Figure 1. Sunsetting three-piece IOL placed in the ciliary sulcus. (All images courtesy Richard Hoffman, MD.)

Most cataract procedures are performed with no complications. The IOL is placed securely in the capsular bag, and information technology stays there for the duration of the patient'south life. Nevertheless, in some cases, the IOL can become dislocated to the point where a secondary intervention is required. In this article, expert surgeons share the techniques they employ when faced with a dislocated lens.
The Scope of the Trouble

According to Richard Hoffman, MD, who is in practice in Eugene, Oregon, IOL dislocations can be divided into five categories:
• A lens that's decentered within an intact capsular pocketbook.
• An IOL that's partially subluxed out of the capsular purse: One haptic is in the bag and i haptic is out, or a haptic is in and the optic and haptic are out.
• A lens that'due south in the sulcus, and then there is a compromised capsular pocketbook. The lens is in the sulcus, and that lens is decentered.
• An IOL that's in the capsular bag, and both are subluxed and decentered.
• An IOL that's completely dislocated and is sitting on the retina.
"Each of these can be approached using multiple techniques, so there isn't one best technique for all scenarios," Dr. Hoffman explains.
Uday Devgan, MD, who is in practice in Los Angeles and a professor at UCLA, notes that the operative report from the original cataract surgery can assistance determine whether there were complications. "Determine if the IOL was placed in the capsular bag, or perhaps in the ciliary sulcus. Loose zonules may take been noted during the original procedure. Was the case uneventful or was there a posterior-sheathing rupture? Finally, annotation which type of IOL was placed and its dioptric power," he says. Videos of how to manage dislocated IOLs tin can be seen on Dr. Devgan's website: cataractcoach.com.
Decentered IOL in the Bag

Some IOLs are decentered merely nevertheless in the bag. This tin occur spontaneously or every bit a outcome of trauma.

Effigy 2. Ahmed segment with 9-0 Prolene suture beingness placed in the capsular bag following cataract extraction.

"The classic case of this is pseudoexfoliation syndrome," says Alan Crandall, Doctor, senior vice-chair of Ophthalmology and Visual Sciences, and director of glaucoma and cataract at the Moran Heart Heart at the Academy of Utah.
For a decentered IOL within an intact capsular handbag, Dr. Hoffman says the all-time approach is to viscodissect the bag open, which can be done many years afterwards the initial surgery, and rotate the lens 90 degrees to centre it. This can be accomplished using three or four paracenteses and a 25-estimate LASIK cannula attached to a vial of dispersive OVD. The hardest part of this process is getting the anterior capsule lifted off of the IOL optic for OVD injection; in one case the viscodissection is started, information technology'southward adequately straightforward to get the bag completely opened up and get the IOL recentered.
Partially Subluxed IOL

If an IOL is partially in the capsular handbag and partially out of the capsular purse, Dr. Hoffman says he would viscodissect the bag open and then identify the part of the IOL that's outside of the capsular bag within the capsular bag. The same technique described above is used to viscodissect the capsular pocketbook open. The IOL can exist rotated and centered if this is required for recentration .
An IOL in the Sulcus

If a iii-slice lens is placed in the sulcus without any type of fixation, the lens will stay centered most of the time. On occasion, the IOL will work its style through the zonules and become decentered. "For these lenses, I will iris-fixate them with 9-0 or ten-0 Prolene," Dr. Hoffman explains.
He adds that direction also depends on the presentation and type of IOL. If there'due south a single-piece lens in the sulcus, information technology typically needs to be replaced with a iii-piece lens. "For patients with a subluxed IOL in front end of a compromised purse, techniques vary," Dr. Hoffman says. "For example, I was just sent a patient who had a subluxed PMMA lens that was in the sulcus, and the posterior capsule was intact. I'm non sure why the surgeon put the lens in the sulcus. And for that patient, rather than fixate information technology to the iris or fixate it to the sclera, I was able to create a posterior capsulorhexis and so capture the optic through that rhexis to center it and stabilize it. So, if a patient has a lens in the sulcus and an intact anterior capsulorhexis, sometimes we can use the anterior capsulorhexis to capture and recenter the optic."
Decentered IOL and Bag

In-the-handbag posterior chamber IOL dislocations can be managed by exchange with an inductive chamber IOL or past repositioning the posterior chamber IOL. 1


Effigy 3. IOL with capsular tension ring subluxed into the anterior sleeping accommodation following blunt trauma.

