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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 402-404

Pulp fiction of optic crack - The imperative irony of reloading a preloaded intraocular lens

1 Medical Officer, Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
2 Medical Officer, Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
3 Chief Medical Officer, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
4 Head of the Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India

Date of Submission06-Aug-2020
Date of Acceptance16-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Prasanna Venkatesh Ramesh
Mahathma Eye Hospital Private Limited, No 6, Tennur, Seshapuram, Trichy - 620 017, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2552_20

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Keywords: D cartridge of Alcon Monarch system, Hoya iSert® (Preloaded), Optic crack, Topical phacoemulsification

How to cite this article:
Ramesh SV, Ramesh PV, Rajasekaran R, Ramesh MK. Pulp fiction of optic crack - The imperative irony of reloading a preloaded intraocular lens. Indian J Ophthalmol Case Rep 2021;1:402-4

How to cite this URL:
Ramesh SV, Ramesh PV, Rajasekaran R, Ramesh MK. Pulp fiction of optic crack - The imperative irony of reloading a preloaded intraocular lens. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2023 Mar 29];1:402-4. Available from: https://www.ijoreports.in/text.asp?2021/1/3/402/319998

A 65-year-old female patient presented with an immature senile cataract in her left eye. Uneventful phacoemulsification was performed under topical anesthesia. During intraocular lens (IOL) implantation of Hoya iSert® yellow, preloaded lens; halfway through insertion, the patient moved her head away from the surgeon, which led to the release of IOL outside the globe [Figure 1]. The IOL was then inspected for damage [Figure 2]; when none could be found, we went ahead with loading the same Hoya iSert® lens into D cartridge of the Alcon Monarch system, with proper folding of IOL as seen in [Figure 3] followed by IOL implantation within the capsular bag. However, after insertion, we noticed that a crack had developed in the mid-periphery of the optic [Figure 4] during the insertion process. Since the IOL was stable and the crack did not extend into the pupillary area, the surgeon decided not to go for primary lens exchange. At one week and one month post-op follow-up, the patient had an uncorrected visual acuity of 20/20 with no complaints of glare, halos, or shadowing. The crack could only be seen on dilatation [Figure 5]. At the 7-month post-op follow-up [Figure 6], the patient presented with visual acuity of 20/20 with Log contrast (Log CS) of 1.53, which was also within normal limits. There was also no history of glare and shadowing reported. The IOL was well centered in the bag with the optic crack not involving the pupillary area, even in dim illumination.
Figure 1: Release of Hoya iSert® yellow, preloaded lens outside the surgical incision

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Figure 2: IOL inspection revealing lens in good condition

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Figure 3: (a-c) Proper loading technique of the aspheric Hoya isSert® IOL into the D cartridge of Alcon Monarch system, which reveals the appropriate loading mechanism, with no evidence of entrapment of either optic nor haptic of the Hoya iSert® IOL in the cartridge

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Figure 4: Crack noted in the mid-periphery of the optic, post IOL implantation in the capsular bag

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Figure 5: One month post-op slit-lamp photography revealing optic crack through the mid-dilated pupil

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Figure 6: (a and b) Slit-lamp photography of anterior segment showing undilated pupil with optically clear IOL optic in the pupillary area, as seen in slit illumination and diffuse illumination, respectively, at the 7-month follow-up. (c) Slit-lamp photograph taken at the 7-month follow-up period, after dilatation revealing the optic crack

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  Discussion Top

IOL cracking usually occurs due to surgeon-related mechanical force or manufacturer-related causes.[1],[2],[3] The probable cause for optic cracking in this scenario might be due to IOL–cartridge incompatibility, which could have played a vital role. Increased optic rigidity was another probable cause, which usually occurs due to reduction in glass transition temperature from refrigerated ophthalmic viscoelastic device.[1],[4]

It is quite an uncommon practice to have a standby IOL for premium preloaded IOLs, as the quality of lens and loading technology expected are of the highest caliber. Also it is very unlikely for the preloaded IOLs to get ejected outside as they are usually snug fit in the surgical wound during ejection into the capsular bag. However, in this scenario, unanticipated head movement by the patient, made the ejection of IOL outside the eye, highlighting the need for a standby IOL despite the lens being preloaded, in view of anticipating such complications.

In this scenario, the Alcon D cartridge of the Alcon Monarch system was utilized for reloading the IOL considering its compatibility with single-piece aspheric designs and its snug fit nature via 2.2 mm incision.[5] Another option in such scenarios would be to increase the wound size to 3.5 mm or larger to enable insertion of the foldable polyacrylic IOL, which has an optic diameter of 6.0 mm, by utilizing lens forceps, but at the cost of losing the benefit of small section (such as better wound healing and low surgically induced astigmatism).[6] Another option for surgeons not willing to compromise on the surgically induced astigmatism would be to leave the patient aphakic till they can procure an alternate IOL for implantation through 2.2 mm incision.

Fortunately, all cracked IOLs do not require explantation as long as it does not affect the visual acuity and contrast sensitivity of the patient, as in this scenario.[3],[7]

This scenario highlights the fact that it is ill-advised to interchange the IOLs and injector. Moreover, in preloaded lenses, which have suffered some mishap, it is better to use a different IOL. The mishap that happened with the preloaded IOL can be returned to the company. And whenever possible, one should arrange for a standby IOL of similar power in view of anticipation of such incidents.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lee JY, Kim JY. Optic fracture of the preloaded intraocular lens during insertion. Korean J Ophthalmol 2016;30:79-80.  Back to cited text no. 1
Balasubramanya R, Rani A, Dada T. Forceps-induced cracking of a single-piece acrylic foldable intraocular lens. Ophthalmic Surg Lasers Imaging 2003;34:306-7.  Back to cited text no. 2
Lee GA, Dal Pra ML. Cracked acrylic intraocular lens requiring explantation. Aust N Z J Ophthalmol 1997;25:71-3.  Back to cited text no. 3
Tetz M, Jorgensen MR. New hydrophobic IOL materials and understanding the science of glistenings. Curr Eye Res 2015;40:969-81.  Back to cited text no. 4
Devgan U. IOL cartridges – which one? [Internet]. Cataract Coach. 2020 [cited 2020 Aug 6]. Available from: https://cataractcoach.com/2020/04/19/iol-cartridges-which-one.  Back to cited text no. 5
Fukami S, Yamamoto N, Murakami K. Intraocular lens roll-up technique: Foldable IOL implantation using forceps through incisions smaller than 3.2 mm. J Cataract Refract Surg 2007;33:2023-7.  Back to cited text no. 6
Khokhar S, Sinha A, Saxena R. Intraoperative fracture of AMO tecnis (silicone) foldable intraocular lens. J Cataract Refract Surg 2006;32:1069-70.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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