None None Iritis Trauma PEX PEX PEX Trauma PEX

UPDATE/REVIEW

Late in-the-bag intraocular lens dislocation:

Incidence, prevention, and management

Howard V. Gimbel, MD, MPH, Garry P. Condon, MD, Thomas Kohnen, MD, Randall J. Olson, MD,Ioannis Halkiadakis, MD

Dislocation of an intraocular lens (IOL) with the capsular bag is a late complication of cataract sur-gery, reported with increasing frequency in recent years. Pseudoexfoliation, uveitis, myopia, andother diseases associated with progressive zonular weakening and capsular contraction are thepredisposing conditions. Capsular tension rings probably help but do not prevent this complica-tion. Management includes IOL exchange, replacement with an anterior or a sutured posteriorchamber IOL, or suturing the IOL through the bag to the iris or the sclera.

J Cataract Refract Surg 2005; 31:2193–2204 Q 2005 ASCRS and ESCRS

J CATARACT REFRACT SURG - VOL 31, NOVEMBER 2005

Continuous curvilinear capsulorhexis (CCC), phacoemul-

sification, and in-the-bag placement of an intraocular lens

(IOL) represent the standard of care for cataract surgery.1

Secure in-the-bag fixation of the IOL is the optimal surgical

outcome but does not guarantee an uncomplicated postop-

erative course. Anterior or posterior capsule opacification

(PCO), capsule shrinkage, and cystoid macular edema(CME) are some well-known complications of state-of-

the-art cataract surgery.

Decentration/dislocation of a posterior chamber IOL

can occur after complicated cataract surgery; the incidence

ranges between 0.2% and 3.0%.2–6 The causes are loss of

Accepted for publication June 7, 2005.

From the Gimbel Eye Centre, Calgary, Alberta, Canada, and theDepartment of Ophthalmology, Loma Linda University, LomaLinda, California, USA (Gimbel, Halkiadakis); the Drexel UniversityCollege of Medicine and the University of Pittsburgh, Pittsburgh,Pennsylvania, USA (Condon); the Klinik fur Augenheilkunde,Johann Wolfgang Goethe-Universitat, Frankfurt, Germany(Kohnen); and the Department of Ophthalmology and VisualScience, University of Utah School of Medicine, Salt Lake City,Utah, USA (Olson).

Supported in part by the Lilian Voudouri Foundation, Athens,Greece (Halkiadakis).

No author has a proprietary or financial interest in any product orinstrument described.

Reprint requests to Howard V. Gimbel, MD, Gimbel Eye Centre,450, 4935–40 Avenue NW, Calgary, Alberta T3A 2N1, Canada.E-mail: [email protected].

Q 2005 ASCRS and ESCRS

Published by Elsevier Inc.

capsular or zonular integrity during surgery or asymmetric

placement of the haptics. Most cases of IOL decentration

present in the first weeks after cataract surgery.

Late in-the-bag dislocation of the IOL has been re-

ported with increasing frequency in recent years (Figure 1).

In contrast to IOL dislocation, bag dislocation occurs as

a result of progressive zonular dehiscence many years aftereven uneventful surgery. There are few reports of this com-

plication in the literature, partly because sufficient time is

necessary for its clinical manifestation. The purpose of

this article is to review the literature regarding the risk fac-

tors for bag dislocation, discuss methods to prevent it, and

present treatment techniques.

INCIDENCE

The first case of spontaneous in-the-bag IOL disloca-

tion was reported by Davison7 as a result of the capsule con-

traction syndrome. Careful review of the literature revealed72 subsequent cases (Table 1).8–27 Several case series

reporting the management of IOL dislocation included

a small number of ‘‘in-the-bag dislocated lenses’’ without

presenting further information and thus were not included

in the present review.28,29 The exact incidence of this com-

plication is not known. A relatively recent survey of 2663

IOLs explanted between 1988 and 2001 reported that ‘‘zon-

ular dehiscence’’ was the reason for explantation in 8 cases(0.3%).30 However, this relatively small number represents

only the tip of the iceberg. An informal poll taken during

a course on complications at the American Academy of

0886-3350/05/$-see front matterdoi:10.1016/j.jcrs.2005.06.053

2193

mailto:[email protected]

UPDATE/REVIEW: LATE IN-THE-BAG IOL DISLOCATION

Ophthalmology annual meeting revealed that in 2001, 20%

of cataract surgeons had encountered this complication.19

Furthermore, two thirds of the reported cases occurred in

the previous 2 years; given the relatively long time frame

for the presentation of this complication, an epidemic

may occur in the future, as predicted by Worst 25 years

ago (personal communication). The time frame for presen-

tation ranges from 4.5 months to 16 years,7–27 but we havetreated cases presenting as late as 18 years after surgery.

