Monocular Diplopia 22 Years After Anterior Chamber Intraocular lens Implantation: A Case Report

Monocular Diplopia 22 Years After Anterior Chamber Intraocular lens Implantation: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Monocular Diplopia 22 Years After Anterior Chamber Intraocular lens Implantation: A Case Report Liu Jinshuo, Xin Chen, Mou Dapeng, Yan Naiqin, Mao Yingyan, Zhu Siquan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6416183/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background： Angle-supported anterior chamber intraocular lenses provide a technically straightforward solution for aphakic eyes lacking capsular support, yet their long-term complications warrant critical attention. We present a case of monocular diplopia occurring 22 years after ACIOL implantation for congenital cataract, analyzing the mechanisms of corneal endothelial loss and surgical management strategies to elucidate the delayed risks associated with anterior chamber IOLs. Case Presentation： A 29-year-old female presented with painless monocular diplopia in her left eye, 23 years after staged bilateral congenital cataract surgery (lensectomy at 6 months, followed by secondary IOL implantation at age 6: right eye in-the-bag IOL, left eye angle-fixated ACIOL due to inadequate capsular support). Examination revealed ACIOL-induced angle obstruction with pupillary distortion (confirmed by ultrasound biomicroscopy) and an endothelial cell density of 1,552.3 cells/mm² in the left eye (vs. 1,271.0 cells/mm² in the right). The patient underwent ACIOL explantation combined with anterior vitrectomy and pupilloplasty to halt progressive endothelial loss and resolve diplopia. At 3-month follow-up, iris architecture remained stable with preserved endothelial density (1,526.8 cells/mm²), though medically controlled elevated IOP (19-26 mmHg) was noted. Ongoing monitoring is maintained. Conclusion ：This case demonstrates a 22-year latency period for ACIOL-related complications, underscoring the need for prompt removal upon visual quality deterioration (e.g., diplopia) or significant endothelial decline. Secondary IOL implantation should be individualized (sulcus vs. scleral-fixated), with lifelong surveillance for IOP, endothelial function, and retinal status. These findings carry critical implications for pediatric IOL selection and lifelong postoperative management. Anterior chamber intraocular lens Pupilloplasty Congenital cataract Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Congenital cataract remains one of the leading causes of childhood visual impairment. While early surgical intervention (recommended within 6 weeks for unilateral dense cataracts and 8 weeks for bilateral cases) is critical for visual development, the optimal intraocular lens (IOL) implantation approach - particularly in eyes with inadequate capsular support - remains controversial. Angle-supported anterior chamber IOLs (ACIOLs) were historically favored for their technical simplicity, but long-term follow-up studies have demonstrated significant risks of corneal endothelial loss and mechanical complications. This study presents a rare case of monocular diplopia occurring 22 years after pediatric ACIOL implantation, analyzing its iris-angle anatomical alterations and endothelial injury mechanisms to elucidate the long-term risks of anterior chamber IOLs in children and inform evidence-based surgical decision-making. Case presentation A 29-year-old female presented with a 2-week history of monocular diplopia in the left eye, unaccompanied by ocular pain or redness. Her medical history was unremarkable for systemic diseases, though she had undergone bilateral congenital cataract extraction at 6 months of age, followed by secondary intraocular lens (IOL) implantation in both eyes at age 6 (right eye: in-the-bag IOL; left eye: angle-supported anterior chamber IOL). Ocular examination revealed uncorrected visual acuity (UCVA) of 0.25 (corrected to 0.6 with -9.00DS/-3.00DC×90) and intraocular pressure (IOP) of 19 mmHg in the right eye, and UCVA of 0.15 (corrected to 0.4 with -8.00DS/-3.00DC×90) with IOP of 20 mmHg in the left eye. Both eyes exhibited pupillary displacement and irregularity. The right eye demonstrated a stable in-the-bag IOL, while the left eye showed a 3×4 mm peripheral iridectomy at the 6 o’clock position and iris root defect at 11 o’clock (Fig. 1). Notably, the left eye’s angle-supported IOL was embedded in the anterior chamber angle with a fibrotic membrane over the pupillary area. Corneal endothelial cell density was 1271.0/mm² in the right eye and 1552.3/mm² in the left eye, with a mean central corneal thickness of 541 μm bilaterally. Axial lengths measured 29.18 mm (right) and 28.83 mm (left). Corneal topography indicated with-the-rule astigmatism (-3.75D; K1=45.00D, K2=48.75D) in the right eye and against-the-rule astigmatism (-2.50D; K1=46.50D, K2=44.00D) in the left. OCT and fundus imaging confirmed high myopia with tessellated fundus changes and peripapillary atrophy arcs in both eyes, without macular abnormalities (Fig. 1). Ultrasound biomicroscopy (UBM) further verified angle obstruction by the anterior chamber IOL and pupillary fibrosis in the left eye. The final diagnosis included monocular diplopia (left eye), bilateral pseudophakia with refractive errors, and postoperative sequelae. After multidisciplinary evaluation, the patient underwent pars plana vitrectomy with IOL explantation and pupilloplasty in the left eye On August 29, 2024, the patient underwent left eye pars plana vitrectomy with intraocular lens (IOL) explantation and pupilloplasty under general anesthesia. The procedure was performed as follows: Following standard disinfection and draping, a lid speculum was placed to expose the left eye. After povidone-iodine conjunctival sac irrigation (90 seconds) and saline rinse, a main incision was created at the nasal superior limbus under microscopic guidance, with an auxiliary incision at the 2 o’clock limbal position. Intraoperatively, the iris was found adherent to the transparent angle-supported IOL. Viscoelastic agent was injected to dissect the iris-IOL interface, and the IOL was explanted through an enlarged incision. A vitrector was