Post cataract surgery refractive surprise due to intraocular lens mislabeling

TL;DR

A patient experienced unexpected vision issues after cataract surgery due to a mislabeled intraocular lens, which was later corrected with a lens exchange.

Contribution

This case highlights mislabeled intraocular lenses as a rare but correctable cause of refractive surprise after cataract surgery.

Findings

A mislabeled intraocular lens caused refractive error in a patient after cataract surgery.

IOL exchange with a correctly labeled lens from a different brand restored normal vision.

Precise biometry and accurate IOL labeling are essential to avoid surgical complications.

Abstract

If an intraocular lens (IOL) is incorrectly labeled, problems can arise for surgeons and patients. Precise biometry is important to accurately determine the IOL power and prevent the implantation of the wrong IOL. Labeling and verifying IOLs with accuracy is crucial to ensuring the best possible results of cataract surgery.

Mislabeling of IOLs can cause unpredictable problems for surgeons. However, we can prevent incorrect IOLs by using precise biometry to determine accurate IOL power and safely implant the correct IOL. A 50‐year‐old female with no medical or ocular history came to our clinic complaining of decreased vision in both eyes that had been ongoing for several months. After being diagnosed with cataracts, primary angle closure suspect, and high hyperopia, the patient underwent phacoemulsification surgery. A posterior chamber IOL was implanted, and visco‐goniosynechialysis was performed. During follow‐up appointments, it was discovered that the patient had an uncorrected visual acuity of 20/50 in her right eye, which was corrected to 20/20 with a + 7.00 D lens. Upon further evaluation, it was determined that the source of the error was due to a manufacturing mislabeling of the IOL power. The patient then underwent successful IOL exchange surgery, and her best‐corrected visual acuity became 20/20 with no significant refraction. This case highlights an uncommon source of refractive surprise after phacoemulsification surgery, successfully managed with IOL exchange surgery using the same IOL power from a different brand.

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