Q: I occasionally see patients with retained lens material after cataract surgery. Do I handle them any differently post-op?

A: “Yes, you do,” says Howell Findley, OD, center director of Commonwealth Eye Surgery, a comanagement and ocular surgery center in Lexington, Ky.

“Retained lens material in the anterior segment is an uncommon occurrence after uncomplicated cataract surgery,” Dr. Findley says. “It occurs when all of the lens cortex or nucleus is not evacuated at surgery. It may be more common in patients with high myopia or small pupils, where lens remnants may hide in the posterior chamber. It may present as early as within one week post-op or as late as 15 years after surgery. When it occurs, retained lens material may result in corneal edema and iritis.”

So, for any patient who presents with sudden-onset decreased vision, iritis or corneal edema (particularly when corneal edema is not expected), consider the possibility of retained lens material. “If not evident on slit-lamp exam, perform gonioscopy to rule out retained lens material in the angle,” Dr. Findley says.

 A 63-year-old white male was referred for the presence of flocculent, whitish material in the anterior segment one week after uneventful phacoemulsification with IOL implantation OS. He was on atropine preoperatively due to miosis. Slit-lamp exam revealed a clear cornea with retained lens material in the inferior angle. IOL was in the bag. Gonioscopy confirmed lens material in the inferior angle. A 67-year-old white male was referred for sudden vision loss OS. He had phacoemulsification 10 years earlier. Slit lamp exam showed corneal edema and retained lens material in the inferior angle. Posterior capsule IOL remained in the capsular bag. Gonioscopy confirmed retained lens material in the inferior angle.
If you find retained lens material, the first step is to increase the topical steroid, he says. “The patient is probably already on prednisolone at QID dosing, so I would increase it to every two hours or maybe switch to Durezol (difluprednate 0.05%, Alcon), which can be dosed QID. Also, if the patient is using generic prednisolone, I would switch them to the name brand.”

Be aware that the retained lens material can be lens cortex or lens nucleus; it can be difficult to tell them apart. “Cortical material may resolve with steroids, but nuclear likely will not,” Dr. Findley says.

In any event, when confronted with retained lens material, contact the surgeon about the situation and coordinate the approach to resolution. For instance, sometimes the associated iritis won’t respond to topical meds, so evacuation of the retained lens material by anterior chamber washout is required, Dr. Findley says.

Significant retained lens material, even without corneal edema, may also best be treated with AC washout, he says. However, immediate washout is not required. Patients with retained lens material that won’t respond to topical steroids should be scheduled to return to the surgeon on an urgent basis. But keep up the increased steroid frequency in the meantime, Dr. Findley adds.