Vol. 30 No. 4 Original Article PDF

Implantation of single-piece hydrophobic acrylic intraocular lens in the ciliary sulcus

Harvey S. Uy, MD, Christopher Sebastian J. Uy, Pik Sha Chan-Uy

ONE of the challenges presented by posterior-capsule
rupture (PCR) during complicated cataract surgery is
intraocular-lens (IOL) implantation for aphakic
correction. Current alternatives to in-the-bag implantation
include anterior-chamber (AC) IOL, iris, scleral, and
sulcus fixation of rigid polymethylmethacrylate (PMMA)
or foldable multipiece IOL.
Ideally, the aphakiccorrection method should be easy to perform, achieve
good anatomic and visual outcomes, maintain the smallincision wound, and avoid postoperative complication.
Sulcus-implantation of a single-piece hydrophobic
acrylic IOL (HAIOL) is a controversial procedure. Recent
case reports demonstrated that this technique leads to
iritis, pigment dispersion, iris atrophy, and the uveitisglaucoma-hyphema syndrome.
We report here the
incidence of pigment-dispersion syndrome (PDS) and
pigmentary glaucoma (PG) in eyes where a single-piece
HAIOL was implanted in the ciliary sulcus.

The medical records of 20 eyes that developed PCR at
the Asian Eye Institute from January 1, 2003 to December
31, 2004, and underwent sulcus implantation of a singlepiece HAIOL (Acrysof SA60AT, Alcon Surgical, Fort Worth,
TX, USA) were reviewed. The SA60AT is the standard
HAIOL used at our center, replacing the multipiece model.
The following data were retrieved: best-corrected visual
acuity (BCVA); manifest refraction; intraocular pressure
(IOP); gonioscopic findings; IOL decentration, dislocation, and need for IOL repositioning; additional intraoperative procedures; surgical time; follow-up duration;
and postoperative complications including PDS, PG,
retinal detachment (RD), cystoid macular edema (CME),
and endophthalmitis.
During follow-up visits, the pupils were dilated to facilitatev examination of the fundus and determination of IOL
centration. IOL decentration was defined as visible optic edge
in a 5-mm mid-dilated pupil. IOL dislocation was defined as
displacement of the entire IOL into the vitreous cavity or
anterior chamber. IOL repositioning was indicated for
double vision, pupillary capture, or astigmatism (0.3
diopters) from IOL tilt. Gonioscopy was performed whenever
IOP exceeded 25 mm Hg by applanation tonometry.
PDS was diagnosed when pigment was present on
anterior-segment structures (aqueous humor, corneal
endothelium, IOL, or trabecular meshwork). PG was
diagnosed when IOP exceeded 25 mm Hg in the presence
of a dark, circumferential band of trabecular-meshwork
hyperpigmentation observed on gonioscopy.
Anterior-chamber-cell grading was based on the system
of Nussenblatt.
Fluorescein angiography (FA) was
performed when BCVA was less than 20/40 or when CME
was suspected.
Descriptive data were reported and statistical analysis
was performed using Microsoft Excel 2000 (Microsoft
Corporation, Redmond, WA, USA).

Surgical Technique
All patients underwent stop-and-chop phacoemulsification by a single surgeon using a standard phacoemulsifier (Legacy 2000, Alcon Surgical, Fort Worth, TX, USA)
and ophthalmic viscoelastic device (OVD). Following PCR,
anterior vitrectomy (AV) was performed using the Advance
Technology Irrigating Ocutome Probe (ATIOP, Alcon
Surgical). For large dropped nuclear material (>1/4 lens
nucleus), phacofragmentation and pars plana vitrectomy
(PPV) was immediately performed by a vitreoretinal
surgeon. After vitrectomy, the anterior capsule was
examined and an HAIOL implanted in the ciliary sulcus
space if adequate support was present (≥1/2 of the
anterior capsule rim). The HAIOL was inserted through
the clear corneal incision into an OVD-filled anterior
chamber using a screw-type injector (Monarch II, Alcon
Surgical, Fort Worth, TX, USA). The leading haptic was
inserted in the ciliary sulcus plane distal to the clear
corneal incision (CCI) and the trailing haptic was guided
with a dialing hook into the ciliary sulcus space proximal
to the CCI. The OVD was a spirated and the pupil
constricted with carbachol. The CCI wound was not
sutured. Postoperatively, ciprofloxacin and prednisolone
acetate eye drops were applied every 4 hours. Postoperative eye examinations were performed 1, 7, 14, and 28
days after surgery, then quarterly thereafter.

