1. Intraocular lens (IOL) Dislocation M.R. Akhlaghi MD

2. IOL dislocation Incidence Intraocular lens (IOL) dislocation has been reported to occur in 0.2% to 1.8% of patients after cataract surgery

3. IOL dislocation Causes: Main cause is sub optimal posterior capsule supports during or early post operative

4. During operation: 1. Unknowingly placement 2. Misjudging haptic placement 3. Misjudging capsule support At least 180 degree of a substantially broad rim of post. capsule at least half of which is in the interior quadrant is necessary for satisfactory PC IOL support. IOL dislocation Causes:

5. Days of weeks after surgery: Spontaneously IOL haptic rotation Spontaneously IOL haptic rotation Zonolar dehiscent Zonolar dehiscent IOL dislocation Causes:

6. Months or years after surgery Trauma Trauma Spontaneously loss of zonolar support. (PEX), Marfan syn. Spontaneously loss of zonolar support. (PEX), Marfan syn. IOL dislocation Causes:

7. Degree of lens malposition Degree of lens malposition Accompanying complications Accompanying complications Symptoms Symptoms IOL dislocation Evaluation:

8. Degree of lens malposition Mild: the optic covering more than ½ pupilary space Mild: the optic covering more than ½ pupilary space Moderate: the optic covering less than ½ pupillary space Moderate: the optic covering less than ½ pupillary space Subluxated: open pupillary space but Subluxated: open pupillary space but in the anterior vitreous in the anterior vitreous Luxated: completely dislocation Luxated: completely dislocation IOL dislocation Evaluation:

9. Symptom & signs is related to degree of malposition: 1. Glare : related to edge of the IOL optic 2. Induced astigmatism 3. Decreased VA 4. Monocular Diplopia 5. Floater like symptoms: in luxated & complete mobile IOL 6. Pupillary block glaucoma: in luxated & complete mobile 7. Retinal trauma (in luxated & complete mobile) IOL dislocation Evaluation:

10. Accompanying complications Inflammation Inflammation increased IOP increased IOP Vitreous incarceration Vitreous incarceration Retinal damage Retinal damage CME CME IOL dislocation Evaluation:

11. The best approach must be determined individually and is based on factors such as clinical circumstances and coexisting complications Methods (non surgical, surgical) Time of surgery Method of surgery IOL dislocation management:

12. Non surgical management Observation is usually recommended for IOLs with simple decentration If aphakic contact lens correction is satisfactory, If systemic or ocular problems prohibit further Surgery If the patient simply elects not to pursue further surgery IOL dislocation management:

13. IOL dislocation management surgical management Usually non surgical methods is not satisfactory or convenient to the most of patients Usually non surgical methods is not satisfactory or convenient to the most of patients

14. IOL dislocation Surgical management: Indications decreased VA persistent CME Increased IOP and inflammation coexisting RD Retain lens material monocular diplopia halo phenomenon fluctuating vision caused by shifting IOL

15. IOL dislocation Time of Surgical management Optimal time for intervention intraoperative IOL dislocation: IOL dislocation days after operation: dislocations occurring distantly:

16. IOL removal IOL removal IOL exchange IOL exchange IOL repositioning IOL repositioning Secondary IOL Secondary IOL IOL dislocation surgical management:

17. Surgical approach Limbal incision: in moderate decentration or subluxated if post. capsule is largely intact Limbal incision: in moderate decentration or subluxated if post. capsule is largely intact Pars plana vitrectomy: In luxated IOL Pars plana vitrectomy: In luxated IOL offer optimal control to achieve the goal of surgery in subluxated IOL specially if posterior migration occurs offer optimal control to achieve the goal of surgery in subluxated IOL specially if posterior migration occurs IOL dislocation surgical management:

18. IOL removal RD RD Inflammation Inflammation Trauma Trauma IOL removal with or without exchange is usually performed for IOLs with damaged haptics, small optics, or highly flexible haptics unsuitable for suture support IOL dislocation surgical management:

19. IOL exchange Risk of endothelial cell trauma Risk of endothelial cell trauma Explantation & reimplantation may risk more corneal endothelial trauma compared with repositioning Explantation & reimplantation may risk more corneal endothelial trauma compared with repositioning Exchange for an AC.IOL causes less trauma to endothelial compared with PC IOL placement Exchange for an AC.IOL causes less trauma to endothelial compared with PC IOL placement IOL dislocation surgical management:

20. IOL Repositioninig Most common elected approach Most common elected approach Three basic approaches Three basic approaches 1. In the residual bag or sulcus 2. iris suture fixation 3. Scleral fixation Repositioning a PC IOL in AC Repositioning a PC IOL in AC may induce chronic iritis, inflammation, and corneal decompensation. IOL dislocation surgical managment:

21. IOL dislocation surgical managment Secondary IOL: (AC,PC) without explanation of dislocation IOL only in unusual circumstances (AC,PC) without explanation of dislocation IOL only in unusual circumstances

22. IOL dislocation Outcomes & complications Final outcomes depends on preoperative macular function preoperative macular function Post operative complication of original cataract surgery (CME & RD) Post operative complication of original cataract surgery (CME & RD) Complication of final operation Complication of final operation

23. In some studies VA > 20/40 50-94% VA > 20/40 50-94% Initial coexisting RD 0-10% Initial coexisting RD 0-10% combined rate of RD0-16% combined rate of RD0-16% IOL dislocation Outcomes & complications

24. Recommendation 1. Anterior vitrectomy (avoid vitreous incarceration) 2. A second IOL should not be placed 3. Frequent topical steroids 4. If indicated IOP-reducing agent 5. Vitreoretinal refferal 6. Careful attention to detect other complications IOL dislocation