Sir,

Cataract surgery in highly myopic eyes presents several challenges to the surgeon, ranging from choosing an appropriate intraocular lens, potentially complicated surgery, to possible postoperative complications. We here report the results of phacoemulsification with implantation of a negative power Big Bagâ„¢ posterior chamber intraocular lens (IOL) implant in both eyes of a patient.

Case report

A 65-year-old Asian lady with high myopia and best-corrected visual acuities of OD 1/60 (−18.0 DSph) and OS 6/60 (−19.0 DSph) was seen in our clinic. She was noted to have bilateral posterior subcapsular cataracts and fundii showed posterior staphyloma, which was confirmed by ultrasound examination. Biometry revealed an axial length of 31.50 and 31.72 mm in right and left eyes, respectively, and predicted IOL power (SRK/T formula) −12 D to achieve postoperative emmetropia. The unusual IOL power prompted us to use the Big Bag™ IOL (SD Ophthalmics), a single-piece foldable acrylic lens (overall diameter 10.35 mm) with a meniscus optic of 6.5 mm diameter and three windowed flat haptics available in 0.5 D steps from −10 to +13 D (Figure 1). The extended Tri-Haptic configuration offers 240∘ contact arc supporting the zonules (Figure 1).

Figure 1
figure 1

Single-piece foldable acrylic lens with three windowed flat haptics.

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Phacoemulsification was performed (right eye followed by the left eye) through a 2.8 mm clear corneal incision. IOL (−10 D) was implanted in the capsular bag after enlarging the incision to 3.2 mm. The capsulorrhexis was 5 mm in diameter and viscoelastic was aspirated with simcoe cannula through the sideport. Lens folding and implantation were difficult owing to the thick edge, and forceps was used instead of the injector. The surgery and the postoperative course remained uneventful. The patient was followed for a year and the IOL maintained excellent centration with good coverage of the pupillary area (Figure 2). The best-corrected postoperative visual acuities were OD 6/12 and OS 6/18. The final refractive error was within 1 D of the predicted refractive error.

Figure 2
figure 2

Well-centred IOL with excellent coverage of the pupillary area.

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Comment

Negative power IOL implants following cataract surgery have been reported using the conventional two-haptic IOL design.1, 2, 3, 4 The larger diameter of the capsular bag seen in highly myopic eyes5 led us to believe that the three-haptic design would prevent lateral displacement of the IOL and a larger optic diameter would minimise the likelihood of symptoms related to the IOL edge. Postoperative result as shown in Figure 2 appears to confirm this belief in this patient.

Negative power lens implants have a thick edge, which makes folding with conventional forceps difficult and the manufacturer recommends a special injector. Our case demonstrates that there is potential for use of this device as a refractive technique for highly myopic patients.