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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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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
(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.
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
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.
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.
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
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.
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
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.