A case of hypermature cataract formation following implantation of a posterior chamber

phakic intraocular lens with a central hole

The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea

So-Hyang Chung

The author has no financial interests to disclose.

• A 29-year-old man showed an anterior subcapsular cataract

and lens swelling in the left eye following implantation of

an implantable collamer lens (ICL) with an hole 4 months ago

at other eye clinic.

• According to his medical record, ICLs (12.6 mm) was

inserted at superior corneal incision and rotated to horizontal

axis.

• Uncorrected distance visual acuity (UDVA) in both eyes

was 20/20 on postoperative day 7, and there was no

intraoperative surgical complication.

Manifest refraction

-1.75Ds : -0.50Dc Ax 155 (0.4) (OS)

IOP 15 mmHg at 2:00 PM (OS)

Anterior chamber depth

2 CT at center, <1/4 CT at periphery (OS)

Vaulting of ICL

½ CT, Inferonasal decentered hole (OS)

Lens

Vertically positioned ICL (OS)

Moderate cortical opacity (OS)

White to white (WTW): 12 mm (OU)

Size of implanted ICLs: 12.6mm (OU)

On first examination

Vision: Hand motion (OS)

Lens

Swelling (OS)

Abnormal aggravation to hypermature

cataract (OS)

Anterior chamber: cells 2+

ICL removal and Cataract extaction

Multifocal IOL implantation (OS)

POD 1 Day

Far vision: 20/30

Intermediate vision: 20/40

Near vison: 20/20

After 1 month after 1st visit

IL-6 : 69.6 pg/mL (Normal: 0~46 pg/mL)

The whitish infiltrates on the explanted ICL surface by slit-lamp microscopy Pro-inflammatory

cytokines in anterior chamber

ELISA

VA OD 1.0Vault 500umRotated to vertical ICL

positionDecentered holeNo cataract

Cataract formation after conventional ICL implantation In the present literature review comprising 2592 eyes,

the occurrence of cataract formation with the latest ICL models was 5.2%.1

Most were reported as nonprogressive or slowly progressive and asymptomatic.

However, in 30.1 % of eyes, the opacity became clinically significant and cataract surgery was performed in 27.9% of eyes.

Previous studies showed that hole-ICL is associated with low postoperative complication rates compared to conventional ICL due to the possible flow of the aqueous humor through the hole.2-4

1. Fernandes P, Gonzalez-Meijome JM, Madrid-Costa D, Ferrer-Blasco T, Jorge J, Montes-Mico R. Implantable collamer posterior chamber intraocular lenses: a review of potential complications. J Refract Surg. 2011;27:765-776.2. Shimizu K, Kamiya K, Igarashi A, Shiratani T. Early clinical outcomes of implantation of posterior chamber phakic intraocular lens with a central hole (Hole ICL) for moderate to high myopia. Br J Ophthalmol. 2012;96:409-412.3. Kamiya K, Shimizu K, Saito A, Igarashi A, Kobashi H. Comparison of optical quality and intraocular scattering after posterior chamber phakic intraocular lens with and without a central hole (Hole ICL and Conventional ICL) implantation using the double-pass instrument. PLoS One. 2013;8:e66846.4. Shimizu K, Kamiya K, Igarashi A, Shiratani T. Intraindividual comparison of visual performance after posterior chamber phakic intraocular lens with and without a central hole implantation for moderate to high myopia. Am J Ophthalmol. 2012;154:486-494.e481.

A low vault and decentration of an hole

A low valut might lead to disturbances in the aqueous flow,

interfering with lens nutrition and causing metabolic

disturbances to the crystalline lens.

The rapid flow of hole5 might cause rapid progression of

cataract especially in low vaulting cases.

Decentered hole might prevent an adequate circulation of

the aqueous humor, which causes increase of pro-

inflammatory cytokine IL-6 in the anterior chamber and

whitish infiltration on the ICL surface.

Possible reason of rapid progression of cataract in the eye with hole-ICL

5. Kawamorita T, Uozato H, Shimizu K. Fluid dynamics simulation of aqueous humour in a posterior-chamber phakic intraocular lens with a central

perforation. Graefes Arch Clin Exp Ophthalmol. 2012;250:935-939

This case demonstrates the rapid progression of the

cataract in a patient with the hole-ICL.

• Although a central hole of ICL was designed to improve

the aqueous humor circulation, low vaulting,

decentrated hole, and rapid flow of hole may induce

the rapid progression of cataract.

• Surgeons might consider faster removal of the hole-ICL

in patients who developed cataract compared to the

patients with conventional ICL.