Sir,

Cataract extraction and intraocular lens (IOL) insertion is the most commonly performed operation on elderly people in Europe.1

In February 2013, HOYA (HOYA Corporation, Singapore, Singapore) recalled certain IOLs due to concerns with postoperative inflammation.2 We describe the first case of sterile postoperative endophthalmitis secondary to a HOYA IOL, requiring explantation.

Case report

A 44-year-old man presented for left cataract assessment, with a known history of Fuchs’ heterochromic cyclitis. On examination, visual acuity was 6/18 with stellate keratic precipitates and cells in the anterior chamber. He had posterior subcapsular lens opacification and a normal fundus.

He underwent phacoemulsification with a +21.5-D HOYA iSert 251 IOL (HOYA Corporation) inserted. He missed his follow-up appointment and presented 3 weeks postoperatively complaining of pain, having prematurely stopped his postoperative maxitrol drops. His visual acuity was hand movements with corneal edema, anterior chamber inflammation and a 1-mm hypopyon. B-scan revealed vitritis and a flat retina.

The patient commenced hourly dexamethasone 0.1%, cyclopentolate 1% three times a day, chloramphenicol 0.5% four times a day, and 400 mg oral moxifloxacin once a day. An aqueous and vitreous biopsy with intravitreal antibiotic (vancomycin and ceftazadine) was performed. No organisms were grown on subsequent culture of the biopsy.

As the intraocular inflammation persisted, oral steroid (40 mg prednisolone daily) was started; however, this failed to control the inflammation. Six weeks postoperatively, in light of HOYA’s recall, the lens was explanted, with concurrent intravitreal triamcinolone (0.1 ml) and intracameral cefuroxime (1 ml). The explanted IOL was returned to HOYA for analysis, the results of which are pending. The inflammation improved the following day, with complete resolution in 1 month. Three months later, following posterior chamber Alcon AcrySof IOL (Alcon, Inc., Fort Worth, TX, USA) insertion his visual acuity was 6/6.

Comment

HOYA voluntarily withdrew a cohort of IOLs (including HOYA iSert 251 lenses) after review of their manufacturing process revealed residual metallic particles on these IOLs.2 The cause was identified, rectified, and HOYA is now manufacturing these IOLs with appropriate regulatory approval. Our patient’s intraocular lens was identified within this cohort.

On the basis of persistent inflammation despite intensive topical and oral steroids, and its swift resolution following explantation of the IOL, we felt the inflammation was due to the IOL rather than a postoperative episode of Fuchs’ heterochromic cyclitis-related uveitis. We therefore present the first reported case of sterile postoperative endophthalmitis following HOYA IOL insertion.