Table of Contents  
Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 38-41

Intraocular Lens Opacification Post Intracameral Air Injection

1 Department of Cornea, Refractive Surgery and Ocular Surface Disorders, Dr. Shroff’s Charity Eye Hospital, Daryaganj, New Delhi, India
2 Dr. Shroff’s Charity Eye Hospital, Daryaganj, New Delhi, India

Date of Submission09-Aug-2019
Date of Decision23-Oct-2019
Date of Acceptance27-Dec-2019
Date of Web Publication07-Sep-2020

Correspondence Address:
Dr. Manisha Singh
Department of Cornea, Refractive Surgery and Ocular Surface Disorders, Dr. Shroff’s Charity Eye Hospital, 5027, Kedarnath Marg, Daryaganj, New Delhi-110002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_15_19

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Several cases of intraocular lens (IOL) opacification have been reported in the past few years following intraocular injection of gas or air in corneal and vitreoretinal surgery. The opacity can be associated with severe reduction in patients’ quality of vision which might necessitate IOL exchange. We report a short case series, an observational study, of IOL opacification following three cases of intracameral air injection in endothelial keratoplasty (EK), a triple procedure (cataract surgery with EK) and Descemet’s membrane detachment (DMD) repair post cataract surgery.

Keywords: Cataract surgery, endothelial keratoplasty, intracameral air injection, intraocular lens opacification

How to cite this article:
Singh M, Patel N, Mathur U. Intraocular Lens Opacification Post Intracameral Air Injection. Niger J Ophthalmol 2020;28:38-41

How to cite this URL:
Singh M, Patel N, Mathur U. Intraocular Lens Opacification Post Intracameral Air Injection. Niger J Ophthalmol [serial online] 2020 [cited 2022 Aug 8];28:38-41. Available from:

  Introduction Top

Endothelial keratoplasty is the current technique of choice for treating corneal endothelial diseases.[1],[2] The attachment of a graft to the host cornea requires a well-formed anterior chamber morphology with appropriate pressure, which can be achieved by filling about 80% of anterior chamber volume with air.[3] There have been several cases in the last few years of intraocular lens (IOL) opacification of hydrophilic acrylic lenses after corneal or vitreoretinal surgery with intraocular injection of either gas or air.[4],[5],[6],[7] The currently available hydrogel or hydrophilic acrylic IOLs are manufactured from different acrylic copolymers with varying water contents. Hydration renders these IOLs flexible and they have an advantage of better tolerability within the eye with high uveal biocompatibility which incites less inflammatory cytologic responses.[8] However, they are the most frequently explanted IOLs today and in 85% of the cases explanation is because of opacification of the lens optic.[9] In this case series, we describe three patients with IOL opacification following air injection limited to pupillary area.

Case 1

A 70‑year‑old man underwent an uneventful left cataract surgery with hydrophilic acrylic IOL implantation elsewhere two years prior to presentation. On examination, he had a best corrected visual acuity (BCVA) of 20/30 in the right eye and 20/200 in the left eye. Slit lamp biomicroscopy revealed stromal oedema with bullae in his left eye suggesting a pseudophakic bullous keratopathy (PBK). An uneventful Descemet’s stripping automated endothelial keratoplasty (DSAEK) was performed in his left eye during which about 8 mm donor disc was inserted into the anterior chamber with aid of sheet’s glide. The apposition between donor tissue and host stroma was achieved by filling the whole anterior chamber with sterile air bubble. Air bubble was released after 10 min leaving 90% of anterior chamber filled with air. Patient was advised to lie in supine position for 4 hours. The postoperative course was uneventful. During the follow up visit at 4 weeks, slit lamp examination showed a well-apposed lenticule and a semi‑circular pattern of white opacification around 4–5 mm in size on the anterior surface of the IOL [Figure 1]a and 1b. The opacification was characterized by fine and white granular deposits. The BCVA was 20/60 which the patient maintained till the last follow-up visit. The patient was also counselled on the possibility and prognosis of an IOL exchange in case the hazy vision became bothersome.
Figure 1 (a) Salit lamp photograph of patient in diffuse illumination post-DSAEK surgery showing a well-apposed lenticule and a whitish opacification on the anterior surface of the IOL. (b) Sblit lamp photograph showing the slit view of the patient post-DSAEK surgery highlighting the opacification on the anterior surface of the IOL characterized by fine and white granular deposit.

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Case 2

A 62-year-old female presented with decreased vision in her left eye 9 days after her cataract surgery with hydrophilic acrylic IOL implantation which was done elsewhere. On examination, her visual acuity was 20/200 in both eyes. Slit lamp evaluation showed endothelial guttae and an immature cataract in the right eye and Descemet’s membrane detachment (DMD) in her left eye. Anterior segment optical coherence tomography (ASOCT) of the left eye showed large DMD involving inferior half of cornea with stromal oedema. Air descemetopexy was done with 90% chamber air fill. At third-week postoperatively, visual acuity was 20/50 in the left eye with attached Descemet’s membrane and her IOL revealed a 3‑mm circumscribed opacification on the anterior surface [Figure 2] resembling tiny bubbles. She maintained a BCVA of 20/50 in her left eye and was quite comfortable with her vision. The patient was informed about the haze on the IOL in the left eye which had remained the same after 2 years of follow up.
Figure 2 Slit lamp photograph of a patient post-air descemetopexy for DMD showing well-circumscribed whitish opacification on the anterior surface of the IOL.

