Management of Dislocated PC IOL - KSOS

392 Kerala Journal of Ophthalmology Vol. XX, No. 4
OPHTHALMIC
S U R G E R Y
Management of Dislocated PC IOL
Dr. Meena Chakrabarti MS, Dr. Valsa T. Stephen MS, Dr. Sonia Rani John DNB, Dr. Arup Chakrabarti MS
Inadequate posterior capsular support or zonular
rupture may allow IOL decentration or dislocation.
Decentered IOLs may occur in 0.2 % to 1.2 % of cases
postoperatively 1 . The specific cause of the displacement
may not be always evident 1,2 .
Various mechanisms include the following
1. Inadequate posterior capsular support due to
posterior capsular rent.
2. Zonular rupture.
3. Accidental placement of IOL through posterior
capsular rent into the anterior vitreous face.
4. Late haptic rotation out of a zone of thin capsular
remnant.
The cause of late spontaneous IOL rotation is
unclear 3,4 . It may follow accidental changes in position,
gravitational effect, accidental finger rubbing or other
contact with the eye. Late dislocation of the IOL can
occur spontaneously or following trauma.
Generally posterior chamber IOL placement is safe if
at least 180 degree of the capsular remnant is intact 5 .
More extensive support is necessary if the capsular
remnant is missing inferiorly or if the capsular margin
on which the haptics are to be positioned is inadequate.
Indications for subsequent surgery 3,4,5 : The
indications for surgical removal include decreased
visual acuity, chronic intraocular inflammation, retinal
detachment and vitreous in the cataract wound
associated with cystoid macular oedema. Although a
Chakrabarti Eye Care Centre, Kochulloor, Trivandrum - 695 011,
E-mail: tvm_meenarup@sancharnet.in
dislocated IOL may be well tolerated for a considerable
period of time by some patients, visual rehabilitation
is usually difficult and surgical intervention may become
necessary.
Surgical Technique: For a subluxated IOL 6,7,8
associated with symptoms, surgery may be performed
by a limbal or parsplana approach. In patients with
less extensive subluxation and posterior capsule that is
intact for most of its part, repositioning can be done
via the limbal route, after minimal or no anterior
vitrectomy. However, in the presence of a sizeable
posterior capsular rent, or posterior dislocation of the
IOL into the vitreous cavity, a parsplana approach is
prefered to acheive the goals of surgery 1 . A thorough
preoperative assessment of the posterior capsular
integrity is necessary to plan the surgical procedure.
The first step of the procedure is to bring the dislocated
IOL into the anterior vitreous in the plane of the pupil.
Fig. 1. After completion of the vitrectomy, injection of
perfluorocarbon liquid between the retina and the
intraocular lens, floats the dislocated intraocular lens
off the retina.

December 2008 M. Chakrabarti et al. - Management of Dislocated PC IOL 393
This is achieved after a complete vitrectomy and release
of vitreous adhesions to the IOL. The IOL is then lifted
off the retinal surface using foreign body forceps or
with the help of perflurocarbon liquids (fig 1).
Late spontaneous in - the - bag intra ocular lens and
capsular tension ring dislocation 9,10 has been reported
in pseudoexfoliation syndrome. Capsular tension ring
implantation in “pseudoexfoliation associated zonular
weakness” does not guarantee long term zonular
stability and capsular bag / IOL positions. In these
patients, parsplana vitrectomy, perflurocarbon liquid
injection to lift up the CTR-IOL-CB complex, grasping
this complex with forceps and bringing it to the
pupillary space transfer across pupil, and with a Mc
Phersons forceps the complex can be explanted through
the cornea scleral incision as a single unit.
Alternatively after PFCL injection 11,12 , the vitrectomy
cutter is used to cut the capsular bag after supporting
it with an illuminated hook followed by removal of the
CTR and IOL separately through a smaller scleral
tunnel.
Once the PC IOL is in the pupillary plane depending on
the integrity of the capsulozonular remnant there are
three options available to the surgeon. These
include 1,2 ,
1. IOL repositioning.
2. IOL explanation
3. IOL exchange.
IOL Repositioning: is performed when adequate
capsulo zonular support is present. The lens may be
repositioned without sutures on to the residual posterior
capsule or fixated by sutures to the iris or the sclera.
Surgical success depends on accurate placement of the
haptics into the ciliary sulcus and this requires
visualization of the residual posterior capsule.
