Secondary Glaucoma Following Uncomplicated Cataract Surgery with Premium Hydrophobic Intraocular Lenses

INTRODUCTION The advent of phacoemulsification, along with refinements in surgical techniques and intraocular lens (IOL) technology, has significantly improved the safety and visual outcomes of cataract surgery. The foldable single-piece hydrophobic acrylic (HA) IOL is among the most commonly used lenses owing to its excellent biocompatibility, long-term stability within the capsular bag, and reduced rates of posterior capsule opacification attributed to its square-edge design.1,2 These IOLs are specifically engineered for in-the-bag placement, and manufacturers do not recommend their implantation in the ciliary sulcus.1,3 Nevertheless, a small proportion of HA IOLs may be unintentionally or deliberately placed in the sulcus, either due to limited intraoperative visibility or in the setting of posterior capsular rupture (PCR). In the event of PCR, decentration and mechanical complications associated with sulcus-placed hydrophobic acrylic IOLs have been well described by Chang and Masket.1 In addition, even in eyes with an intact posterior capsule, chronic elevation of intraocular pressure (IOP), pigment dispersion, recurrent uveitis, and UGH-related phenomena have been reported in association with decentered or malpositioned HA IOLs placed in the sulcus.2,4 We present a series of cases with raised IOP secondary to the premium IOLs in the presence of intact posterior capsule. Although the IOL is the cause for raised IOP, based on the clinical features at presentation, duration of problem, and the severity of disc damage, the treatment options could vary. A detailed description of various clinical presentations, their management options and outcomes has been summarized in this article. CASE REPORTS Case 1 A 45-year-old gentleman presented with pain redness in his left eye following an uneventful cataract surgery in his left eye, elsewhere, a month ago. His best-corrected distance visual acuity (BCVA) was 20/20, N6 in both eyes. Examination of the right eye was unremarkable, left eye showed clear cornea, deep anterior chamber with + 3 cells and inferonasally decentered IOL with the visible superior haptic with intact posterior capsule Figure 1a. IOP was 18 mmHg in the right and 28 mmHg in the left eye on three antiglaucoma medications (AGM). Gonioscopy revealed open angles in both the eyes with increased pigmentation of the trabecular meshwork in the left eye. Fundus examination was normal with healthy optic discs in both the eyes. He was treated with topical steroids and topical and oral AGM, however the IOP was uncontrolled. Hence, IOL explanation and exchange with three-piece acrylic IOL in the sulcus was performed under local anesthesia. The explanted single piece hydrophobic IOL was found to have one broken haptic, leading to IOL decentration Figure 1b and the anterior capsulorrhexis had a tear. Postoperative course was uneventful with visual acuity of 20/20, N6 and IOP of 16 mmHg on one combination AGM (that needed to be continued) and well-centered IOL Figure 1c at 12 months of follow-up. The possible reason for long term requirement of AGM could be the excess trabecular pigmentation in that eye with compromised trabecular function.Figure 1: (a) Slit lamp photograph showing inferonasally decentered IOL (arrow), (b) shows the explanted single piece hydrophobic IOL with one broken haptic (arrow), (c) shows post IOL exchange with a 3-piece IOLCase 2 A 62-year-old gentleman presented with pain redness in the right eye one month after cataract surgery. His BCVA was 20/30, N6 in right eye and 20/20, N6 in the left eye. Examination of the right eye showed clear cornea, deep anterior chamber with +2 cells and inferiorly decentered IOL. On examination, the superior haptic was noted to be in the sulcus and inferior haptic in the bag with intact capsulorrhexis margin and intact posterior capsule Figure 2, left eye showed early nuclear sclerosis. IOP was 34 mmHg and 18 mmHg in the right and left eye respectively without AGM. Gonioscopy revealed open angles with increased pigmentation of the trabecular meshwork in the right eye compared with the left eye. Fundus examination showed 0.6 cupping with excavation and localized thinning of the inferior neuroretinal rim (NRR) in the right eye and healthy disc in the left eye although the visual fields were normal in both the eyes. He was treated with 3 topical AGMs and oral Acetazolamide. IOL explantation and exchange with a 3-piece acrylic IOL was performed under local anesthesia. The explanted IOL had a torn haptic leading to decentration. Postoperatively, the IOP was well controlled and did not require any AGM. The IOP was 10 mmHg and well centered IOL at the 1-year follow-up.Figure 2: Slit lamp photograph showing decentered IOL (yellow arrow) and intact capsulorrhexis margin (blue arrow)Case 3 A 72-year-old gentleman presented with pain and redness in the left eye of 1-month duration. There was no trauma or any precipitating event. He had cataract surgery conducted 4 years ago in his left eye and was started on topical AGM post cataract surgery, which he was continuing. His BCVA was 20/20, N6 in both eyes. IOP was 12 mmHg in RE and 30 mmHg on 3 AGM in the LE. Examination of the RE was unremarkable and LE showed clear cornea, deep anterior chamber with grade 2 relative afferent