Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Visual Outcome and Complications of Late Implanted

Anterior Chamber Intraocular Lens
Sujit Kumar Biswas1*, Soma Rani Roy1, Aparajita Raihan 2, Tangila Mohona3
1
Consultant, Chittagong Eye Infirmary & Training Complex, Chittagong, Bangladesh.
2
Associate Consultant, Chittagong Eye Infirmary & Training Complex, Chittagong, Bangladesh.
3
Research Officer, Institute of Community Ophthalmology, Chittagong, Bangladesh.

Corresponding Author: Sujit Kumar Biswas1*

ORCID ID: 0000-0002-7006-5788

Abstract:- I. INTRODUCTION

 Aim: Posterior capsular tear is a common intraoperative

To observe the visual outcome and complications of complication during cataract surgery. Most of the time,
late implanted anterior-chamber intraocular lens posterior capsular tear is associated with vitreous loss,
(ACIOL) in eyes with insufficient or absent posterior which increases the risk of expulsive hemorrhage, cystoid
capsular support. macular edeme, corneal edema due to endothelial
decompensation, secondary glucoma and retinal detachment
 Material and Methods: that compromise the visual outcome [1]. After vitreous loss,
Observational study of 52 eyes of 51 patients over a it is mandatory to do limited anterior vitrectomy and
period of 2 years. All eyes underwent late implantation placement of a posterior chamber intraocular (PCIOL) lens
of ACIOL after 3 months of primary surgery (aphakia), if capsular support is sufficient. In the case of insufficient
which were not eligible for posterior chamber IOL capsular support, ACIOL, iris claw lens or scleral fixation
implantation due to different causes. Patients were kept lenses are alternative procedures for these patients [1]. Other
aphakic with good anterior vitrectomy or pars plana clinical scenarios, such as previous aphakic patients,
vitrectomy for 3 months to reduce inflammation. ACIOL dislocated lens, decentered IOL, zonule degeneration and
was then implanted with clear corneal incision after that capsular dialysis which also need anterior vitrectomy and
period. Patients were observed for 18 to 48 months. secondary ACIOL implantation [2, 3]. But ACIOL
implantations has several complications such as persistent
 Result: uveitis, persistent rise of IOP, hyphema, corneal endothelial
Mean age of the patients was 57.69±14.64 years loss etc. which ultimately results in poor visual outcome.
with a female predominance (55.8%). Major indications Most of these complications are associated with immediate
for surgery were posterior capsular tear (57.70%) and ACIOL implantation in cases of huge posterior capsular tear
subluxated crystalline lens (19.2%). Pre- and post- and vitreous loss [1,4]. To give a better visual outcome and
operative LogMar visual acuity was 1.51±0.29 and to minimize the worse complications like secondary
0.31±0.28 respectively. Ninety percent (90.04%) eyes glaucoma and uveitis in cases of large PC rent with vitreous
achieved 6/18 or better vision in the Snellen chart. A loss, we did delay ACIOL implantation after 3 months of
total of 9 eyes (17.30%) developed some complications. primary surgery in 52 eyes of 51 patients. In this article we
No patients developed persistent raised IOP finally. are sharing our experience of delayed ACIOL implantation
in the vitrectomized aphakic eye, which has been less
 Conclusion: frequently discussed in literature.
Late implantation of secondary ACIOLs results in
good visual outcome and greatly reduced some II. MATERIAL AND METHODS
complications such as persistent rise of intraocular
pressure (IOP), persistent uveitis and cystoid macular This is an interventional study done at Chittagong Eye
edema. Infirmary & Training Complex during the period of 2 years
starting from 01.04.2019 to 31.03.2021. Fifty-two eyes of 51
Keywords:- Late Implanted Anterior Chamber Intraocular patients underwent late implantation of ACIOL after 3
Lens (ACIOL), Posterior Capsular Support, Persistent Rise months of primary surgery (aphakia). All patients who were
of IOP, Persistent Uveitis and Cystoid Macular Edema. not eligible for PCIOL due to big per operative capsular
tear, subluxated lens, late onset capsular block syndrome,
ectopia lentis, decentered IOL, zonular dialysis were kept
aphakic for 3 months. Among those who had good vision
with +10 diopters were included in the study. Aphakic
patients with retinal disease, corneal disease, known cases of
glaucoma, and optic nerve diseases were excluded. Included

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
patients have a history of good anterior limited or core The postoperative final corrected LogMar visual acuity was
vitrectomy with dropped nucleus or cortical matter removal, 0.31±0.28. More than ninety percent (90.04%) eyes
surgical peripheral iridectomy, good suturing of sclera- achieved 6/18 or better vision in the best corrected Snellen
corneal wound. The study was approved by the local chart in the final follow up [Table 01, fig. 04]. A total of 9
institutional review board (IRB) and conducted according to patients (17.30%) developed some complications as shown
the principles of the 2013 revision of the Declaration of in figure 05. No patients developed persistent raised IOP
Helsinki. finally.

