Intraocular lens tilt due to optic-haptic junction distortion following intrascleral haptic fixation with the Yamane technique

Abstract

Purpose: To report two patients with a complication of Yamane intrascleral haptic fixation surgery (ISHF) with the Zeiss CT Lucia 602 lens: severely tilted intraocular lens (IOL) leading to significantly decreased vision in the early post-operative period.

Observations: We report two patients presenting with severely tilted IOL implants one day and one month following Yamane ISHF. The first patient is a monocular 81-year-old woman referred for treatment of cornea edema. Initial surgery involved replacement of an anterior chamber lens with a CT Lucia 602 posterior chamber lens using Yamane technique and Descemet's stripping endothelial keratoplasty. The patient returned at one month follow-up with poor vision and IOL tilt observable at the slit lamp through a peripheral iridectomy site. Explanation of the Zeiss lens revealed haptic distortion at the optic-haptic insertion point such that each haptic was about 45° off axis to the plane of the optic in approximately equal and opposite directions. The second patient, a 75-year-old woman, was referred with a completely dislocated lens-bag complex in the right eye. The initial operative treatment for this patient included pars plana vitrectomy, retrieval and removal of the dislocated lens-bag complex, and placement of a Zeiss 602 lens via Yamane ISHF technique. On the first postoperative day, the patient was count fingers in the right eye with an intraocular pressure of 5 mm Hg and obvious IOL tilt on slit lamp examination. Explanation of the lens revealed severely distorted haptics relative to the optic by more than a 60-degree angle on both sides. In both cases, initial surgery was performed with an IOL inspected prior to implantation and found to have normal appearing haptics. At the end of each case, there was adequate centration and no tilt of the IOL. Management in both patients included removal of the defective lens and placement of a new, same power CT Lucia 602 lens via the Yamane technique. Visual acuity improved from CF to 20/30 best corrected after reoperation in both cases.

Conclusions and importance: In summary, we describe a complication of Yamane ISHF with the CT Lucia 602 lens in which there is lens tilting associated with distortion at the optic-haptic fastening zone in the early postoperative period. In the event of a titled lens following Yamane ISHF, awareness of this complication may help surgeons consider lens replacement, as the haptics may be permanently distorted or damaged.

Keywords: Cataract surgery complication; Intraocular lens exchange; Intrascleral haptic fixation; Tilted intraocular lens; Yamane technique; Zeiss lens.

Fig. 1

Clinical images of post-operative IOL tilt in Patient 1. Gonioscopic view on slit lamp exam reveals the haptic through the peripheral iridectomy (red arrow) which appears to be at a 30–40° angle relative to the IOL optic (yellow arrow). The optic can be seen to be tilted relative to the plane of the iris in this image as well (A). After placing iris retractors the intra scleral haptic fixated IOL can be seen to be severely tilted (B). The tilted Zeiss CT Lucia 602 lens removed from this patient's eye in one piece can be seen to have both haptics distorted in roughly equal and opposite directions relative to the optic (C). The replacement Zeiss 602 lens after Yamane ISHF prior to removing the iris retractors and trocars can be seen to be planar with no evidence of tilt or decentration. The lens remained in this configuration through the post-operative course (D).

Fig. 2

Clinical images of post-operative IOL tilt in Patient 2. At the end of the patient's first surgical procedure, the Zeiss CT Lucia 602 lens can be seen in planar configuration with excellent centration. This is just prior to removing trocars and conclusion of surgery (A). The view under the surgical microscope of this same IOL at the beginning of her second surgery. The lens is now severely tilted (B). Upon removal of the severely tilted IOL (which was cut in half during extraction) the haptics can be seen to be distorted 60–80° in opposite directions relative to the optic (C).

Fig. 3

Scleral buckling during DSAEK in Patient 1. Still from Patient 1 surgical video which demonstrates scleral collapse of the eye as DSAEK graft is being pulled into the eye from Busin glide. At this moment there are likely significant torquing forces placed on the haptics of the intrascleral haptic fixated lens which could lead to rotation at the optic-haptic junction and subsequent tilt of the lens.