PROPOSED MECHANISMS

A predisposing condition was identified in 90% of

reviewed cases of in-the-bag IOL dislocation. Pseudoexfolia-tion was the most common, accounting for more than

50% of cases. Other common conditions were uveitis,7,21,23

trauma,11,16,23 vitrectomy,12,21,23 and increased axial

length.11,17

One or more mechanisms may have resulted in post-

operative capsule dislocation: preoperative zonular weak-

ness, surgical trauma to the zonules, capsule contraction

syndrome, and postoperative trauma. The exact contribu-tion of each mechanism probably varies on a case-by-case

basis.

Zonular weakness is a well-described feature in eyes

with pseudoexfoliation syndrome,31 high myopia, and cer-

tain connective tissue disorders (eg, Marfan’s syndrome,

homocystinuria, hyperlysinemia, Ehlers-Danlos syndrome,

scleroderma, and Weil-Marchesani’s syndrome)32 and may

be observed after vitreoretinal surgery. Moreover, zonulesbecome more friable as patients age, especially patients

with pseudoexfoliation.33 Although some reports17,24 im-

ply that surgical trauma might be a cause of luxation, no

Figure 1. In-the-bag IOL subluxated inferiorly 15 years after implantation.

J CATARACT REFRACT SURG -2194

pseudophacodonesis was noted immediately after surgery

in any reported case.

Continuous curvilinear capsulorhexis had been per-

formed in all but 3 of the described cases,13,23 and this

syndrome was virtually unreported before the advent

of CCC.34 However, it was the advent of CCC thatmade secure in-the-bag fixation popular. Capsule contrac-

tion was identified in several but not all the reported

cases.7–10,19,20 Nishi et al.8 describe a case with capsule

shrinkage and in-the-bag IOL dislocation without signifi-

cant contraction of the capsule opening. They attribute

the capsule shrinkage to the small diameter of the IOL,

which reduced the centrifugal forces of the haptics on

the equator of the bag and thus on the zonules. Althoughthe capsule contraction syndrome may occur after a can-

opener capsulotomy,7 more cases are reported following

CCC than after can-opener capsulotomy. This may be be-

cause more in-the-bag surgeries have been performed

since CCC was described.

The sphincter effect of fibrosis around an intact CCC

appears to be a factor in the development of significant

capsule shrinkage.35 In that way, CCC, especially if thediameter is small, may be a significant factor in the presen-

tation of this syndrome. Some degree of capsule contraction

is common in most eyes after cataract surgery,36 but pro-

found capsule shrinkage has been described in cases

with pseudoexfoliation,7,32,37 diabetes mellitus,38,39 uve-

itis,7 pigmentary retinal degeneration,40 and myotonic dys-

trophy.41 Capsule contraction presents as early as 3 months

after cataract surgery and in the presence of solid zonulesupport does not lead to significant IOL displacement.7 In

cases with late IOL dislocation, the progressive weakening

of already compromised zonules may make them vulnera-

ble to continuous centripetal forces and cause their rupture.

Finally, major or minor trauma (eg, repeated eye rub-

bing)16,23 to the zonules may contribute to bag dislocation.

Histological reports of explanted lenses are scarce. Ac-

cording to some reports, residual epithelial cells werefound between the loops and optic edge, forming a Soem-

mering’s ring cataract.8,10,12 Lens epithelial cell prolifera-

tion may increase the IOL–capsular bag mass and in that

way contribute to increased zonular stress by weight ef-

fects.14 The location of zonular disruption is also not clear.

Shigeeda et al.17 describe 2 cases of dislocation without pre-

disposing factors and report that no part of the zonule was

attached to the bag, implying that disruption occurred atthe insertion site to the bag.

The contribution of PCO and neodymium:YAG

(Nd:YAG) laser capsulotomy to the syndrome is another

obscure point. Neodymium:YAG capsulotomy had been

performed in one third of the described cases. In 2 cases,

capsulotomy was performed 3 weeks and 1 month before

subluxation.24 In these cases, the impact of laser energy

VOL 31, NOVEMBER 2005


may have put an additional burden on already compro-

mised zonules and was the triggering event for the sublux-

ation. Furthermore, the need for capsulotomy is an

indicator of significant cell proliferation and of increased

capsular bag weight.

In 7 cases of relatively young patients (mean age 61years), no predisposing condition was identified. However,

subtle signs of pseudoexfoliation may not be readily recog-

nized or may not be recorded.

PREVENTION

The recognition of predisposing factors for this com-

plication suggests a modified approach in cases at risk.

The advancement in microsurgical techniques makes sur-

geons more daring in completing phacoemulsification in

eyes with partial breakdown of zonular support.42 Caution,

however, should be given to implanting a posterior cham-ber IOL in the capsular bag in eyes with compromised zon-

ules when progressive zonular damage is anticipated.

