severe z syndrome with the plate haptic silicone hinged accommodating iol n.
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Severe Z Syndrome with the Plate-Haptic Silicone Hinged Accommodating IOL. Leonard H Yuen, MD MPH MRCOphth Shu -Yen Lee, MD FAMS Wei-Han Chua, MD FAMS SINGAPORE NATIONAL EYE CENTRE (SNEC). The authors have no financial interest in the subject matter of this poster. Background.

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severe z syndrome with the plate haptic silicone hinged accommodating iol

Severe Z Syndromewith the Plate-Haptic SiliconeHinged Accommodating IOL

Leonard H Yuen, MD MPH MRCOphth

Shu-Yen Lee, MD FAMS

Wei-Han Chua, MD FAMS


The authors have no financial interest

in the subject matter of this poster

  • The Crystalens (Bausch & Lomb, USA) accommodating IOLs are gaining popularity for patients hoping to obtain functional distance and mid-range vision following crystalline lens removal
  • Recently case reports of accommodating lens tilting described as “Z Syndrome” have been published following uneventful cataract surgery 1,2,3,4 particularly with the Crystalens AT45.5,6

(Bottom picture courtesy: J Cazal, MD, and C. Verges, MD)


In a previous case series of Z syndrome, the use of Nd:YAGcapsulotomywas successful in treating the lens tilt even after 9 weeks postoperatively.1

However, we believe that this treatment is effective only in mild cases.

  • To our knowledge this is the first reported case of Severe Z Syndrome with the Crystalens AT52SE, which warranted intraocular repositioning of the lens to restore anatomical positioning and achieve optimal visual outcome.
case report
Case Report

A 45-year old female high myope with a manifest refraction of OS -11.00 -0.25 x 090 (DBCVA 20/20) underwent uneventful cataract surgery.

Intraoperatively, a clear corneal incision was made and Amviscviscoelastic was used. A 5.5mm complete circular capsulorrhexiswas done and a +10.0 dioptre (D) Crystalens AT52SE was implanted in the bag. No complications, specifically capsular bag rupture or zonulysis, were observed.

POD 1: UCVA 20/80 and slit lamp examination was unremarkable

POW 3: DBCVA 20/20 with a manifest refraction of OS -1.00 -1.00 x 005

POW 4: Pt noticed a decrease in UCVA. Manifest refraction OS -1.50 -2.00 x 175

POW 12: Immigrated abroad and presented to the Singapore National Eye Centre


UCVA at this point was 20/400, with a manifest refraction of OS +1.50 -4.00 x 100 (DBCVA 20/50). A near addition of +2.00 could only achieve N18, equivalent to Snellen 20/120

Slit lamp examination

showed a dramatic

forward protrusion of

the inferior optic-

haptic junction that

encroached into the

anterior chamber

beyond the plane of

the dilated pupil


Superior anterior capsular phimosis with optic capture was noted, with encapsulation of the superior haptic within the bag. Theinferior portion of the optic was squeezed forward. Retro-illumination revealed capsular wrinkling.


Treatment with neodymium:YAG laser capsulotomy was considered,

but the severity of the tilting deterred the decision of doing so

and subsequent intraocular manipulation was performed.

Intraoperatively the inferior lens haptic was freed from the capsular fibrosis and iris hooks were used to immobilize the iris and to immobilize the pupil maximally. The superior haptic was enveloped firmly by the fibrosed capsule and thus left unmanipulated. The optic was pressed backwards and the haptic hinges vaulted posteriorly to its anatomical position.


First day postoperatively, UCVA was 20/25 OS;

At one month, UCVA was 20/20, with a manifest

refraction of plano -0.75 x 15. A +2.00D near add lens

allowed her to read N5, equivalent to Snellen 20/20.

There was obvious flattening of the inferior iris:

Preop: +1.50 -4.00 x 100

Postop: Plano -0.75 x 15




ASOCT confirmed a

posteriorly vaulted IOL


The Crystalens AT52SE is a biconvex silicone plate IOL with an enlarged 5.0

mm optic. Its hinges are designed to move anteriorly during accommodation

to achieve near focus.


The lens’ square edge design reduces posterior capsule opacity however its

effectiveness is unknown in patients under 50 years of age7 as in this patient.

The hinged accommodative mechanism of the Crystalens is believed to

be capsule dependent. Capsular fibrosis can however impede the axial

movement, and in cases of asymmetric capsular fibrosis the IOL can

decentrate.6 Its makeup of silicone material has not been shown to

increase lens decentration or tilting.3,4


Pointers suggested to reduce the incidence of Z-Syndrome:

  • Appropriately sized capsulorrhexis (5.5 to 6.0mm, as in this case)
  • Round CCC with the anterior capsule covering the plate haptics7
  • Cortical removal7
  • Capsular polishing5
  • Ophthalmic viscoelastic devices (OVD) should also be entirely removed from behind the lens and the IOL gently nudged backwards at the final stages of cataract surgery.

We are unaware of reports of asymmetric tilting with other types of IOLs.

Mild Z-Syndrome with the Crystalens were remedied by Nd:YAG capsulotomy.1

In this severe case, which resembles more like the letter “N”, surgical

repositioning is more appropriate. Previous reports have suggested IOL

exchange6 as an option however in this case IOL exchange would have been

difficult as the haptic was entrenched within the superior capsule adhesions.


The authors believe that

there is no uniform

treatment to treat this

syndrome, however the

severity of the

configuration of the IOL

and its relation to the

capsule will help guide

the surgeon to the

appropriate management



1. Yuen L, Trattler W, Boxer Wachler B. Two Cases of Z syndrome with the Crystalens after uneventful cataract surgery. J Cataract Refract Surg. 2008 Nov;34(11):1986-9.

2. Arkin C, Ozler SA, Mentes J. Tilt and decentration of bag-fixated intraocular lenses: a comparative study between capsulorhexis and envelope techniques. Doc Ophthalmol. 1994;87(3):199-209.

3. Hayashi K, Harada M, Hayashi H, Nakao F, Hayashi F. Decentration and tilt of polymethylmethacrylate, silicone, and acrylic soft intraocular lens. Ophthalmology. 1997 May;104(5):793-8.

4. Jung CK, Chung SK, Baek NH. Decentration and tilt: silicone multifocal versus acrylic soft intraocular lenses. J Cataract Refract Surg. 2000 Apr;26(4):582-5.

5. Jardim D, Soloway B, Starr C. Asymmetric vault of an accommodating intraocular lens. J Cataract Refract Surg. 2006;32:347-350.

  • Cazal J, Lavin-Dapena C, Marin J, Verges C. Accommodative Intraocular Lens Tilting. Am J Ophthalmol. 2005 Aug;140(2):341-4.