introduced to excise fibrotic membranes over the pupillary area. A 10-0 polypropylene suture was threaded through a lamellar incision at the nasal 8 o’clock position and externalized at the temporal 4 o’clock site. Iris reconstruction was achieved using the Siepser sliding knot (SFT) technique to approximate the superior peripheral iridectomy and reshape the pupil. Residual anterior vitreous and fibrotic membranes were excised, followed by intracameral pressure normalization (Tn). Postoperative care included tobramycin-dexamethasone ointment and a soft hydrophilic contact lens. On postoperative day 1, uncorrected visual acuity (UCVA) in the left eye measured 0.3 with an intraocular pressure (IOP) of 26 mmHg. Slit-lamp examination revealed mild conjunctival injection, a clear cornea with well-sealed incisions, and a moderately irregular pupil (3.0 mm diameter) with sutured inferior peripheral iridectomy. Topical gatifloxacin, recombinant bovine basic fibroblast growth factor (bFGF), tobramycin-dexamethasone, and pranoprofen were initiated. At the 1-week follow-up, UCVA improved to 0.5 (IOP: 25 mmHg), prompting the addition of carteolol and brinzolamide/timolol for IOP control. Corneal endothelial cell density (ECD) remained stable at 1,521.9/mm²(Fig. 2). By 1 month postoperatively, UCVA stabilized at 0.5 (IOP: 26 mmHg), with persistent pupillary irregularity and nasal displacement. Notably, iris atrophy was observed, and the antiglaucoma regimen was adjusted to latanoprost, brinzolamide/timolol, and sodium hyaluronate, while anti-inflammatory agents were discontinued.Three-month follow-up demonstrated maintained UCVA of 0.5 (IOP: 19 mmHg), stable ECD (1,526.8/mm²), and secure iris sutures at the 6 o’clock position (Fig. 3). Anterior segment OCT confirmed proper suture placement with mid-depth anterior chamber and flattened iris contour (Fig. 4). Humphrey visual field testing revealed no glaucomatous defects, and fundus examination showed no progression of high myopia-related changes (cup-to-disc ratio: 0.4; ). Long-term monitoring of IOP and endothelial function was advised biannually. Discussion and conclusions Congenital cataract, defined as lens opacities present at birth or developing during early infancy due to genetic or developmental abnormalities, represents one of the most prevalent pediatric ocular disorders and a leading cause of childhood blindness and amblyopia [1] ，Globally, over 200,000 children are blind due to congenital cataracts, accounting for 10%–38% of pediatric blindness cases [2] 。The timing of surgical intervention depends on multiple factors, including patient age, cataract density and morphology, and laterality (unilateral or bilateral). For unilateral congenital cataracts, the first few weeks of life constitute a critical period for visual development; failure to provide adequate optical stimulation during this window may lead to irreversible amblyopia [3] 。 While consensus remains elusive regarding the optimal timing for mild, non-dense unilateral cataracts—particularly in preverbal children—dense unilateral cases, which carry higher amblyogenic risks than bilateral cataracts, generally require surgery within six weeks postnatally [4] 。Serafino et al. [5] demonstrated that bilateral dense congenital cataracts should similarly be addressed within eight weeks of birth, with the second eye operated within one week of the first procedure to minimize binocular form deprivation amblyopia. Notably, even when diagnosed beyond the critical developmental period, prompt cataract extraction remains essential to clear the visual axis and maximize visual potential [6] 。The current gold-standard surgical approach involves microincision lens aspiration combined with anterior and posterior capsulorhexis and limited anterior vitrectomy. Traditional manual continuous curvilinear capsulorhexis (CCC) techniques face unique challenges in pediatric eyes due to iris elasticity-induced shallowing of the anterior chamber, heightened capsular elasticity, and viscous lens cortex, often complicating capsular management [7] This patient was diagnosed with congenital cataracts at age 2 and underwent bilateral cataract extraction, followed by secondary intraocular lens (IOL) implantation at age 6. While the right eye successfully received an in-the-bag IOL, the left eye—likely due to insufficient capsular integrity and zonular support—required implantation of an angle-fixated anterior chamber IOL (ACIOL). In cases lacking capsular support, IOL fixation techniques must balance anatomical constraints, surgical complexity, and long-term risks. Alternative approaches such as scleral-sutured or sutureless fixation, iris fixation, or angle-supported fixation are employed when the posterior or anterior capsule is compromised by trauma, complicated surgery, severe infection (e.g., endophthalmitis), or inflammatory conditions (e.g., uveitis). Each method carries distinct trade-offs in surgical difficulty, operative time, and intra-/postoperative complications. Though ACIOLs are widely adopted for their technical simplicity, their proximity to the corneal endothelium and angle structures raises risks of bullous keratopathy, peripheral anterior synechiae (PAS), and secondary glaucoma—particularly with improper sizing. Oversized ACIOLs may induce pupil ovalization, iris atrophy, and chronic inflammation, while undersized lenses predispose to dislocation, endothelial damage, and glaucoma [8] 。 In this case, over two decades post-implantation, the patient exhibited significantly reduced corneal endothelial cell density (below age-matched norms) and progressive enlargement/ displacement of the peripheral iridectomy, resulting in an irregular, eccentric pupil and severe visual disturbances. To address monocular diplopia while mitigating further endothelial loss, the surgical team elected explantation of the ACIOL combined with anterior vitrectomy and pupilloplasty, prioritizing minimal tissue trauma to resolve both diplopia and the latent threat of endothelial decompensation. The ACIOLwas originally designed to provide reversible refractive correction for high myopia and astigmatism [9] 。 