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Sir,

Pseudoexfoliation syndrome is an age-related condition in which abnormal fibrillar extracellular material accumulates within ocular tissues. The presence of pseudoexfoliation is of particular importance in those patients undergoing cataract surgery, as it is associated with an increased risk of perioperative complications such as zonular dehiscence, capsular rupture, and vitreous loss.1,2 Recently, a previously unrecognised complication following routine cataract surgery, namely spontaneous late dislocation of the intraocular lens (IOL), has been described in such patients.3 The authors found that the mean time from surgery to presentation with this complication was 7 years, with the longest interval being 9 years and 6 months. We describe a patient with pseudoexfoliation syndrome in whom spontaneous dislocation of the IOL occurred 14 years after cataract extraction.

Case report

A 77-year-old male underwent uncomplicated right extracapsular cataract extraction (ECCE) and insertion of a sulcus fixed Pearce tripod polymethyl methacrylate (PMMA) posterior chamber IOL in 1987. He was known to have pseudoexfoliation, although no zonular weakness was noted at the time of his surgery. He had previously undergone uncomplicated left endocapsular cataract extraction with insertion of a Pearce tripod IOL and had no significant past medical history of note. He was followed up regularly in the years following his surgery for monitoring of his intraocular pressure, which was always within normal limits. However, 14 years after undergoing surgery to his right eye, he presented to the ophthalmic department with a 1-day history of reduced vision in this eye. On examination, his visual acuities were counting fingers only in the right eye and 6/9 in the left eye. The posterior capsular remnants and IOL in his right eye were found to be subluxed inferiorly with the superior haptic tilted anteriorly through the pupil margin (Figure 1). There was no evidence of subluxation of the IOL in his left eye. His intraocular pressures were within normal limits in both eyes. Fundoscopy revealed early age-related macular degeneration. After 4 days, he underwent removal of the dislocated IOL was along with the capsular remants. An anterior vitrectomy was performed and an anterior chamber IOL was inserted. Postoperatively, his visual acuity improved to 6/6 with appropriate spectacle correction, and his intraocular pressure remained within normal limits. His visual status has remained stable during subsequent follow-up.

Figure 1
figure 1

Clinical photograph of the displaced IOL haptic, accompanied by a photo of the Pearce tripod lens.

Full size image

Comment

To our knowledge, this is the longest time interval that has been described for spontaneous dislocation of an IOL in a patient with pseudoexfoliation. While the precise aetiology of this recently recognised complication is not fully understood, postmortem findings in eyes with pseudoexfoliation suggest that late decentration of the capsular bag and remnants is related to zonular weakness.4 As with the study of Jehan et al3 we can only speculate about whether the type of IOL used contributes to late onset. It will be of interest to note if the current range of posterior chamber IOLs causes similar problems in years to come. Ophthalmologists should be aware that potentially serious complications can occur in patients with pseudoexfoliation syndrome for a considerable period of time after cataract surgery, and these patients should be warned accordingly.