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Case 3

A 55‑year‑old man who had a bilateral Fuch’s dystrophy and immature senile cataract with visual acuity of 20/400 in both eyes underwent a triple procedure of phacoemulsification with foldable hydrophilic acrylic IOL implantation and DSAEK in his right eye. He had an uneventful postoperative course. Intraocular lens opacification was documented at 4 weeks on slit lamp evaluation. Patient was on follow up for over two years and maintained a visual acuity of 20/60. He was informed that the cause of the suboptimal visual acuity was the IOL haze and was offered IOL exchange but he declined. The posterior segments were examined at all follow up visits in these cases and were all within normal limits.

  Discussion Top

Faulty manufacturing as well as packaging processes have been suggested to play a role in primary IOL opacification.[10],[11],[12] Causes of secondary opacification are multifactorial. They include all factors which bring about disruption of the blood-aqueous barrier like systemic inflammatory diseases such as diabetes mellitus and hypertension,[13] multiple surgeries, injection of exogenous air, gas or recombinant tissue plasminogen activator.[6] These causes are of great importance as the location of opacification has always been on the central portion of the IOL optic that was not secluded from the aqueous and vitreous fluid by the capsule. An intact anterior capsule that covers the rest of the IOL surface seems to be protective against opacifiaction of the IOL.[14]

Schrittenlocher et al.[4] retrospectively analyzed 564 patients who underwent Descemet membrane endothelial keratoplasty (DMEK), IOL opacification was seen in 2.5% of these cases and they found a strong association between IOL opacification and the number of re-bubbling. Similarly Dhital et al.[15] described three cases of IOL opacification of hydrophilic IOLs in complicated, traumatized eyes with a history of intraocular gas use. Morgan‑Warren et al.[16] in their study concluded that repeated exposure to intracameral air and elevated IOP are major etiological factors for the opacification after DSAEK. Ahad et al.[17] observed a reduced rate of opacification after reducing the time of full chamber air tamponade from 1 hr to 10 min. The duration between surgery and the onset of IOL opacification in most reported cases ranged from 1 month to 6 years.[13],[15],[18] Similarly in our cases IOL opacification was documented at or beyond third week. We believe that the causative factor for IOL opacification in our cases would be direct contact between the IOL and exogenous air for considerable amount of time. Postoperative inflammation with break down in blood aqueous barrier promotes release of proteins, cells and calcium which leads to metabolic changes in the microenvironment of the anterior chamber. The contact of the IOL surface with intracameral air in the presence of high calcium content in anterior chamber can enhance crystallization and hence cause IOL opacification.[15],[19] Also Khurana and Werner[6] have suggested in their study that increased hydrolyzation of the polyacrylate on exposure of IOL surface to air forms free carboxylic acid groups that in turn triggers biomineralization, thus covering the IOL optic with calcium phosphate crystals. Another study[12] has proposed that the inflammatory reaction after vitrectomy or factors that breakdown the blood-aqueous barrier like diabetes or postoperative medication could be responsible for facilitating biomineralization of IOL material. A study by Yildirim et al.[14] on investigations of the IOL opacification concluded that Alizarin red and Von Kossa staining was positive for calcium further corroborating that the deposits are indeed calcium.