Its primary advantage lies in surgical simplicity compared to scleral-sutured fixation, offering easier mastery and effective refractive improvement while bypassing capsular integrity requirements. However, ACIOLs are contraindicated in cases of corneal endothelial or angle structure compromise. Critical to outcomes is precise sizing: oversized ACIOLs exert excessive pressure on the iris root and angle recess, leading to pupil ovalization, iris atrophy, hemorrhage, and iridocyclitis [10] 。Proximity to corneal endothelium and angle structures heightens risks of bullous keratopathy, glaucoma, and peripheral anterior synechiae (PAS) [11] 。While iris-claw lenses similarly occupy anterior segments, their mid-peripheral fixation may reduce angle-related complications [12] Iris fixation techniques (e.g., two-point fixation at the optic-haptic junction) minimize suture-related trauma but carry risks of iris chafing, pigment dispersion, and chronic inflammation, particularly with late suture breakage at fixation holes. Notably, Parekh et al. [13] reported zero suture-induced subluxations in 7-year follow-ups using hole-free direct iris suturing. Surgical selection must prioritize anatomical suitability: shallow anterior chambers preclude ACIOLs, while iris trauma contraindicates iris fixation. In uncomplicated cases, multiple techniques achieve comparable visual outcomes, though long-term safety and surgical efficiency require balanced consideration [14, 15] 。Undersized ACIOLs risk mobility-induced endothelial damage, uveitis, PAS, and glaucoma [16] 。 Mechanistically, most rigid PMMA ACIOLs impose mechanical endothelial trauma through chronic friction during ocular movements [17] ； while their low refractive indices increase lens thickness—potentially exacerbating endothelial apoptosis via persistent proximity [9] 。 Compounding this, the nasal IOL edge’s shorter endothelial distance (a consistent anatomical feature) accelerates cell loss through microtrauma and localized inflammation [18] 。 Thus, clinical decisions must weigh correction efficacy against longitudinal safety, with particular attention to high-risk anatomies (e.g., shallow anterior chamber, narrow angle)，Endothelial loss pathophysiology involves dual mechanical and inflammatory pathways: [19] (1) The nasal IOL edge’s proximity directly correlates with cell depletion (P5° ACA reduction) in 95% of cases may impair aqueous outflow, inducing oxidative stress [20] 。 Surgical factors compound these risks: IOL instability perpetuates endothelial friction, while excessive iris contact promotes pigment-mediated inflammatory cascades [21, 22] 。 Collectively, endothelial attrition reflects synergistic anatomical, design-related, and postoperative inflammatory insults, necessitating multidimensional mitigation strategies In China, early-generation ACIOL were largely abandoned due to high postoperative complication rates. While the introduction of flexible-loop ACIOL designs subsequently reduced adverse events, persistent concerns over improper fixation and corneal contact—leading to progressive endothelial cell loss—have rendered them obsolete in contemporary practice, with ciliary sulcus fixation now serving as the predominant alternative. Future research should prioritize: (1) development of novel biomaterials and contact-free IOL fixation technologies to enhance biocompatibility and mechanical stability; (2) systematic accumulation of long-term follow-up data, particularly regarding ECD decay patterns and glaucoma incidence, to strengthen evidence-based surgical selection; and (3) multicenter collaborations to validate next-generation techniques. Through such innovations, capsular bag-independent IOL fixation may achieve optimized safety profiles while addressing complex clinical scenarios in aphakic rehabilitation. Abbreviations ACIOL:Anterior Chamber Intraocular lens, IOL: Intraocular lens ,D: Diopter; UBM: Ultrasound biomicroscopy; OCT: Optical coherence tomography. ECD: endothelial cell density Declarations Ethics approval and consent to participate This study did not involve animal experiments or clinical trials. However, all patient-related procedures were reviewed and approved by the Ethics Committee of Beijing Tongren Hospital, Capital Medical University (Approval granted by Prof. Ningli Wang, Director of the Hospital). Consent for publication No identifiable patient information or images are included in this manuscript. Written informed consent for publication of the case details was obtained from the patient prior to submission. Availability of data and materials All clinical data and diagnostic results related to this case are fully accessible. The patient explicitly consented to public disclosure of anonymized data during our consultation. Competing interests The authors declare no financial or non-financial competing interests. Funding Not applicable. Authors' contributions Liu jinshuo: Data acquisition, manuscript drafting. Xin Chen and Mou dapeng: Diagnosis, critical manuscript revision. Yan naiqin and Mao yingyan: Patient examination, consent acquisition, manuscript revision. Zhu siquan and Wang Ningli: Surgical intervention, manuscript revision. All authors reviewed and approved the final manuscript. Acknowledgements Not applicable. Authors' information (optional) No additional information required References Li L, Wang X, Liu C, Wang S, Wang X.Incidence Rate of Secondary Glaucoma Following Congenital Cataract Surgery: An In-Depth Systematic Review and Meta-Analysis. Am J Ophthalmol 2024,265:176-188. Liu Y, Liu Z.Psychosocial Impact of Patching in Unilateral Congenital Cataract. JAMA Ophthalmol 2024,142(6):510-511. Long V, Chen S, Hatt S.Surgical interventions for bilateral congenital cataract. Cochrane Database Syst Rev 2006,2006(3):Cd003171. Shiels A, Hejtmancik JF.Biology of Inherited Cataracts and Opportunities for Treatment. Annu Rev Vis Sci 2019,5:123-149. Serafino M, Trivedi RH, Levin AV, Wilson ME, Nucci P, Lambert SR, Nischal KK, Plager DA, Bremond-Gignac D, Kekunnaya R et al .Use of the Delphi process in paediatric cataract management. Br J Ophthalmol 2016,100(5):611-615. Serafino M, Castellucci G, Banderali G.Delphi Process in the Management of Pediatric Cataract. Dev Ophthalmol 2016,57:107-108. Nihalani BR, VanderVeen DK.Technological advances in