For the scenario in which the IOL is in the capsular bag and the whole bag has come loose and subluxed , Dr. Hoffman says he will typically fixate the haptics of the IOL to the sclera using 9-0 Prolene.
In these cases, the lens does well for 12 to 14 years after routine cataract surgery, but then starts to sublux because of weakened zonules. "The lens will dislocate," Dr. Crandall says. "How to manage this depends on whether you see the patient before it is completely dislocated. If you lot come across the patient after the lens has dropped all the way back, then you accept to include the retinal service in the treatment. However, once the lens is brought up, a number of dissimilar techniques can be used to fixate the lens."
Dr. Crandall notes that his treatment of pick depends on the IOL that has been implanted and the patient's vision before surgery. "If the patient's vision was good, the IOL is not damaged and the handbag is intact or has a capsular tension band, I would identify the optic-haptic junction either intraoperatively or preoperatively," he explains. "I would and then mark 180 degrees from that, open upward the conjunctiva, clear off dorsum to 3 to 4 mm posterior, so find the surgical limbus and go two mm posterior to that and brand an incision into the sclera," he explains.
Then, he makes a lasso, lassoes the lens and the secures it to the sclera with 8-0 Gore-Tex, which is an off-label utilise, or with 9-0 or ten-0 Prolene sutures. He notes that there are a few different means to accomplish this. One instance is an ab externo scleral suture loop fixation technique. two
Garry Condon, Doc, professor of ophthalmology at the Drexel Academy Higher of Medicine, Allegheny Programme, in Pittsburgh, Pennsylvania, has described a simplified modification to the ab externo suture loop-fixation technique, designed to spare the superior conjunctiva and sclera in patients with meaning pseudoexfoliative glaucoma, in case a futurity filtration surgery is needed. 3
A description of Dr. Condon's technique: Under anesthesia, he creates a superotemporal one-mm paracentesis with a diamond bract. Sodium hyaluronate 1% is injected through the paracentesis to provide inductive sleeping room stability and to keep the vitreous posterior during IOL manipulation. The surgeon then uses a diamond blade to create a 1-mm inferotemporal incision, through which two Grieshaber iris hooks are placed. This enhances temporal visibility of the decentered PC-IOL-capsular bag complex, fifty-fifty with poor student dilation.

Effigy 4. Pseudophakic middle with unmarried intact segment and decentered piggyback IOL requiring iris fixation for recentration.

The surgeon then uses Precipitous Westcott scissors to create a 3-mm vertically oriented, temporal, conjunctival and Tenon'southward sheathing dissection two mm posterior to the limbus. Then, a diamond bract is used to create a three-mm, ane-third-thickness scleral groove ii mm posterior to the limbus. Next, at i terminate of the fractional-thickness groove, a single 1-mm, full-thickness stab incision is made through the sclera.
The surgeon then passes a ix-0 polypropylene double-armed suture on a long curved needle (D8229, Ethicon) through the margin of the partial-thickness scleral groove contrary the stab incision, up through the optic-haptic portion of the IOL-capsular bag circuitous, and out the peripheral cornea. If the needle won't laissez passer hands through the complex, the surgeon tin can apply counter traction with an intraocular microforceps to ensure successful passage of the needle. Then, a 30-caste iris hook is passed through the total-thickness scleral incision to recollect the polypropylene suture inductive to the posterior capsule IOL-capsular pocketbook complex.
The surgeon and so cuts the needle so the suture can be tied at the scleral groove. To allow subsequent IOL centration, a slipknot is placed, and the same process is repeated at the nasal aspect to secure the fellow optic-haptic portion of the IOL-capsular bag complex. The nasal polypropylene suture needle pass and ane-mm stab incision for suture retrieval counter the temporal sites to forbid IOL tilt. The surgeon adjusts the suture tension on both haptics to centre the IOL before securing and burial the knots. A single buried 8-0 polyglactin suture is used to close the conjunctiva. Too, express 23-guess pars plana vitrectomy either early on or at the conclusion of fixation may exist necessary, depending on the extent of vitreous involvement with the dislocated IOL-capsular bag complex.
According to Dr. Crandall, another option is to go underneath, the same style as described above, simply then dock the lens with a 26- or 27-ga needle inserted through a stab incision 180 degrees away. "Then, you pull that out and reverse information technology," he says. "This fourth dimension, you go above the bag and simply exterior. Both options are piece of cake and fast, and they work very well. So, you've secured the IOL complex."
However, if the patient's preoperative vision wasn't good or the lens is damaged, the surgeon may need to do a lens replacement. "If it's an older PMMA lens, then you must brand an incision that'due south at to the lowest degree 5, 5.5, or maybe half dozen mm depending on the implant," Dr. Crandall advises. "Once the old lens has been removed, you tin can implant a lens like the Alcon CZ70BD, which is a large PMMA lens that has eyelets on information technology. You just put the lens in, and you've already got sutures through the eyelets. You pull them out posterior to the limbus. In this case, you've obviously made a large incision that will require sutures. It works well, merely it's not the preferred technique because these optics ordinarily have some other problems, and you lot're risking glaucoma, infections, et cetera."
IOL Lying on the Retina