The effect of these lens deposits on vision range from mild (insignificant) to severe visual impairment due to scattering of light on the calcified lens surface. Neuhann et al.[20] reported explanation of 106 hydrophilic acrylic IOLs from patients who had visual disturbances caused by postoperative opacification of the lens optic. In all of our patients the IOL opacification was not observed to be progressing either anatomically (in size) or functionally (visual acuity) enough to warrant any drastic surgical steps. We did give the option of IOL exchange to our patients which they declined as they were comfortable with their vision. In these cases if significant decrease in visual acuity occurs, they warrant an IOL exchange as procedures like neodymium-doped yttrium-aluminium-garnet laser treatment or mechanical scraping are ineffective in removing the deposits from the IOL.[14]In summary IOL opacification may result from a direct contact between the IOL surface and exogenous air. Clinicians should bear in mind this rare but significant complication. It is important not to jump into additional surgery of IOL exchange, rather patients who develop this condition should be followed up and any increase in the size of the opacification and/or drop in visual acuity documented. If such a situation arises, an IOL exchange becomes necessary.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms and the patients gave consent that their images and other clinical information be reported in the journal.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Price MO, Price FW. Descemet’s stripping endothelial keratoplasty. Curr OpinOphthalmol 2007;18:290-4.  Back to cited text no. 1
Busin M, Madi S, Santorum P, Scorcia V, Beltz J. Ultrathin descemet’s stripping automated endothelial keratoplasty with the microkeratome double pass technique: two year outcomes. Ophthalmology 2013;120:1186-94.  Back to cited text no. 2
Brockmann T, Brockmann C, Maier AK, Schroeter J, Pleyer U, Bertelmann E et al. Clinicopathology of graft detachment after Descemet’s membrane endothelial keratoplasty. Acta Ophthalmol 2014;92:e556-61.  Back to cited text no. 3
Schrittenlocher S, Penier M, Schaub F, Bock F, Cursiefen C, Bachmann B. Intraocular lens calcifications after (triple-) descemet membrane endothelial keratoplasty. Am J Ophthalmol 2017 179:129-36.  Back to cited text no. 4
Giers BC, Tandogan T, Auffarth GU, Choi CY, Auerbach FN, Sel S et al. Hydrophilic intraocular lens opacification after posterior lamellar keratoplasty − a material analysis with special reference to optical quality assessment. BMC Ophthalmol 2017;17:150.  Back to cited text no. 5
Khurana RN, Werner L. Calcification of a hydrophilic acrylic intraocular lens after pars plana vitrectomy. Retin Cases Brief Rep 2018;12:204-6.  Back to cited text no. 6
Milojcic C, Latz C, Tandogan T, Auffarth GU, Holz FG, Choi CY et al. Opacification of a hydrophilic acrylic intraocular lens after DMEK: a material analysis. Ophthalmologe 2017;114:832–7.  Back to cited text no. 7
Abela-Fomanek C, Amon M, Schauersberger J et al. Uveal and capsular biocompatibility of 2 foldable acrylic intraocular lenses in patients with uveitis or pseudoexfoliation syndrome: comparison to a control group. J Cataract Refract Surg 2002;28:1160-72.  Back to cited text no. 8
Mamalis N. Complications of foldable intraocular lenses requiring explanation or secondary intervention—2001 survey update. J Cataract Refract Surg 2002;28:2193-201.  Back to cited text no. 9
Werner L, Hunter B, Stevens S, Chew JJ, Mamalis N. Role of silicon contamination on calcification of hydrophilic acrylic intraocular lenses. Am J Ophthalmol 2006;141:35-43.  Back to cited text no. 10
Nakanome S, Watanabe H, Tanaka K, Tochikubo T. Calcification of Hydroview H60M intraocular lenses: aqueous humor analysis and comparisons with other intraocular lens materials. J Cataract Refract Surg 2008;34:80-6.  Back to cited text no. 11
Habib NE, Freegard TJ, Gock G, Newman PL, Moate RM. Late surface opacification of Hydroview intraocular lenses. Eye (Lond) 2002;16:69-74.  Back to cited text no. 12
Cao D, Zhang H, Yang C, Zhang L. Akreos Adapt AO intraocular lens opacification after vitrectomy in a diabetic patient: a case report and review of the literature. BMC Ophthalmol 2016;16:82.  Back to cited text no. 13
Yildirim TM, Auffarth GU, Labuz G, Bopp S, Son HS, Khoramnia XX. Material analysis and optical quality assessment of opacified hydrophilic acrylic intraocular lenses after pars plana vitrectomy. Am J Ophthalmol 2018;193:10-9.  Back to cited text no. 14
Dhital A, Spalton DJ, Goyal S, Werner L. Calcification in hydrophilic intraocular lenses associated with injection of intraocular gas. Am J Ophthalmol 2012;153:1154-60.  Back to cited text no. 15
Morgan‑Warren PJ, Andreatta W, Patel AK. Opacification of hydrophilic intraocular lenses after descemet stripping automated endothelial keratoplasty. Clin Ophthalmol 2015;9:277-83.  Back to cited text no. 16
Ahad MA, Darcy K, Cook SD, Tole DM. Intraocular lens opacification after descemet stripping automated endothelial keratoplasty. Cornea 2014;33:1307-11.  Back to cited text no. 17
Pandey SK, Werner L, Apple DJ, Kaskaloglu M. Hydrophilic acrylic intraocular lens optic and haptics opacification in a diabetic patient: bilateral case report and clinicopathologic correlation. Ophthalmology 2002;109:2042-51.  Back to cited text no. 18
MacLean KD, Apel A, Wilson J, Werner L. Calcification of hydrophilic acrylic intraocular lenses associated with intracameral air injection following DMEK. J Cataract Refract Surg 2015;41:1310-4.  Back to cited text no. 19
Neuhann IM, Werner L, Izak AM, Pandey SK, Kleinmann G, Mamalis N et al. Late postoperative opacification of a hydrophilic acrylic (hydrogel) intraocular lens: a clinicopathological analysis of 106 explants. Ophthalmology 2004;111:2094-101.  Back to cited text no. 20


  [Figure 1], [Figure 2]

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