pupillary defect (RAPD), pigment deposits on the IOL with one haptic in sulcus and the other in the bag with fibrosed anterior capsular margin with intact posterior capsule. Gonioscopy revealed open angles with increased pigmentation of the trabecular meshwork in the left eye. Fundus examination showed healthy disc in the right eye and 0.9 cupping with bipolar notch in the left eye and visual field examination showed incomplete biarcuate scotoma sparing fixation in the left eye. In view of uncontrolled IOP, advanced glaucoma, he underwent trabeculectomy with Mitomycin C in the left eye. Since there was a significant time lapse after cataract surgery with fibrosed anterior capsular margin and could not open the capsule for redialing, we felt that IOL explantation/exchange would compromise the trabeculectomy that was performed and hence did not exchange the IOL. The postoperative course was uneventful. He maintained visual acuity of 20/20 with stable central field at 2 years of follow-up and well controlled IOP of 14 mmHg with a diffuse bleb. Case 4 A 58-year-old gentleman presented with pain redness in left eye 1 year after cataract surgery. His BCVA was 20/25, N6. IOP was 16 mmHg in the RE and 26 mmHg on 3 AGM in the LE. Examination of the RE was unremarkable with good pseudophakia. The LE showed clear cornea, deep anterior chamber, grade 2 RAPD, tear in the anterior capsular margin, decentered IOL with intact posterior capsule Figure 3a. Ultrasound biomicroscopy confirmed IOL in the sulcus with intact posterior capsule and IOL in close contact with the posterior iris surface Figure 3b. Gonioscopy revealed open angles with increased pigmentation of the trabecular meshwork in the left eye. Fundus examination of the right eye showed healthy optic disc and left eye showed 0.8 cupping with inferior notch with corresponding superior visual field defect. He underwent IOL repositioning, (placing the haptics perpendicular to the anterior capsular tear) along with trabeculectomy with MMC. Postoperatively patient did well with stable vision and IOP of 8 mmHg and well-centered IOL at 6 months of follow-up Figure 3c.Figure 3: (a) Slit lamp photograph showing a tear in the anterior capsular margin with the IOL positioned in the sulcus, nearly adherent to the posterior iris surface; (b) ultrasound biomicroscopy confirming an intact posterior capsule; and (c) postoperative image demonstrating a well-centered IOL following redialing to a vertical orientation, combined with trabeculectomy and mitomycin-C applicationCase 5 A one eyed, 60-year-old gentleman with primary open angle glaucoma on treatment with 2 topical AGM with well controlled IOP, opted for a topical cataract extraction, which was performed elsewhere 2 months ago. Post cataract extraction, his IOP was uncontrolled and was referred to us for further management. His BCVA was 20/40, N6 in the left eye and No light perception in the right eye due to advanced glaucoma. IOP was 32 mmHg on 4 topical AGM and oral acetazolamide. Examination of the left eye showed clear cornea, deep anterior chamber with intact capsulorrhexis and a hydrophobic IOL in the sulcus Figure 4a and b. Gonioscopy revealed open angles with increased pigmentation of the trabecular meshwork in the left eye. Fundus examination showed 0.9 cupping with bipolar notch in the left eye. He underwent IOL redialing; the IOL was dialed in the bag after separating and inflating the intact capsular bag. Two topical AGMs and a short course of oral acetazolamide were needed postoperatively. His visual acuity was maintained at 20/25 and IOP was 14 mmHg with two topical AGMs Figure 4c.Figure 4: (a) Slit-lamp photograph on retro-illumination showing an intact capsulorrhexis (arrow); (b) single-piece IOL positioned in the sulcus (arrow); and (c) postoperative image demonstrating the IOL placed within the capsular bag (arrow), with the optic well covered by the anterior capsular margin following IOL redialingDISCUSSION Various complications have been described following sulcus placement of Acrylic hydrophobic IOLs, including, pigment dispersion syndrome with secondary IOP elevation, recurrent iridocyclitis, uveitis-glaucoma-hyphema (UGH) syndrome, cystoid macular oedema and lens decentration leading to edge glare.1-5 These IOLs are designed for in-the-bag placement and are not suitable for sulcus placement as the haptics are large, relatively bulky, rough and have unpolished edges.1,6 When placed in the sulcus, the planar haptics come in contact with the posterior pigmented iris surface and lead to iris chaffing, pigment dispersion, chronic inflammation and UGH syndrome.2-4 The overall loop-to-loop dimension of these lenses is 13.0 mm, which is inadequate for many eyes when placed in the ciliary sulcus and may result in decentration of the lens, particularly in large eyes or in the presence of zonular weakness.1,7,8 In the presence of a torn haptic or a damaged lens the degree of decentration is further exacerbated.1 The square edge optic design, the thick unpolished haptics cause mechanical trauma and chaffing of the posterior iris surface resulting in pigment dispersion, secondary glaucoma, chronic uveal inflammation and UGH syndrome.2-5,9-11 Sulcus-compatible IOLs should ideally have posteriorly angulated haptics or smooth, rounded optic edges to minimize iris chafing.6,7 Polymethyl methacrylate (PMMA) lenses have round