Late In-the-bag Intraocular Lens Dislocation: Outcomes of Different Surgical Techniques to Correct Intraocular Lens Position Ramón Lorente, Victoria de Rojas, Paula Vázquez de Parga Hospital Cristal Piñor Spain Authors have no financial interest

Introduction Late in-the-bag dislocation of intraocular lens Potential late complication of cataract surgery Incidence is unknown Caused by progressive zonular dehiscence many years after uneventful surgery1-5 Predisposing factors1-5 Pseudoexfoliation Trauma Uveitis Status after vitrectomy Long axial length Certain special considerations for management Surgical options differ Optimum approach for each case is unclear1-6

Purpose To evaluate the surgical outcomes for the correction of in-the-bag intraocular lens dislocation using different surgical techniques Reposition with ab externo scleral fixation (SFIOL) Exchange for an anterior chamber IOL (ACIOL) Exchange for an iris-claw IOL (ICIOL)

Patients & Methods Retrospective single surgeon interventional case series Identification of all patients with in-the-bag dislocated IOLs undergoing surgery consecutively by the same experience surgeon (RL) at Hospital Cristal Piñor from January 2005 to December 2008 Retrospective chart review & data collection from medical records age/sex interval surgery - IOL dislocation dislocation site and grade type of IOL / Capsular Tension Ring (CTR) predisposing factors management technique pre & postoperative BCVA pre & postoperative IOP surgical complications Main outcome measure: Postoperative best-corrected visual acuity

Results * * 1 case bilateral

Results 17 6 1 5 1 Number of surgeries to correct position of in-the-bag dislocated IOLs in each year of the study

Results 6Personal classification Lorente 2008 Grade I Grade II Grade III

Results 7

Results * * § p=0.0001 Postoperative BCVA ≥ 20/40 in 62.06% ≥ 20/25 in 24.13% § statistically significant difference p=0.0001 *No significant difference p=0.390

Discussion Mean interval from original surgery to IOL dislocation in the current series was 9.05 ± 3.8 years. Similar long time frames for presentation were previously reported in the literature1-4. Given this long time interval for presentation, its incidence is expected to increase in the future3 as it did during the current study (see graph in slide 6) A predisposing condition was identified in 62,06% of the eyes in our study. Pseudoexfoliation was the most common condition, accounting for 55 % of the cases, in agreement with previous findings of recent cases series1-5. The recognition of risk factors for this complication is of particular interest since it would allow using a modified approach in cases at risk The management of in-the-bag IOL dislocation may be difficult and requires certain special considerations for management. The surgical management approach depends on surgeon preferences and speciality and the clinical features of an individual case, including type of IOL and presence of capsular tension ring, stage and site of IOL dislocation, and coexisting ocular pathology1-6

Discussion Surgical approaches include IOL repositioning and IOL exchange. IOL repositioning using ab external scleral fixation 7 offers the advantages of a closed-system, minimally invasive method of scleral fixation for IOL decentration and this was the technique used in 10 cases of our study. The advantage of repositioning and suturing the IOL is that it can be accomplished without a large limbal incision, minimizing the trauma to the corneal endothelium and postsurgical astigmatism Whether to use an anterior or sutured posterior chamber IOL if the IOL is exchanged is a matter of controversy. There is no consensus on the indications, relative safety or efficacy of these alternatives8. Contrary to the results of Hayashi4, mean BCVA improved significantly after surgery in the current study, probably because other surgical alternatives to IOL exchange for SFIOL were used in our series. There was no significant difference in postoperative BCVA between SFIOL and ACIOL. The 2 eyes with ICIOL achieved BCVA of 0,4 (with associated macular disease) and 0,6 respectively. This latter alternative had not been considered in previous series of in-the-bag IOL dislocation and it´s being successfully employed to correct aphakia in eyes without capsular support9 Glaucoma was detected in 15 eyes and was the most common complication, as previously noted by other authors4

Conclusion References Reasonable good outcomes with a low rate of complications were found in this retrospective case series of in-the-bag IOL dislocation using three surgical alternatives: repositioning using ab externo scleral suture fixation, exchange for anterior chamber IOL or and iris-fixated IOL. Mean BCVA improved significantly after surgery to correct IOL position Although the number of cases was small, iris-fixated IOL, an option not considered previously, seems a promising alternative in the surgical management of this condition. Pseudoexfoliation was the most common predisposing factor and glaucoma the most common and significant long term complication. Early surgical intervention and close monitoring of eyes with pseudophacodonesis is recommended. Conclusion References 1 Jehan Ophthalmology 2001 2 Gross Am J Ophthalmol 2004 3 Gimbel J C R S 2005 4 Hayashi Ophthalmology 2007 5 Kim Ophthalmology 2008 6 Lorente Ponencia SEO 2008 7 Chan J C R S 2006 8 Wagoner Ophthalmology 2003 9 Güell J Cataract Refract Surg 2005