Postoperative pseudophacodonesis has been described in

these eyes after the implantation of a posterior chamber

IOL in the bag42 and should be monitored closely because

this may evolve to complete luxation.20

Several measures to prevent bag dislocation have been

suggested.43 The CCC diameter should be smaller thanthe optic,1 but a particularly small opening should be

avoided.19 Although no correlation between capsulorhexis

size and postoperative capsulorhexis constriction has been

found,44 some authors suggest that performing small CCCs

increases capsule fibrosis and shrinkage.36 According to

their theory, capsule contraction is initiated by interaction

between the IOL and lens epithelial cells, so a small CCC

would result in greater interaction as a result of a wider con-tact. If capsulorhexis fibrosis and contracture are detected,

relaxing cuts with an Nd:YAG laser should be performed.

During phacoemulsification, particular attention

should be paid to preserving the integrity of zonules. Chop-

ping techniques are thought to be least traumatic to the

zonules.43 Aspiration of cortex directed in a tangential fash-

ion rather than perpendicular to the zonules may decrease

the incidence of zonular dehiscence.43 Meticulous cortexcleaning is advocated in all cases. This may be technically

difficult in eyes with pseudoexfoliation due to the small pu-

pil, poor resistance by the zonules, and possible lens

subluxation.

Intraocular lens material and design may affect capsule

contraction and IOL dislocation. Single-piece poly(methyl

methacrylate) (PMMA) IOLs may counteract capsule

shrinkage better than 3-piece PMMA IOLs.17,23 In mostreviewed cases, however, 1-piece PMMA lenses were im-

planted. More stress on the zonules may have been neces-

sary during implantation of 1-piece PMMA IOLs than

J CATARACT REFRACT SURG -

of 3-piece IOLs. It may also simply reflect the fact that

the 1-piece PMMA was the most widely used IOL at the

time of implantation. It has also been suggested that a 3-

piece hydrophobic acrylic IOL may reduce CCC contrac-

tion through a combination of decreased anterior capsule

fibrosis and greater haptic rigidity.19,35 Several recent re-ports support that 1-piece acrylic IOLs may induce more

capsule contraction or offer less haptic resistance to con-

traction than 3-piece acrylic lenses (C. Reitz Pereira, MD,

‘‘Anterior Capsule Contraction Syndrome with the AcrySof

SA60 AT Acrylic Lens,’’ presented at the annual meeting of

the American Academy of Ophthalmology, Anaheim, Cali-

fiornia, USA, November 2003).45,46 Hydrophobic acrylic

IOLs are now the most commonly used IOLs in the westernworld.1 However, several cases of acrylic in-the-bag IOL

dislocation have been described,17,24 and the implantation

of this IOL may reduce but cannot prevent capsule contrac-

tion.47 It is clear that plate-haptic silicone IOLs35 induce

the most capsulorhexis contracture, suggesting they may

be contraindicated in high-risk cases.

Capsular tension rings (CTR) seem to provide a reason-

able preventive measure.14,20,23 They are indicated in casesin which there is zonular rupture or dehiscence after blunt

or surgical trauma or in cases of inherently weak zonules, as

in pseudoexfoliation.48–50 It has been shown that CTRs

may prevent intraoperative zonular rupture51 and reduce52

but not prevent47,53,54 postoperative capsule shrinkage.

Capsular tension rings may also prevent capsule folds

and in that way reduce the rate of PCO.1,48 It is our opinion

that in the absence of significant zonular dehiscence, rou-tine CTR implantation in cases at risk may reduce the inci-

dence of postoperative IOL dislocation because of the

resistance to capsule contraction.55 We have found that in

most cases of explanted IOLs, there was asymmetric cap-

sule contraction in areas not supported by IOL haptics.

Eyes with zonular dehiscence or weakness are at greater

risk for developing asymmetrical capsule shrinkage and

dislocation because the remaining zonules cannot resistthe centripetal forces exerted by the anterior capsule rim.54

A CTR provides additional support to the bag by main-

taining the circular contour of the capsular bag and achiev-

ing an even distribution of centripetal forces to the entire

bag circumference. Thus, an excess of centripetal force

to the remaining zonules is avoided. In cases with compro-

mised zonules before or during surgery, CTRs do not totally

safeguard against late dislocation.43 In our experience, 2late dislocations of a bag with the IOL and a CTR in place

have occurred. It is reasonable to assume that withmarginal

zonule support (w50%) to begin with and progressive zon-

ular dehiscence, as in pseudoexfoliation, decentration and

dislocation of the IOL is only a matter of time. The younger

the patient, the more the risk for this late complication. A

modified CTR with scleral fixation has been developed,56

VOL 31, NOVEMBER 2005 2195


Table 1. Demographic and clinical data of patients with in-the-bag IOL dislocation.

