In-the-bag Intraocular Lens Dislocation Research Articles

Inflammatory reaction in eyes with late in-the-bag intraocular lens dislocation.

To investigate the inflammatory reaction in eyes with late in-the-bag intraocular lens (IOL) dislocation. This prospective clinical study with fellow-eye comparison consists of 76 of the patients (76 eyes) with late in-the-bag IOL dislocation enrolled in the LION trial. The main outcome measure was anterior chamber flare before surgery measured with a laser flare meter in photon counts per millisecond (pc/ms). The dislocation was graded as 1 (small: optic still covering the visual axis), 2 (optic equator close to the visual axis) or 3 (optic decentred beyond the visual axis, but the IOL-capsule complex partly visible in the pupillary area). The secondary aim was to compare intraocular pressure (IOP) before surgery. Flare levels before surgery were significantly higher in the dislocation eyes than in the fellow eyes with a median flare of 21.5 (range 5.4-135.7) pc/ms versus 14.1 (2.0-42.9) pc/ms, respectively (p ˂ 0.001). A regression analysis of log-transformed flare values showed that the dislocation eyes had a non-significant tendency towards higher flare in dislocation grade 1 with a median flare of 24.6 (5.4-135.7) pc/ms compared to grade 2; 19.6 (6.5-41.5) pc/ms (p = 0.06), and no significant difference compared to grade 3; 19.4 (10.2-53.5) pc/ms (p = 0.47). The IOP was significantly higher in the dislocation eyes than in the fellow eyes (p ˂ 0.001). Eyes with late in-the-bag IOL dislocation had increased flare levels compared to their fellow eyes. This suggests that inflammation is part of the clinical picture of late in-the-bag IOL dislocation.

Long-term risk of suture breakage after scleral fixation of late in-the-bag intraocular lens dislocation with a polypropylene 10-0 suture.

To investigate the long-term risk of suture breakage after scleral fixation with a polypropylene 10-0 suture in eyes with late in-the-bag intraocular lens (IOL) dislocation. Oslo University Hospital, Oslo, Norway. Retrospective case series. Patients operated with scleral suturing of late in-the-bag IOL dislocation from 2007 to 2016. 192 eyes (176 patients) operated with scleral suture (polypropylene 10-0 suture) fixation of a dislocated IOL-capsule complex were identified; 91 patients (47%) were men. The mean follow-up after the operation was 6.2 (95% CI, 5.7-6.7) years, and 98 patients (56%) deceased during the study. 11 eyes (6%) (11 patients) had suture breakage that required reoperation with a mean time of 5.5 (3.4-7.6) years after IOL repositioning surgery. These patients had a mean age of 73.5 (67.9-79.2) years at the time of the operation for late in-the-bag IOL dislocation vs 81.3 (79.8-82.9) years for patients who did not experience this complication ( P = .004). No cases of late endophthalmitis were registered. The long-term risk of suture breakage was quite low after scleral fixation of late in-the-bag IOL dislocation, particularly in the oldest patients. Hence, the polypropylene 10-0 suture seems to be a safe option for scleral fixation in this patient group.

Intraocular Inflammation in Eyes Operated for Late In-the-bag intraOcular lens dislocatioN (LION): A Randomized Clinical Trial

To compare the intraocular inflammation after 2 surgical approaches for late in-the-bag intraocular lens (IOL) dislocation. Prospective, randomized, parallel-group clinical trial. We randomly assigned 100 patients (100 eyes) referred to Oslo University Hospital (tertiary referral center) with late in-the-bag IOL dislocation into IOL repositioning by scleral suturing (n=49) or IOL exchange with retropupillary fixation of an iris-claw lens (n=51). Patients were examined before surgery and 2 weeks, 6 weeks, and 6 months after surgery. The main outcome measure was anterior chamber laser flare, measured with a laser flare meter as photon counts per millisecond (pc/ms). Two weeks following surgery, median flare values were 28.9 pc/ms (range, 7.9-140) in the repositioning group and 31.6 pc/ms (range, 9.8-92.3) in the exchange group (P=.83). Flare levels were still elevated after 6 weeks with no difference between the groups (P=.93), whereas it decreased to baseline levels after 6 months. Six weeks following surgery, the central retinal thickness was similar (P=.97); cystoid macular edema (CME) was found in 4 and 5 patients, respectively (P=.85); and the mean best corrected visual acuity was 0.17 (95% CI 0.09, 0.25) and 0.21 (95% CI 0.09, 0.32) logarithm of the minimum angle of resolution, respectively (P=.61). This study revealed similar levels of intraocular inflammation following IOL repositioning and IOL exchange. There was no significant difference regarding risk of CME and visual outcome. The prolonged elevation in postoperative flare indicates a possible requirement for an extended anti-inflammatory treatment period after these operations.

