• Written By: Ramana S. (Bob) Moorthy, MD
    Cataract/Anterior Segment, Uveitis

    This retrospective study found ultrasound biomicroscopy (UBM) to be a valuable tool in confirming the presence of IOL haptic-induced ocular irritation and in guiding the management of these patients.

    The authors reviewed records from 20 pseudophakic patients who underwent UBM examination to confirm suspicion of misplacement of IOL haptics.

    The mean time to presentation was approximately five years after phacoemulsification but varied from one to 288 months. All patients had undergone phacoemulsification. IOL placement was planned for the sulcus in 10 eyes (50 percent) and in-the-bag in eight eyes (40 percent).

    IOL haptics misplacement was confirmed by UBM in all suspected cases. In 75 percent of the eyes, one haptic was embedded in the iris; in 35 percent, it extended into the ciliary body process; and in 10 percent, it extended into the pars plana. Focal iris thinning/atrophy was detected by UBM in 15 percent of cases and focal angle closure in 25 percent.

    IOL exchange was performed in 40 percent of patients. The remaining 60 percent were kept under observation, with the addition of topical steroids and/or cycloplegics in eyes that demonstrated anterior chamber inflammation and IOP-lowering medications in eyes with persistent elevated IOP or glaucoma.

    There are several aspects of this paper that I found intriguing:

    1. It is clear that the placement of even modern three-piece acrylic IOLs in the sulcus can in some cases result in inflammation, hemorrhage or glaucoma.
    2. Many patients may have only a single manifestation or some combination of manifestations of uveitis, hyphema or vitreous hemorrhage, cystoid macular edema and/or glaucoma. Six of the 20 eyes (30 percent) eyes had three or four of these clinical manifestations. These eyes were more likely to undergo pars plana vitrectomy and IOL exchange and placement of either an anterior chamber IOL or a sulcus sutured posterior chamber IOL.
    3. The vast majority of eyes were managed medically. With extensive follow-up, it is clear that many patients can have their symptoms treated with success. However, multiple recurrences of hyphema, gradual elevation of IOP and development of CME all may occur eventually in many of these patients over months or years. Thus, patients suspected of or diagnosed as having this condition should be followed closely. IOL exchange is definitive therapy for the treatment of this IOL placement complication.
    4. Although this study was biased due to its retrospective nature and selective patient inclusion, confirmation of IOL haptic position by UBM is extremely accurate when historical and clinical data suggest the diagnosis of IOL haptic-induced inflammation.
    5. IOL-induced or -associated inflammation is an important cause of anterior uveitis. It should not be ignored and is most readily diagnosed based on historical information from the patient. Other causes of inflammation should also be ruled out in these cases as well.