September 2008




In My Hands

Increasing PICS patients points to possible epidemic

by Samuel Masket, M.D.


Misplaced IOLs in ciliary sulcus resulting in iris chafing

Figure 1: Extensive iris transillumination defects in a case with a one-piece acrylic IOL placed in the sulcus at cataract surgery complicated by posterior capsule rupture five years earlier. The patient experienced multiple bouts of vision “white out” from micro-hyphemas and required three glaucoma medications. At surgery I exchanged the IOL for a three-piece silicone IOL and sutured the haptics to the iris. One year later, she requires no glaucoma medications and has not experienced any bouts of inflammation or bleeding.

Figure 2: Focal iris transillumination defect in the nasal iris in an eye just six weeks following implantation of a one-piece toric IOL; the surgeon inadvertently missed the capsule bag with the one offending haptic which induced inflammation. The remainder of the IOL was encased on the capsule bag. At surgery I was able to reopen the capsule bag and place the haptic within the capsule, eliminating the problem.

Source for both: Samuel Masket, M.D.

Single-piece acrylic IOLs (AcrySof, Alcon, Fort Worth, Texas) have been highly successful and currently represent approximately half of the IOLs implanted worldwide. However, these artificial lenses are designed specifically for the capsule bag, as indicated by the package insert. They are not intended to be placed—either whole or in part—in the ciliary sulcus as the material’s tacky surface character, which helps maintain centration, can induce posterior iris chafing. Moreover, the plano configuration of the thick haptics are not suited for the ciliary sulcus. Inadvertent surgeon error in placing one-piece acrylic IOLs anterior to the capsule bag has resulted in a reappearance of cases with the posterior iris chafing syndrome (PICS), which all but disappeared after the use of capsulorhexis and capsule bag IOL implantation were employed routinely.

In 1986, building on the work of Stephen Johnson, M.D., and others, I defined PICS by identifying the problem of certain lens implant materials contacting the posterior iris surface and inducing a variety of problems, notably inflammation, hyphema, and elevated IOP similar to the symptoms of uveitis-glaucoma-hyphema syndrome. Later I also noted that PICS could also induce vitreous hemorrhage.

Starting in the late 1980s, capsulorrhexis was developed and disseminated, and the great majority of IOLs were then placed inside the capsular bag. As a result, PICS was rarely—if ever—seen. Another contributing factor was that most IOLs were three-piece lenses that had thin haptic material and were designed to go either in the capsular bar or ciliary sulcus. However, it is clear that one piece acrylic IOLs are intended only for the capsule bag.

At the Film Festival at the 2008 ASCRS∙ASOA Symposium & Congress, the grand prize-winning video, Watch the Haptic!, showcased two patients with PICS. Produced by Fernando C. Trindade, M.D., Belo Horizonte, Brazil, the video referenced my work and demonstrated successful management of PICS by amputating the offending haptic of a single piece acrylic IOL.

PICS resurfaces

Perhaps because of my interest in this matter, a number of patients with iris chafing syndrome have been referred to me in recent years, in turn giving me a skewed view of the commonality of the problem. However, I have explanted at least a dozen of these lenses that were improperly implanted. Common surgical errors included placing one haptic in the bag and the other anterior to the capsulotomy. Additionally, there were cases with an incomplete anterior circular capsulotomy that resulted in the IOL being placed only partially within the confines of the capsule. Finally, there were cases with posterior capsule rupture in which the surgeon deliberately placed the one-piece IOL in the ciliary sulcus. The resulting problem is that he patients develop chronic chafing of the posterior iris surface, intermittent bleeding, inflammation, and elevated IOP. My experience in managing these cases suggests that the majority require surgical correction, but all can achieve successful outcomes. Most often I have removed the IOLs and replaced them with an IOL that is appropriate for the ciliary sulcus. In other cases I have been able to reopen the anterior capsulotomy and reposition an errant haptic, and I also amputated the offending haptic in one case, as has been beautifully demonstrated by Dr. Trindade in his award-winning video.

Surgeons need to be aware

The reason to bring light to this subject is that the condition is almost invariably due to surgeon “pilot error” and should be preventable. In addition, single-piece acrylic IOLs are increasing in popularity and additional similar products are entering the marketplace. The Advanced Medical Optics (Santa Ana, Calif.) one-piece acrylic Tecnis IOL is now available, and others will soon gain Food and Drug Administration approval. Surgeons should be made aware of this potential problem and consider use of alternative IOLs should the capsulorrhexis go awry or the posterior capsule develop a rent. Furthermore, surgeons must have strict assurance that both haptics of the single-piece IOL are placed within the lens capsule bag at the close of surgery. On a final note, surgeons must prevent post-op hypotony and shallowing of the anterior chamber as this could potentially lead to one or both of the loops escaping the capsule bag.

Regarding surgical outcomes in the repaired eyes, invariably the iris chafing syndrome has been halted, the glaucoma medications stopped over time, and the patients have been gratified. Clinical examples are noted in the photos.

Contact Information

Masket: 310-229-1220,


Dr. Masket is in private practice in Los Angeles and is clinical professor of ophthalmology at the Jules Stein Institute, Geffen School of Medicine, University of California at Los Angeles. He has financial interests with Alcon (Fort Worth, Texas).

Increasing PICS patients points to possible epidemic Increasing PICS patients points to possible epidemic
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