Indian Journal of Ophthalmology - Case Reports

: 2022  |  Volume : 2  |  Issue : 2  |  Page : 399--401

An unusual case of hide and seek with a broken piece of a preloaded trifocal intraocular lens following an uneventful phacoemulsification

Tanie Natung, Thangjam A Singh, Ishita Pandey, Oinam S Devi 
 Department of Ophthalmology, North Eastern Indira Gandhi Regional Institute of Health and Medical Science (NEIGRIHMS), Shillong, Meghalaya, India

Correspondence Address:
Tanie Natung
Department of Ophthalmology, North Eastern Indira Gandhi Regional Institute of Health and Medical Science (NEIGRIHMS), P.O. Mawdiangdiang, Shillong - 793 018, Meghalaya


Breakage of an intraocular lens (IOL) haptic during implantation is a rare complication of cataract surgery. We report here a case of a broken fragment of a trifocal IOL playing hide and seek and causing corneal edema repeatedly after an uneventful phacoemulsification and preloaded trifocal IOL (AT LISA tri 839MP) implantation. It was ultimately removed successfully and the patient achieved good vision. It is postulated that the broken piece of IOL migrated to and fro, from sulcus to anterior chamber. The breakage of IOL should also be kept in mind in the case of postoperative corneal edema when other causes have been ruled out.

How to cite this article:
Natung T, Singh TA, Pandey I, Devi OS. An unusual case of hide and seek with a broken piece of a preloaded trifocal intraocular lens following an uneventful phacoemulsification.Indian J Ophthalmol Case Rep 2022;2:399-401

How to cite this URL:
Natung T, Singh TA, Pandey I, Devi OS. An unusual case of hide and seek with a broken piece of a preloaded trifocal intraocular lens following an uneventful phacoemulsification. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Dec 3 ];2:399-401
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Full Text

Breakage of intraocular lens (IOL) usually occurs during IOL exchange, and they are known to cause corneal edema.[1] However, these have also been reported to occur during IOL implantation.[2],[3] Usually, these cause late postoperative corneal edema.[4],[5] There is a single case report of acrylic trifocal IOL being damaged during implantation.[6] Here, we report a case of a repeatedly missing fragment of a preloaded trifocal IOL. To the best of our knowledge, this is the first such report.

 Case Report

A 63-year-old man underwent an uneventful phacoemulsification with preloaded trifocal IOL implantation ( AT LISA tri 839MP + 19.50 D, Carl Zeiss, Germany) for an intumescent cataract in the right eye (OD) under topical anesthesia. On postoperative day 1, his best corrected visual acuity (BCVA) was 6/6p, N6 at 30 cm, and M6p at 60 cm. Postoperatively, moxifloxacin 0.5% with dexamethasone 0.1% (Vigadexa eye drop, Novartis, India) was prescribed one drop six times daily. On postoperative day 2, the patient experienced diminished vision in the operated eye. On examination, his BCVA was 6/36 and N36. Slit-lamp examination (SLE) OD revealed conjunctival injection, corneal edema in the inferior and central cornea with descemet's membrane (DM) folds [Figure 1]a and grade 1 cells. A transparent broken piece of IOL was seen hazily in the inferior anterior chamber (AC) lying in contact with corneal endothelium [Figure 1]a and [Figure 1]b. The IOL was found to be slightly decentered. The broken piece was found to be mobile on ocular movements. The patient was taken up immediately for its removal. However, to our utter surprise, the broken IOL piece could not be traced intraoperatively despite a thorough search [Figure 2]a. Moreover, AT LISA tri lens is transparent and has no yellow chromophores that made it even more difficult to visualize. Postoperatively, Vigadexa eye drop one drop six times daily, hypertonic saline 5% (Chlonia eye drop, Choroid, India) one drop 4 times daily, and Chlonia 6% eye ointment at bed time were prescribed. The same day and the next day also, the broken piece of IOL was not seen in the AC under SLE. It was postulated that probably the broken piece of IOL had migrated back to the posterior chamber/sulcus on lying down. The patient was advised to continue the same treatment and report immediately in the case of diminution of vision. The patient continued to have good vision. BCVA was 6/6, N6 at day 14. The broken IOL piece was not seen in the subsequent visits. Thirty-six days postoperatively, the patient presented again with diminished vision OD. On examination, his BCVA was 6/24. SLE showed corneal edema and DM folds inferiorly extending to the central area. The same broken piece of IOL was noted in the inferior AC. Moxifloxacin 0.5% eye drop four times daily and pilocarpine 2% eye drop stat and at bed time were prescribed to prevent the broken piece of IOL from migrating back to the sulcus through the pupil on lying down. Next day, the fragment could be seen intraoperatively [Figure 2]b and was removed successfully [Figure 3]a. The fragment was clean, sharp edged and triangular in shape (approx. 4 × 2 mm). The site of the fracture was at the junction of optic and haptic [Figure 3]b. Postoperatively, the IOL was found to be slightly decentered [Figure 4]a but was stable. At 1-month post second surgery, the corneal edema cleared up [Figure 4]b and the BCVA was 6/6, N6, and M6.{Figure 1}{Figure 2}{Figure 3}{Figure 4}


