Ophthalmic Surgery, Lasers and Imaging Retina

Case Report 

Manual Removal of Intraocular Lens Silicone Oil Droplets and Dystrophic Calcifications Using a Nitinol Loop: A Case Series

Kareem Moussa, MD; Theodore Leng, MD, MS; Julius T. Oatts, MD; Robert B. Bhisitkul, MD, PhD; David G. Hwang, MD; Jay M. Stewart, MD

Abstract

Deposition of dystrophic calcifications on the posterior surface of silicone intraocular lenses (IOLs) has been reported in patients with asteroid hyalosis. Accumulation of silicone oil droplets on the posterior surface of silicone IOLs in silicone-filled eyes has also been reported. Recently, a novel technique to manually remove dystrophic calcifications using a nickel titanium loop (Finesse Flex Loop; Alcon, Fort Worth, TX) was described, obviating the need for IOL exchange. Here, the authors report their outcomes with this technique in five eyes with IOL dystrophic calcifications as well as one eye with IOL silicone oil droplet accumulation.

[Ophthalmic Surg Lasers Imaging Retina. 2017;48:422–426.]

Abstract

Deposition of dystrophic calcifications on the posterior surface of silicone intraocular lenses (IOLs) has been reported in patients with asteroid hyalosis. Accumulation of silicone oil droplets on the posterior surface of silicone IOLs in silicone-filled eyes has also been reported. Recently, a novel technique to manually remove dystrophic calcifications using a nickel titanium loop (Finesse Flex Loop; Alcon, Fort Worth, TX) was described, obviating the need for IOL exchange. Here, the authors report their outcomes with this technique in five eyes with IOL dystrophic calcifications as well as one eye with IOL silicone oil droplet accumulation.

[Ophthalmic Surg Lasers Imaging Retina. 2017;48:422–426.]

Introduction

Dystrophic calcification of intraocular lenses (IOLs) has been reported in patients with asteroid hyalosis who have undergone cataract extraction with implantation of silicone IOLs.1,2 Attempts at removing these deposits via pars plana vitrectomy (PPV) and polishing of the posterior IOL surface have been met with varying levels of success,3–5 with multiple reports of eyes requiring explantation of the IOL.1,2,6–8 Similarly, the accumulation of silicone oil droplets on the posterior surface of silicone IOLs has been described in silicone-oil filled eyes.9–11 Recently, Schachar and Leng described the use of a 27-gauge nickel titanium (nitinol) loop with concave lines (Finesse Flex Loop; Alcon, Fort Worth, TX), typically used to assist with the removal of epiretinal and internal limiting membranes in macular surgery, to successfully remove IOL dystrophic calcifications.12 Here, we report outcomes using this technique in five eyes with IOL dystrophic calcifications, as well as one eye with IOL silicone oil droplets.

Case Report

Case 1

A 61-year-old man was referred for evaluation of bilateral blurry vision and glare for the past year. He had undergone sequential uncomplicated cataract extraction with implantation of a silicone posterior chamber IOL 12 years prior and had undergone sequential Nd:YAG posterior capsulotomy 2 years prior. On examination, he was found to have visual acuities of 20/30 in both eyes. Slit-lamp examination showed bilateral granular deposits on the posterior surface of the IOLs (Figure 1; only right eye shown) and asteroid hyalosis. He underwent sequential 25-gauge sutureless PPV followed by removal of the granular deposits from the central portion of the IOL to clear the visual axis. We utilized the same technique described by Schachar and Leng; however, we used a 25-gauge nitinol loop instead of the 27-gauge version to remove the deposits.12 At 6-month follow-up, his visual acuity had improved to 20/20 in the right eye and 20/25 in the left eye and he reported resolution of symptoms. Slit-lamp examination showed continued clearance of the visual axis without recurrence (Figure 2, only right eye shown).


            Slit-lamp photograph of the right eye showing accumulation of granular deposits on the posterior surface of the intraocular lens at the preoperative visit.

Figure 1.

Slit-lamp photograph of the right eye showing accumulation of granular deposits on the posterior surface of the intraocular lens at the preoperative visit.


            Slit-lamp photograph of the right eye showing continued clearance of the visual axis without recurrence of the granular deposits at 6-month follow-up.

Figure 2.

Slit-lamp photograph of the right eye showing continued clearance of the visual axis without recurrence of the granular deposits at 6-month follow-up.

Case 2

A 71-year-old man was referred for evaluation of blurry vision and glare in the left eye for the past year. He had undergone sequential uncomplicated cataract extraction with implantation of a silicone posterior chamber IOL 30 years prior. On examination, he was found to have visual acuities of 20/25 in the right eye and 20/50 in the left eye. Slit-lamp examination showed granular deposits on the posterior surface of both IOLs; however, the left IOL was more affected than the right. He had asteroid hyalosis in both eyes. He underwent the same procedure described above (Video 1), and at 6-month follow-up, his visual acuity in the left eye had improved to 20/25. He reported resolution of symptoms, and slit-lamp examination showed continued clearance of the visual axis without recurrence.