Case Ref No Age*/ SexTime fromSurgery (Y) Predisposing Conditions YAG IOL Surgical Intervention Final VA

1 7 88/M 0.6 PEX No 3-piece silicone L-E-AC-IOL 20/252 7 62/M 4 Pars planitis Yes 3-piece PMMA L-PPV-E-AC-IOL 20/253 8 58/M 3 None No Single piece L-E-sutured PC IOL d4 9 48/M 3 None AL 27.6 mm No 3-piece PMMA L-suture 20/155 10 63/M 6 PEX d PMMA L-E-sutured PC IOL d6 10 82/M 3 PEX d PMMA L-E-sutured PC IOL d7 10 57/F 2 PEX–diabetes S/P PPV d PMMA L-E-sutured PC IOL d8 10 83/F 4 PEX–glaucoma d PMMA L-E-sutured PC IOL d9 10 76/F 3 PEX–glaucoma d PMMA L-E-sutured PC IOL d10 11 47/M 1.5 Trauma AL 36.58 mm Yes 1-piece PMMA PPV-E-CL 20/2511 12 71/M 1.9 Diabetes S/P PPV No d L-PPV-E-sutured PC IOL 20/2512 B 13 69/M 8 RP–trauma? Yes d L-E-sutured PC IOL 20/3013 B 13 69/M 8 RP Yes d L-E-sutured PC IOL 20/6014 B 14 76/M 6.5 PEX–glaucoma–RD repair Yes 1-piece PMMA L-E-sutured PC IOL HM15 B 14 76/M 7.8 PEX–glaucoma–RD repair Yes 1-piece PMMA Suture HM16 14 55/M 9.6 PEX–glaucoma Yes 3-piece PMMA L-PPV-E-ACIOL 20/4017 14 76/M 9.3 PEX No 1-piece PMMA L-E-ACIOL 20/2018 14 69/F 6 PEX No Silicone L-E-ACIOL 20/2519 14 78/F 4.7 PEX Yes 1-piece PMMA L-E-ACIOL 20/3020 14 73/F 6.2 PEX–glaucoma No 1-piece PMMA L-E-ACIOL 20/4021 14 62/F 6.5 PEX–glaucoma Yes 1-piece PMMA L-E-ACIOL 20/2022 15 80/F 12 PEX-SB d d d d23 16 68/M 2 Eye rubbing Trauma-atopic

dermatitisNo d L-E- CL d

24 17 55/M 4 None No 3-piece acrylic L-PPV-E-sutured PCIOL 20/2025 17 64/M 4 None No 3-piece silicone L-PPV-E-sutured PCIOL 20/2026 17 75/M 8 AL 27.21mm Yes 3-piece PMMA L-PPV-E-sutured PCIOL 20/2027 17 63/M 5 None No 3-piece acrylic L-PPV-E-sutured PCIOL 20/2028 18 72/F d Chronic ACG d Silicone PPV-suture 20/2029 18 68/M d PEX d PMMA PPV-suture 20/2030 19 67/F 5 PEX–glaucoma d 3-piece silicone L-E-AC IOL d31 19 62/F 6.5 PEX d 3-piece silicone L-E-AC IOL d32 20 86/F 9 PEX–diabetes Yes 1-piece PMMA None d33 20 75/M 7 PEX–diabetes Yes Silicone L-PPV-E-ACIOL d34 20 69/M 5 PEX Yes 1-piece PMMA L-E-ACIOL 20/2035 B 21 57/M 5 Pars planitis S/P PPV No PMMA L-PPV-E-sutured PCIOL 20/2036 B 21 57/M 5 Pars planitis S/P PPV No PMMA L-PPV-E-sutured PCIOL 20/2037 22 32/M 9 S/P PPV d d PP-suture 20/5038 23 74/M 5 PEX d 1-piece PMMA L-PPV-E-ACIOL 20/2539 23 65/F 10 Diabetes–trauma S/P PPV d 1-piece PMMA L-PPV-E-ACIOL 20/3040 23 75/F 11 Eye rubbing–trauma d 3-piece PMMA L-PPV-E-ACIOL 20/2041 23 79/M 4 Posterior uveitis d 1-piece PMMA L-PPV-E-ACIOL 20/10042 B 23 62/F 4 Uveitis/sarcoid d 1-piece PMMA PPV-sutured 20/4043 B 23 62/F 5 Uveitis/sarcoid d 1-piece PMMA PPV-sutured 20/3044 23 83/M 6 PEX d Chiron CM16UB L-PPV-E-ACIOL 20/3045 23 78/F 10 PEX d 1-piece PMMA L-PPV-E-ACIOL 20/5046 B 23 88/M 10 PEX d 1-piece PMMA L-PPV-E-ACIOL 20/3047 B 23 88/M 10 PEX d 1-piece PMMA L-PPV-E-ACIOL 20/3048 23 80/F 5 RP d 1-piece PMMA L-PPV-E-ACIOL 20/4049 23 76/F 8 PEX d 3-piece PMMA L-PPV-E-ACIOL 20/7050 B 23 90/M 6 PEX d 3-piece PMMA PPV-sutured 20/2551 B 23 90/M 6.5 PEX d 3-piece PMMA PPV-sutured 20/4053 23 72/M 4 None d 3-piece PMMA L-PPV-E-sutured PCIOL 20/40

J CATARACT REFRACT SURG - VOL 31, NOVEMBER 20052196


Table 1 (cont.)

