TNOA Journal of Ophthalmic Science and Research

: 2020  |  Volume : 58  |  Issue : 2  |  Page : 112--114

Late-onset single-piece foldable intraocular lens-induced pigmentary glaucoma: A new management strategy

Gurudatha Pavan Kumar, Srinivasan Kavitha, Rengaraj Venkatesh 
 Department of Glaucoma, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Puducherry, India

Correspondence Address:
Dr. Srinivasan Kavitha
Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Cuddalore Main Road, Thavalakuppam, Puducherry - 605 007


Phacoemulsification with foldable intraocular lens (IOL) implantation is the standard of care offered for a cataract. Single-piece acrylic (SPA) IOL is designed to be placed in the bag and not suitable for sulcus implantation. If implanted in sulcus, it can lead to pigmentary glaucoma, due to constant friction with the iris, leading to pigment release, which blocks trabecular meshwork. We report the case of pigment dispersion glaucoma due to sulcus-implanted SPA presented 3 years after cataract surgery. It was managed successfully by an IOL exchange where we could implant a foldable three piece IOL into the intact capsular bag.

How to cite this article:
Kumar GP, Kavitha S, Venkatesh R. Late-onset single-piece foldable intraocular lens-induced pigmentary glaucoma: A new management strategy.TNOA J Ophthalmic Sci Res 2020;58:112-114

How to cite this URL:
Kumar GP, Kavitha S, Venkatesh R. Late-onset single-piece foldable intraocular lens-induced pigmentary glaucoma: A new management strategy. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2023 Jan 28 ];58:112-114
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Full Text


Single piece acrylic (SPA) IOLs are designed to be implanted in the capsular bag. Secondary pigment dispersion syndrome (PDS) or pigment dispersion glaucoma (PDG) can occur if they are inadvertently placed in the ciliary sulcus and has been described previously.[1],[2],[3] Time of presentation varies from months to years post-cataract surgery.

We report a case of sulcus-implanted SPA-induced secondary PDG 3 years after uneventful cataract surgery, which was alleviated by explanting the SPA, where a three-piece foldable IOL was successfully implanted into the capsular bag.

 Case Report

A 35-year-old female whose right eye (RE) was operated for cataract 3 years ago presented to us with redness, pain, and sudden onset of defective vision in her RE for 3 days. Her visual recovery was good postsurgery, and she was asymptomatic till few months ago. She developed the recurrent episodes of similar complaints which used to get relieved with the application of some eye drops given by her physician, elsewhere. On presentation, her best-corrected visual acuity was 6/6P in RE and 6/6 in the left eye (LE). Intraocular pressure (IOP) measured with Goldmann applanation tonometer was 52 mmHg in RE and 14 mmHg in LE. Ocular examination revealed circumcorneal congestion, corneal epithelial edema, normal anterior chamber depth, and hyphema of 1 mm in RE. Temporal clear corneal phacoemulsification scar was noted. A SPA, with inferior decentration, was seen in the sulcus. Capsulorhexis margin was found to be fused with the intact posterior capsule. Fundus evaluation, through a hazy media showed a cup-to-disc ratio of 0.6 in the RE. Examination of the LE showed posterior subcapsular cataract and a normal fundus with a cup-to-disc ratio of 0.6.

She was started on topical steroids and anti-glaucoma medications (timolol, dorzolamide, and brimonidine) in the RE. In the next few days, her symptoms improved and IOP reduced to 24 mmHg. Gonioscopic examination showed open angles in both eyes, with 360° heavily pigmented trabecular meshwork in the RE. A diagnosis of SP-FIOL-induced secondary PDG was made. She was advised to continue the medications and to review with us after a week. On follow-up, her RE was quiet with IOP of 10 mmHg. She was advised to taper steroids, continue antiglaucoma medications, and to review after 2 weeks.

The patient was lost to follow-up but presented 6 weeks later with similar complaints once she stopped the medications. IOP was 33 mmHg in the RE. After discussing with the patient, we proceeded for SPA explantation and exchange with 3-piece FIOL.

Through a 4-mm “L” shaped limbal tunnel [Figure 1]a in the superotemporal quadrant, the SP-FIOL which was upside down in the sulcus was explanted in toto [Figure 1]b. Capsular bag was found to be intact. After the peeling of fibrous ring in rhexis margin [Figure 1]c, capsular bag was successfully opened with high-density viscoelastic (Viscoat®, Alcon Laboratories, Inc. Fort Worth, TX), residual cortical fibers were aspirated and capsular polishing was done. A 3-piece foldable acrylic IOL (Sensar AR40e, Abbott Medical Optics Inc., USA) was implanted inside the bag and dialed into the position [Figure 1]d. Topical antibiotic eye drops and prednisolone acetate 1% eye drops in tapering doses were prescribed.{Figure 1}

At 2 months postoperative visit, her UCVA was 6/6 and IOP was 10 mmHg in the RE, without any antiglaucoma medications.


PDS secondary to sulcus placed SPA is a well-known reported entity.[1],[2],[3],[4],[5] The design and the dimensions of SPA make it incompatible for sulcus implantation. Both the optic and haptic along with square edges make the IOL thick and bulky and when it comes in contact with the iris causes significant chaffing and pigment release. Being smaller than the sulcus width, SPA tend to move freely when implanted in the sulcus leading to constant rubbing of the posterior surface of the iris which, in turn, leads to inflammation and iris pigment release that blocks the trabecular meshwork causing raised IOP.[2] The solution lies in preventing the contact between the two. Ultrasound biomicroscopy can help in detecting the contact between the two and guide in treating the condition either by IOL repositioning/exchange or haptic amputation.[6]

LeBoyer et al. reported three cases of haptic-induced ciliary sulcus irritation which were treated with IOL explanation.[1] Uy and Chan[3] reported a series on 20 eyes with SPFIOLs placed in the ciliary sulcus following posterior capsule rupture. Thirty-five percent of the eyes developed pigment dispersion, and 15% developed secondary PDG. Hong et al. reported a case series of 6 Asian eyes with PDG, due to iris chaffing by single-piece acrylic IOL occurring within a month post-cataract surgery which were relieved by capsular repositioning of IOL or replacing with three-piece IOL.[5]

In our case, PDG occurred 3 years after cataract surgery. We planned for IOL exchange. Intraoperatively, we could successfully open up the capsular bag and implanted a 3-piece foldable IOL into it. IOL exchange, into the bag in this late onset secondary PG have never been reported so far. Even though the same SPA could have been re-implanted, it was deferred because the make and model of the lens, also the appropriate cartridge was not known.

In scenarios where in-the-bag implantation of IOL is not possible, it is safe to place a multipiece IOL in the sulcus than a SPA.[7] In our case, even though the capsular bag was intact SPA was found freely in the sulcus. Previous operating surgeon might have accidentally placed the SP-FIOL in sulcus or might have misjudged the position of IOL to be in the bag. It is interesting to note that the PDG presented 3 years postcataract surgery. To the best of our knowledge, IOL exchange where the new IOL could be implanted into the bag, 3 years post cataract surgery has not been reported till now in the Asian eyes.


Our case report supports the fact that SP-FIOL is not friendly for sulcus placement and iris chaffing with PDG can occur. Our report highlights the fact that the capsular bag could be reopened even years after the primary surgery and should be given a try before proceeding for the sulcus placement during IOL exchange. Furthermore, one can consider implanting the same SPA into the bag if the make and model of IOL is known.

Declaration of patient consent

The authors certify that they had obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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