Sulcus-fixated IOLs for Negative Dysphotopsia

We read the article by Burke and Benjamin1 with great interest as it underscores some key features regarding negative dysphotopsia. The paper adds to our understanding of the condition and how patients with chronic negative dysphotopsia may benefit from anteroposterior placement of the intraocular lens (IOL) optic. All 5 of their cases reported negative dysphotopsia with various original IOLs centered in the capsular bag and overlapped by the anterior capsulotomy edge. All patients had immediate relief of symptoms when an IOL exchange was performed, placing the new IOL in the ciliary sulcus, above the anterior capsule. As their exchange IOL was uniformly a sulcus-placed square-edged high-refractive-index acrylic IOL (Acrysof, Alcon Laboratories, Inc.), the article helps to dispel the concept that IOLs of that type are the chief cause of negative dysphotopsia symptoms. As we have reported,2 the final common pathway for negative dysphotopsia is a capsular-bag-fixated IOL of any design and material. Our article stressed that both ciliary sulcus placement and anterior capture of the optic above the capsular bag (reverse or anterior optic capture) were highly successful, as a piggyback IOL could be to a lesser extent. Moreover, our ultrasound biomicroscopy analysis indicated that increased posterior chamber depth was not a contributing factor to negative dysphotopsia. In agreement with the Vámosi et al. study,3 we found that bag-to-bag exchange for an IOL of a different design is unlikely to cure negative dysphotopsia. While the true epidemiology of negative dysphotopsia with regard to individual IOL types is unclear, it is likely that certain characteristics of the optic increase the risks; among those could be surface reflectivity. What is remarkable about the Burke and Benjamin article is that their IOL of choice is often impugned as a cause of negative dysphotopsia; however, when the IOL was placed anterior to the capsule edge, all patients were asymptomatic. We tend to disagree that their article supports the Holladay theory of etiology for the “enigmatic penumbra.”4 Rather, the evidence of the Burke and Benjamin paper confirms that negative dysphotopsia occurs with an IOL with an overlapping anterior capsule. While the authors suggest that anteroposterior placement of the IOL moves the penumbra away from visibility and they contend that negative dysphotopsia symptoms resolve over time owing to opacification of the capsule remnant, there is literature evidence that in some cases chronic negative dysphotopsia may be helped by relaxing or removing the nasal anterior capsule remnant with the neodymium:YAG laser.5,6 Given no forward movement of the IOL with laser treatment, credence is paid to the theory that negative dysphotopsia may be induced by the optical interaction of the anterior capsule remnant and anterior surface of the IOL optic.7 It would seem that the cause of negative dysphotopsia is likely multifactorial but that negative dysphotopsia may be prevented if the IOL optic is placed anterior to the capsule edge. An anti-dysphotopic IOL design to preclude this condition is under evaluation.

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