Case Ref No Age*/ SexTime fromSurgery (Y) Predisposing Conditions YAG IOL Surgical Intervention Final VA

54 23 87/M 13 None d 3-piece PMMA PPV-sutured d55 23 69/M 4 None d 3-piece PMMA PPV-sutured 20/2056 23 58/M d Iritis d 1-piece PMMA L-PPV-E-ACIOL CF57 23 74/M 10 Trauma d d L-PPV-E-ACIOL 20/7058 23 83/F 7 PEX d d L-PPV-E-ACIOL 20/3059 23 76/M 6.5 PEX d 1-piece PMMA L-E-ACIOL 20/3060 23 78/M 6 PEX d AMO PC 43NB L-PPV-E-ACIOL 20/2561 23 76/M 5 Trauma d 1-piece PMMA PP-sutured 20/10062 23 73/M 7.5 PEX d 1-piece PMMA L-PPV-E-ACIOL 20/10063 23 52/M 5 RD repair d 1-piece PMMA PPV-sutured 20/2564 24 67/M 11 PEX Yes PMMA L-E-ACIOL 20/2565 24 74/M 3 PEX–glaucoma Yes Acrylic L-E-ACIOL 20/3066 24 79/M 6 PEX Yes PMMA L-E-ACIOL 20/2867 24 90/F 6 PEX–iritis Yes Acrylic L-E-ACIOL 20/3368 24 92/M 6 PEX Yes PMMA L-E-ACIOL 20/10069 B 25 41 16 Gyrate atrophy Yes PMMA L-E-ACIOL 20/5070 B 25 41 15 Gyrate atrophy Yes PMMA L-E-ACIOL 20/5071 B 26 37/M 8 RP d d L-AV-E-sutured PCIOL d72 B 26 39/M 6 RP d d L-AV-E-sutured PCIOL d73 27 49/F 0.5 Acute ACG No 1-piece PMMA None 20/20

ACGZ angle-closure glaucoma; ALZ axial length; BZ bilateral case; L-E-ACIOLZ limbal incision, lens exchange, replacement with anterior chamber IOL;

L-E-CLZ limbal incision lens, exchange for contact lens; L-E-sutured PC IOLZ limbal incision, lens exchange, replacement with sutured posterior chamber

IOL; L-PPV-E-ACIOLZ limbal incision and pars plana vitrectomy, lens exchange, replacement with anterior chamber IOL; PEXZ pseudoexfoliation; PMMAZpoly(methyl methacrylate); PPV Z pars plana vitrectomy; PPV-E-CL Z pars plana vitrectomy, lens exchange for contact lens; PPV-E-sutured PC IOL Z pars

plana vitrectomy, exchange for sutured posterior chamber IOL; PPV-suture Z pars plana vitrectomy and suturing the IOL; RD Z retinal detachment; RP Zretinitis pigmentosa; SB Z scleral buckle; S/P Z after; VA Z visual acuity; YAG Z Nd:YAG capsulotomy

*Age at the time of presentation

and it would be useful if in-the-bag fixation were elected in

the presence of compromised zonules. However, implanta-

tion of the modified CTR is technically difficult and there isalways the risk for capsule dehiscence during placement

and suturing.57

Alternative IOL fixation sites have also been proposed

as a preventive measure to IOL dislocation in patients with

pseudoexfoliation. Implantation of the IOL in the ciliary

sulcus, transscleral fixation, and primary implantation of

an anterior chamber IOL have been advocated.14,37 With

sulcus implantation, an optic-capture technique to reducethe possibility of iris chafing and subsequent flare58 may

be considered. This method involves capturing the IOL op-

tic through the anterior capsulorhexis opening.59 Most

surgeons agree, however, that given the rate of this syn-

drome and the availability of CTRs, a posterior chamber

IOL should be implanted in patients without preopera-

tive or intraoperative zonular dehiscence.43 Alternative im-

plantation sites should be considered in patients who havecompromised zonules at the time of the surgery. Finally, to

avoid dislocation of the IOL into the vitreous after pars

plana vitrectomy, the preservation of the anterior hyaloid

membrane has been advocated.12

J CATARACT REFRACT SURG -

MANAGEMENT

When the IOL with the capsular bag is luxated, man-

agement may be difficult. Although selected cases

with subluxated IOLs are managed with observation,20

most clinically significant IOL dislocations are repaired

surgically. The most common indications for surgery are

decreased visual acuity, monocular diplopia, and halos.Rarely, glaucoma,15,20 uveitis–glaucoma–hyphema syn-

drome,20 or retinal detachment (RD)23 dictate surgical

intervention.

In managing dislocated IOLs, several questions arise.

