The incidence of displaced posterior chamber intraocular lenses (PCIOL) after cataract surgery has been reported to range from 0.2% to 2.8%.1,2 The occurrence of two dislocated PCIOLs is rare. We evaluated the outcomes of three patients, each with two foldable posterior intraocular lenses dislocated to the vitreous cavity in pseudoexfoliation syndrome.
Case reports
Three patients underwent surgery for dislocation of two posterior chamber foldable IOLs. Preoperative visual acuities (VA) ranged from 20/300 to 20/400 (table 1). In brief, a two port pars plana vitrectomy was performed using an anterior chamber maintainer with limbal infusion to free the IOLs from surrounding vitreous so they could gently float to the posterior pole (fig 1). At this point, additional anterior vitrectomy with peripheral scleral depression was performed to allow removal of as much anterior vitreous as possible. The haptic could then be grasped safely with retinal forceps, and the first lens was elevated into the mid‐vitreous. The endoilluminator probe was then removed and a second intraocular forceps introduced. Using the coaxial operating microscope light for illumination, the lens optic was grasped with the second forceps, passed into the anterior chamber and removed by limbal extraction. The second lens was then removed in the same fashion and a new IOL was placed by transscleral fixation.3
Figure 1 A two port pars plana vitrectomy was performed using an anterior chamber maintainer with limbal infusion to free the intraocular lenses from surrounding vitreous so they could gently float to the posterior pole.
Table Clinical findings in patients with multiple dislocated intraocular lenses.
| Patient (eye) | Age (years) | Sex | Pre‐phaco VA | Post‐phaco VA | Time of first dislocation | Cause of dislocation | Time of placement of second lens | Time of second dislocation | Pre‐vitrectomy VA | Post‐vitrectomy VA |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 75 | F | 20/300 | 20/40 | POD #17 | Zonular laxity and poor capsular support | Sulcus IOL at POD # 28 | POD2 #15 | 20/400 | 20/30 |
| 2 | 80 | F | 20/400 | 20/40 | POD #15 | Zonular laxity and poor capsular support | Sulcus IOL at POD # 22 | POD2 #20 | 20/300 | 20/50 |
| 3 | 60 | M | 20/200 | 20/20 | POD #10 | Zonular laxity and poor capsular support | Sulcus IOL at POD # 25 | POD2 #14 | 20/300 | 20/50 |
Phaco, phacoemulsification and intraocular lens (IOL) implantation; VA, Snellen visual acuity; POD, postoperative day; POD2, postoperative day after sulcus IOL.
All three patients had pseudoexfoliation syndrome but no complications were noted during the initial cataract surgeries. The initial dislocation in all cases followed minimal blunt ocular trauma. The second dislocation occurred spontaneously 7–15 days following placement of the secondary sulcus lens. All procedures were performed as described above within 2 days of presentation. Follow up ranged from 6 months to 3 years; postoperative visual acuities ranged from 20/30 to 20/50. No complications developed in the postoperative period.
Comment
Postoperative complications of dislocated IOLs include retinal detachment, cystoid macular oedema, and vitreous haemorrhage.4 The behaviour and risk of having multiple dislocated IOLs within the vitreous cavity is not well known and, to our knowledge, there has been only one case report of multiple dislocated IOLs.5
Treatment options include observation, medical therapy (pharmacological miosis), repositioning, removal, IOL exchange, or placement of a second IOL into the eye.6,7,8 If dislocation is noted to occur intraoperatively, attempts to retrieve the PCIOL without the use of posterior vitrectomy techniques may be associated with severe posterior segment complications and should be avoided. The temptation to place an anterior chamber IOL (ACIOL) at this time also should be resisted since the potential for complications is difficult to predict, and the presence of an ACIOL may render subsequent management more complex.9
Although the initial dislocation in all cases followed minimal blunt ocular trauma, the presence of two dislocated PCIOLs within the vitreous cavity, and the fact that dislocations occurred within 10–20 days, both for the first and second PCIOL likely indicate that residual capsule support was inadequate to place a sulcus lens. Vitrectomy and repositioning with scleral fixation or intraocular lens exchange should be considered first at the time of primary PCIOL dislocation, rather than secondary sulcus fixation of a second PCIOL in pseudoexfoliation syndrome.
In conclusion, pseudoexfoliation syndrome seems to be a risk factor for dislocated foldable IOLs in the vitreous cavity after cataract surgery.10 Eyes with two foldable IOLs in the vitreous cavity after cataract surgery are at risk of developing posterior segment complications such as retinal detachment, vitreous haemorrhage, and macular oedema. However, performing two port pars plana vitrectomy, with limbal extraction and transscleral fixation of a new IOL results in improved visual acuity and rapid rehabilitation without further complications.
Footnotes
Supported in part by the Fundacion Arevalo‐Coutinho para la Investigacion en Oftalmologia (FACO), Caracas, Venezuela.
The authors have no proprietary or financial interest in any products or techniques described in this article.
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