Refractive Surprise Due To Tilted Intraocular Lens Following Cataract Surgery

To report a case of refractive surprise noted three months after uncomplicated phacoemulsification cataract surgery 

This case was managed at the ophthalmology department at Central Middlesex Hospital, UK. 

A 66-year-old lady presented with reduced vision in the left eye, following cataract surgery 3 months prior. Her operative notes stated that the capsulorrhexis ran out inferiorly due to patient movement and was retrieved using Little’s manoeuvre.

To improve her vision, she was referred for posterior capsulotomy. At the laser clinic, minimal posterior capsular opacification was noted. However, her visual acuity was LogMAR 0.5 unaided, improving to 0.14 pinhole. Subjective refraction was -1.25/-0.50 x 100 (spherical equivalent of -1.5D), achieving LogMAR 0.0, though the postoperative aim was emmetropia. Biometry and surgical records confirmed that the correct intraocular lens (IOL) had been inserted. Corneal topography did not indicate any significant corneal astigmatism or ectasia, and repeat biometry showed similar values to pre-surgery. Dilated examination revealed a tilted IOL, which was adherent to the iris inferiorly with no retained viscoelastic. This was confirmed with anterior segment optical coherence tomography. 

The patient initially requested laser correction of the myopic outcome. However, after detection of the tilted IOL, she underwent IOL exchange. During the surgery, the inferior haptic of the single piece IOL was found in the sulcus with the anterior and posterior aspects of the capsular sac fibrosed together almost 360°. The single piece IOL was replaced with a 3-piece IOL in the ciliary sulcus. Her post-operative vision improved to LogMAR 0.2 unaided. 

Refractive outcomes following cataract surgery are gaining increasing significance within the NHS, as patients’ expectations around spectacle independence rise. Determining the cause of refractive surprise requires a stepwise approach, including subjective refraction, a dilated examination, corneal topography and careful review of preoperative biometry, surgical records and IOL selection. In this case, laser surgical correction of the myopic outcome would not have corrected this patient’s visual symptoms, as she had poor-quality vision due to a tilted IOL. We advise delaying laser capsulotomy in the presence of a refractive surprise until the underlying cause has been established.