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BLOG: One-piece acrylic IOL in the sulcus: don’t do it

January 07, 2022

1 min read

Disclosures: Aref reports being a speaker for Aerie and receiving Allergan research support.

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Rarely, cataract surgeons may be faced with a scenario where the posterior capsule is compromised at the time of the planned IOL implantation. This unforeseen scenario requires careful consideration of the choice and positioning of the IOL.

Ahmed Aref

Although a one-piece acrylic IOL may have been the preferred option, it is not an appropriate choice when implantation will no longer be in the capsular bag but rather in the ciliary groove. Surprisingly, despite long-standing evidence pointing to the risks of implanting a one-piece acrylic IOL into the ciliary groove, this still happens. In fact, I personally deal with the after-effects of these cases at least once or once a year.

Slit lamp photograph showing a one-piece acrylic IOL in the sulcus space. Iris transillumination defects are visible over time, indicating rubbing of the iris pigment epithelium due to contact and rubbing with the acrylic haptics of the IOL. The pattern of this iris transillumination defect follows the curvature of the underlying temporal haptic, which is misplaced in the sulcus space. This patient presented with severe secondary glaucoma and visual field loss due to improper positioning of the IOL at the time of her initial cataract surgery.

One-piece acrylic IOLs are not suitable for implantation in the ciliary groove because their relatively thick and bulky haptic can rub against the pigment epithelium of the posterior iris and cause rubbing of the iris and release of pigment particles in the anterior chamber (Figure). Pigment particles from the anterior chamber tend to deposit in the trabecular meshwork and lead to increased resistance to aqueous flow, increased IOP, and risk of glaucomatous optic neuropathy and associated irreversible vision loss.

Appropriate options for IOL implantation in the circumstances of a compromised posterior capsule and planned implantation in the ciliary sulcus include three-piece acrylic IOLs (with a thinner haptic composed of PMMA or polyvinylidene fluoride ), three-piece silicone IOLs or one-piece PMMA lenses. Surgeons should become familiar with these IOL options in the event of unforeseen intraoperative events and the need to change course from the original plan.

  • Reference:
  • Chang DF, et al. J Refractory cataract surgery. 2009; doi: 10.1016 / j.jcrs.2009.04.027.