gms | German Medical Science

27. Kongress der Deutschsprachigen Gesellschaft für Intraokularlinsen-Implantation, Interventionelle und Refraktive Chirurgie (DGII)

Gesellschaft für Intraokularlinsen-Implantation, Interventionelle und Refraktive Chirurgie (DGII)

11.04. - 13.04.2013, Heidelberg

Tackling the malpositioned IOL

Meeting Abstract

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  • Abhay Vasavada - Ahmedabad/IND

Deutschsprachige Gesellschaft für Intraokularlinsen-Implantation, Interventionelle und Refraktive Chirurgie. 27. Kongress der Deutschsprachigen Gesellschaft für Intraokularlinsen-Implantation, Interventionelle und Refraktive Chirurgie (DGII). Heidelberg, 11.-13.04.2013. Düsseldorf: German Medical Science GMS Publishing House; 2013. Doc13dgii021

doi: 10.3205/13dgii021, urn:nbn:de:0183-13dgii0219

Veröffentlicht: 5. April 2013

© 2013 Vasavada.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen ( Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.



Dealing with a ‘malpositioned’ IOL is a challenge for the surgeon. The issues are manifold: the cause of subluxation/dislocation of the IOL, the extent of dislocation, the type of IOL, the presence or absence of vitreous in the anterior chamber and co-existing ocular morbidities. All these factors will influence the surgical strategy and more importantly, the outcome for the patient.

Here, we will present different cases that will show varying presentations of IOL malpositioning, and their remedial options.

Case 1: Asymmetric placement of Single-Piece Acrylic IOL

A 66 year-old lady, with a history of previous laser PI done, was planned for cataract surgery with multifocal IOL implantation. Following an uneventful surgery, a single-piece hydrophobic acrylic, multifocal IOL implantation was planned. However, during IOL implantation, the pupil started constricting, and once the IOL was placed, it was difficult to determine whether it had gone in the bag completely or not. The surgeon did not attempt to manipulate any further and closed the eye.

She presented to us 1 month after the original surgery, with an IOP of 26 mm Hg and best-corrected vision of 612. Dilated exam revealed that the one haptic of the IOL was in the bag and the other was in the sulcus. In 180 degrees, the anterior and posterior capsule had fused (Figure 1 [Fig. 1]).

What is the next step for this patient?

The important point to note here is that the single piece design has thick haptics. These tend to rub in the ciliary body region, and produce recurrent low-grade uveitis, pigment dispersion and worsening of glaucoma. We have shown this very effectively by UBM analysis of eyes with single piece acrylic IOL in the sulcus [1]. Therefore, it should not be left in the ciliarysulcus.

After proper counselling patient was taken up for IOL repositioning. The plan was to try and reopen the capsular bag, and reposition the IOL in the bag. In case, at any stage, the capsular bag would be compromised, the plan was to explant the single piece IOL and place a 3-piece IOL in the ciliarysulcus.

Using high viscosity cohesive ophthalmic viscosurgical device (OVD) and a spatula, the capsular bag was gently viscodissected and opened up (Figure 2 [Fig. 2]). Subsequently the IOL was dialed in the bag (Figure 2 [Fig. 2]).

Postoperatively, the vision improved to 6/6(p) and IOP came down to 15 mm Hg.

Take home message: Single piece acrylic IOL should not be placed in the ciliary sulcus. If detected in the early postoperative period, the capsular bag can be opened up to reposition the IOL in the bag. If this is not possible, still explant the IOL and place a 3-piece IOL in the ciliary sulcus.

Case 2: IOL dislocated posteriorly with good anterior capsule support

A 62 year-old man was operated for a posterior polar cataract 10 years ago. Intraoperatively there was a posterior capsule rupture. However, using the rest of the posterior capsule as a support, a single-piece hydrophobic acrylic IOL was implanted in the bag. 10 years later, he presented with a dimunition of vision for 6 months.

