Cataract, cataracta meaning waterfall in Latin, is the opacification of lens. Cataract surgery traces its origin back to ancient times with techniques like Couching practised by Sushruta in 6th century BCE. Jacques Davies performed first documented ECCE in 1750. Sir Nicholas Harold Ridley invented intraocular lens and pioneered intraocular lens surgery for cataract. Surgical management for Cataract has come a long way to the modern phacoemulsification, femtosecond laser cataract surgery (FLACS) with reduction in complications and better outcome. Small incision cataract surgery has evolved over time. Though hyphaema, iris prolapse, TASS, endophthalmitis, PCO are some of the complications of cataract surgery, opacification of PCIOL is the most vision threatening as the gains of the surgery are reversed. Hence, it is often termed as Tertiary cataract.1

CASE 1

A 50 year old female complaints of diminution of vision since 1 year. She has a history of cataract surgery BE, RE followed by LE, 1 week apart, 5 years     ago. Hydrophilic PCIOL was used. Surgery was uneventful. Post operatively, patient showed better visual outcome with BCVA 6/9 in RE and 6/6p in LE.     She is known case of Diabetes and Hypertension since 5 years. Since 1 year, she has developed diminution of vision, gradual in onset and progressive in nature. On dilated slit lamp examination, an opacified PCIOL in RE was seen. However, lens in the other eye remained uninvolved. IOL exchange with secondary IOL implantation was planned. Post operative outcome was satisfactory with 6/12 on first post o

Table 1: Case Representation of Case 1.

CASE 2

A 65 year old male complaints of diminution of vision since 3 months in BE. He gives history of cataract surgery in RE 6 years back. Hydrophilic PCIOL was used and surgery was uneventful. Postoperatively patient had satisfactory visual outcome of 6/6p in RE. He is non diabetic, non hypertensive. Since 3 months, he has diminution

of vision, gradual in onset and progressive. On dilated slit lamp examination, opacified PCIOL in RE and NS3 + cortical cataract in LE. IOL exchange with secondary IOL implantation was planned. Post operative outcome was satisfactory with 6/9p on first post operative day. Histopathology of opacified PCIOL revealed calcium deposits on IOL

Table 2: Case Representation of Case 2.

CASE 3

A 63 year old female with complaints of diminution of vision since 2 months. She gives history of BE cataract surgery LE followed by RE, 1year apart, 3 years back. Hydrophilic PCIOL was used and surgery was uneventful. She had visual outcome of 6/6p in BE. She is known case of hypertension and     diabetes since 6 years and on medication. Since 2 months, she has developed

diminution of vision, gradual in onset and progressive. On dilated slit lamp examination, clear PCIOL in RE, opacified PCIOL in LE. IOL exchange with secondary IOL implantation was planned. Post operative outcome was satisfactory with 6/9 on first post operative day. Histopathology of opacified PCIOL revealed calcium deposits on IOL

Table 3: Case Representation of Case 3.

With the recent advances in cataract surgery and management of its complications, opacification of PCIOL is a nullifier of the gains of surgery. Hydrophilic PCIOLS tend to develop opacification more than hydrophobic. Calcium deposition is one of the major causes of opacification.2 the supersaturation of aqueous humour with calcium crystals may be the   cause of the development of calcium deposits made composed of calcium phosphate salts. Both the inner and exterior surfaces of the IOL may be calcified. Two deposit patterns that were discovered by investigations using scanning electron microscopy (SEM) and light microscopy. Irregular granular deposits on exterior part or granular deposits arranged inline pattern within   IOL. It has been reported that polymethyl metacrylate modified in a way to    increase the hydroxyl groups on the surface which resulted in the formation of octa calcium phosphate on its surface.3 The hydroxyapatite overgrowth on the polymeric components of the IOL is accelerated by the presence of phosphate and hydroxyl ions on the polymers. Systemic diseases like Diabetes might predispose to calcium deposition on IOL, however, mechanism is largely unknown. Protein deposition on IOL might be due to deposition of immune complexes as a result of antigen antibody reaction.4 the process of opacification is also believed to be aided by disruption of the blood-aqueous barrier brought about by inflammation to lens materials, systemic diseases. Presence of UV blocking agents in IOL for protection against UV B radiation, largely absorbed by lens stroma, might exacerberate the opacification.5 Presence of posterior capsule rent and vitreous touch might exacerbate the opacification.

PCIOL opacification poses major threat to visual gains after cataract surgery. The only management for this is IOL exchange with secondary IOL implantation, which poses significant other intra and post-operative risks to patient, but visual outcome restored successfully, if rest is being attended to cautiously.

1. Gupta, G., Goyal, P., Bal, A., Jain, A. K., & Malhotra, C. (2020). Pearly white intraocular lens opacification - "Tertiary cataract". Indian journal of ophthalmology, 68(1), 188–189. https://doi.org/10.4103/ijo.IJO_205_19
2. Channabasappa S, Girimallanavar S, Jose AA et.al. Tertiary cataract- a rare postoperative complication after cataract surgery: a case study. Int J Health Sci Res. 2021; 11(9):133-136  DOI: https://doi.org/10.52403/ijhsr.20210920
3. Khakshoor, Hamid & Gharaee, Hamid & Vejdani, Amirhossein & Shafiee, Masoud & Shahabian, Masoud. (2013) . Clinicopathological Report of Three Cases of Opacification in Hydrophilic Acrylic Intraocular Lenses. Iranian Journal of Ophthalmology. 25. 238-243.
4. PRAJAKTA MODAK. OPACIFIED FOLDABLE INTRAOCULAR LENS AFTER CATARACT SURGERY MANAGED WITH INTRAOCULAR LENS EXCHANGE. Indian J.Sci.Res. 10 (1): 203-204, 2019. DOI: 10.32606/IJSR.V10.I1.00031
5. Moesen, I., Maudgal, P. C., & Foets, B. (2006). Late opacification of hydroview intraocular lenses: report of 11 cases. Bulletin de la Societe belge d'ophtalmologie, (299), 13–18.