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We present a case of early post-intraocular collamer lens (ICL) implantation posterior subcapsular cataract, which resolved spontaneously after 1 week.

Intraocular collamer lens were bilaterally implanted in a 36-year-old healthy highly myopic man (manifest refraction right eye −10, −0.25 × 45°, left eye −7.75 −0.75 × 5°) with mild subclinical keratoconus and otherwise normal eyes. Corrected distance visual acuity (CDVA) of each eye was 1.0. The calculated ICL models were VICM 13.2 − 10.0 Dpt and VICM 13.2 − 8.5 Dpt.

Uneventful ICL implantations were performed by the same surgeon (TK) (Our standard protocol included pupil dilatation with tropicamide eye drops, topical anaesthesia with Xylocaine gel 2%, intracameral injection of Lidocaine-Hcl 1% and hyaluronic acid 2% viscoelastic, ICL implantation through a 3-mm-wide sclerocorneal tunnel, and a 1-mm-wide paracentesis).

The ICL haptics was tucked under the iris without touching the anterior capsule. The pupil was constricted with intracameral injection of acetylcholine, and a superior iridotomy was performed using an aspiration cutter. No intraoperative adverse effects were noted in either surgery.

Postoperative medication included ofloxacin and dexamethasone eye drops 4 times a day and Diamox 250 mg every 6 hr for 24 hr. One day postoperatively of the left eye and 2 days postoperatively of the right eye both ICLs were in the correct position, with intra ocular pressure (IOP) of 24 and 26 mmHg and uncorrected distance visual acuity (UDVA) was 1.0 and 0.9 in the right and left eyes, respectively. No lens opacity was seen in either eye, and vaulting was +1 in both eyes.

On the next day, the patient reported a decrease in left eye visual acuity. Upon examination, UDVA was 1.0 on the right eye and 0.3 on the left eye. CDVA on the left eye was 0.5. IOP was 17 mmHg with normal ICL position in both eyes. Surprisingly, a sutural star-shaped (rosette) cataract was seen in the posterior lens cortex of the left eye (Fig. 1A), with clear lens nucleus and anterior cortex (Fig. 1B). The postoperative course of the right eye was uneventful. Five days later, the patient reported of spontaneously improvement on the left eye. UDVA improved to 0.96, and the lens opacity was barely detectable. IOP on the right/left eye was 24/23 mmHg, respectively. Dexamethasone eye drops were replaced with Diclofenac, and Diamox therapy 125 mg bid was continued for another week. Two weeks later, the UDVA was 1.0, and the crystalline lens on the left eye was again clear (Fig. 1C). Vaulting ranged from +1 to +2, and the iridotomies were open in both eyes. From the 3rd month onwards, the IOP was normal in both eyes.

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Figure 1.  (A) Sutural star-shaped (rosette) cataract in the posterior lens cortex of the left eye 2 days postoperatively. (B) Clear lens nucleus and clear anterior cortex and anterior capsule of the left eye 2 days postoperatively. (C) Clear crystalline lens with no trace of opacity in retroillumination, left eye, 2 weeks postoperatively.

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We have no obvious explanation neither for the appearance nor for the disappearance of the opacification.

One possible cause might be traumatic: the morphology of this cataract is reminding of the otherwise pathognomonic contusion cataract (Viestenz & Kuchle 2004), and acute contusion cataract can dissolve spontaneously (Ajamian 1993; Rofagha et al. 2008).

We do not have any evidence during or after the surgery that the anterior capsule was touched. As the surgeon did definitely not touch the posterior crystalline lens, a direct surgery related lens injury can be excluded.

Other possible pathomechanism for temporary lens opacification might be metabolic stress owing to one or more triggers: the surgical procedure, disturbance of aqueous flow, immediate rise in intraocular pressure or medication. The mild IOP rise could indicate aqueous flow pathology.

This first described posterior rosette cataract after ICL implantation should be added to the possible complications, including anterior cataract (Kohnen et al. 2010), glaucoma (Kohnen et al. 2010), retinal tear (Atul et al. 2011) and more. The spontaneous reversal indicates that we should not rush to treat surgically but better follow for several weeks.

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