An Epidemic of Dislocated IOLs?

Garth Stevens Jr. MD

Eye Care Center of VirginiaMary Washington Eye Care Center

Financial Disclosure

The speaker is a paid consultant to Allergan, Inspire, and Abbott Medical Optics

Observation

» Increased incidence of IOL dislocation the last 5 years

Incidence over time

Retina Institute of Virginia (379.39,996.53)

» 2006: 12» 2007: 17» 2008: 23» 2009: 22» 2010: 23

Eye Care Center of Virginia» 2000 to 2006: 14» 2007: 12» 2008: 15» 2009: 18» 2010: 15

Question: is there an increased incidence of dislocated IOLs over the last decade?

Davis et al Ophthalmology 2009, 116, 664-670.

86 cases in bag pathology specimens» 2000-2006: 27» 2006-2008: 59

Associated diagnosis» Pseudoexfoliation (PXF) 50%» Vitreo-retinal surgery 19%» Trauma 16%» Unknown 23%» Uveitis 2%

Incidence of IOL dislocation

Unclear, older reports from 1980s 0.2 to 3%, no good recent data. Certainly less than 1% with modern cataract surgery techniques

Clark .2% 10 y period others 0.6% over 10 y, with 2% with phakodonesis

How many of you have experienced in the bag dislocations, out of bag dislocations??

Role of capsular phimosis

Mechanisms» Preop zonules weak, surgery, capsular

contraction, post op trauma Exerts traction on zonules and may be

related to dislocations» Should we avoid small capsulorhexis in

high risk patients?

Capsular phimosis as a cause of dislocation

Open questions

Do capsular tension rings decrease the incidence of late dislocation of IOLs in PXF? » Probably yes with the Cionni ring and scleral

fixation

Should we ensure that capsulotomy openings are larger in PXF to avoid capsular contraction syndrome?

Cofactors in DislocationsEARLY Capsular rupture Capsular instability

LATE Pseudo-exfoliation Vitreoretinal surgery Trauma Uveitis Cataract surgery

complications Yag capsulotomy Capsular contraction

syndrome

Dislocated with attached capsule

Courtesy J. Astruc

Iris sutured IOL

10-0 prolene

Primary treatment concerns

When to intervene» Pseudo-phakodonesis» Subluxation» Dislocation

Factors» Age

Surgical decisions

Replace or reposition» Replace

– Damaged haptic– Opacified optic

» One piece PMMA IOL with suturing eyelets in haptics

» Scleral fixation with prolene or Gore-Tex sutures

Alternative» AC IOL» In bag suturing to

sclera or iris» Fibrin glue to haptics

under sclera

90 y o, 20 y after cataract surgery, 3 y after suturing of left eye, 20/400 preop, 20/40 post op, removal retained lens material