pediatric cataract surgery. Semin Ophthalmol 2010,25(5-6):271-274. Narváez J, Nam E.Iris fixation of unstable anterior chamber intraocular lenses. Journal of Cataract and Refractive Surgery 2016,42(7):961-964. Doors M, Cals DW, Berendschot TT, de Brabander J, Hendrikse F, Webers CA, Nuijts RM.Influence of anterior chamber morphometrics on endothelial cell changes after phakic intraocular lens implantation. J Cataract Refract Surg 2008,34(12):2110-2118. Jin GJ, Crandall AS, Jones JJ.Changing indications for and improving outcomes of intraocular lens exchange. Am J Ophthalmol 2005,140(4):688-694. Drolsum L.Long-term follow-up of secondary flexible, open-loop, anterior chamber intraocular lenses. J Cataract Refract Surg 2003,29(3):498-503. Aron-Rosa DS, Aron JJ.Effect of preoperative YAG laser anterior capsulotomy on the incidence of posterior capsule opacification: ten year follow-up. J Cataract Refract Surg 1992,18(6):559-561. Parekh P, Green WR, Stark WJ, Akpek EK.Subluxation of suture-fixated posterior chamber intraocular lenses a clinicopathologic study. Ophthalmology 2007,114(2):232-237. Elderkin S, Tu E, Sugar J, Reddy S, Kadakia A, Ramaswamy R, Djalilian A.Outcome of descemet stripping automated endothelial keratoplasty in patients with an anterior chamber intraocular lens. Cornea 2010,29(11):1273-1277. Chu MW, Font RL, Koch DD.Visual results and complications following posterior iris-fixated posterior chamber lenses at penetrating keratoplasty. Ophthalmic Surg 1992,23(9):608-613. Marques FF, Marques DM, Osher RH, Freitas LL.Longitudinal study of intraocular lens exchange. J Cataract Refract Surg 2007,33(2):254-257. Galvis V, Villamil JF, Acuña MF, Camacho PA, Merayo-Lloves J, Tello A, Zambrano SL, Rey JJ, Espinoza JV, Prada AM.Long-term endothelial cell loss with the iris-claw intraocular phakic lenses (Artisan®). Graefes Arch Clin Exp Ophthalmol 2019,257(12):2775-2787. Doors M, Berendschot TT, Webers CA, Nuijts RM.Model to predict endothelial cell loss after iris-fixated phakic intraocular lens implantation. Invest Ophthalmol Vis Sci 2010,51(2):811-815. Yoon Hy, Byun Y-S, Kim HS, Chung S-H.Cornea Endothelial Cell Loss Before and After Explantation of Artisan and Artiflex Iris-Fixated Phakic Intraocular Lenses. American Journal of Ophthalmology 2025,270:52-60. Yamaguchi T, Negishi K, Yuki K, Saiki M, Nishimura R, Kawaguchi N, Tsubota K.Alterations in the anterior chamber angle after implantation of iris-fixated phakic intraocular lenses. J Cataract Refract Surg 2008,34(8):1300-1305. Dick HB, Budo C, Malecaze F, Güell JL, Marinho AA, Nuijts RM, Luyten GP, Menezo JL, Kohnen T.Foldable Artiflex phakic intraocular lens for the correction of myopia: two-year follow-up results of a prospective European multicenter study. Ophthalmology 2009,116(4):671-677. Nemcova I, Pasta J, Hladikova K, Komarc M, Pospisilova D, Nemec P, Tesar J, Kratky V, Sin M.Myopic Correction with Iris-Fixated Phakic Intraocular Lenses: Twelve-Year Results. J Ophthalmol 2021,2021:7027793. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6416183","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":462983570,"identity":"0a8f6a98-f677-4729-976f-605be4aa41e7","order_by":0,"name":"Liu Jinshuo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBACNvnzD4x//rGR42dvPkCcFj4JHoZixoY0Y8meYwnEaZEDavnM2HAo0eBGjgGRDpPuPbi5cMeBBIMDOR9vvGGwk9NtIKRF5lyy8cwzd/IkD5zdbDmHIdnY7AAhLQwJZgY8bM+K+Q72bpPmYTiQuI0ILeY/eNgOJzYc5nlGpBaJHANj3rbDiROO8bARqYXnWILhjDOgQGYztpxjQIRf5NubDxh8qABGpfzjhzfeVNjJEdSCAiR4iIwaZC2k6hgFo2AUjIIRAQASLUZidxTCZwAAAABJRU5ErkJggg==","orcid":"","institution":"Beijing Tongren Eye Center, Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Liu","middleName":"","lastName":"Jinshuo","suffix":""},{"id":462983572,"identity":"b01e3da5-3ba4-4c70-910b-8372c4389930","order_by":1,"name":"Xin Chen","email":"","orcid":"","institution":"Beijing Tongren Eye Center, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Chen","suffix":""},{"id":462983574,"identity":"9d7f3c61-e4b2-4550-9af8-e3b4c8597583","order_by":2,"name":"Mou Dapeng","email":"","orcid":"","institution":"Beijing Tongren Eye Center, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mou","middleName":"","lastName":"Dapeng","suffix":""},{"id":462983576,"identity":"22c1f463-be13-4de5-b8ca-2a41b0196157","order_by":3,"name":"Yan Naiqin","email":"","orcid":"","institution":"Daqing Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Naiqin","suffix":""},{"id":462983577,"identity":"07ae23fa-07c3-46ed-8ad1-cce5b6fb4670","order_by":4,"name":"Mao Yingyan","email":"","orcid":"","institution":"Beijing Tongren Eye Center, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mao","middleName":"","lastName":"Yingyan","suffix":""},{"id":462983579,"identity":"0482b1d6-cddd-466c-8d6c-af333473b949","order_by":5,"name":"Zhu Siquan","email":"","orcid":"","institution":"Captial Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhu","middleName":"","lastName":"Siquan","suffix":""},{"id":462983580,"identity":"0cc153ba-7ccd-48a6-b2a1-afb4d55bfee6","order_by":6,"name":"Wang Ningli","email":"","orcid":"","institution":"Beijing Tongren Eye Center, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Ningli","suffix":""}],"badges":[],"createdAt":"2025-04-10 04:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6416183/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6416183/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83767521,"identity":"64baa4fd-08e4-4a0d-b044-f0b4ebf3e475","added_by":"auto","created_at":"2025-06-02 11:30:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":310458,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative Evaluation of the Left Eye\u003c/strong\u003e\u003cbr\u003e\n \u003cstrong\u003eA.\u003c/strong\u003e Anterior segment imaging demonstrates an angle-supported anterior chamber intraocular lens (AC-IOL) with pupillary distortion and iris atrophy at the haptic contact sites. A large inferior iridectomy (3×4 mm) is noted at the 6 o'clock position, accompanied by an iris root defect at 11 o'clock (\u003cem\u003earrow\u003c/em\u003e). Fibrotic encapsulation of the IOL appears as a whitish retro-pupillary membrane.\u003cstrong\u003eB.