Remove opacified IOLs sooner rather than later

COSTA DO SAUIPE, Brazil – Opacified IOLs must be replaced as soon as possible, Tadeu Cvintal, MD, advised surgeons here during the Brazilian Congress on Cataract and Refractive Surgery.

IOL opacification manifests in numerous ways, Dr. Cvintal said. Often the patient does not notice any change in quality of vision, but he or she might begin complaining of glare and reduced visual acuity a year after implantation.

The longer a surgeon waits to remove an opacified IOL, “the harder it gets due to a progressive, abnormal adherence between the lens and the capsule and due to a capsule rupture already present, which is aggravated during surgery,” Dr. Cvintal said.

At first, Dr. Cvintal said, when opacified IOLs were encountered, “we didn’t know why the lens adhered so tightly to the capsule.” The analysis of a few cases showed that lime granules that formed just below the IOL surface attracted lens epithelial cells, which grew toward the limy opacity.

Surgeons need to be prepared for the potential difficulties associated with replacing an adherent lens, Dr. Cvintal said. For instance, zonules might be broken and dislocated, and the capsule might begin to come out with the lens when the lens is pulled. At other times, large IOL haptics could break the zonules. Any manipulation increases the possibility of breakage because the zonules are weakened, he added.

Removal and replacement of an opacified IOL can be traumatic surgery, but Dr. Cvintal noted that simple techniques might save the capsule and reduce the trauma caused by the procedure.

In serious opacification cases, a severely luxated capsule may remain after lens removal. The remaining capsule may not be sufficient to sustain a replacement lens. Surgeons must be prepared to fixate the appropriate lens for that particular patient, Dr. Cvintal said.

“Special techniques allow you to remove the lens from the capsular bag without destroying the zonules. One is to use a very sharp needle tip to break the capsule,” Dr. Cvintal said. When it is impossible to remove the haptic, it can simply be cut off and left in. While not ideal, leaving the haptic in the bag is better than destroying and removing the capsule, he said. Trying to remove the lens through a very small incision is a mistake that will make patients suffer more, he warned.

Above all, “it is crucial to encourage the patient to have the lens replaced at the first sign of opacity, before there is too much adherence,” Dr. Cvintal said.