In cases where the IOL is completely dislocated onto the retina, Dr. Hoffman coordinates with a retina specialist. "If it was a iii-piece lens, the retina specialist would exercise a vitrectomy and pull the lens up, and then I would iris-fixate it," he says. "Simply, I don't do that anymore because there's likewise much iridodonesis and pseudophacodonesis.

Figure v. Subluxed IOL/capsular bag/capsular tension ring in a patient with pseudoexfoliation.

The lens tends to movement effectually a lot and sometimes causes chronic hyphemas or uveitis. And so, in those situations, I now accept the retina surgeon bring the lens up into the anterior sleeping accommodation, and then I remove the lens. So, I will scleral-fixate a new lens using a scleral incarceration technique. The latest one is the Yamane technique."

The Yamane technique for transconjunctival intrascleral fixation of an IOL was recently prospectively studied in 100 eyes of 97 consecutive patients with aphakia, dislocated IOL or subluxated crystalline lens who underwent posterior sleeping room sutureless implantation of an IOL. four This technique consists of making two angled incisions parallel to the limbus using 30-gauge, thin-wall needles. The haptics of an IOL are externalized with the needles and are cauterized to make a flange of the haptics; then, the flange is pushed back and fixed into the scleral tunnels. The IOLs are stock-still with verbal centration and axial stability.
Preoperatively, the mean best-corrected visual acuity was 0.25 logMAR units (around 20/35 Snellen), which significantly improved postoperatively to 0.11 (slightly worse than 20/25) at six months, 0.09 (slightly worse than 20/24) at 12 months, 0.12 (20/26) at 24 months, and 0.04 (slightly worse than 20/20) at 36 months.
Mean corneal endothelial cell density decreased from 2,341 cells/mm 2 preoperatively to 2,313 cells/mm 2 , 2,240 cells/mm ii , two,189 cells/mm2 and 2,244 cells/mm 2 postoperatively at six, 12, 24, and 36 months, respectively, and hateful IOL tilt was 3.four ±ii.v degrees. Postoperative complications included iris capture by the IOL in eight eyes (8 percent), vitreous hemorrhage in five optics (v pct), and cystoid macular edema in one eye (i percent). No patients experienced postoperative retinal detachment, endophthalmitis or IOL dislocation.
According to Dr. Crandall, the surgeon should apply any technique he is comfy with. "If yous have non performed some of these techniques, I call back it's a good idea to watch some other surgeon exercise them in person and non just on YouTube, because many subtleties of the techniques are edited out. Many of these subtleties can brand the surgery much easier," he adds. REVIEW

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ii. Chan CC, Crandall Equally, Ahmed IK. Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: Clinical results. J Cataract Refract Surg 2006;32:i:121-eight.
three. Kirk TQ, Condon GP. Simplified ab externo scleral fixation for late in-the-purse intraocular lens dislocation. J Cataract Refract Surg 2022;39:3:489.
iv. Yamane S, Sato South, Maruyama-Inoue M, Kadonosono Chiliad. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology 2022;124:8:1136-1142.