\u003c/strong\u003e Ultra-widefield fundus imaging reveals high myopia-related changes, including tessellated fundus, peripapillary atrophy (\u003cem\u003earrowhead\u003c/em\u003e), and a cup-to-disc ratio of 0.4. Retinal vasculature remains intact without pathologic alterations.\u003cstrong\u003eC.\u003c/strong\u003e Macular OCT scan demonstrates suboptimal image clarity due to media opacity; however, no structural abnormalities such as macular edema or epiretinal membrane are detected.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6416183/v1/840def16291c9728e9f87dd9.png"},{"id":83766575,"identity":"d9309a62-a964-40ea-99f0-245d4303fc70","added_by":"auto","created_at":"2025-06-02 11:14:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":256348,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative Evaluation at 1 Month\u003c/p\u003e\n\u003cp\u003eA. Anterior segment photography demonstrates iris sutures at the 6 o'clock position (arrow), partial pupillary centration, and mild iris atrophy. The anterior chamber depth remains moderate.B. Ultra-widefield fundus imaging confirms stable high myopia-related changes, including tessellated fundus and peripapillary atrophy, without evidence of retinal detachment or vasculopathy.C. Macular OCT reveals intact retinal layers with no cystoid edema or photoreceptor abnormalities.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6416183/v1/ae888efc51bf8665606cb01f.png"},{"id":83766579,"identity":"cf791ede-bed5-4a38-b55b-43cda6e763da","added_by":"auto","created_at":"2025-06-02 11:14:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":531108,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative Evaluation at 3 Months\u003c/p\u003e\n\u003cp\u003eA. Slit-lamp photography shows persistent pupillary irregularity with nasal displacement, secure iris sutures at 6 o'clock (arrowhead), and stable iris atrophy.B. Optic disc stereophotography demonstrates a cup-to-disc ratio of 0.4 without glaucomatous changes, consistent with high myopia-related optic nerve features.C-D. High-magnification slit-lamp images detail the iris suture site (asterisk) and residual iridectomy defect (hashtag), showing no signs of inflammation or suture erosion.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6416183/v1/bf6c5fd9f9dd6e2d9004791f.png"},{"id":83766847,"identity":"9d977f60-4b64-4e96-917a-a59f58a9e66c","added_by":"auto","created_at":"2025-06-02 11:22:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":147554,"visible":true,"origin":"","legend":"\u003cp\u003eAnterior Segment OCT at 3 Months Postoperatively\u003c/p\u003e\n\u003cp\u003eA. Cross-sectional OCT at 256°-70° meridian illustrates flattened iris contour at the suture site (arrow), mid-depth anterior chamber, and absence of IOL.B. Oblique scan at 257°-77° meridian confirms proper suture integration (dotted line) and stable anterior chamber architecture.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6416183/v1/0847d6141b1fefab6976f3dd.png"},{"id":109762630,"identity":"c105373e-0dae-49df-883c-3a0ba4e2d7b0","added_by":"auto","created_at":"2026-05-22 07:31:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1671554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6416183/v1/06b26774-95ae-4991-8246-2b48fa1c738f.pdf"},{"id":83766580,"identity":"6c54a092-c079-413f-bf13-f3ed5b08788d","added_by":"auto","created_at":"2025-06-02 11:14:54","extension":"rar","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":29125209,"visible":true,"origin":"","legend":"","description":"","filename":"supplement.rar","url":"https://assets-eu.researchsquare.com/files/rs-6416183/v1/bae146f127cb900b83954f6d.rar"}],"financialInterests":"No competing interests reported.","formattedTitle":"Monocular Diplopia 22 Years After Anterior Chamber Intraocular lens Implantation: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eCongenital cataract remains one of the leading causes of childhood visual impairment. While early surgical intervention (recommended within 6 weeks for unilateral dense cataracts and 8 weeks for bilateral cases) is critical for visual development, the optimal intraocular lens (IOL) implantation approach - particularly in eyes with inadequate capsular support - remains controversial. Angle-supported anterior chamber IOLs (ACIOLs) were historically favored for their technical simplicity, but long-term follow-up studies have demonstrated significant risks of corneal endothelial loss and mechanical complications. This study presents a rare case of monocular diplopia occurring 22 years after pediatric ACIOL implantation, analyzing its iris-angle anatomical alterations and endothelial injury mechanisms to elucidate the long-term risks of anterior chamber IOLs in children and inform evidence-based surgical decision-making.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 29-year-old female presented with a 2-week history of monocular diplopia in the left eye, unaccompanied by ocular pain or redness. Her medical history was unremarkable for systemic diseases, though she had undergone bilateral congenital cataract extraction at 6 months of age, followed by secondary intraocular lens (IOL) implantation in both eyes at age 6 (right eye: in-the-bag IOL; left eye: angle-supported anterior chamber IOL). Ocular examination revealed uncorrected visual acuity (UCVA) of 0.25 (corrected to 0.6 with -9.00DS/-3.00DC×90) and intraocular pressure (IOP) of 19 mmHg in the right eye, and UCVA of 0.15 (corrected to 0.4 with -8.00DS/-3.00DC×90) with IOP of 20 mmHg in the left eye. Both eyes exhibited pupillary displacement and irregularity. The right eye demonstrated a stable in-the-bag IOL, while the left eye showed a 3×4 mm peripheral iridectomy at the 6 o’clock position and iris root defect at 11 o’clock (Fig. 1). Notably, the left eye’s angle-supported IOL was embedded in the anterior chamber angle with a fibrotic membrane over the pupillary area. Corneal endothelial cell density was 1271.0/mm²\u0026nbsp;in the right eye and 1552.3/mm²\u0026nbsp;in the left eye, with a mean central corneal thickness of 541\u0026nbsp;μm bilaterally. Axial lengths measured 29.18 mm (right) and 28.83 mm (left). Corneal topography indicated with-the-rule astigmatism (-3.75D; K1=45.00D, K2=48.75D) in the right eye and against-the-rule astigmatism (-2.50D; K1=46.50D, K2=44.00D) in