The mean age of the patients was 66.3 ± 13.7 years (range,
46 to 87). Seventeen of 20 eyes (85%) developed vitreous
loss. Four eyes (20%) underwent phacofragmentation and
PPV for removal of dropped lens material while 13 (65%)
underwent AV. None of the CCI needed enlargement for
HAIOL insertion. The average operating time was 43.9 ±
33.5 minutes (range, 11 to 137). The average follow-up
duration was 17.2 ± 9.4 months (range, 6 to 36).
Postoperatively, all HAIOL remained centered and well
positioned. No HAIOL needed repositioning. All eyes had
postoperative BCVA equal to or better than 20/40. The
mean manifest refractive sphere was –0.50± 0.7D (range,
+1.25 to –2.00). The mean manifest cylindrical refraction
was –1.2 ± 0.8D (range, 0 to –2.50).
Transient corneal edema was observed in 7 eyes (44%),
transient AC inflammation (>1+AC cells) in 7 (35%), and
transient IOP rise (>25 mm Hg) in 4 (20%). Two eyes
had postoperative BCVA of 20/40 due to macular
degeneration. Two patients developed transient CME.
One patient developed pseudophakic RD two years after
surgery but eventually obtained BCVA of 20/25 after
successful RD repair (Table 1).
Seven of 20 eyes (35%) developed PDS with deposition
of brown pigment material on the corneal endothelium,
HAIOL, and trabecular meshwork (TM). Of these, 3 eyes
(15%) developed PG that necessitated additional IOPlowering treatment. PG manifested 6, 9, and 24 months
after surgery among these 3 eyes. The mean duration to
onset of PG was 13.0 ± 9.6 months (range, 6 to 24). Two of
these 3 eyes later underwent filtering surgery by a glaucoma

A recent review of literature concluded that there was
insufficient evidence to substantiate the superiority of any
method for achieving pseudophakia after PCR.
while easy to implant, are associated with uveitis, glaucoma,
and corneal decompensation because they chafe the
anterior iris, erode the angles, or contact the corneal
Scleral fixation avoids these problems but
is more invasive, technically difficult, and associated with
posterior-segment complications like endophthalmitis.
Iris-fixated IOLs are associated with short recovery times,
good visual outcomes, stable surgical results, and low
complication rates but are not widely available and have
steep learning curves.
Sulcus implantation using a rigid,
large optic, single-piece PMMA IOL has been an effective
method for aphakic correction.
2, 8, 10
However, PMMA IOLs
require enlargement of the surgical incision, which
increases the risk for intraoperative hypotony, choroidal
detachment, hemorrhage, vitreous incarceration, and
Multipiece foldable HAIOLs have been
used for sulcus fixation and produce good visual outcomes,
but are associated with a higher decentration rate.
Moreover, implantation of any of these IOL models into
the ciliary sulcus may produce PDS and PG.
Since 1999, the Acrysof SA60AT has achieved widespread use. At our institution, this model has replaced
multipiece foldable HAIOLs as the standard for aphakic
correction. We initially surmised that the SA60AT may be
suitable for sulcus implantation because of several
biomechanical qualities: (1) Planar haptics that limit axial
displacement and reduce the incidence of decentration/
dislocation and A-constant unpredictability, (2) Singlepiece haptics that withstand greater deformation forces
and provide improved handling characteristics and greater
tolerance for surgical manipulation, (3) Thinner optics
that allow greater separation from the posterior iris
surface, minimizing chafing of the iris by the optic leading
to less risk for uveitis and pupillary block.
biocompatibility, however, has not been fully established.
Some investigators have demonstrated fewer small-cell
deposits on the surface of HAIOL implanted in uveitic
eyes while others reported a greater affinity of foreign body
giant cells for HAIOL surface.
This series demonstrated that single-piece, sulcusimplanted HAIOL was associated with a significant risk
for PDS and PG. Chafing of the posterior pigmented iris
by the unpolished, thicker haptics of these HAIOLs results
in the release of iris pigments which are then carried to
the TM. In small amounts, these pigments are phagocytosed by the endothelial cells of the trabecular beams
without leading to IOP elevation. With greater particulate
loads, obstruction of the intertrabecular spaces or
Schlemm’s canal leads to occlusion of outflow facility and
IOP elevation. PG may develop months or years after onset
of PDS. Pigment regression may sometimes lead to
remission of PG.
10, 19
For eyes with single-piece HAIOL previously implanted
in the ciliary sulcus, regular visits are needed to monitor
IOP and examine the anterior segment for PDS. Antiinflammatory and IOP-lowering medications may be
indicated for these patients. IOL exchange, laser trabeculoplasty, or filtering surgery should be considered for
patients with recalcitrant IOP elevation.
The ultrasound
biomicroscope is useful for evaluating iris-IOL contact and
may identify patients at greater risk for PDS and PG.
While single-piece HAIOLs are easily implanted in the
sulcus, the risk for developing potentially sight-threatening
complications discourage the use of this technique. We
recommend using the multipiece HAIOL or single-piece
PMMA IOL that may have lesser propensity to cause PDS
and PG. If alternative IOLs are unavailable, a secondary
implantation should be considered.

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