Risk of Breaking Haptic of Trifocal IOL and Its Management.

Fracture of an intraocular lens (IOL) haptic is a rare complication of cataract surgery. A broken haptic can cause serious damage in the anterior and posterior segments. To the best of our knowledge, a broken haptic in a high-quality, commercially available trifocal IOL has not been documented in the literature. Prompt and proactive action at 1 day postoperatively aided in addressing the complication and restoring the vision. We suggest that the ophthalmologist performed a thorough evaluation on the 1st postoperative day and take immediate action after a discussion with the patient and relatives.

Introduction

The volume of intraocular lens (IOL) implantation procedures is rapidly increasing, especially in urban area of rapidly evolving economies.[1] The main indication for IOL implantation is compromised visual function due to cataract that is affecting vision-related quality of life. Patient expectations of cataract surgery are high, and trifocal IOLs are a good option to allow good functional vision at all distances and maintain patient satisfaction.[2] Trifocal IOLs are composed of high-quality material and more costly compared to conventional IOLs.[3] Patients expect excellent quality of vision after trifocal IOL implantation. However, complications can occur during or after surgery. Broken IOL haptics can cause serious damage in the anterior and posterior segment.[45] In cases with an intraoperative complication, prompt action in consultation with the patients can mitigate long-term sequelae and medicolegal litigation.

We present the clinical course and management of a rare intraoperative complication of haptic breakage of a trifocal IOL.

Case Report

A 70-year-old male presented to the clinic with complaints of gradual onset of dimming vision in both eyes that was affecting his daily living activities. Both eyes were hyperopic with a refraction of + 6.00 − 1.00 × 160° in the right eye and + 5.00 − 1.00 × 140° in the left eye. The patient was suspected to have anisometropic amblyopia in the right eye.

Slit lamp examination (Topcon Corp., Tokyo, Japan) indicated normal anterior segments bilaterally. On gonioscopy, the anterior chamber angle was occludable with shallow anterior chamber of moderate grade. The pupil was round and briskly reactive to light. The lens had Grade 1 opacity in the right eye and Grade 2 nuclear sclerosis in the left eye. Dilated funduscopy was performed after pupil dilation with one drop of 0.5% tropicamide and repeat instillation (once) after 20 min. The retina was examined with a + 90 D lens (Volk Optical Inc., Mentor, OH, USA) and an indirect binocular ophthalmoscope (Keeler Ltd., Windsor, UK). The central and peripheral retina was normal in the right eye. The optic nerve head was normal.

The patient was offered cataract surgery with implantation of a trifocal IOL (Zeiss Inc., Jena, Germany) to improve vision, correct the refractive error, and relieve angle narrowing. A trifocal IOL was implanted in the right eye. There were no intraoperative complications, and the postoperative follow-up was uneventful. One week postoperatively, distance vision was 20/32+.

Two weeks after surgery in the right eye, a trifocal IOL was implanted in the left eye. The surgery was uneventful. On the 1st postoperative day, the patient complained of double vision in the left eye. On slit lamp examination of the left eye, the IOL was decentered inferiorly. The patient was taken to operation theater within an hour. At the onset of surgery up entry into the anterior chamber, we noted that one of the haptics was broken [Figure 1]. We reviewed the video of IOL implantation surgery and found that haptic had broken inside the cartridge during injection of the lens into the capsular bag. The lens was explanted and replaced with another trifocal lens of similar specifications.

Figure 1

Trifocal intraocular lens with broken inferior haptic after it was introduced into the anterior chamber before explantation 1 day after primary intraocular lens implantation surgery

At 1 day, 1 week, and 3 months after explantation and exchange surgery, vision in the left eye was 20/20 for distance and N1 for near without any correction.

Discussion

Exchange and explantation of IOL have been documented from the USA that mainly reports implantation of an IOL of the incorrect power or placement at the wrong axis.[6] A previous report has been published of lens implantation providing good vision until breakage of polyimide haptics 12 years after surgery.[7] However, noting a broken haptic on the 1st postoperative day based on patient complaints of diplopia, as in our case, is unusual. Video recording of the surgical procedure enabled us to note the presence of broken haptic in the cartridge. IOL manufacturing companies should ensure adequate quality controls and system checks to avoid similar incidents. Cataract surgeons are advised to carefully inspect the IOL before insertion to ensure that it is patent and free of defects. In case of lens haptic breakage, surgeon should explant and exchange the lens. Thorough discussions are advised with patient and relatives to mitigate patient stress and reduce the chances of litigation.[8]

A thorough inspection is required during preparation and implantation of a Zeiss trifocal IOL to minimize the risk of haptic breakage and resulting lens decentration causing monocular diplopia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.