Case 3

An 83-year-old man was referred for evaluation of posterior lens opacification in both eyes. At the age of 67 he underwent sequential bilateral cataract extraction with silicone IOL implantation for visually significant cataracts. He reported being satisfied with the visual outcome and was not seen for 12 years. At age 79, he presented with a 1-year history of decreased vision in both eyes. His symptoms were largely related to glare. Vision was 20/20 in the right eye and 20/40 in the left eye, with granular posterior capsular opacifications and asteroid hyalosis noted in both eyes. Three years later, his symptoms of glare and loss of contrast had progressed with a slight reduction in acuity. Nd:YAG capsulotomy was performed first in the left eye and then the right eye. The patient had initial reduction in glare, but after another year, his original symptoms had fully returned and there was increased granular opacification of the posterior surface of the lens. A 25-gauge sutureless PPV was performed and the opacifications were removed with a 27-gauge nitinol loop.12 The following day, the patient noted significant reduction in glare and improvement in contrast and color discrimination. One month later, an identical procedure was performed on his other eye. Three months after surgical removal of these dystrophic calcifications in both eyes, his visual acuity was 20/20 in both eyes with a dramatic reduction in glare. Final follow-up at 14 months found visual acuity to be 20/20 in both eyes.

Case 4

A 70-year-old woman was referred for evaluation of progressive blurry vision in her right eye for 3 months. She had undergone uncomplicated cataract surgery in the right eye approximately 15 years prior to presentation, with placement of a silicone IOL in the capsular bag. Three years prior to presentation, she underwent retinal detachment repair with silicone oil placement following traumatic globe rupture, with silicone oil removal 5 months later. Following silicone oil removal, she was noted to have silicone oil droplets on the posterior surface of the IOL and was referred to us for evaluation. On examination, her best-corrected visual acuity was 20/200 in the right eye. Slit-lamp examination of the right eye was notable for temporal iris atrophy and a three-piece posterior chamber IOL in the capsular bag with numerous silicone oil droplets on the posterior surface of the optic, as well as a Soemmering ring (Figure 3). Fundus examination was notable for an epiretinal membrane and macular edema. She underwent standard 25-gauge sutureless PPV, followed by removal of the deposits from the posterior surface of the IOL to clear the visual axis using a 25-gauge vitrector, 25-gauge soft tip, and 25-gauge nitinol loop (Video 2). The vitrector was moderately successful in removing the silicone oil droplets; however, some central droplets remained, which were ultimately removed with the nitinol loop. We did not find the soft tip to be useful in removing these droplets. On examination 1 month later, visual acuity improved to 20/150 and the visual axis was clear of silicone oil droplets (Figure 4).


            Slit-lamp photograph of the right eye showing accumulation of silicone oil droplets on the posterior surface of the intraocular lens at the pre-operative visit.

Figure 3.

Slit-lamp photograph of the right eye showing accumulation of silicone oil droplets on the posterior surface of the intraocular lens at the pre-operative visit.


            Slit-lamp photograph of the right eye showing clearance of the visual axis at the postoperative month 1 visit.

Figure 4.

Slit-lamp photograph of the right eye showing clearance of the visual axis at the postoperative month 1 visit.

Discussion

Asteroid hyalosis is a condition in which multiple small opacities composed of phospholipids float in normal vitreous.13 Deposits on silicone IOLs in eyes with asteroid hyalosis have been reported to be similar to hydroxyapatite, composed of calcium and phosphate.2 These IOL opacities are typically quite adherent to the posterior IOL surface, and being densely distributed can be visually significant.5 Many of these patients undergo Nd:YAG capsulotomy in an attempt to remove these deposits, though this can lead to recurrence.7 Additionally, prior capsulotomy can make IOL exchange technically challenging.

Recently, Schachar and Leng reported a novel technique for removing these deposits using standard 25-gauge sutureless PPV and a nitinol loop.12 The instrument is inserted into the superotemporal trocar and the nitinol loop is used to create repeated passes across the posterior lens surface. We have found this technique to manually remove these deposits to be an excellent alternative to IOL exchange. Similar to their report, we found no scratches on the posterior lens surface, and the procedure took less than 30 minutes. In our experience, this technique is both efficient and effective, with excellent visual acuity outcomes and no evidence of recurrence at up to 14-month follow-up.

The accumulation of silicone oil droplets on silicone IOLs in silicone oil-filled eyes was first described in 1996 and has since been reported in a number of studies.9–11 These droplets can be visually significant and may necessitate IOL exchange, a surgical procedure with associated cost and time. In 2009, researchers at Moorfields Eye Hospital described a novel procedure to successfully remove silicone oil droplets from the posterior surface of silicone IOLs using hydroxypropyl methylcellulose 2% in three eyes.14 Other studies have reported successful removal of these droplets using novel compounds or surgical tools in in vitro settings.15,16 In this report, we successfully removed these droplets using surgical instruments that are readily available in modern vitreoretinal surgery centers, rendering the visual axis optically clear. We found Schachar and Leng's technique for removing dystrophic calcifications using a nitinol loop to be equally efficacious at removing residual silicone oil droplets following initial removal with the vitreous cutter.

In summary, we found using the nitinol loop with simple mechanical maneuvers to remove deposits on the posterior surface of IOLs to be a versatile technique that is safe, efficient, and effective. It is a viable alternative to IOL exchange.

References

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Authors

From the Department of Ophthalmology, University of California — San Francisco, San Francisco (KM, JTO, RBB, DGH, JMS); and Byers Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, CA (TL).

The UCSF Department of Ophthalmology is supported by an unrestricted grant from Research to Prevent Blindness, New York, as well as funding support from That Man May See, San Francisco, CA.

Dr. Leng received personal fees from Alcon during the conduct of this study, as well as personal fees from Regeneron, Zeiss, Iridex, and Thrombogenics; grants from StemCells; and grants and personal fees from Genentech and Allergan outside the submitted work. The remaining authors report no relevant financial disclosures.

Address correspondence to Jay M. Stewart, MD, UCSF Department of Ophthalmology, 10 Koret Way, K301, San Francisco, CA 94143-0730; email: jay.stewart@ucsf.edu.

Received: July 13, 2016
Accepted: January 17, 2017

10.3928/23258160-20170428-09

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