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Surgical Technique | Surgeon's Corner

Management of 2 Intraocular Lenses in the Same Eye FREE

Andrés Emanuelli, MD; William E. Smiddy, MD
[+] Author Affiliations

Author Affiliations: Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Florida.


JAMA Ophthalmol. 2013;131(1):86-87. doi:10.1001/jamaophthalmol.2013.563.
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Objective To present options for managing a patient with a dislocated intraocular lens (IOL) in the presence of a second, nondislocated IOL.

Methods A review of 3 consecutive cases and the surgical maneuvers used in managing them.

Results The anterior chamber IOL was removed after scleral fixating the dislocated posterior chamber IOL in 1 case with corneal disease. The foldable, dislocated, original posterior chamber IOL was manipulated around an existing posterior chamber IOL and then removed at the limbus in 2 other cases. The visual acuity and retained IOL were stable in all 3 eyes.

Conclusions Existing techniques with minimal modifications can be applied to managing an eye with a dislocated IOL and a coexisting nondislocated IOL with satisfactory results, but treatment needs to be customized to the specific situation.

A posteriorly dislocated intraocular lens (IOL) may be well tolerated in some cases but may be associated with clinically significant signs and symptoms, including visual loss due to cystoid macular edema, refractive errors, and floaters sufficient to prompt removal of the dislocated IOL.1 Management options for a posterior chamber IOL (PCIOL) have been extensively presented.24 In unusual circumstances, a second IOL is implanted without removing a dislocated PCIOL, usually when the first IOL dislocates during cataract surgery. Although this may be well tolerated, the initial PCIOL may cause sufficient visual symptoms to require surgical management, much the same as for a solo PCIOL. In such cases, the second IOL presents additional surgical challenges to executing definitive management. The purpose of this report is to present 3 cases in which a second IOL had been inserted without removal of the initial IOL; these 3 cases were managed based on the unique clinical features of each.

We present a consecutive, single-surgeon (W.E.S.) series of 3 patients with 2 IOLs in the same eye in which a PCIOL was posteriorly dislocated. The selected management option was based largely on the stability of the nondislocated IOL and any underlying pathology of the patient.

CASE 1

A 69-year-old women who had undergone Descemet stripping endothelial keratoplasty had cataract surgery and anterior chamber IOL (ACIOL) implantation because of an intraoperative PCIOL dislocation. A pupilloplasty had been performed, and 1 haptic of the ACIOL was scarred into a high peripheral anterior synechiae. The PCIOL was previously floating freely in the vitreous cavity and was tolerable, at which time the best-corrected visual acuity (BCVA) measured 20/100. Eventually, it came to rest immediately behind the ACIOL, further decreasing vision.

A pars plana vitrectomy was performed. The initial PCIOL was sutured to the sclera using the technique of scleral suture fixation for repositioning acrylic IOLs identical to reports for a solo dislocation.5,6 Polypropylene sutures (9-0) were introduced via a 27-gauge needle 1 mm posterior to the limbus through the bed of a partial-thickness, limbus-based scleral flap at the 1:30 and 7:30 meridians to lasso more inferior haptic and then the superior haptic. The knots were covered under the scleral flap. The incarcerated ACIOL haptic was cut and retained rather than risking an iridodialysis or further corneal damage; the rest of the ACIOL was removed through a superior scleral tunnel (video 1). The BCVA was stable at 20/100, limited by the preexisting corneal pathology.

CASE 2

A 85-year-old man had an apparently nonmobile, dislocated silicone plate IOL 2 years after undergoing cataract surgery in his left eye. The cataract surgeon placed a second posterior PCIOL in the ciliary sulcus 1 month later. Two months after placement of the secondary PCIOL, the patient complained of mild blurred vision, but a large floater in the shape of the silicone plate haptic IOL was identified. His BCVA was 20/70, and there was macular edema. A pars plana vitrectomy was performed to remove the silicone plate IOL by grasping it with serrated Rapazzo forceps and sliding it around the sulcus-fixated IOL into the anterior chamber; the sulcus-fixated PCIOL was gently and temporarily subluxed superiorly to admit the plate haptic PCIOL into the anterior chamber. The plate haptic IOL was uneventfully removed through a scleral tunnel. Intravitreal preservative-free triamcinolone acetonide was injected at the end of the procedure (video 2). The BCVA in his left eye was 20/40, and the cystoid macular edema was resolved 13 months after surgery.

