Surgical Removal of a Retained Lens Fragment After Cataract Surgery May Improve Patient Outcomes

Just the other week, one of our residents presented a case on a retained lens fragment (RLF) that he had to manage at the local VA hospital. He presented his case and approach during our monthly M&M conference. He noted that his patient had a straightforward cataract and was doing well on POD#1. The patient was scheduled for follow-up in 2 weeks but presented earlier with "foggy vision." 

The resident noted some sectoral cornea edema, normal IOP, mild AC inflammation, and no injection or pain (less concern for endophthalmitis). He presented the case to the attending physician who asked if he had performed a gonioscopic exam on the patient. The resident replied no and promptly performed the gonioscopy, which revealed the RLF. The patient was taken to surgery and the RLF was removed without incident. 

Around the same time, I had a patient on whom I had performed an intraocular lens exchange with intrascleral haptic fixation (ISHF) earlier this year. Despite his uncomplicated case with a good postoperative result, he has some mild chronic inflammation and developed CME a few months after surgery. The iritis/CME resolved with topical treatment. There was no IOL malposition or iris chafe, which typically causes CME in ISHF. It was only after we performed a gonioscopic exam that we noticed a small RLF. What I failed to mention is that his original cataract surgery was 10 years prior! The patient underwent successful removal of the RLF with resolution of his iritis and CME. 

In this installment of Viewpoints, I'll discuss a recent paper by Matarazzo and colleagues that discusses investigating the incidence of RLF in the anterior chamber over a 6-year period. This study out of the UK reviewed almost 100,000 cases and identified 122 cases of RFL (0.124%). They found that patients had improved vision after RLF removal and that six eyes (4.9%) required endothelial keratoplasty (EK) despite RLF removal. 

Of interest to me was that the study noted that patients with longer eyes had a higher rate of RLF. Additionally, those on systemic alpha-blockers (eg, tamsulosin) had a higher rate of RLF. Both factors make sense to me. In my experience, it is not uncommon that in longer eyes or those with intraoperative floppy iris syndrome (IFIS) that nuclear fragments may get stuck behind the iris. I take special effort to make sure that I double check for retained fragments in these situations. 

Another more common situation involves lens fragments stuck in the angle entangled in dispersive OVD. I learned a trick from a friend and mentor, Dr Robert Cionni, for these cases. The "Cionni swirl" takes a few seconds at the end of the case but has been helpful in preventing RLF.

The procedure is simple. After removal of OVD from the eye with IA, take a 27g cannula on a syringe filled with BSS and squirt in to the superior and inferior angle. I have noted two things since starting this practice: 1) there can be a significant amount of retained OVD even after IA, and 2) from time-to-time, lens fragments not otherwise visualized appear and are easily removed. Anecdotally, I have noticed more frequent fragments in femtosecond laser cataract cases, although I have not formally studied this.

Even though the rate of RLF reported was quite low, the negative effects can be significant. As with my resident's patient, a high percentage (43.5%) of patients in this study were diagnosed after the first post-op visit. Often these patients are diagnosed as having postoperative uveitis before the RLF is identified.

Additionally, these patients can have corneal edema and, in some cases, need eventual EK (even with successful removal of the RLF). The reasons for this are numerous and were not fully studied in this paper. Some risk factors identified in this paper that may predispose a patient for EK are delayed diagnosis of RLF, inflammation, and those requiring gonioscopy to diagnose. 

Certainly, all cataract surgeons will experience an RLF at some point.  Depending on the size and makeup (cortical vs nuclear), these fragments can be managed medically and/or surgically. In general, I find that surgical removal of the RLF is better for patient outcomes and may decrease the need for endothelial keratoplasty.

However, additional surgical interventions can increase complications, risk, and certainly increase cost. Each case should be managed individually.  What is clear is that RLF can be difficult to diagnose and should remain high on the differential of a postoperative cataract patient that who presents with increasing inflammation and/or corneal edema. Lastly, gonioscopic evaluation of the these patients can be helpful in identifying small lens fragments that may be causative of the patient's exam findings. 

Sumit (Sam) Garg, MD, is the vice chair of clinical ophthalmology and an associate professor in the Department of Ophthalmology at the Gavin Herbert Eye Institute, University of California, in Irvine. He specializes in corneal and cataract surgery as well as laser refractive surgery.

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