The first is whether the IOL should be removed or

exchanged or can be repositioned. The advantage of re-

positioning and suturing the IOL is that it can be accom-

plished without a large limbal incision. By avoidinga limbal incision for IOL removal, trauma to the corneal en-

dothelium and postsurgical astigmatism are reduced. Fur-

thermore, exchanging the IOL in the bag for an anterior

chamber or a sutured posterior chamber IOL is not always

easy and involves the risk for vitreous prolapse and choroi-

dal bleeding.23 Oshika9 described a simple technique for

fixating a subluxated bag. Through a corneal stab incision,

VOL 31, NOVEMBER 2005 2197


a double-armed polypropylene suture is passed 1 over and

1 under the haptic and out through the sulcus

(Figures 2 and 3). Oshika reports good long-term fixation

with this technique.

Similar to Oshika, we found penetration of the capsu-

lar bag very difficult, if not impossible, in cases of minimumzonular support without countertraction. This is most

easily obtained using a 25- or 27-gauge sharp nesting nee-

dle (gauge depends on the size of the suture needle used,

which should be confirmed as appropriate before entering

the eye). Because of late suture failure, a 9-0 nylon,

9-0 polypropylene, or 8-0 Gore-Tex suture should be used

and neither knot is easy to bury. By starting the nesting nee-

dle perpendicular to the ocular surface at either end of

Figure 3. The haptic and capsular bag are sutured to sclera. Sutures are

tied episclerally, and the knot is rotated and buried in the sclera or left

in a half-scleral-thickness trough parallel to the limbus.

Figure 2. A double-armed 9-0 polypropylene suture with a long curved

needle is introduced through a stab incision. One needle goes over the

haptic and capsular bag under the iris and out through the ciliary sulcus.

The other needle penetrates the capsular bag under the haptic and exits

through the ciliary sulcus. To simplify capsular bag penetration, an oppos-

ing 25-gauge, sharp nesting needle is used to penetrate the bag just in-

side the haptic.


a half-thickness scleral incision that is 3.0 mm long and

1.5 mm posterior to the limbus, the knot will reside in

this trough and not erode through the conjunctiva. The ex-

cess suture on the knot should be cut. This is best done with

a metal 15-degree blade. The nesting needle should engage

the capsular bag just inside the haptic, whichmakes placingthe suture needle in the nesting needle a simple step. The

second pass is above the IOL–bag complex into the nesting

needle, now placed at the other end of the short, partial-

thickness sclerotomy.

The nesting needle also helps position the bag for easy

visualization even when the pupil is small. This is such an

advantage that it is best to place both sutures before tying

either one so that bag mobility is maintained, thereby en-hancing suture placement and visualization. Because 9-0

nylon and 8-0 Gore-Tex are special-order items with the

long-curved needles, tying a short segment of 10-0 nylon

attached to the appropriate needle to 9-0 nylon or 8-0

Gore-Tex with a 1-1-1 configuration to keep the knot small

and leave the cut ends at least 2.0mm long facilitates passing

the entire knot complex easily through even a 27-gauge

opening created by the nesting needle.Alternatively, fixation of the IOL to the iris with mod-

ified McCannel suturing can be considered.43,60–62 If the

IOL–bag complex can be temporarily held in position

with a second instrument, a 10-0 polypropylene suture

on a long curved needle (Alcon PC-7 or Ethicon CIF-4)

can be passed through a corneal paracentesis to incorporate

a bite of peripheral iris as well as fibrotic lens capsule and

the IOL haptic. The needle is then passed up through thecapsule and peripheral iris and brought out through clear

cornea (Figure 4). Some retraction of the iris over the hap-

tic with nylon iris retractors (Grieshaber) or a hand-held

instrument can facilitate proper passage of the needle and

ensure inclusion of the haptic. Although the 2 suture

ends can be retrieved through a common paracentesis cre-

ated over the haptic to complete the knot, a Siepser sliding-

knot technique provides more precise knot tensioning andbetter security.63,64

Transient stabilization of the IOL–bag is critical to al-

low suturing. In cases of simple subluxation, a second in-

strument placed through the limbus into the anterior

chamber may be adequate for IOL–bag manipulation and

haptic visualization. Although some patients demonstrate

a more posterior dislocation, a connecting remnant of re-

sidual zonule often exists, which allows retrieval ofthe IOL–bag from a relatively anterior approach. An oph-

thalmic viscosurgical device can be strategically injected

through a pars plana sclerotomy performed in the meridian

of the residual zonule to ‘‘float’’ the lens upward and into

position (Figure 5). A second instrument is then placed

through the sclerotomy to provide support during suturing

(Figure 6).



Figure 4. A: Subluxated IOL within the capsular bag before surgery. B: Suture passed via corneal paracentesis through iris and includes haptic and capsular

bag. Second instrument manipulates IOL–bag and assists with visualization. C: Second needle passed under opposite haptic. D: Sutures tied with IOL–bag

fixed to peripheral iris. Some ovalization of the pupil is evident.

