Unique approach to managing a posteriorly dislocated IOL

Reviewed by George Beiko, MD

St. Catharines, Ontario-When a three-piece IOL intended for sulcus placement dislocates posteriorly during an IOL exchange procedure, cataract surgeons can consider several possible strategies.

The options include leaving the dropped lens in the posterior segment while implanting either a posterior chamber or anterior chamber IOL or simply leaving the patient aphakic with the dropped IOL. Alternatively, surgeons might attempt posterior-assisted levitation of the dislocated implant or seek assistance of a vitreoretinal surgeon.

When deciding among these approaches, surgeons may take into account a variety of factors that include their own experience and skill set, the age of the patient, the anatomy of the eye, and the availability of a vitreoretinal colleague.

When faced with this clinical scenario in an 85-year-old man with a history of vitrectomy with endolaser for retinal detachment repair, George Beiko, MD, implemented a novel, gravity-based solution. He had the patient turn over onto his abdomen so that the man’s head extended over the end of the operating table face down.

Inventive approach

Lying on the floor on his back so that he was looking up at the patient and with a colleague shining a flashlight in the patient’s eye, Dr. Beiko watched the IOL float anteriorly.

Next, he injected viscoelastic into the anterior chamber and externalized the haptics. After having the patient turn over onto his back, Dr. Beiko successfully completed the exchange procedure with sulcus placement of a new three-piece IOL.

When a three-piece IOL intended for sulcus placement dislocates posteriorly during an IOL exchange procedure, George Beiko, MD, implemented a novel, gravity-based solution. He had the patient turn over onto his abdomen so that the patient head extended over the end of the operating table face down. Courtesy of George Beiko, MD

Key to the approach

 “The key to my approach was the patient’s history of treatment for a dropped nucleus and retinal detachment,” said Dr. Beiko. “I would not advocate it in a non-vitrectomized eye.”

He added that he does not have access to a vitreoretinal surgeon at his center. Dr. Beiko is in private practice, St. Catharines, Canada; assistant professor of ophthalmology, McMaster University; and a lecturer in the department of ophthalmology, University of Toronto.

The patient presented with a complaint of diplopia. The involved eye had a retinal detachment 15 years earlier. Two years thereafter, the eye underwent cataract surgery that was complicated by a dropped nucleus so that vitrectomy, endolaser, and sulcus placement of a three-piece IOL was performed.

More surgery

About a decade later, the patient underwent uncomplicated cataract surgery in the fellow eye with placement of an in-the-bag posterior chamber IOL and a plano result. He had about -5 D of myopia in the eye with the sulcus-placed IOL and about 200° to 250° of intact posterior capsule.

Dr. Beiko’s original plan was to remove the primary IOL and replace it with another three-piece IOL in the sulcus. After injecting and positioning the replacement IOL and verifying its stability, Dr. Beiko cut the first lens and removed it.

The newly implanted IOL dislocated to the retina when he hydrated the eye as he prepared to close the case.

George Beiko, MD

E: George.beiko@sympatico.ca

This article was developed based on an article that Dr. Beiko presented at the 2015 American Academy of Ophthalmology meeting. He has no relevant financial interests to disclose.