In patients with insufficient pupillary dilatation iris
hooks or retractors may be used to allow a more
accurate assessment of the posterior capsule. Since
the use of capsulorhexis has become wide spread,
the peripheral anterior capsule is left intact and
frequently serves as adequate support for the
sulcus fixation of the dislocated PC IOL. Repositioning
of a posterior chamber IOL into the anterior chamber
has also been reported, but this approach is not
recommended due to chronic chafing of the iris by
the IOL.
IOL removal and or exchange options 13 are
usually exercised during surgery when the IOL has been
damaged (e.g. broken haptic), when appropriate
instrumentation to reposit the IOL is unavailable, or
when highly flexible haptics make the IOL unsuitable
for sulcus fixation. IOL exchange may sometimes be
appropriate for plate haptic IOL which are slippery and
difficult to grasp than PMMA lenses. Serrated or
diamond dusted forceps are recommended when
handling these IOLs. Repositioning may be particularly
challenging with silicon plate haptic lenses because they
are extremely floppy and difficult to manipulate. Also,
since they are non expansible and sized for capsular
fixation, centration with sulcus placement may be sub
optimal because it requires a longer dimension.
Implantation of a second IOL without removing the
first IOL has been reported, but this approach is not
generally recommended.
In patients for whom repositioning of posterior chamber
IOLs proves problematic, an intraoperative decision
may be made to remove or replace the lens with an
anterior chamber IOL or a scleral suture-fixated
posterior chamber IOL. Exchanging for a scleral
sutured- IOL has been simplified by new IOL designs
that incorporate positioning holes at the point of
maximum haptic curvature. Alternatively, exchange for
an anterior chamber IOL may be a faster, easier and
less traumatic to the corneal endothelium 14,15,15,17 .
Newer AC IOL designs avoid mechanical side effects
that accompanied earlier designs.
Scleral fixated PC IOLs are technically more complex
than AC IOL implants. They carry a high risk of intra
ocular hemorrhage because of penetration of the ciliary
body. The major disadvantage of this technique is that
it leaves a potentially permanent partial thickness fistula
through the sclera, around the 10 0 prolene suture. This
surgical technique requires a thorough anterior
vitrectomy. IOL power calculation is difficult due to
posteriorly placed optic of the IOL.
It is important to verify the position of the scleral fixated
IOL because 2 prolene sutures are its sole support and
the position of the lens is the most important factor
contributing to post-operative refraction. A one piece,

394 Kerala Journal of Ophthalmology Vol. XX, No. 4
all PMMA, 10 0 vaulted, 13.5 mm haptic spread IOL
provides excellent optic centration and haptic
stabilization, when the haptic positioning holes are
placed at the point of greatest haptic spread and one
trans-scleral suture pass per haptic is made. A scleral
entry point 18,19,20 0.50 mm to 0.75 mm from the surgical
limbus avoids the major arterial circle and the entire
ciliary body and provides true ciliary sulcus placement
of the IOL.
Scleral fixation sutures 21,22,23 were first introduced for
implantation of secondary IOLs from the limbal or
parsplana approach or even for placement of a primary
PC IOL in the absence of adequate capsulozonular
support. Although a wide variety of techniques have
been described, all have the following common
objectives:-
1. Proper suture attachments to the IOL haptic.
2. Proper scleral sutures positioned to avoid
torsion,decentration or damage to intraocular
structures.
a b
c d
Fig. 2 a-d Technique for scleral suture fixation. (2a) Suture is
threaded through a 27-guage straight needle with a
hole in the bevel. Needle and suture are introduced
into the vitreous cavity 1mm posterior to the limbus
through the bed of a partial thickness scleral flap.
Slack is created in the suture along the shaft of the
needle by withdrawing it slightly. Under direct
visualization the haptic is threaded through the loop
along the shaft of the needle, using an intraocular
forceps to grasp the optic. (2b) The needle is
withdrawn, and the suture is tied under the scleral
flap. (2c) Similar procedure is performed for the other
haptic (2d). Side view of 2c.
3. Proper scleral flap sutures to avoid externalization
of the fixation sutures and reduce the risk of
endophthalmitis.