the left. OCT and fundus imaging confirmed high myopia with tessellated fundus changes and peripapillary atrophy arcs in both eyes, without macular abnormalities (Fig. 1). Ultrasound biomicroscopy (UBM) further verified angle obstruction by the anterior chamber IOL and pupillary fibrosis in the left eye. The final diagnosis included monocular diplopia (left eye), bilateral pseudophakia with refractive errors, and postoperative sequelae. After multidisciplinary evaluation, the patient underwent pars plana vitrectomy with IOL explantation and pupilloplasty in the left eye\u003c/p\u003e\n\u003cp\u003eOn August 29, 2024, the patient underwent left eye pars plana vitrectomy with intraocular lens (IOL) explantation and pupilloplasty under general anesthesia. The procedure was performed as follows: Following standard disinfection and draping, a lid speculum was placed to expose the left eye. After povidone-iodine conjunctival sac irrigation (90 seconds) and saline rinse, a main incision was created at the nasal superior limbus under microscopic guidance, with an auxiliary incision at the 2 o’clock limbal position. Intraoperatively, the iris was found adherent to the transparent angle-supported IOL. Viscoelastic agent was injected to dissect the iris-IOL interface, and the IOL was explanted through an enlarged incision. A vitrector was introduced to excise fibrotic membranes over the pupillary area. A 10-0 polypropylene suture was threaded through a lamellar incision at the nasal 8 o’clock position and externalized at the temporal 4 o’clock site. Iris reconstruction was achieved using the Siepser sliding knot (SFT) technique to approximate the superior peripheral iridectomy and reshape the pupil. Residual anterior vitreous and fibrotic membranes were excised, followed by intracameral pressure normalization (Tn). Postoperative care included tobramycin-dexamethasone ointment and a soft hydrophilic contact lens.\u003c/p\u003e\n\u003cp\u003eOn postoperative day 1, uncorrected visual acuity (UCVA) in the left eye measured 0.3 with an intraocular pressure (IOP) of 26 mmHg. Slit-lamp examination revealed mild conjunctival injection, a clear cornea with well-sealed incisions, and a moderately irregular pupil (3.0 mm diameter) with sutured inferior peripheral iridectomy. Topical gatifloxacin, recombinant bovine basic fibroblast growth factor (bFGF), tobramycin-dexamethasone, and pranoprofen were initiated. At the 1-week follow-up, UCVA improved to 0.5 (IOP: 25 mmHg), prompting the addition of carteolol and brinzolamide/timolol for IOP control. Corneal endothelial cell density (ECD) remained stable at 1,521.9/mm²(Fig. 2). By 1 month postoperatively, UCVA stabilized at 0.5 (IOP: 26 mmHg), with persistent pupillary irregularity and nasal displacement. Notably, iris atrophy was observed, and the antiglaucoma regimen was adjusted to latanoprost, brinzolamide/timolol, and sodium hyaluronate, while anti-inflammatory agents were discontinued.Three-month follow-up demonstrated maintained UCVA of 0.5 (IOP: 19 mmHg), stable ECD (1,526.8/mm²), and secure iris sutures at the 6 o’clock position (Fig. 3). Anterior segment OCT confirmed proper suture placement with mid-depth anterior chamber and flattened iris contour (Fig. 4). Humphrey visual field testing revealed no glaucomatous defects, and fundus examination showed no progression of high myopia-related changes (cup-to-disc ratio: 0.4; ). Long-term monitoring of IOP and endothelial function was advised biannually.\u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cp\u003eCongenital cataract, defined as lens opacities present at birth or developing during early infancy due to genetic or developmental abnormalities, represents one of the most prevalent pediatric ocular disorders and a leading cause of childhood blindness and amblyopia \u003csup\u003e[1]\u003c/sup\u003e，Globally, over 200,000 children are blind due to congenital cataracts, accounting for 10%–38% of pediatric blindness cases \u003csup\u003e[2]\u003c/sup\u003e。The timing of surgical intervention depends on multiple factors, including patient age, cataract density and morphology, and laterality (unilateral or bilateral). For unilateral congenital cataracts, the first few weeks of life constitute a critical period for visual development; failure to provide adequate optical stimulation during this window may lead to irreversible amblyopia \u003csup\u003e[3]\u003c/sup\u003e。\u0026nbsp;While consensus remains elusive regarding the optimal timing for mild, non-dense unilateral cataracts—particularly in preverbal children—dense unilateral cases, which carry higher amblyogenic risks than bilateral cataracts, generally require surgery within six weeks postnatally\u003csup\u003e\u0026nbsp;[4]\u003c/sup\u003e。Serafino et al. \u003csup\u003e[5]\u003c/sup\u003e demonstrated that bilateral dense congenital cataracts should similarly be addressed within eight weeks of birth, with the second eye operated within one week of the first procedure to minimize binocular form deprivation amblyopia. Notably, even when diagnosed beyond the critical developmental period, prompt cataract extraction remains essential to clear the visual axis and maximize visual potential \u003csup\u003e[6]\u003c/sup\u003e。The current gold-standard surgical approach involves microincision lens aspiration combined with anterior and posterior capsulorhexis and limited anterior vitrectomy. Traditional manual continuous curvilinear capsulorhexis (CCC) techniques face unique challenges in pediatric eyes due to iris elasticity-induced shallowing of the anterior chamber, heightened capsular elasticity, and viscous lens cortex, often complicating capsular management\u003csup\u003e\u0026nbsp;[7]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThis patient was diagnosed with congenital cataracts at age 2 and underwent bilateral cataract extraction, followed by secondary intraocular lens (IOL) implantation at age 6. While the right eye successfully received an in-the-bag IOL, the left eye—likely due to insufficient capsular integrity and zonular support—required implantation of an angle-fixated anterior chamber IOL (ACIOL). In cases lacking capsular support, IOL fixation techniques must balance anatomical