The dislocated IOL–bag complex will generally exhibit

a prominent anterior phimotic ring (Figure 7, A). Each

edge of this robust portion of capsule can be temporarily

transfixed with a transcameral straight needle (Ethicon

STC-6) passed limbus to limbus while iris fixation is

carried out (Figures 7, B, C, and D). Another option for

temporary support is a nylon iris retractor placed appropri-

ately through clear cornea to directly support an IOL via anavailable positioning hole or haptic–optic junction.

Some degree of well-tolerated pupil ovalization often

occurs with this form of fixation. In any of these approaches,

proper vitrectomy techniquesmust be used to avoid vitreous

incarceration or traction at the conclusion of surgery.

Methods to suture fixate the existing IOL–bag complex

to sclera or peripheral iris have the advantage of avoiding

J CATARACT REFRACT SURG - V

the increased manipulation and larger incision associated

with IOL explantation and exchange. Leaving the IOL in

the bag rather than attempting to strip the capsule from

the IOL simplifies refixation. Since 1976, the historical suc-

cess of McCannel’s retrievable iris suture technique for IOL

repositioning has supported its continued use for fixing

a malpositioned IOL haptic to peripheral iris. Applying

this technique to refix the IOL–bag complex to peripheraliris reduces the potential late complications of scleral

sutures including suture breakage and suture-related

endophthalmitis.

Several techniques for repositioning and suturing

a completely dislocated IOL to the iris, sulcus, or pars plana

have been described.65 Most require a vitreoretinal ap-

proach, and only a few18,22,27 have been tried in cases in

OL 31, NOVEMBER 2005 2199


which the entire bag is luxated. According to these tech-

niques, the IOL is extracted from the capsular bag with a

vitreous cutter. This is not technically easy, and, in somecases, may not be possible.23 However, some describe

good results using these techniques. Hanemoto et al.18 de-

scribe a modification of the lasso procedure,66 using an in-

travitreal cow-hitch girth knot to suture the lens in the

ciliary sulcus. In this technique, the knot is created outside

the eye. Nakashizuka et al.22 describe a similar technique

for pars plana fixation (Figures 8 and 9). Kokame et al.29

describe a modification of temporary haptic externalizationfor placement of scleral fixation sutures, initially described

by Chan.65 The IOL is brought to the anterior chamber, and

Figure 5. Ophthalmic viscosurgical device injected through a pars plana

sclerotomy to float the IOL upward if it is dangling in the vitreous.

Figure 6. After OVD is placed posterior to the IOL–bag via a pars plana

sclerotomy, an iris spatula is used for support during suturing if necessary.


the capsule is dissected with a vitreous cutter. One haptic at

a time is externalized through a clear corneal incision. The

haptic is sutured using a long, curved needle, which is then

passed backward. A second instrument through a scleros-

tomy is used to grab the suture (Figure 10).

The dislocated IOL was sutured in 13 of 67 cases de-scribed by the Dislocated In-the-Bag Intraocular Lens Study

Group.23 Complications encountered were 1 case of redis-

location, 1 of RD, and 1 of retinal chaffing during reposi-

tioning. In the other cases, the IOL was exchanged with

an anterior chamber (35 cases) or a sutured posterior

chamber (19 cases) IOL.

The second question inmanaging a dislocated IOL–bag

complex is whether to use a limbal or pars plana approachfor removal and replacement. A pars plana approach is the

only technique available for IOLs entirely dislocated into

the vitreous cavity. It has the advantage of allowing easy

retrieval of the IOL if the IOL is dislocated posteriorly

and of affording management of potential coexisting retinal

complications. Pars plana vitrectomy and IOL exchange

through a limbal incision were performed inmost instances

in the largest case series.23 However, the surgical approachin this large case series is biased by the vitreoretinal specialty

of the authors. The limbal approach with or without ante-

rior vitrectomy may be sufficient in cases in which the

IOL is partially subluxated and still in the posterior cham-

ber. The advantage of the limbal approach is that it avoids

pars plana entry and its attendant complications.

The third consideration is whether to use an anterior or

a sutured posterior chamber IOL if the IOL is exchanged. Ina recent review of all pertinent literature,67 the American

Academy of Ophthalmology concluded that there is insuf-

ficient evidence to support the superiority of scleral or iris-

sutured posterior chamber IOLs over open-loop anterior

chamber IOLs. Sutured posterior chamber IOLs are associ-

ated with similar rates of corneal edema, glaucoma, and

CME as open-loop anterior chamber IOLs. Furthermore,

potential complications of transscleral sutures includesuture-knot exposure, endophthalmitis, intraocular hem-

orrhage, torsion or malposition of the IOL, and broken

sutures causing repeat dislocation.68 Most patients experi-

encing in-the-bag subluxation of the IOL have a predis-

posing condition including pseudoexfoliation with or

without glaucoma or uveitis.