CASE 3

A 74-year-old woman had cataract surgery in her right eye, but the single-piece acrylic PCIOL became dislocated and immobilized in the inferior vitreous base soon thereafter, so the cataract surgeon placed a second posterior PCIOL in the ciliary sulcus 1 month later. Seven years after the placement of the secondary PCIOL, the patient started to complain of decreased vision in down gaze due to the now mobile acrylic PCIOL. The patient recalled several falls due to not being able to see well looking downward. Her BCVA was 20/25, but it varied with the position of the dislocated IOL. A pars plana vitrectomy was performed to remove the dislocated acrylic PCIOL by grasping it with intraocular forceps and directing it to the anterior chamber through a temporal, crescent-shaped posterior capsular opening without disrupting the position of the already-placed PCIOL (video 3). Her BCVA was 20/25, and the PCIOL was centered and stable 6 months after surgery.

Various techniques have been shown to be effective in the management of a posteriorly dislocated IOL,7 but reports regarding the management of a dislocated PCIOL in the presence of a second IOL are limited.8,9 As exemplified in these cases, several factors influence devising a definitive treatment plan. The first step is to determine which IOL to explant. For case 1, the ACIOL was explanted, and the initial IOL was sutured to the sclera using the technique of scleral suture fixation to minimize exacerbation of the corneal pathology and Descemet stripping endothelial keratoplasty. For case 2, the plate haptic PCIOL was explanted by sliding it over the stable 3-piece PCIOL already in the sulcus. A similar maneuver was used for similar reasons in case 3. The flexibility of the foldable PCIOL and the need for only slight decentration or zonular disruption of the existing sulcus- or bag-fixated IOL make this a surprisingly viable option. In all cases, the retained IOL remained stable postoperatively. Removing only one of the IOLs lessens the risks of IOL explantation, such as hyphema, iridodialysis, and damage to corneal endothelium, and would avoid the need to insert yet a third IOL, which might possibly be an ACIOL that carries even further risks to the corneal endothelium or other anterior segment structures. An alternative approach would be to remove the dislocated IOL through an enlarged pars plana incision,8 but that would seem to risk complications due to vitreous base manipulation more than would the technique of manipulating the foldable IOL around the stable one.10

The surgical management of a second dislocated IOL in an eye needs to be tailored to the individual patient and depends on the underlying ocular pathology. Familiar, established procedures can be used to accomplish such objectives with stable, successful recovery of visual acuity.

Correspondence: William E. Smiddy, MD, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136 (wsmiddy@med.miami.edu).

Submitted for Publication: April 26, 2012; final revision received May 29, 2012; accepted June 1, 2012.

Author Contributions: Drs Emanuelli and Smiddy had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by an unrestricted grant from Research to Prevent Blindness and by National Eye Institute Core Center grant P30 EY014801.

Online-Only Material: The Author Interview is available here.

