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IntraocularLensDislocationTreatment&Management
Author:LihtehWu,MDChiefEditor:HamptonRoy,Sr,MDmore...
Updated:Sep29,2015

MedicalCare
SelectionoftreatmentinthecaseofadecenteredIOLshouldbebasedonthe
patient'ssymptoms,needs,andexpectations.
Observation:Intheabsenceofsymptomsandnoevidenceofinflammatory
sequelae,observationisanoption.InthecaseofanACIOLassociatedwitha
peakedorovalpupil,carefulobservationiswarrantediftherearenosignsor
symptomsofintraocularinflammation.
Miotics:IfsymptomsfromadecenteredPCIOLareinfrequentandlimitedto
evening,duetoadilatedpupil,thesepatientsmaybetreatedconservativelyby
usingatopicalmioticsuchaspilocarpine0.51%qhs.Atrialofmioticagentsmay
bewarrantedpriortoremovingorrepositioninganimplant.
ObservationmayberecommendedindislocatedIOLsifthefollowingconditionsare
met:
TheIOLisnotmobile.
Therearenoretinalcomplications.
Thepatientissatisfiedwithaphakicspectaclecorrectionorcontactlenses.

SurgicalCare
Whenmoresevereanddisablingsymptomsorifinflammationispresentwiththe
potentialforfurthercomplicationsinthefuture,treatmentshouldincludeeither
repositioning,explanting,orexchangingthedecenteredIOL. [12]Selectionof
treatmentisbasedonthepatient'ssymptoms,visualneeds,andexpectations,and
anassessmentofwhichoptionislikelytoprovidethebestlongtermbenefitwith
theleastrisk.
IOLreposition:AnIOLmaybecomedecenteredduetoeitherinsufficient
zonularsupportortoirregularfibrosisoftheposteriorcapsule.Inthecaseof
inadequatesupport,earlyinthepostoperativeperiodthesurgeonmay
attempttorotatetheIOLsurgicallywherethereisclinicalevidenceof
sufficientcapsuleandzonulestosupporttheimplant.Ahelpfulmaneuveris
thebouncetestwheretheopticispushedgentlytowardeachhapticto
ensurespontaneousrecentration.
IOLrepositionwithMcCannelsutures:Insomecases,repositioningmaybe
supplementedbytheuseoftransirisIOLfixation(McCannel)suture.
IOLexplantation:CertaincircumstanceswarrantremovalofanIOLwithout
secondaryIOLimplantation.Thisisdeterminedonanindividualbasisand
takingintoaccountthepatient'sexpectation.
IOLexchange:Themostcommonindicationsforremovalorexchangeofa
modernPCLarewrongIOLpowerandmalposition.Deformationofthe
implantduetoirregularcapsularfibrosismaymakesimplerotation
insufficienttoproperlycentertheIOL.TheIOLmaybeexchangedforan
ACIOL,asulcusfixatedIOLwithorwithoutMcCannelsutures,a
transsclerallysuturedPCIOL,oraposterioririsclawIOL. [13]
TodeterminewhethertherisktobenefitratiofavorsIOLexchangeover
observation,thesurgeonshouldconsiderthefollowing:
Severity,duration,andchronologyoftheproblem
Responsetononsurgicaltreatment
NaturalhistoryofaspecificIOL
Likelihoodthatsurgicalremovalwouldprovidesubstantialreliefor
benefits
Easeofsurgicalremovalandpotentialforaggravatingorcreating
additionalcomplications
Statusoftheothereye
Patientandfamilyexpectationsandvisualneeds
Lifeexpectancyandoverallhealthofthepatient
SeveralindicationsforsurgicalinterventionexistforadislocatedIOL.Ifthepatient
isnotsatisfiedorcannottolerateaphakicspectaclecorrectionorcontactlensesorif
thereisconcomitantretinalpathology,suchasaretinaldetachment,surgerymust
beconsidered.
Severalsurgicaloptionsareavailable.Theseoptionsincluderemoval,exchange,or
repositioningoftheIOL.Amultitudeoftechniqueshasbeendescribedonhowto
grasp,suture,andplacetheIOL.RepositioningoftheIOLintotheciliarysulcusor
overcapsularremnantswithlessthanatotalof6clockhoursofinferiorcapsular
supportisnotastablesituation,asmanyofthoserepositionedIOLswillendup