The safety of anterior chamber IOLs or sutured poste-

rior chamber IOLs in these complicated cases has not beenwell studied. An anterior chamber IOL was implanted in 35

eyes and a sutured posterior chamber IOL in 19 of the eyes

included in the present review. Complications occurred in

8 eyes (22.8%) after anterior chamber IOL implantation

and in 1 eye (5.2%) after exchange with a sutured posterior

chamber IOL. After an eye with an anterior chamber IOL

experienced a pupillary block,20 3 eyes suffered CME,



Figure 7. A: Dislocated IOL in the bag suspended by zonule remnant. B: Transcameral straight needle temporarily transfixes edge of anterior capsule for

support before the first peripheral iris suture is placed. C: Opposite edge of anterior capsule is transfixed while second iris fixation suture is placed. D: Sutures

tied and fixation completed.

1 eye had an RD, 1 eye had a vitreous hemorrhage, and

2 eyes had iritis.23 There were no reported corneal compli-cations. All but 1 of these eyes had lens exchange and pars

plana vitrectomy. It is not clear whether the complications

can be attributed solely to the anterior chamber IOL.

In our experience, eyes with pseudoexfoliation with or

without glaucoma tolerate an anterior chamber IOLwell. In

contrast, anterior chamber IOLsmaynot bewell tolerated in

eyes with uveitis. In these eyes, an anterior chamber IOL

may exacerbate the associated disease, compromising theanatomy and function of the anterior segment. Eight eyes

with uveitis were included in the present review. An anterior

chamber lens was implanted in 4 eyes. In 1 eye with iritis,

implantation of an anterior chamber IOL resulted in a severe

reaction and the final vision was counting fingers.23

J CATARACT REFRACT SURG - V

Alternatives to angle-supported anterior chamber IOLs

are iris-fixated IOLs. These IOLs also provide an excellentoption for patients who suffer from severe dislocation of

the IOL and require explantation of the dislocated lens, in-

cluding the capsular bag. The Artisan and Verisyse aphakic

IOLs (Figure 11) have a total diameter of 8.5 mm (in special

indications 7.5 mm) and a 5.0 mm optic. The IOL is im-

planted through a scleral tunnel incision and fixated on

the iriswith an enclavationmaneuver. The IOL is usually po-

sitioned in the horizontal position, centered on the entrancepupil. Enclavation can be achieved with needles or specially

designed forceps. In secondary implantation, enclavation on

the anterior iris parts is sometimes very difficult because the

posterior segment has had a vitrectomy and therefore the iris

diaphragm is very loose. Another option,whichwas recently

OL 31, NOVEMBER 2005 2201


described,69 is fixation of the iris-fixated IOL from behind

the iris (in the posterior chamber). When this fixation tech-

nique is performed, the IOL has to be securely held after it isplaced behind the iris; enclavation is then done from anteri-

or to fixate the claws to posterior iris tissue.

Figure 8. The cow-hitch technique. The neck of the loop (broken circle) is

grasped with an intraocular forceps. This technique requires capsular bag

removal.

Figure 9. The IOL haptic is engaged with the cow-hitch loop introduced

via a sclerostomy.


Figure 10. Intraocular lens is anteriorly subluxated into the anterior cham-

ber through the pupil and over the iris. One haptic is externalized through

a clear corneal incision. A 10-0 Prolene suture loop double-attached to

a long curved needle is looped and tightened in a secure knot around

the externalized haptic. The blunt side of the curved needle is used to

pass the suture through the clear corneal incision, posterior to the iris

where the sutures are retrieved with a vitreous forceps with an opening

proximal to the end-griping jaws through the fixation sclerotomy. The

long curved needle is cut off, and the sutures around the haptic are pulled

through fixation sclerostomy. The externalized haptic is reimplanted and

the fixation suture tied. This technique also requires capsular bag removal.

Figure 11. The right eye of 63-year-old patient who was aphakic for more

than 30 years and corrected with soft contact lenses became contact-lens

intolerant. An aphakic Versiyse IOL (optic diameter 5.4 mm, total length

8.5 mm) was implanted. The large iridectomy at 12 o’clock was previous

surgery 30 years ago.



The fourth question is the timing of the intervention.

Managing a subluxated lens is much easier and has fewer

complications than managing a completely dislocated

lens. Pseudophacodonesis should be closely monitored

and any decentration treated early.

Review of described cases with in-the-bag IOL disloca-tion revealed that the prognosis of eyes with this syndrome

with any method of management is quite good and most

eyes regain their preoperative visual acuity.

In conclusion, late in-the-bag IOL dislocation is a

potential late complication of cataract surgery in which

in-the-bag IOLs were used and is more likely to happen

in certain predisposed eyes. Prognosis after treatment is

generally good. Several measures for preventing and man-aging this complication have been reviewed.

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