). The white, semilucent opacification grew from the periphery to the center of the optic. After medical treatment, opacification disappeared from the center to the periphery of the IOL in both cases.
Hydrophobic acrylic IOLs are increasingly being used because of higher biocompatibility and low incidence of PCO, compared to other IOLs [5, 6]. However, even hydrophobic acrylic IOLs have optical complications, known as glistening and light scattering. Glistening is the accumulation of fluid in the form of microvaculoes inside the IOLs, and light scattering on the surface of IOL is related to a hydration-related substance [3, 7, 8, 9, 10]. Usually, these two types of opacifications inside the optics are known not to affect visual acuity and optical aberrations [8, 11]. Unlike the two irreversible complications above, the reversible opacification observed in our cases caused visual impairment and ocular discomfort.
The causes of IOL opacification are diverse [3, 12]. Calcium is the most common cause of IOL opacification, especially in hydrophilic IOLs. Generally, calcium-related IOL opacification is irreversible, with a late onset over 3 months, and sometimes severe enough to impair visual performance [10, 13, 14, 15, 16, 17]. The risk factors of calcium-related IOL opacification are known to be diabetes mellitus, uveitis, postoperative inflammation, and intraocular calcium concentration [18, 19, 20]. However, considering the reversibility and short interval between IOL implantation and opacification in our cases, calcium deposit is not likely, though it cannot be completely excluded.
In our cases, the cloudy opacification started from peripheral optics and extended concentrically toward the center. Considering the clinical features of the connection between IOL opacities and anterior capsulorhexis, temporary growth of lens epithelial cell (LEC) cannot be completely excluded as a possible cause of IOL opacity. It is known that LECs can frequently grow out onto the IOL surface and can sometimes cause IOL decentration and capsular phimosis [21, 22]. Although, LEC outgrowth is known to be less severe on the hydrophobic acrylic IOL surface in comparison to hydrophilic IOLs,  one previous study revealed that LEC growth on hydrophobic acrylic IOLs was common and reached maximum at 30 days after surgery and then resolved spontaneously .
The early onset of opacification and its resolution with IOP control or topical steroid in our cases also suggests a possible relationship between the postoperative ocular environment and the opacification. Although a definite anterior chamber reaction was not observed in Case 1, a mild anterior chamber reaction was observed in Case 2. Even in Case 1, it is possible that some temporary inflammation existed and completely resolved before the follow-up visit and that IOL opacification was observed only in the quiet eye. In addition, instillation of Xalatan (latanoprost, prostaglandin analogue) might increase the vascular leakage in this case. Our group previously reported a similar, reversible, and bilateral IOL opacification of hydrophilic IOLs (Akreos MI-60, Baush & Lomb) in a diabetic patient who received bone marrow transplantation for chronic myelogenous leukemia . In that case, the bilateral IOL opacification was completely resolved after intravitreal injection of anti-vascular endothelial growth factor, in effort to control cystoid macular edema .
There are previous reports of delayed-onset-type toxic anterior segment syndrome (TASS) with inflammatory plaque deposits on the IOL surface [23, 24]. Typical manifestations of TASS are acute onset (12–48 h after surgery), limbus-to-limbus corneal edema, and small amount of hypopyon. However, intense use of topical steroid in the early postoperative period can mask the typical TASS signs and can cause atypical and delayed manifestations, such as reversible IOL opacifications as in our cases. The resolution effect of potent topical steroid in Case 2 may also raise the possibility of TASS. Recently, an outbreak of subacute-onset of TASS related to hydrophobic acrylic IOLs was reported . In that report, the time of onset of included 147 cases varied from 1 day to 88 days after surgery . The common signs accompanied were accompanied by corneal edema, fibrinous inflammation and hypopyon . However, a reversible IOL opacification was not reported. It seems that subacute or late onset TASS is not rare and may be related to various causes [23, 26, 27].
The limitation of this study is that the findings are mostly observational. Therefore, the materials and mechanisms of IOL opacification are still unknown. However, IOL explantation for laboratory test was not granted in both cases because IOL opacification disappeared with topical medications and patients’ visual complaints were completely resolved.
In summary, we report two cases of completely reversible opacification of hydrophobic acrylic IOL (Tecnis ZCB00), observed within 2 months after surgery. Either temporary LEC outgrowth or delayed-atypical TASS can be the possibility.
This work was partially supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (Grant number: HI-15C1653), and a core grant from Research to Prevent Blindness (Albert Einstein College of Medicine).
Availability of data and materials
All data are available upon request to the corresponding author at firstname.lastname@example.org
DJK and CYP were responsible for the conception and design of the study. DJK and CYP acquired the data. RSC, CYP analyzed and interpreted the data. DJK and CYP wrote the draft. RSC and JKL revised the manuscript critically. All authors have read and approved the final manuscript.
Ethics approval and consent to participate
This study followed the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board of Dongguk University, Ilsan Hospital, Goyang, South Korea (IRB no. 2017–19).
Consent for publication
We obtained informed consent to publish the case report and any accompanying images from the patient in case 2 and from the patient’s son in case 1.
The authors declare that they have no competing interests.
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- 22.Gayton JL, Apple DJ, Peng Q, Visessook N, Sanders V, Werner L, Pandey SK, Escobar-Gomez M, Hoddinott DS, Van Der Karr M. Interlenticular opacification: clinicopathological correlation of a complication of posterior chamber piggyback intraocular lenses. J Cataract Refract Surg. 2000;26(3):330–6.CrossRefPubMedGoogle Scholar
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