Year : 1984 | Volume
: 32 | Issue : 6 | Page : 508--512
Complications associated with the use of intraocular lenses
Verinder S Nirankari, Richard D Richards
Department of Ophthalmology School of Medicine University of Maryland, Baltimore, USA
Verinder S Nirankari
Department of Ophthalmology School of Medicine University of Maryland, Baltimore 1201
|How to cite this article:|
Nirankari VS, Richards RD. Complications associated with the use of intraocular lenses.Indian J Ophthalmol 1984;32:508-512
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Nirankari VS, Richards RD. Complications associated with the use of intraocular lenses. Indian J Ophthalmol [serial online] 1984 [cited 2020 Jul 11 ];32:508-512
Available from: http://www.ijo.in/text.asp?1984/32/6/508/30855
Cataract extraction is one of the most successful surgical procedures in ophthalmology. Intraocular lens (IOL) implantation at the time of cataract extraction has gained worldwide popularity, and its use has been increasing steadily. This has been partly due to the optical problems associated with the use of aphakic glasses and the long term problems of aphakic contact lenses, including loss, deposits, corneal vascularization, etc.
In the United States, a national study on IOL's was begun in 1978, which was approved by the FDA, to determine the safety and effectiveness of IOL's in the correction of aphakia ,. Since that time, there has been an overall increase in the number of IOL's implanted in the U.S.A. Since 1978, over one million IOL's have been used comprising 70% of all cataract extractions.
Complications associated with the use of IOL's are also increasing due in part to longer follow-up and increased use of IOL's. We report our experiences of these complications.
SUBJECTS, METHODS AND OBSERVATIONS
Patients referred to the Department of Ophthalmology, University of Maryland with intraocular lens related complications are reported. Since these are all referral patients, we can only speculate on the incidence of such complications following intraocular lens insertions, and no statistical studies on this data are possible.
Complications could be divided into early and late.
The early complications seen by us included
We have seen six cases of pseudophakic bacterial endophthalmitis involving anterior chamber (AC) lenses in four eyes and posterior chamber (PC) lenses in two eyes, [Figure 1]. The offending organism was staph epidermidis in three eyes, staph aureus in one eye, streptococcus species in one eye, and klebsiella in one eye. 7 he 1OL was removed in five cases due to uncertainty of lens sterility, and formation of pupillary and cyclitis membranes, limiting visualization of the posterior segment of the eye. This was followed by a pars plana vitrectomy and injection of appropriate intravitreal intravenous and topical antibiotics . Five/six eyes achieved a satisfactory visual result, whereas one eye was no NLP and was subsequently enucleated.
2) Pseudophakic bullous keratopathy
This was seen in 17 patients immediately following IOL implantation where the cornea did not clear following surgery [Figure 2]. The AC lens was used in 11 eyes, the iris supported (IS) in 5 eyes and the PC lens in one eye. Most of these eyes had difficulty during surgery with possible IOL-corneal touch. The one eye with the PC lens had stripped. Descemets membrane during insertion with resultant corneal edema [Figure 3]. In four eyes corneal specular microscopy of the other eye disclosed low cell counts and marked pleomorphic cell morphology. All 17 eyes underwent corneal transplantation with removal of the IOL in nine eyes and retention in seven eyes. Eleven/seventeen eyes had satisfactory visual results of 20/70 or better. Reasons for poor vision in the remaining six eyes included cystoid macular edema in four eyes, and corneal rejection in one eye. The one eye with corneal rejection was regrafted and has achieved a postoperative visual acuity of 20/60.
3) Uveitis-Glaucoma-Hyphema (UGH) Syndrome
These were seen in two patients immediately following insertion of an AC lens. They both prevented with severe uveitis, hypopyon and hyphema, and elevated intraocular pressures resistant to medical therapy [Figure 4]. They were both flexible AC lenses and following removal, both patients have had return of visual acuity to 20/40  and 20/30 .
4) Pupillary block glaucoma
This was seen in six eyes following IOL insertion. These were AC lenses in four eyes and IS lenses in two eyes. The anterior hyaloid face plugged the pupillary opening with iris bombe and elevated intraocular pressure. In one eye the referring surgeon removed the IOL followed by wound dehiscence and loss of the eye. In three eyes the attack was broken by vigorous dilatation and in the other two cases laser iridotomies was successful during the acute phase in breaking the attack.