smooth edges and thin haptics (although not angulated) may be suitable for sulcus placement.9 A three piece hydrophobic acrylic IOL despite having a square edge design of the optic, possess thin, posteriorly angulated C-shaped haptics, and are considered suitable for sulcus placement in the event of an anterior capsulorrhexis tear or posterior capsular rupture.1,9,10 Clinical symptoms suggestive of secondary pigment dispersion syndrome include recurrent episodes of pain and redness following cataract surgery.2,5 Telltale signs include anterior chamber flare and cells, pigment deposition on the anterior capsule and IOL surface, most prominent on the haptics, peripheral optic and haptic-optic junction.2,11 Dilated examination would reveal the IOL malposition, deformation or damaged IOL and its relationship to the capsular bag and the iris.1,12 The IOL may be decentered or subluxated with either normal or raised IOP. Gonioscopy shows increased trabecular meshwork pigmentation in the operated eye compared with the fellow eye.5,13 The dilated gonioscopy and ultrasound biomicroscopy are most important to evaluate changes in the peripheral angle and in the ciliary sulcus.11,12 In the early postoperative period, the alternate causes of raised IOP such as retained viscoelastic, and steroid response should be excluded.14 In late presentations, undiagnosed primary glaucoma should be ruled out by examination of the fellow eye.13,15 Several reports have described secondary pigment dispersion and glaucoma following complicated cataract surgery with posterior capsular rupture.2-5 Chang et al., described complications of sulcus-placed hydrophobic acrylic IOLs in eyes with and without posterior capsular rupture.1 Inadvertent sulcus placement may occur even after apparently uncomplicated cataract surgery, particularly in the presence of intraoperative miosis.16 Re-dilation with intracameral adrenaline and confirmation of capsulorrhexis margins can help prevent accidental sulcus placement.16 If a break in IOL haptic is noted intraoperatively, explantation of the IOL and IOL exchange are recommended due to the risk of decentration and or IOL displacement to the sulcus.1,17 In the presence of a capsulorrhexis tear, careful in-the-bag placement of the IOL with haptics oriented perpendicular to the tear may improve IOL stability.1,18 In cases of large capsular tears or posterior capsular rupture, PMMA lenses or three-piece foldable IOLs are safer options for sulcus implantation.1,9,16,18 Management of IOL-induced pigmentary glaucoma ranges from medical therapy to IOL repositioning, IOL exchange, and glaucoma filtering surgery.6-19 Treatment depends on the stability and position of the IOL, integrity of the capsular bag, duration since cataract surgery, and severity of glaucomatous damage.19,20 Early cases with intact capsular support may be managed with IOL re-dialing into the bag,1,20 Damaged or unstable IOLs are best managed with IOL exchange using a three-piece posterior chamber IOL with an adequate optic diameter.1,9,10 In eyes with established optic nerve damage, combined IOL surgery and glaucoma filtering surgery may be required.15 In long-standing cases with extensive capsular fibrosis, IOL exchange may be unsafe and glaucoma surgery alone may be necessary.15 In the presence of compromised TM function, long-term AGM may be required for IOP control.15 In our series, case 1 and 2 had recent cataract surgery with decentred IOL most likely due to the torn IOL haptic, underwent IOL exchange and the IOP was controlled. In case 3, the presentation was after 4 years with advanced glaucoma and fibrosed capsule hence only trabeculectomy with MMC was performed. In case 4, presentation was after one year with advanced disc damage. However, the IOL could be repositioned and trabeculectomy with MMC was performed simultaneously. In case 5, there was preexisting glaucoma that was medically controlled. The IOP was high following cataract surgery and the sulcus placement of hydrophobic IOL was the likely cause as steroid response was ruled out. Since the presentation was within 2 months after surgery, the bag could be visco inflated and the IOL was dialled in the bag. This helped to control pigment dispersion, inflammation and the IOP was well controlled although needed same number of AGM as prior to cataract surgery. To summarize, single-piece hydrophobic acrylic IOLs should be placed only within the capsular bag.1,9 The capsulorrhexis should be adequate enough for safe surgery and to ensure complete cover of the optic edge eliminating the possibility of IOL edge related pigment dispersion.19 In an event of PCR, a three piece foldable IOL or PMMA lenses are safer alternatives for sulcus placement.1,9,10,16 In the presence of a torn anterior capsulorrhexis, in-the-bag IOL placement with haptic orientation away from the tear is recommended. To prevent IOL displacement, the anterior chamber shallowing should be avoided. Use of air bubble as a tamponade or intracameral pilocarpine for miosis would help IOL from displacing anteriorly. In small-pupil surgery, confirmation of in-the-bag IOL placement at the end of surgery is critical to prevent postoperative complications.16 These simple measures can prevent serious sight threatening complications following an uneventful cataract surgery with premium IOLs. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.