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Figure 4The step design within the forceps imprint is well maintained (original magnification×500)（略）
Figure 5Slitlamp examination of case 2 shows a forceps imprint in the central 3.6mm region 1 month postoperatively（略）
Figure 6Wavefront analysis revealed refractions similar to the manifest refraction and no particular aberrations related to the forceps imprint were observed in case 2 （略）
In our report, in case 1, a 3mm “onaxis” imprint of the forceps was observed on the lens anterior surface covered with granular substances. This is the first situation we met in which the functional zone of MIOL was “damaged”. Eventually, we opted for an IOL exchange for the following reasons: (1) The patient was subjectively not satisfied with the visual outcome. After 2 weeks followup, the UCDVA, BCDVA and BDCNVA were not significantly improved. (2) The characteristic material and design of ReSTOR MIOL is more fragile and its onaxis injury on the optic surface may compromise the visual function. (3) Many reports [9,13] showed that granular deposits on the optical surface were associated with a significant decrease in visual acuity. In our case, haze or granularity present on the surface of the lens optic corresponding to marks, theoretically should have an effect on the visual performance. (4) With the AcrySof lens, although its adhesiveness is associated with advantages such as low ACO and PCO rates, it rendered explantation of this singlepiece design more difficult with time[14]. (5) To evaluate whether or not; and if so, then to what extent, the apodized diffractive–refractive optic of the AcrySof ReSTOR IOL is altered when it is implanted in the wrong manner.
Scanning electron microscopy (SEM) is the gold standard for evaluating morphologic details of IOL surfaces[7,1517]. Studies of the surface quality of diffractive PMMA and refractive silicone (SA40N, Array) MIOLs have been published[18]. The results show that the MIOL surface structure is not more sensitive to manipulation during folding than that of monofocal IOL. Until now, no study of the surface quality of AcrySof ReSTOR IOL has been reported. In case 1, SEM showed that the step design of ReSTOR MIOL was well maintained and that the granular substances were less dense than that of other reports. It appears as though impairment of the optical qualities of the MIOLs is not to be expected. The vision dissatisfaction of case 1 might related to insufficient adaption of the lens or her high expectation.
Internal optic aberration in pseudophakic eyes consists of that of the posterior corneal surface, ocular media, and IOL. However, because the posterior corneal surface and ocular media generally have little aberration, what is derived from the IOL is thought to predominate in internal optic aberrations[1921]. The OPD (optical path difference) internal map displays the refractive status of the eye owing to internal aberrations by subtracting the effects of the corneal front surface from the total aberrometry. For intraocular surgery, the internal OPD map allows for determination of the centeration of the IOL and the optical effect of the surgery[22]. In case 2, there are no particular changes related to the forceps imprint observed on the OPD map.
The reason for the forceps imprint is that we grasped the IOL at the central optic zone unintentionally. We recommend implanting the AcrySof ReSTOR IOL carefully according to the companys instructions. The forceps should grasp the IOL at the junction of the optic and haptic. Recently, Evangelista et al[23] proposed the Sfold implantation technique for the AcrySof intraocular lens as a good alternative.
To our knowledge, this is the first report of forceps imprint in AcrySof ReSTOR IOL. Although the optical qualities of the IOLs were not specifically evaluated in this study, strong evidence does not exist that suggests the onaxis forceps imprint can significantly compromise visual acuity.
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