5) Lens dislocation
This was seen in six eyes. Four eyes had PC lenses, one which dislocated into the anterior chamber and had to be removed [Figure 5], three which were partially dislocated inferiorly due to capsular/zonular rupture following extracapsular cataract extraction [Figure 6].
The late complications seen by us have included
1) Pseudophakic bullous keratopathy
This was seen in 21 eyes after an average follow-up of 1.5 years. Fourteen of these eyes had IS lenses and seven had AC lenses.
2) Cystoid macular edema
This was seen in 26 eyes, many who also developed progressive corneal edema. This was in many cases resistant to topical and systemic medications, including corticosteroids and antiprostaglandins. In a few cases following removal of the 10L, the CME resolved with improvement in visual acuity. However, in the majority of cases the CME was persistent with cystoid macular degeneration aad visual acuity in the range of 20/400 or worse.
3) Persistent uveitis
This was seen in 16 eyes, many whom also had CME. There were 11 eyes with IS lenses and five eves with AC lenses who required persistent topical steroid therapy to suppress inflammation.
Other less frequent complications seen by us have included angle neovascularization with updrawn pupils, with AC lenses in four eyes [Figure 7], pupillary capture of a PC lens in two eyes [Figure 8], ocular tenderness with AC lenses in six eyes, and sphincter and iris atrophy with IS lenses in 16 eyes. Twenty six eyes have been referred with posterior capsule opacification in pseudophakic eyes. The use of the YAG laser was successful in all eyes to create satisfactory optical openings in their posterior capsules.
Intraocular lens implantation has become a highly successful surgical procedure. Its use in the United States has been increasing steadily, such that last year over 70% of all cataract extractions (40,000 eyes) also underwent simultaneous IO L implantation . However, on reviewing the data, one also sees that the use of iris supported lenses has shown a marked decline from about 70% in 1978 to only 6% in 1982. Also, there has been a corresponding increase in the use of AC lenses and especially PC lenses during the same period .
Reasons for the high rate of visual success in IOL surgery has been due to careful conducted prospective long term studies, , careful patient selection  use of microsurgery and extracapsular cataract extraction techniques,  the improvement of IOL design, assurance of lens stability, and the use of corneal specular microscopy to evaluate preoperative and postoperative endothelial cell morphology .
Complications associated with the use of IOL's are also being seen more frequently. The early disasters of Barraguer' experience with IOL's  certainly should serve as a reminder that long term follow-up is essential as many of the effects, especially corneal edema, may not be evidenced early on. Complications reported have included pseudophakic endophthalmitis, ,, pseudophakic bullous keratopathy, especially with progressive endothelial cell loss following use of iris supported lenses, , the UGH syndromes, , pupillary block glaucoma  cystoid macula edema ,(15) and lens dislocation .
The FDA study has also confirmed what lens investigators have known, that is all these complications are seen more frequently with iris supported lenses followed by AC lenses and least frequently with posterior chamber lenses. This may be due to the fact that the iris does riot serve as an adequate support for an intraocular lens and the resultant persistent uveitis and pigment dispersion produces progressive endothelial cell loss and cystoid macular edema . This may be also partly due to the longer term followup with the 1S and AC lenses, but may also be due to the fact that extracapsular cataract extraction with microsurgical techniques and the use of a PC lens does seem to produce less endothelial cell loss and a lower incidence of CME 
Complications with the use of IOL's seen by us are similar to those previously reported ,,,,,,,,, It is distressing to note that IOL related complications have become a large source of referral to the Cornea Service, University of Maryland. Pseudophakic bullous keratopathy, both early and late, seem to be the most frequent cause of corneal transplantation at our institute. A combination of progressive endothelial cell loss and persistent cystoid macular edema also appears to be a frequent surgical dilemma generally associated with an uncertain prognosis(15).
Intraocular lens implantation is an extremely successful and satisfying procedure for both the surgeon and the patient. However, it requires, from the surgeon's point of view, great attention to detail, including microsurgical techniques, proper patient selection, evaluation of the corneal endothelium, asepsis and excellent quality control of the intraocular lens to assure the long term success of this procedure. To be stampeded into doing this surgery indiscriminately, whether by neglect of the 'above principles or by patient pressure will only cause a repetition of the previous mistakes of the early investigators .
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