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dislocatingagain.TransscleralsuturingorIOLexchange(removalofthedislocated
IOLandplacementofaflexibleopenloopACIOL)isrecommendedinthesecases.
In1996,Kelmanproposedatechniquecalledposteriorassistedlevitation,in
whichnuclearfragmentsordislocatedIOLsintotheanteriorvitreousare
retrievedthroughaparsplanasclerotomyandtheinsertionofacyclodialysis
spatula,aneedle,oraviscosurgicaldevice.However,thismaneuvercanbe
complicatedwithretinaldetachmentorcystoidmacularedemaandshould
notbeperformedatall.
IftransscleralsuturingoftheIOLisplanned,modificationstotheusual
placementofthesclerotomiesaremade.Twotriangularscleralflapsare
made180degreesapartinthehorizontalmeridian.Then,twosclerotomies
aremade11.5mmposteriortothelimbusundertheflaps.Theinfusion
cannulaissuturedtotheusualposition.Acompletevitrectomyisperformed,
payingcloseattentiontoremovingallvitreousandcapsularattachmentsto
theIOL,makingitfreelymobile.Theposteriorhyaloid,ifstillattached,is
peeled.ThisallowstheIOLtogentlyfallovertheposteriorpoleoftheeye.
IftheIOLdoesnothavepositioningholes,theedgeoftheIOLiselevated
withalightedvitreoretinalpickorhook.Ifpositioningholesarepresent,the
IOLmaybeengagedthroughthembythepickorhook.TheIOLiselevated
intothemidvitreouscavity,andtheopticisgraspedwithserratedjawforeign
bodyforcepsordiamondcoatedforceps.Thehapticsshouldnotbegrasped,
ortheywillbebent.
Aspirationthroughthesiliconesofttippedcannulaalsohasbeenusedinthe
retrievalandmanipulationoftheIOL,butthistechniquemayresultin
inadvertentvitreoretinaltraction.
Siliconeplatelensesaredifficulttomanipulate,and,incertaincases,
standardtechniqueswillnotsuffice.Theendocryoprobehasbeenusedto
engagetheIOL,butdiamondcoatedforcepsaremuchsafer.Itis
recommendedthatthegaspressurebeloweredto525psitoavoidfreezing
theentireshaft.Anotherproblemisthattransscleralsuturingisnotanoption
becausecheesewiringthroughthesiliconewilloccur.
Liquidperfluorocarbons,suchasPerflubron,canbeusedtofloattheIOLto
thepupillaryplane.
OncetheIOLisengagedandelevated,itisbroughttotheposterior
chamber.Onehapticmaybebroughtinfrontoftheiris.Theotherhaptic
maybepositionedinthesulcus.UsingaSinskeyhookeitherthrougha
limbalstabincisionorthroughthesclerotomy,theIOLisrotatedintoplace.
Ifmorethanatotalof6clockhoursofcapsularsupportarepresent
inferiorly,onemayelecttorepositiontheIOLintothesulcuswithoutsuturing
it.
Ifthereisnotenoughcapsularsupport,eithertransscleralsuturesoriris
suturesarenecessary.Severaltechniqueshavebeendescribed.
IftheIOLhaspositioningholes,thehapticsarerotateduntiltheyare
intheverticalmeridian.Singlearmed90Prolenesuturesare
graspedwithintraocularforcepsandintroducedthroughthe
sclerotomies.Theyarepassedthroughthepositioningholesfrom
posteriortoanterior.Thesuturesaretiedtothesclerotomiesunder
thescleralflaps.
Withtheintraocularsnare,oneofthehapticsmaybelooped,and,at
thesametime,a70Prolenesuturecanbetiedtoit.
Anotheroptionistotemporarilyexternalizethehapticsthroughthe
sclerotomiessothattheycanbetiedwith100Prolenesutures.This
techniquemaycauseperipheralretinabreaksorbleeding.TheIOLis
repositionedintothesulcus,andthesuturesaresecuredtothe
sclerotomy.
Needleguidedtechniquesalsohavebeendescribedwherea90or
100Prolenesuturemaybethreadedretrogradeuptheboreofafive
eighthsinch25gaugeneedle.Theendofthesuturethatisnot
threadedisretrievedthroughthehuboftheneedle.Thisresultsina
sutureloop.Theneedlewiththesutureisinsertedthroughthebase
ofthescleralflap.AstheIOLisbeinggraspedbyforceps,thehaptic
ismanipulatedintotheloopthen,thesutureistiedunderthescleral
flaps.
Undercertainsituations,anIOLmustbeexchanged.Forinstance,ifthe
dislocatedIOLisdamaged(ie,brokenhaptic),itmustberemoved.The
damagedIOLmayberemovedthroughtheparsplanaorthroughalimbal
incisionatthesurgeon'sdiscretion.Parsplanaremovalincreasestheriskof
retinaldetachmentandseverechoroidalbleeding.
ThesurgeonhasthechoiceofsuturingaposteriorIOLorinsertingan
ACIOL.ModernflexibleopenloopACIOLsdonotappeartoresultin
thecomplicationsseenwitholdertypes(ie,cornealdecompensation,
uveitisglaucomahyphemasyndrome).
AnotheroptionistomanipulatethedislocatedIOLintotheanterior
chamberandleaveitthere.Potentialdrawbacksofthisoptionare
endothelialcellandtrabecularmeshworkdamage.Thistechnique
workswellwith3piecepolymethylmethacrylate(PMMA)IOLSbut
requiresaperipheraliridectomytopreventpupillaryblock.
Perfluorocarbonliquidsareveryusefulifaretinaldetachmentisalso
present.Theperfluorocarbonliquidbubbledisplacesthesubretinalfluid
throughtheretinalbreaksreattachingtheretinaand,atthesametime,
servesasacushionbetweentheIOLandtheretina.Thus,theretinais
protectedfrompotentialdamagefromIOLimpactduringsurgical
manipulation.Ifasiliconeplatelensisdislocated,specialcarewiththeuse
ofperfluorocarbonliquidsisnecessary.Ithasbeenreportedthatthese
lensesoften"skateorglide"onthebubbleacrosstheretina.Inaddition,

