Spontaneous IOL–CTR dislocation

Abstract

Scherer et al.1 report 2 cases of late-onset in-the-bag intraocular lens (IOL) and capsular tension ring (CTR) dislocation in pseudoexfoliation syndrome; they opted to explant the entire bag–IOL–CTR complex for an anterior chamber IOL. In both cases, the capsular bag complex, which was still in the retropupillary plane, appeared to have sunset syndrome and would have been amenable to repositioning with suture loop scleral fixation of the existing CTR, as previously reported.2,3 Although explantation may appear to be technically easier, the possibility of vitreous traction pulling the entire complex into the anterior chamber and out of the eye, the large incision required, and the placement of an anterior chamber IOL are potentially serious risks that are reduced with the elegance of a small-incision, minimally invasive suture-repositioning technique. We prefer to use a high tensile strength 9-0 polypropylene suture with an ab-externo technique and have found this to be successful.3 Although we also use iris fixation for dislocated posterior chamber IOLs, attempts to suture the IOL or CTR to the iris are difficult and potentially hazardous in this setting. Because of the progressive nature of the proteolytic enzymatic degradation of the zonule that occurs in pseudoexfoliation syndrome, we often recommend a sutured capsular tension device such as the modified CTR or the capsular tension segment in advanced cases of zonulopathy. Furthermore, we strongly advocate early surgical intervention in new-onset or worsening pseudophacodonesis or IOL subluxation. Finally, the use of neodymium:YAG anterior capsule relaxing incisions in the postoperative period may reduce the centripetal traction and capsular contraction syndrome that is often associated with in-the-bag IOL decentration.