From Tilt To Toxicity: Recurrent Sulcus Iol Instability In An Aniridic Eye

Eyes with congenital aniridia present unique challenges during cataract surgery due to abnormal anterior segment anatomy and the absence of an iris barrier. Sulcus implantation of posterior chamber intraocular lenses (IOLs) following posterior capsular rupture may lead to significant postoperative complications in these patients. This case report aimed to highlight the challenges and potential complications of sulcus-fixated intraocular lens implantation in eyes with congenital aniridia, and to emphasize the importance of early recognition and definitive management of recurrent IOL instability to prevent endothelial damage and secondary glaucoma. 

Al-Azhar University Hospital – Damietta

We report a case of a 21 years old male patient with congenital aniridia and nystagmus who underwent complicated phacoemulsification cataract surgery with posterior capsular tear, managed by implantation of a 3-piece IOL in the ciliary sulcus. Following blunt ocular trauma, the patient presented with ocular pain, redness, elevated intraocular pressure (IOP), and reduced vision. Slit-lamp examination revealed a tilted sulcus-fixated IOL with one haptic incarcerated in the anterior chamber angle, resulting in secondary glaucoma. Surgical IOL repositioning was initially attempted; however, early recurrence of IOL tilt occurred within three days, accompanied by severe anterior segment inflammation, corneal edema, markedly elevated IOP, and direct haptic–endothelial touch. Given the recurrent instability and progressive endothelial compromise, urgent explantation of the sulcus-fixated IOL with anterior vitrectomy was performed, and the eye was left aphakic. Postoperatively, aggressive anti-inflammatory and IOP-lowering therapy resulted in resolution of ocular inflammation, improvement in corneal clarity, and stabilization of IOP. The patient is currently under observation, with secondary visual rehabilitation planned once the eye is quiet.

Sulcus-fixated IOLs may be poorly tolerated in aniridic eyes, particularly following trauma. Recurrent IOL instability with endothelial touch warrants prompt IOL explantation rather than repeated repositioning. A staged approach with delayed secondary scleral-fixated IOL implantation may offer a safer long-term solution in such high-risk eyes.