 Surgical Technique of Primary Surgery: IV. DISCUSSION

Done in case of only a huge posterior capsular tear
which is insufficient for implantation of PCIOL and It is common practice to implant an open loop haptic
subluxated lens, good anterior vitrectomy with a surgical ACIOL after performing a limited anterior vitrectomy in a
peripheral iridectomy, suturing of corneo-scleral/corneal large posterior capsular tear with compromised capsular
wound, thus patient left aphakic. In the case of dropped support to a PCIOL in the sulcus and also in the absence of
nucleus/cortical matter, pars plana vitrectomy with removal posterior capsule in some clinical situations such as
of nucleus/cortical matter with one surgical peripheral dislocation of lens, decentration of IOL, ectopia lentis.
iridectomy, was done as primary surgery. All patients were Various literature demonstrates vitreous loss during surgery
left aphakic for at least 3 months for resolving inflammation can lead to visual impairment, but modern management with
with oral ciprofloxacin 500mg twice daily for 7 days, partial anterior vitrectomy followed by ACIOL implantation
cycloplegic eye drop for 2 weeks, topical broad spectrum by an expert surgeon can minimize the complications and
antibiotic for 2 weeks and topical corticosteroid a tapering visual outcome is good. But still, some immediate and
dose for a total of 2 months. After 3 months follow up, we delayed complications are also reported. Increased incidence
checked the anterior chamber for anterior evidence of of glaucoma, persistent uveitis, retinal detachment, cystoid
inflammation, fundus evaluation and vision improvement macular edema are associated with immediate implantation
with aphakic spectacles. In favourable cases, ACIOLs are of ACIOL [1].
implanted as secondary surgery.
Here we left the eyes aphakic for 3 months to resolve
 Surgical Technique of Second Surgery: inflammation and then implant an ACIOL with a clear
A 6 mm clear corneal incision was done at superior corneal tunnel followed by suturing. On the first post-
limbus with keratome under local anesthesia. A tunnel of 6 operative day, 50 eyes (96%) showed minimal signs of
mm was done in the clear cornea with the help of a crescent inflammation, one patient (1.95%) developed toxic anterior
knife and entered into the anterior chamber with a keratome. segment syndrome (TASS) and the patient was treated
A small amount of viscoelastic material (dispersive) accordingly, but in final follow up patient was dropped out
material was put in the anterior chamber and the open-loops and one patient (1.95%) had moderate inflammation with
ACIOL was placed into the anterior chamber with the help mild hypopyon which was subsequently resolved with
of McPherson forceps. ACIOL was placed horizontally and topical corticosteroid. One patient (1.95%) had raised IOP
removed all viscoelastic materials. The wound was closed on the first postoperative day due to vitreous hemorrhage
with a 10-O nylon suture [fig. 01]. Subconjunctival broad and subsequently reduced it to normal level after treatment
spectrum antibiotics and corticosteroids were given to every with antiglucoma medication but finally developed
patient and they closed the eye with a pad and bandage for pseudophakic bullus keratopathy with poor visual outcome
24 hours. Post operatively, all patients were treated with oral with counting finger 3 meters. Striate keratopathy occurred
ciprofloxacin 500mg twice daily for 7 days, cycloplegic eye in 2 patients (3.84%), which was resolved within 2 weeks.
drop for 1 week, topical broad spectrum antibiotic for 2 Focal retinal detachment with macular edema was seen in
weeks and topical corticosteroid in a tapering dose for a one patient (1.95%) and after 5 months, one patient (1.95%)
total of 2 months. Patients received spectacles after was suffering from rhegmatogenous retinal detachment,
refraction and followed from 18 months to 48 months. which subsequently underwent retinal detachment surgery
and achieved good (6/12) vision. One patient (1.95%)
III. RESULTS having corneal scar and anterior chamber IOL was tilted due
to an irregular pupil with poor visual outcome. Pale optic
Fifty-two eyes of 51 patients were included in this disc was seen in one patient (1.95%) with a cup disc ratio of
study. The mean age of the patients was 57.69±14.64 years. 0.8 having moderate vision. In our study we compared the
Majority of the patients were female (55.8%, n=29) and outcome of late implantation of ACIOL with other studies.
males were 42.3%, [n=22] [fig. 02]. One male patient had Mean log MAR visual acuity in our study was comparable
both eyes operated due to subluxated lens. Major indications to other studies and the complications in our study were
for surgery were posterior capsular tear (57.70%, n=30) and surprisingly low compared to others (Table 02). Different
subluxated crystalline lens (19.2%, n=10), other causes were studies showed the range of macular edema from 8-24%. In
zonular dialysis (n=2), ectopia lentis (n=1), late onset our study, the macular edema was 1.9 % which is lower than
capsular block syndrome (n=1), membranous cataract (n=1), other studies [4,5,6]. Different studies show a very wide
decentered intraocular lens (n=4) and traumatic cataract range of short and long term IOP rise from 4.1% to
(n=1) [fig. 03]. Preoperative LogMar visual acuity 100%. Kwong et al. showed all patients with primary
uncorrected and corrected was 1.51±0.29 and 0.47±0.35. ACIOL developed secondary glaucoma finally [7]. In