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perfluorocarbonliquidsmakethegraspingoftheIOLsomewhatmore
difficultbymakingtheIOLmoreslippery.Iftheretinaisnotdetached,the
useofperfluorocarbonliquidsprobablyisnotnecessary.
Oncertaincases,anACIOLispresentinadditiontothedislocatedIOL.
Surgicalmanagementofthesecasesismademoredifficultbythepresence
oftheACIOL,especiallyifaconcomitantretinaldetachmentispresent.The
vitreoretinalsurgeonhasseveraloptions.
ThesurgeonmayopttoremovetheACIOL,repositionthedislocated
IOL,orsuturethedislocatedIOL.
AnotheroptionistoleavetheACIOLandremovethedislocatedIOL.
ThedislocatedIOLmayberemovedviatheparsplanaorthrougha
limbalincision.Ifparsplanaremovalisentertained,a7mmpartial
thicknessscleralgrooveiscreated3mmposteriorandparalleltothe
superiorlimbus.Thisgrooveshouldbecontiguouswithoneofthe
superiorsclerotomies.80silksuturesshouldbepreplacedthrough
thelipsofthescleralgroove.OncetheIOLisreadytobeextracted,
themicrovitreoretinal(MVR)bladeisusedtoextendthesclerotomy
intothescleralgroovetomakeitfullthickness.AftertheIOLis
removed,thepreplacedsuturesaretied.Thisareaisinspectedby
indirectophthalmoscopy.Ifneeded,retinopexyisapplied.
Ifextractionthroughalimbalincisionisplanned,theACIOLmustbe
removedfirst.Then,thedislocatedIOLisbroughttotheanterior
chamberandremovedthroughthelimbalwound.TheACIOLis
reinserted.Thelimbalwoundisclosedwith100nylonsutures.The
sclerotomiesareclosedintheusualfashion.
AlthoughdislocatedfoldableIOLsweretraditionallytreatedwithremovalof
thelensandexchangetoaPMMAIOL,onereportdemonstratesthe
feasibilityofusingexistingsurgicaltechniquestorepositionthedislocated
foldableIOLs.
Asuturelesstechniquehasrecentlybeendescribed. [14]A27gaugeneedle
ispassedthroughtheciliarysulcus,allowingexternalizationoftheIOL
haptics.Alamellarscleraldissectionisperformed,andthehapticsarethen
fixedintothisscleraltunnel.Usingthistechnique,theauthorsreportminimal
tiltandothercomplications.