constraints, surgical complexity, and long-term risks. Alternative approaches such as scleral-sutured or sutureless fixation, iris fixation, or angle-supported fixation are employed when the posterior or anterior capsule is compromised by trauma, complicated surgery, severe infection (e.g., endophthalmitis), or inflammatory conditions (e.g., uveitis). Each method carries distinct trade-offs in surgical difficulty, operative time, and intra-/postoperative complications. Though ACIOLs are widely adopted for their technical simplicity, their proximity to the corneal endothelium and angle structures raises risks of bullous keratopathy, peripheral anterior synechiae (PAS), and secondary glaucoma—particularly with improper sizing. Oversized ACIOLs may induce pupil ovalization, iris atrophy, and chronic inflammation, while undersized lenses predispose to dislocation, endothelial damage, and glaucoma\u003csup\u003e\u0026nbsp;[8]\u003c/sup\u003e。\u0026nbsp;In this case, over two decades post-implantation, the patient exhibited significantly reduced corneal endothelial cell density (below age-matched norms) and progressive enlargement/ displacement of the peripheral iridectomy, resulting in an irregular, eccentric pupil and severe visual disturbances. To address monocular diplopia while mitigating further endothelial loss, the surgical team elected explantation of the ACIOL combined with anterior vitrectomy and pupilloplasty, prioritizing minimal tissue trauma to resolve both diplopia and the latent threat of endothelial decompensation.\u003c/p\u003e\n\u003cp\u003eThe ACIOLwas originally designed to provide reversible refractive correction for high myopia and astigmatism\u003csup\u003e\u0026nbsp;[9]\u003c/sup\u003e。\u0026nbsp;Its primary advantage lies in surgical simplicity compared to scleral-sutured fixation, offering easier mastery and effective refractive improvement while bypassing capsular integrity requirements. However, ACIOLs are contraindicated in cases of corneal endothelial or angle structure compromise. Critical to outcomes is precise sizing: oversized ACIOLs exert excessive pressure on the iris root and angle recess, leading to pupil ovalization, iris atrophy, hemorrhage, and iridocyclitis \u003csup\u003e\u0026nbsp;[10]\u003c/sup\u003e。Proximity to corneal endothelium and angle structures heightens risks of bullous keratopathy, glaucoma, and peripheral anterior synechiae (PAS) \u003csup\u003e\u0026nbsp;[11]\u003c/sup\u003e。While iris-claw lenses similarly occupy anterior segments, their mid-peripheral fixation may reduce angle-related complications\u003csup\u003e\u0026nbsp;[12]\u003c/sup\u003e \u0026nbsp;Iris fixation techniques (e.g., two-point fixation at the optic-haptic junction) minimize suture-related trauma but carry risks of iris chafing, pigment dispersion, and chronic inflammation, particularly with late suture breakage at fixation holes. Notably, Parekh et al.\u003csup\u003e\u0026nbsp;[13]\u003c/sup\u003e \u0026nbsp;reported zero suture-induced subluxations in 7-year follow-ups using hole-free direct iris suturing. Surgical selection must prioritize anatomical suitability: shallow anterior chambers preclude ACIOLs, while iris trauma contraindicates iris fixation. In uncomplicated cases, multiple techniques achieve comparable visual outcomes, though long-term safety and surgical efficiency require balanced consideration\u003csup\u003e\u0026nbsp;[14, 15]\u003c/sup\u003e。Undersized ACIOLs risk mobility-induced endothelial damage, uveitis, PAS, and glaucoma\u003csup\u003e\u0026nbsp;[16]\u003c/sup\u003e。\u0026nbsp;Mechanistically, most rigid PMMA ACIOLs impose mechanical endothelial trauma through chronic friction during ocular movements \u003csup\u003e\u0026nbsp;[17]\u003c/sup\u003e；\u0026nbsp;while their low refractive indices increase lens thickness—potentially exacerbating endothelial apoptosis via persistent proximity\u003csup\u003e\u0026nbsp;[9]\u003c/sup\u003e。\u0026nbsp;Compounding this, the nasal IOL edge’s shorter endothelial distance (a consistent anatomical feature) accelerates cell loss through microtrauma and localized inflammation\u003csup\u003e\u0026nbsp;[18]\u003c/sup\u003e。\u0026nbsp;Thus, clinical decisions must weigh correction efficacy against longitudinal safety, with particular attention to high-risk anatomies (e.g., shallow anterior chamber, narrow angle)，Endothelial loss pathophysiology involves dual mechanical and inflammatory pathways:\u003csup\u003e\u0026nbsp;[19]\u003c/sup\u003e (1) The nasal IOL edge’s proximity directly correlates with cell depletion (P\u0026lt;0.05)。and (2) angle narrowing (\u0026gt;5° ACA reduction) in 95% of cases may impair aqueous outflow, inducing oxidative stress \u003csup\u003e\u0026nbsp;[20]\u003c/sup\u003e。\u0026nbsp;Surgical factors compound these risks: IOL instability perpetuates endothelial friction, while excessive iris contact promotes pigment-mediated inflammatory cascades\u003csup\u003e\u0026nbsp;[21, 22]\u003c/sup\u003e。\u0026nbsp;Collectively, endothelial attrition reflects synergistic anatomical, design-related, and postoperative inflammatory insults, necessitating multidimensional mitigation strategies\u003c/p\u003e\n\u003cp\u003eIn China, early-generation ACIOL were largely abandoned due to high postoperative complication rates. While the introduction of flexible-loop ACIOL designs subsequently reduced adverse events, persistent concerns over improper fixation and corneal contact—leading to progressive endothelial cell loss—have rendered them obsolete in contemporary practice, with ciliary sulcus fixation now serving as the predominant alternative. Future research should prioritize: (1) development of novel biomaterials and contact-free IOL fixation technologies to enhance biocompatibility and mechanical stability; (2) systematic accumulation of long-term follow-up data, particularly regarding ECD decay patterns and glaucoma incidence, to strengthen evidence-based surgical selection; and (3) multicenter collaborations to validate next-generation techniques. Through such innovations, capsular bag-independent IOL fixation may achieve optimized safety profiles while addressing complex clinical scenarios in aphakic rehabilitation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACIOL:Anterior Chamber Intraocular lens, IOL: Intraocular lens ,D: Diopter; UBM: Ultrasound biomicroscopy; OCT: Optical coherence tomography. ECD: endothelial cell density\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not involve animal experiments or clinical trials. However, all patient-related procedures were reviewed and approved by the Ethics Committee of Beijing Tongren Hospital, Capital Medical University (Approval granted by Prof. Ningli Wang, Director of the Hospital).