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 it stays there for the duration of the patient’s life. However, 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 use when faced with a dislocated lens.

The Scope of the Problem

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 bag.

• An IOL that’s partially 
subluxed out of the capsular bag: One haptic is in the bag and one haptic is out, or a haptic is in and the optic and haptic are out.

• A lens that’s in the sulcus, so there is a compromised capsular bag. 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 help determine whether there were complications. “Determine if the IOL was placed in the capsular bag, or perhaps in the ciliary sulcus. Loose zonules may have been noted during the original procedure. Was the case uneventful or was there a posterior-capsule rupture? Finally, note which type of IOL was placed and its dioptric power,” he says. Videos of how to manage dislocated IOLs can be seen on Dr. Devgan’s website:

Decentered IOL in the Bag

Some IOLs are decentered but still in the bag. This can occur spontaneously or as a result of trauma.

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

“The classic example of this is pseudoexfoliation syndrome,” says Alan Crandall, MD, senior vice-chair of Ophthalmology and Visual Sciences, and director of glaucoma and cataract at the Moran Eye Center at the University of Utah.

For a decentered IOL within an intact capsular bag, Dr. Hoffman says the best approach is to 
viscodissect the bag open, which can be done many years after the initial surgery, and rotate the lens 90 degrees to center it. This can be accomplished using three or four paracenteses and a 25-gauge LASIK cannula attached to a vial of dispersive OVD. The hardest part of this procedure is getting the anterior capsule lifted off of the IOL optic for OVD injection; once the viscodissection is started, it’s fairly straightforward to get the bag completely opened up and get the IOL recentered.

Partially Subluxed IOL

If an IOL is partially in the capsular bag and partially out of the capsular bag, Dr. Hoffman says he would
viscodissect the bag open and then place 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 bag open. The IOL can be rotated and centered if this is required for recentration.

An IOL in the Sulcus

If a three-piece 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 way through the zonules and become decentered. “For these lenses, I will iris-fixate them with 9-0 or 10-0 Prolene,” Dr. Hoffman explains.

He adds that management also depends on the presentation and type of IOL. If there’s a single-piece lens in the sulcus, it typically needs to be replaced with a three-piece lens. “For patients with a
subluxed IOL in front of a compromised bag, 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 not sure why the surgeon put the lens in the sulcus. And for that patient, rather than fixate it to the iris or fixate it to the sclera, I was able to create a posterior capsulorhexis and then 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-bag posterior chamber IOL dislocations can be managed by exchange with an anterior chamber IOL or by repositioning the posterior chamber IOL.

Figure 3. IOL with capsular tension ring subluxed into the anterior chamber 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 see the patient after the lens has dropped all the way back, then you have to include the retinal service in the treatment. However, once the lens is brought up, a number of different techniques can be used to fixate the lens.”

Dr. Crandall notes that his treatment of choice 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 bag is intact or has a capsular tension ring, I would identify the optic-haptic junction either intraoperatively or preoperatively,” he explains. “I would then mark 180 degrees from that, open up the conjunctiva, clear off back to 3 to 4 mm posterior, and then find the surgical limbus and go 2 mm posterior to that and make 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 use, or with 9-0 or 10-0 Prolene sutures. He notes that there are a few different ways to accomplish this. One example is an 
ab externo scleral suture loop fixation technique.2

Garry Condon, MD, professor of ophthalmology at the Drexel University College of Medicine, Allegheny Program, 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 significant pseudoexfoliative glaucoma, in case a future filtration surgery is needed.3

A description of Dr. Condon’s technique: Under anesthesia, he creates a 
superotemporal 1-mm paracentesis with a diamond blade. Sodium hyaluronate 1% is injected through the paracentesis to provide anterior chamber 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, even with poor pupil dilation.

Figure 4. Pseudophakic eye with single intact segment and decentered piggyback IOL requiring iris fixation for recentration.

The surgeon then uses Sharp Westcott scissors to create a 3-mm vertically oriented, temporal, conjunctival and Tenon’s capsule dissection 2 mm posterior to the limbus. Then, a diamond blade is used to create a 3-mm, one-third-thickness scleral groove 2 mm posterior to the limbus. Next, at one end of the partial-thickness groove, a single 1-mm, full-thickness stab incision is made through the sclera.

The surgeon then passes a 9-0 polypropylene double-armed suture on a long curved needle (D8229, Ethicon) through the margin of the partial-thickness scleral groove opposite the stab incision, up through the optic-haptic portion of the IOL-capsular bag complex, and out the peripheral cornea. If the needle won’t pass easily through the complex, the surgeon can apply counter traction with an intraocular microforceps to ensure successful passage of the needle. Then, a 30-degree iris hook is passed through the full-thickness scleral incision to retrieve the polypropylene suture anterior to the posterior capsule IOL-capsular bag complex.

The surgeon then 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 1-mm stab incision for suture retrieval counter the temporal sites to prevent IOL tilt. The surgeon adjusts the suture tension on both haptics to center the IOL before securing and burying the knots. A single buried 8-0 polyglactin suture is used to close the conjunctiva. Also, limited 23-gauge pars plana vitrectomy either early or at the conclusion of fixation may be 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 way as described above, but 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 it,” he says. “This time, you go above the bag and just outside. Both options are easy and fast, and they work very well. Then, 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 make an incision that’s at least 5, 5.5, or maybe 6 mm depending on the implant,” Dr. Crandall advises. “Once the old lens has been removed, you can implant a lens like the Alcon CZ70BD, which is a large PMMA lens that has eyelets on it. 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, but it’s not the preferred technique because these eyes usually have some other issues, and you’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 three-piece lens, the retina specialist would do a vitrectomy and pull the lens up, and then I would iris-fixate it,” he says. “But, I don’t do that anymore because there’s too much iridodonesis and pseudophacodonesis.

Figure 5. Subluxed IOL/capsular bag/capsular tension ring in a patient with pseudoexfoliation.

The lens tends to move around a lot and sometimes causes chronic hyphemas or uveitis. So, in those situations, I now have the retina surgeon bring the lens up into the anterior chamber, and then I remove the lens. Then, 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 chamber sutureless implantation of an IOL.4 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 fixed with exact 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/mm2, 2,240 cells/mm2, 2,189 cells/mm2 and 2,244 cells/mm2 postoperatively at six, 12, 24, and 36 months, respectively, and mean IOL tilt was 3.4 ±2.5 degrees. Postoperative complications included iris capture by the IOL in eight eyes (8 percent), vitreous hemorrhage in five eyes (5 percent), and cystoid macular edema in one eye (1 percent). No patients experienced postoperative retinal detachment, endophthalmitis or IOL dislocation.

According to Dr. Crandall, the surgeon should use whatever technique he is comfortable with. “If you have not performed some of these techniques, I think it’s a good idea to watch another surgeon do them in person and not just on YouTube, because many subtleties of the techniques are edited out. Many of these subtleties can make the surgery much easier,” he adds.  REVIEW

1. Gross JG, Kokame GT, Weinberg DV; Dislocated in-the-bag intraocular lens study group. In-the-bag intraocular lens dislocation. Am J Ophthalmol 2004;137:4:630-635. 
2. Chan CC, Crandall AS, Ahmed IK. Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: Clinical results. J Cataract Refract Surg 2006;32:1:121-8.
3. Kirk TQ, Condon GP. Simplified ab externo scleral fixation for late in-the-bag intraocular lens dislocation. J Cataract Refract Surg 2013;39:3:489.
4. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology 2017;124:8:1136-1142.