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
another study by Evereklioglu et al., where 4.1% of the keratopathy, which subsequently resolved and gained 6/12
patients developed delayed secondary glaucoma with vision.One patient with vitreous hemorrhage and post-
secondary ACIOL done with adequate vitrectomy [8]. A operative rise of IOP subsequently developed bullus
study conducted by GS Negre ei et al., in vitrectomised eye, keratopathy, most probably due to endothelial
32% of patients developed late onset glaucoma after decompensation.
ACIOL implantation [6]. In our study of 52 eyes with late
implantation of ACIOL (after 3 months of primary surgery), V. CONCLUSION
one patient (1.92%) developed postoperative IOP rise for a
short period resulting from vitreous hemorrhage and Delayed implantation of secondary ACIOL may be a
subsequently developed bullus keratopathy with poor vision. good option in attaining good visual acuity and
Here the retinal detachment was 1.92% (n=1), which is minimization of severe complications like persistent rise of
comparable to other studies that range from 0-6% [5,6,9]. IOP, persistent uveitis, cystoid macular edema. A controlled
Different literature describes that implantation of ACIOL primary anterior vitrectomy and remaining aphakic for 3
increased corneal endothelial cell loss [10]. We did not months to control inflammation will facilitate the outcome.
perform the endothelial cell count of corneas pre- and after
ACIOL implantation to assess the endothelial cell loss. In  Tables
our study, only 2 patients (3.84%) developed striate

Table 1 Pre- and Postoperative Visual Acuity

Visual Acuity Range Preoperative UCVA Preoperative BCVA First PO UCVA Final UCVA Final BCVA
6/6 – 6/18 00 73.10% 48.10% 67.30% 90.40%
6/24 – 6/60 00 23.10% 28.80% 30.80% 7.70%
<6/60 100 3.80% 23.10% 1.90% 1.90%
Total 100 100% 100% 100% 100%
Note:, UCVA-uncorrected visual acuity, BCVA-best corrected visual acuity, PO- post operative.

Table 2 Comparison with Other Studies.

Parameters Our Study Mahapatra et al.[4] Khan M A et al.[9]
Sample size (n) 52 90 33
Preoperative mean Log Mar VA 1.51±0.29 1.59±0.44 1.66±0.74
Preoperative mean Log Mar VA 0.31±0.28 0.36±0.33 0.4±0.39
Complications (%)
Retinal detachment 1.92 2.2 -
Corneal decompensation /PBK 1.92 - -
Toxic anterior segment syndrome-TASS 1.92 - -
Persistently raised IOP - 4.4 3
Persistant uveitis - 2.2 -
IOL tilt 1.92 1.1 -
Cystoid macular edema 1.92 8.8 3
Epiretinal membrane - - 6.1
Pale disc 1.92 - -
Note: PBK-pseudophakic bullus keratopathy

 Figures

Fig 1 ACIOL Implanted with Wound Closure with 2 Nylon

(10-O) Sutures. Fig 2 Gender Distribution

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Fig 3 Indications of Surgery

Fig 4 Pre- and Postoperative Visual Acuity

Fig 5 Complications of Surgery.

Note: PBK-Pseudophakic Bullus Keratopathy.Ote: RD- Retinal Detachment, SK-Striate Keratopathy, TASS-Toxic Anterior
Segment Syndrome

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Volume 8, Issue 10, October – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Limitation: No endothelial cell count in pre- and [10]. Pechméja J, Guinguet J, Colin J, Binder PS. Severe
postoperative period. endothelial cell loss with anterior chamber phakic
intraocular lenses. J Cataract Refract Surg
 Conflict Of Interest: No commercial/financial interest. 2012;38:1288-92.

 Authors Contribution

 Sujit Kumar Biswas- Concept, design, manuscript

preparation
 Soma Rani Roy-Manuscript review, grammatical
correction
 Aparajita Raihan- Literature review
 Tangila Mohona- Statistical analysis

 Funding/Financial Support: No institutional funding.

 Acknowledgement: We would like to thank Dr. Ahmadur

Rahman Research Center.

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