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo identifiable patient information or images are included in this manuscript. Written informed consent for publication of the case details was obtained from the patient prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll clinical data and diagnostic results related to this case are fully accessible. The patient explicitly consented to public disclosure of anonymized data during our consultation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial or non-financial competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLiu jinshuo: Data acquisition, manuscript drafting.\u003c/p\u003e\n\u003cp\u003eXin Chen and Mou dapeng: Diagnosis, critical manuscript revision.\u003c/p\u003e\n\u003cp\u003eYan naiqin and Mao yingyan: Patient examination, consent acquisition, manuscript revision.\u003c/p\u003e\n\u003cp\u003eZhu siquan and Wang Ningli: Surgical intervention, manuscript revision.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo additional information required\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLi L, Wang X, Liu C, Wang S, Wang X.Incidence Rate of Secondary Glaucoma Following Congenital Cataract Surgery: An In-Depth Systematic Review and Meta-Analysis. \u003cem\u003eAm J Ophthalmol\u0026nbsp;\u003c/em\u003e2024,265:176-188.\u003c/li\u003e\n \u003cli\u003eLiu Y, Liu Z.Psychosocial Impact of Patching in Unilateral Congenital Cataract. \u003cem\u003eJAMA Ophthalmol\u0026nbsp;\u003c/em\u003e2024,142(6):510-511.\u003c/li\u003e\n \u003cli\u003eLong V, Chen S, Hatt S.Surgical interventions for bilateral congenital cataract. \u003cem\u003eCochrane Database Syst 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Artisan and Artiflex Iris-Fixated Phakic Intraocular Lenses. \u003cem\u003eAmerican Journal of Ophthalmology\u0026nbsp;\u003c/em\u003e2025,270:52-60.\u003c/li\u003e\n \u003cli\u003eYamaguchi T, Negishi K, Yuki K, Saiki M, Nishimura R, Kawaguchi N, Tsubota K.Alterations in the anterior chamber angle after implantation of iris-fixated phakic intraocular lenses. \u003cem\u003eJ Cataract Refract Surg\u0026nbsp;\u003c/em\u003e2008,34(8):1300-1305.\u003c/li\u003e\n \u003cli\u003eDick HB, Budo C, Malecaze F, G\u0026uuml;ell JL, Marinho AA, Nuijts RM, Luyten GP, Menezo JL, Kohnen T.Foldable Artiflex phakic intraocular lens for the correction of myopia: two-year follow-up results of a prospective European multicenter study. \u003cem\u003eOphthalmology\u0026nbsp;\u003c/em\u003e2009,116(4):671-677.\u003c/li\u003e\n \u003cli\u003eNemcova I, Pasta J, Hladikova K, Komarc M, Pospisilova D, Nemec P, Tesar J, Kratky V, Sin M.Myopic Correction with Iris-Fixated Phakic Intraocular Lenses: Twelve-Year Results. \u003cem\u003eJ Ophthalmol\u0026nbsp;\u003c/em\u003e2021,2021:7027793.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anterior chamber intraocular lens, Pupilloplasty, Congenital cataract","lastPublishedDoi":"10.21203/rs.3.rs-6416183/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6416183/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground：\u003c/strong\u003eAngle-supported anterior chamber intraocular lenses provide a technically straightforward solution for aphakic eyes lacking capsular support, yet their long-term complications warrant critical attention. We present a case of monocular diplopia occurring 22 years after ACIOL implantation for congenital cataract, analyzing the mechanisms of corneal endothelial loss and surgical management strategies to elucidate the delayed risks associated with anterior chamber IOLs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation：\u003c/strong\u003eA 29-year-old female presented with painless monocular diplopia in her left eye, 23 years after staged bilateral congenital cataract surgery (lensectomy at 6 months, followed by secondary IOL implantation at age 6: right eye in-the-bag IOL, left eye angle-fixated ACIOL due to inadequate capsular support). Examination revealed ACIOL-induced angle obstruction with pupillary distortion (confirmed by ultrasound biomicroscopy) and an endothelial cell density of 1,552.3 cells/mm² in the left eye (vs. 1,271.0 cells/mm² in the right). The patient underwent ACIOL explantation combined with anterior vitrectomy and pupilloplasty to halt progressive endothelial loss and resolve diplopia. At 3-month follow-up, iris architecture remained stable with preserved endothelial density (1,526.8 cells/mm²), though medically controlled elevated IOP (19-26 mmHg) was noted. Ongoing monitoring is maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e：This case demonstrates a 22-year latency period for ACIOL-related complications, underscoring the need for prompt removal upon visual quality deterioration (e.g., diplopia) or significant endothelial decline. Secondary IOL implantation should be individualized (sulcus vs. scleral-fixated), with lifelong surveillance for IOP, endothelial function, and retinal status. These findings carry critical implications for pediatric IOL selection and lifelong postoperative management.\u003c/p\u003e","manuscriptTitle":"Monocular Diplopia 22 Years After Anterior Chamber Intraocular lens Implantation: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 11:14:47","doi":"10.21203/rs.3.rs-6416183/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad23d5e3-00f3-4049-bf2c-e460e2280e77","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-20T09:13:33+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T09:25:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 11:14:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6416183","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6416183","identity":"rs-6416183","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}