There are a few case reports of breakage of monofocal IOLs (PMMA or acrylic) and a single case of Trifocal IOL.[2],[3],[4],[5],[6] The broken piece of IOL can cause serious damage to the anterior and posterior segments.[4],[5],[6],[7]

Trifocal IOLs are composed of high-quality material and has advantages of greater flexibility and stability. The properties in hydrophobic acrylic IOLs make them less prone to breakage. However, they are still susceptible to damage during implantation either due to manufacturing defect(s) or improper handling. Our patient developed corneal edema on the second day following an uneventful phacoemulsification and preloaded trifocal IOL (AT LISA tri 839MP) implantation for an intumescent cataract. We did not encounter any problem during implantation. Based on the history and timeline of symptoms, it is hypothesized that the broken piece of IOL was initially located in the sulcus/PC and later on (day 2) migrated to the AC when it was visualized for the first time. The IOL piece migrated back to the sulcus on lying down, leading to failure of finding it during the first attempted removal and in subsequent few visits. Use of pilocarpine eye drop was helpful to constrict the pupil so that the broken IOL piece does not migrate back into the sulcus even though it causes more inflammation. It is possible that the breakage of IOL could be either due to manufacturing defect or improper lens folding and tear within the injector during the implantation.


Trifocal IOL haptic breakage and dislocation of fragment into the AC is a rare complication. Retention of IOL fragment should also be considered in early onset corneal edema after cataract surgery when other causes have been ruled out. In our case, there was repeatedly missing broken IOL piece since it was mobile and migrated back and forth to the sulcus and AC. Such cases can cause repeated corneal edema leading to diminished visual acuity. A thorough inspection is required before, during, and after implantation of preloaded IOL to minimize such complications.

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.

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Conflicts of interest

There are no conflicts of interest.


1Hoffman RS, Fine IH, Packer M. Retained IOL fragment and corneal decompensation after pseudophakic IOL exchange. J Cataract Refract Surg 2004;30:1362-5.
2Kirkpatrick JNP, Cook SD. Broken intraocular lens during cataract surgery. Br J Ophthalmol 1992;76:509.
3Ainsworth JR, Spencer AF. Haptic breakage in one-piece poly (methylmethacrylate) intraocular lenses. J Cataract Refract Surg 1991;17:863-4.
4Capitena CE, Gamett K, Pantcheva MB. Delayed presentation of retained acrylic intraocular lens (IOL) fragment after uncomplicated cataract surgery. Am J Ophthalmol Case Rep 2016;3:5-7.
5Gokhale NS. Late corneal edema due to retained foldable lens fragment. Indian J Ophthalmol 2009;57:230-1.
6Alasbali T. Risk of breaking haptic of trifocal IOL and its management. Middle East Afr J Ophthalmol 2016;23:321-2.
7Elwan MM. A novel technique for extraction of dropped broken haptics of hard posterior chamber intraocular lens. Retin Cases Brief Rep 2021;15:22-3.