Smiddy WE, Flynn HW Jr. Management of dislocated posterior chamber intraocular lenses.  Ophthalmology. 1991;98(6):889-894
PubMed
Smiddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated intraocular lenses.  J Cataract Refract Surg. 1995;21(1):64-69
PubMed
Sarrafizadeh R, Ruby AJ, Hassan TS,  et al.  A comparison of visual results and complications in eyes with posterior chamber intraocular lens dislocation treated with pars plana vitrectomy and lens repositioning or lens exchange.  Ophthalmology. 2001;108(1):82-89
PubMed   |  Link to Article
Mittra RA, Connor TB, Han DP, Koenig SB, Mieler WF, Pulido JS. Removal of dislocated intraocular lenses using pars plana vitrectomy with placement of an open-loop, flexible anterior chamber lens.  Ophthalmology. 1998;105(6):1011-1014
PubMed   |  Link to Article
Mello MO Jr, Scott IU, Smiddy WE, Flynn HW, Feuer W. Surgical management and outcomes of dislocated intraocular lenses.  Ophthalmology. 2000;107(1):62-67
PubMed   |  Link to Article
Smiddy WE, Flynn HW Jr, Kim JE. Retinal detachment in patients with retained lens fragments or dislocated posterior chamber intraocular lenses.  Ophthalmic Surg Lasers. 1996;27(10):856-861
PubMed
Kim SS, Smiddy WE, Feuer W, Shi W. Management of dislocated intraocular lenses.  Ophthalmology. 2008;115(10):1699-1704
PubMed   |  Link to Article
Williams DF, Del Piero EJ, Ferrone PJ, Jaffe GJ, , McDonald HR, Peters MA. Management of complications in eyes containing two intraocular lenses.  Ophthalmology. 1998;105(11):2017-2022
PubMed   |  Link to Article
Jain R, Gilhotra JS. Removal of posteriorly dislocated posterior chamber intraocular lens without removing stable anterior chamber intraocular lens—slide under technique.  Retina. 2011;31(7):1421-1423
PubMed   |  Link to Article
Wong KL, Grabow HB. Simplified technique to remove posteriorly dislocated lens implants.  Arch Ophthalmol. 2001;119(2):273-274
PubMed

Figures

Tables

References

Smiddy WE, Flynn HW Jr. Management of dislocated posterior chamber intraocular lenses.  Ophthalmology. 1991;98(6):889-894
PubMed
Smiddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated intraocular lenses.  J Cataract Refract Surg. 1995;21(1):64-69
PubMed
Sarrafizadeh R, Ruby AJ, Hassan TS,  et al.  A comparison of visual results and complications in eyes with posterior chamber intraocular lens dislocation treated with pars plana vitrectomy and lens repositioning or lens exchange.  Ophthalmology. 2001;108(1):82-89
PubMed   |  Link to Article
Mittra RA, Connor TB, Han DP, Koenig SB, Mieler WF, Pulido JS. Removal of dislocated intraocular lenses using pars plana vitrectomy with placement of an open-loop, flexible anterior chamber lens.  Ophthalmology. 1998;105(6):1011-1014
PubMed   |  Link to Article
Mello MO Jr, Scott IU, Smiddy WE, Flynn HW, Feuer W. Surgical management and outcomes of dislocated intraocular lenses.  Ophthalmology. 2000;107(1):62-67
PubMed   |  Link to Article
Smiddy WE, Flynn HW Jr, Kim JE. Retinal detachment in patients with retained lens fragments or dislocated posterior chamber intraocular lenses.  Ophthalmic Surg Lasers. 1996;27(10):856-861
PubMed
Kim SS, Smiddy WE, Feuer W, Shi W. Management of dislocated intraocular lenses.  Ophthalmology. 2008;115(10):1699-1704
PubMed   |  Link to Article
Williams DF, Del Piero EJ, Ferrone PJ, Jaffe GJ, , McDonald HR, Peters MA. Management of complications in eyes containing two intraocular lenses.  Ophthalmology. 1998;105(11):2017-2022
PubMed   |  Link to Article
Jain R, Gilhotra JS. Removal of posteriorly dislocated posterior chamber intraocular lens without removing stable anterior chamber intraocular lens—slide under technique.  Retina. 2011;31(7):1421-1423
PubMed   |  Link to Article
Wong KL, Grabow HB. Simplified technique to remove posteriorly dislocated lens implants.  Arch Ophthalmol. 2001;119(2):273-274
PubMed

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