We reported a case of spontaneous resolution of trifocal IOL opacification following acute clouding. Although acute clouding of IOLs have been described by Liu et al. [6], both lenses in that study remained cloudy postoperatively for l h and 8 min in vivo, respectively. Therefore, a new IOL was implanted. However, the IOL in our case exhibited clearing within three postoperative hours.
After conducting photochemistry with the 400-420 nm wavelength of ultraviolet rays for 5 months, the patient suffered from bilateral radiation cataract. Toto et al. [7] reported that inflammatory infiltrates could be detected immunohistochemically in the anterior segment of both the eyes with cataract, induced with ultraviolet-B radiation exposure. However, there are no reports describing acute clouding associated with inflammation in bilateral radiation cataracts.
Pseudocataract could occur spontaneously because of calcium and phosphate accumulation, which results in hydroxyapatite crystal formation [8, 9]. Such delayed IOL opacification usually occurs after a few postoperative months [4], unlike our case. Tyagi et al. [1], Dhoot et al. [5], Liu et al. [6], and Helvaci et al. [10] reported that intraoperative clouding of hydrophilic and hydrophobic IOLs could be caused by sudden changes in temperature. In addition, the acute clouding reported by Tyagi et al. [1] lasted for approximately 3 h and disappeared spontaneously, and the opacification reported by Helvaci [10] resolved the following day. The opacification of two trifocal IOLs of the same company as ours reported by Liu et al. [8] persisted for 1 h and 8 min, respectively, without any equilibration in vivo, and the second IOL became transparent 5 min later in vitro. Eventually, both IOLs were explanted, and an IOL of another brand (ZCB200, Allergan, Dublin, Ireland) was implanted. Severe fluctuations in temperature were also observed in the IOL in our case. However, acute clouding disappeared within three postoperative hours. Based on the aforementioned cases, the manufacturer’s instructions state that the IOL should be at room temperature at the time of surgery to avoid temporary clouding of the lens optic following implantation. However, the time of resolution of the temporary clouding has not been elucidated, and there have been no reports of the spontaneous resolution of clouding of hybrid hydrophilic and hydrophobic IOLs. Considering that the package and storage buffer were intact, the acute IOL opacification could have resulted from sudden changes in temperature; therefore, we observed the condition and did not perform explantation. Regarding the formation of acute clouding, we hypothesized that the air inside the IOL was released when the temperature suddenly increased, resulting in microbubbles. Microbubbles and light refraction led to the appearance of clouding. When air dissolution reached an equilibrium both in water and the IOL, the clouding disappeared spontaneously.
The IOL in our case (ATLISA tri 839MP) illustrated the effect of environment on the transparency of hydrophilic acrylic material (25%) with hydrophobic surface properties in cataract surgery. We could not confirm whether or not acute clouding could alter the mechanical, chemical, or geometric characteristics of the IOL polymer. Long-term changes in the IOL should be investigated in the subsequent follow-ups. The appropriate temperature should be maintained during the storage and transport of IOLs to avoid transient clouding due to temperature fluctuations. IOLs should be handled carefully by the surgeon and kept at room temperature for some time before implantation to prevent clouding.
