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First Author: L.Steeples UK
Co Author(s): W. Ho
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To document the cause and visual outcome of pigment deposits on an intraocular lens (IOL) following routine cataract surgery.
Instrument related IOL damage has previously been described including scratches, cracks, folds and impressions. Linear lens deposits following implantation through hexagonal cartridges have also been reported. IOL damage/deposits may be temporary or permanent and can result in visual symptoms such as haloes or impaired vision. Phacoemulsification cataract surgery was performed routinely in a high volume cataract service. A disposable non-toothed stainless steel lens loading forcep (Malosa Medical, UK) was used to load a hydrophilic IOL lens (Bausch and Lomb Akreos AO) into the manufacturers single-use lens injector system. The IOL was grasped with the forceps across the optic according to the manufacturers loading advice. Following implantation distinctive linear glistening metallic pigment deposits were noted on the anterior and posterior lens optic surface, crossing the visual axis. These deposits matched the shape and configuration of the jaws of the forceps used to grasp the IOL.
Post-operative visual acuity, refractive outcome and visual symptoms are provided. Anterior segment photograph including detailed IOL images are presented to detail the appearance and configuration of the pigment deposits. High-magnification photographs of the responsible forceps are included.
Best corrected visual acuity was 0.02 LogMAR 1 week post-operatively. The lens deposits were easily detected across the optic surfaces and involved the visual axis. The deposits were un-changed 4 weeks later. The patient has had no visual symptoms. No post-operative complications occurred. In our case the lens deposits resulted from contact between the forcep jaws and optic with instrument pigment transfer onto the lens surface. Despite this there was no evidence of lens scratch/indentation to suggest excessive force or mechanical compression accounted for pigment transfer. The deposits were obvious immediately post-implantation. Similar and persistent lens deposits on this IOL have been reported in two patients by different authors from our centre. The deposits were reported as a post-operative finding rather than an intra-operative complication. These were attributed to an earlier model of this disposable lens forceps that was withdrawn. A new forcep model was introduced and used in this case. We have replaced the involved forcep with a non-disposable titanium alternative and are aware of no similar complications.
Pigment transfer from forceps onto the optic surface appears to create long-lasting deposits corresponding to the contact area between the two materials. No adverse clinical or visual outcomes occurred despite persistent deposits in our patient. Furthermore, no attempts were made to remove the deposits intra-operatively with no adverse outcome. In fact any attempts to remove such fine, widespread deposits may cause further IOL or capsule damage and is best avoided. In asymptomatic patients with lens deposits surgical intervention is not indicated. Some surgeons advocate avoiding grasping the optic when preparing IOLs for implantation. However, the manufacturer of this particular lens provides instruction to gently grasp the full IOL optic with forceps to remove from the holder. We propose the transfer of pigment may relate to the polishing technique used on the jaw areas of the forcep during manufacturing with subsequent transfer of small particles onto the IOL. There may also be a possible material affinity for acrylic lenses. We suggest use of non-disposable instrument for lens loading despite the apparent cost-effectiveness and non-sterilisation benefits of disposable forceps.