In any scleral suture fixation procedures, the IOL is
first retrieved, then a suture loop is introduced through
the pars plana region into the vitreous cavity and
around the IOL and the suture is firmly secured to the
sclera. The technique that is commonly used for
repositioning the dislocated PC IOL with scleral sutures
in given below 24,25 (Fig. 2)
IOL torsion and decentration can be avoided by accurate
ciliary sulcus placement and adequate excision of bulky
capsular remnant and cortical matter. Histopathological
studies have shown little or no fibrosis around the
a b c
d
f g
Fig. 3. 10-0 prolene suture on an STC6 plus (ethicon) needle.
Is passed at 10’o clock, docked on a 30 guage needle
at 4’o clock (a) and pulled out with the later diagonally
(b). A Sinskey hook pulls out the suture from superior
corneo-scleral section. The prolene suture is then tied
to the PC IOL haptic(d). The PC IOL is then delivered
into the posterior chamber with Mc Pherson
forseps(e). The sutures are pulled at 4’o clock and
10’o clock meridians (f). A single posterior scleral bite
is taken and sutures are tied to themselves (g)
e

December 2008 M. Chakrabarti et al. - Management of Dislocated PC IOL 395
sutured PC IOL haptics. Therefore, a non dissolving
suture material must be used since it provides the sole
means of support at the ciliary sulcus 24 .
Iris fixation sutures 25 requires passing a suture through
the cornea, iris, around the IOL haptic and back through
cornea and iris. Placement of the needle is not accurate
making IOL centration a challenging task. Other
disadvantage includes the increased risk of inviting a
chronic iris mediated intra ocular inflammation 12 .
Fig 3 a-g describes the technique of two point scleral
fixator that we have been using for several years and it
has given us predictable results 12,13 .
Alternatively a 4 –point scleral fixation can be
performed where the suture passage is made twice,
ensuring adequate anchorage, centration and
eliminating torsion.
Boris Malyugin 26 et al described a technique for
repositioning and trans scleral fixation of a dislocated
plate – haptic foldable collamer posterior chamber
intraocular lens. The displaced IOL was positioned in
the anterior chamber, and a double armed suture or a
curved needle was fixed to the sclera at 10.30 O’ clock
position. The needle then entered the globe and passed
through the superior haptic eyelet of the IOL and was
withdrawn through the scleral wound on the opposite
side. The inferior haptic was fixed at 4.30 and 7.30 o’
clock and provided the mirror reflection of the suture
path of the upper fixed haptic. This technique may be
an useful alternative to lens removal and exchange.
Richard Hoffman 27 et al decribed a technique of scleral
fixation without conjuctival dissection. The scleral
tunnel technique for scleral fixation utilizes a scleral
pocket initiated through a peripheral clear corneal
incision. Full thickness passage of a doubled arm suture
through scleral pocket and conjunctiva with subsequent
retrieval of the suture ends through the external corneal
incision for tying avoids the need for conjunctival
dissection, and a sutured wound closure.
A new technique that relies on glue 28 to implant IOLs
in eyes that lack posterior capsular support was
described by Agarwal et al. They used biological glue
(a quick acting surgical fibrin sealant derived from
human plasma with both hemostatic and adhesive
properties) to perform scleral fixation in a case of
dislocated IOL. Using microrhexis forceps the haptic of
the PMMA non-foldable IOL is grasped and externalized
under the previously prepared scleral flap. Fibrin glue
is applied on the bed of the flap and the flap is closed
in position. In the 12 eyes in their series there were no
notable postoperative complications such as
postoperative inflammation, hyphema, decentration,
glaucoma or corneal oedema on regular follow up.
However a long term follow up is necessary to validate
the efficacy of the procedure.
Surgical Results: The incidence of retinal
detachment following vitrectomy for dislocated PC IOLs
is given in Table 1. In recent series,approximately
70 % of patients achieved a final visual acuity ³
20/40. But surgical series are difficult to compare
accurately due to nonhomogenicity of the variety of
management techniques used.
Table 1. Results of PPV for Dislocated PC IOLs
Study Total RD before RD after Cumulative
(Year) patients PPV PPV
1. Blodi et al 32 4 3 7
(1992) (12.5 %) (9.3 %) (21.9 %)
2. Scott 343 25 19 44
(2003) (7.3 % ) (5.5 %) (12.8 %)
3. Smiddy 100 4 4 8
(2003) (4.0 %) (4.0 %) (8.0 %)
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Surg News Europe/ Asia-Pacific Edition March 2008