Quiz: Why does the IOL optic look cloudy?

This patient had cataract surgery with the same IOL about 18 years ago and she did very well for many years. Then she noticed that the vision in the right eye seemed to be decreasing and not as good as in the first eye. Both initial surgeries went well without complications and both eyes received the same brand IOL with the same power. She is close to emmetropia in both eyes. What is going on here?

She was told that a YAG laser capsulotomy would help to open the suspected cloudy posterior capsule, so it was performed. But the vision remained about the same. The patient is 20/30 in the right eye and 20/25 in the left eye, but she says the vision is just foggy and cloudy in the right eye. The Snellen acuity does not tell the whole story and her most challenging visual issue is night driving, particularly with oncoming car headlights.

The patient was able to find her original IOL implant cards which showed the Ciba Vision MemoryLens as the implant. This IOL has a history of cases of IOL optic opacification as reported by experts such as Liliana Werner, MD, PhD.

Other IOL models have also suffered from cases of optic opacification, with the most common seeming to be hydrophilic acrylic IOLs, though other types of IOLs have been implicated as well. The causes are often calcification of the optic, deposition of other minerals, degradation of the material, influx of water into certain IOLs, surface staining from dyes, and more.

The patient above has a similar issue with opacification of the optic material. The haze is within the optic itself and despite undergoing an YAG laser capsulotomy, the visual symptoms remain. Notice that these opacities are not as pronounced on the retro-illumination photo, but are clearly visible on direct illumination.

What are the options for this patient? Essentially there are two options:

Option 1: Live with it. If the vision is still reasonably good and the symptoms are in the mild to moderate range, then the best option may be to do nothing. The patient can be monitored for future changes.

Option 2: Perform an IOL exchange. This requires an addition trip to the operating room and the associated risks from another intra-ocular surgery. With a prior YAG capsulotomy, there will likely be vitreous prolapse when explanting the opacified IOL, so a limited anterior vitrectomy will be needed. If the IOL can be removed without further damaging the capsular bag, then a three-piece sulcus IOL can be placed. If the capsular support becomes compromised then the patient will need a scleral or iris fixated IOL, or perhaps an anterior chamber IOL (AC IOL).

If you are going to do an IOL exchange, be warned that extensive calcification of the optic material makes it much stiffer and harder. This means that techniques of rolling, folding, or cutting the IOL may not work, and a larger incision to explant could be required.

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