Consultations
Avitreoretinalspecialistshouldbeconsultedwheneverthiscomplicationoccurs.
Medication

ContributorInformationandDisclosures
Author
LihtehWu,MDAsociadosdeMaculaVitreoyRetinadeCostaRica
LihtehWu,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,AmericanSocietyofRetinaSpecialists,AssociationforResearchin
VisionandOphthalmology,ClubJulesGonin,MaculaSociety,PanAmericanAssociationofOphthalmology,RetinaSociety
Disclosure:Receivedincomeinanamountequaltoorgreaterthan$250from:BayerHealthQuantelMedicalHeidelbergEngineering.
Coauthor(s)
RafaelAlbertoGarca,MD
Disclosure:Nothingtodisclose.
RobertHGraham,MDConsultant,DepartmentofOphthalmology,MayoClinic,Scottsdale,Arizona
RobertHGraham,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,ArizonaOphthalmologicalSociety,AmericanMedical
Association
Disclosure:PartnerreceivedsalaryfromMedscape/WebMDforemployment.
SpecialtyEditorBoard
SimonKLaw,MD,PharmDClinicalProfessorofHealthSciences,DepartmentofOphthalmology,JulesSteinEyeInstitute,UniversityofCalifornia,LosAngeles,David
GeffenSchoolofMedicine
SimonKLaw,MD,PharmDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,AssociationforResearchinVisionandOphthalmology,
AmericanGlaucomaSociety
Disclosure:Nothingtodisclose.
SteveCharles,MDDirectorofCharlesRetinaInstituteClinicalProfessor,DepartmentofOphthalmology,UniversityofTennesseeCollegeofMedicine
SteveCharles,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,AmericanSocietyofRetinaSpecialists,MaculaSociety,Retina
Society,ClubJulesGonin
Disclosure:Receivedroyaltyandconsultingfeesfor:AlconLaboratories.
ChiefEditor
HamptonRoy,Sr,MDAssociateClinicalProfessor,DepartmentofOphthalmology,UniversityofArkansasforMedicalSciences
HamptonRoy,Sr,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,AmericanCollegeofSurgeons,PanAmericanAssociationof
Ophthalmology
Disclosure:Nothingtodisclose.
AdditionalContributors

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BrianAPhillpotts,MD,MD
BrianAPhillpotts,MD,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,AmericanDiabetesAssociation,AmericanMedical
Association,NationalMedicalAssociation
Disclosure:Nothingtodisclose.
Acknowledgements
TeodoroEvans,MDConsultingSurgeon,VitreoRetinalSection,ClinicadeOjos,CostaRica
Disclosure:Nothingtodisclose.

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