Slit-lamp examination revealed aphakia in the pupillary area. The IOL could not be seen in primary gaze on the slitlamp, but was seen in the anterior vitreous in a supine position. The margin of the original posterior capsule rupture could be clearly visualized, and anterior chamber was free of any vitreous (Figure 3 [Fig. 3]).

We counseled the patient regarding explantation of the dislocated IOL with possible re-fixation of another IOL.The surgical strategy was to perform a pars planavitrectomy, explant the single-piece IOL and re-fixate another IOL depending on the available anterior capsular support.

As a first step, a 23-gauge, pars planavitrectomy was performed on the Infiniti Vision System® (Alcon, USA) The parameters used for vitrectomy were: cut rate of 2,500/minute, vacuum 300 mm Hg, aspiration flow rate 25 cc/minute and irrigation bottle height 50 cm H2O. Thorough vitrectomy was performed to ensure that the IOL was free of all surrounding vitreous. Using a bimanual technique and microincision grasping forceps, the IOL was gently brought out into the anterior chamber. A dispersive ophthalmic viscosurgical device (OVD), Viscoat, was injected in the anterior chamber to coat the corneal endothelium. A temporal clear corneal incision of 2.4 mm was fashioned. The IOL was explanted using a special wire-loop passed through the Alcon ‘A’ cartridge. This special device has been innovated by Dr. Arup Bhowmick from Kolkata, India. This device enables ‘reverse folding’ of the IOL, i.e. it allows the entire IOL to fold back into the cartridge and be removed a very small incision.

Once the IOL was explanted, the anterior capsule support was assessed, and was judged to be adequate for a sulcus IOL fixation. A 3-piece Acrysof® IOL was implanted in the sulcus, and the optic was captured through the anterior capsulorhexis margin. At the end, intracameraltriamcinoloneacetonide (preservative-free) was injected in the anterior chamber to detect presence of any residual vitreous.

Postoperatively, at 1 month, the patient achieved a best-corrected visual acuity of 20/30 with a very stable and centred IOL. He maintained the same IOL centration and stability even at 1.5 years postoperatively (Figure 4 [Fig. 4]).

Take home message: Perform an adequate vitrectomy to ensure that the IOL is free of all coating vitreous. Use an appropriate IOL explantation strategy that is least traumatic to the eye. Finally, very critically assess the available capsular support and then decide the site of IOLfixation.

Case 3: IOL dislocated posteriorly with no capsular support

A 68 year-old gentleman had an injury to the eye, and presented with dimunition of vision. Examination revealed IOL dislocated into the anterior vitreous. However, there was no visible anterior or posterior capsule support (Figure 5 [Fig. 5]).

Just as in the previous case, an adequate vitrectomy was performed through the pars plana approach. The IOL was then elevated and brought into the anterior chamber, it was a single piece hydrophilic acrylic IOL. It was explanted through a small incision using the same wired loop snare device as mentioned in the case above.

In absence of capsular support, we prefer to fixate the IOL to the sclera. In this case, weperformed an intrascleral fixation of a foldable 3-piece IOL, using the technique described by Dr. Gabor Scharioth and then modified by Dr. Amar Agarwal.

Other alternatives include performing a conventional sutured scleral fixation, sutured posterior iris fixation of the IOL or an anterior chamber IOL implantation.

Take home message: In absence of adequate capsular bag support, fixate the IOL to the sclera, iris or implant it in the anterior chamber.

Thus, each case of a ‘malpositioned’ IOL is different. Depending on the extent of malpositioning, the type of IOL and the surgeon’s comfort, the management changes. It will be beneficial for the surgeon to be familiar with various IOL exchange/explantation techniques.


Vasavada AR, Raj SM, Karve S, Vasavada V, Vasavada V, Theoulakis P. Retrospective ultrasound biomicroscopic analysis of single-piece sulcus-fixated acrylic intraocular lenses. J Cataract Refract Surg. 2010 May;36(5):771-7. DOI: 10.1016/j.jcrs.2009.11.027 Externer Link