Management of late in-the-bag IOL dislocation with exchange and scleral fixation of IOL with the transfixion technique

Introduction: Late in-the-bag intraocular lens (IOL) dislocation is a serious complication of cataract surgery. Patient and clinical findings: A 70-year-old woman with a history of left eye cataract surgery presented with progressively decreasing vision that had worsened over the past 6 months. In the left eye, the uncorrected distance visual acuity (UDVA) was counting fingers at 5 m, the corrected distance visual acuity (CDVA) was 20/25 (+12.25 −1.25 × 180), and the intraocular pressure was normal. An anterior segment examination revealed severe inferior dislocation of the IOL-capsular bag complex. Diagnosis, intervention, and outcomes: The patient was diagnosed with late in-the-bag IOL dislocation and underwent IOL–capsular bag complex explantation with sulcus-sutured IOL implantation using a new scleral fixation technique that included transfixion of a foldable acrylic IOL with polytetrafluoroethylene suture. The postoperative outcome was good; the UDVA was 20/70, and the CDVA was 20/25, and there were no postoperative complications such as infection, suture erosion, iritis, uveitis, vitreous hemorrhage, or retinal detachment. Conclusions: Late in-the-bag IOL dislocation was safely managed with IOL–capsular bag complex explantation and scleral fixation of a foldable posterior chamber IOL. This transfixion technique can be used for scleral fixation in patients with late in-the-bag IOL dislocation.

Corneal endothelial status in different grades of late spontaneous in-the-bag IOL dislocation.

To evaluate corneal endothelial cell density (ECD) in the eyes with different grades of late spontaneous in-the-bag intraocular lens (IOL) dislocation. A prospective study included seventy-eight patients who applied for IOL dislocation. Overall 80 eyes were divided into four grades based on the in-the-bag IOL dislocation classification. All eyes underwent a complete ophthalmological examination. ECD was evaluated using in vivo corneal confocal microscopy. Median corneal ECD was 1929 (1022-2958)cells/mm2 of all the patients. The lowest number of ECD was in grade 2 (grade 1 median ECD 1990.33 (1182-2425.33)cells/mm2, grade 2-1577.0 (1022-2958)cells/mm2, grade 3-2205.84 (1259-2807.67)cells/mm2 and grade 4-2072.17 (1045-2581.0)cells/mm2). A statistically significant difference was observed between the median of ECD of grade 2nd and 3rd (p = 0.023). By grouping cases into those with and without glaucoma, we found that corneal ECD was significantly lower in eyes with glaucoma compared with eyes without glaucoma in grades 3 and 4 (p < 0.05), while in other grades, the difference did not reach the significance level. We divided the corneal ECD of all eyes into two categories ≤ 1500cells/mm2 and > 1500cells/mm2. Logistic regression demonstrated that the odds of having corneal ECD less than 1500 cells/mm2 increased by 3.5-fold if patients with IOL dislocation had been diagnosed with glaucoma previously. Late spontaneous in-the-bag IOL dislocation reduced corneal ECD. Previously diagnosed glaucoma was the most common comorbidity. This condition has a significant impact on corneal ECD for patients with IOL dislocation.

Late in-the-bag intraocular lens dislocation.

This review aimed to evaluate the cumulative incidence, patient characteristics, predisposing conditions, and treatment outcomes for late in-the-bag intraocular lens (IOL) dislocation. Literature searches in PubMed (MEDLINE), Embase, and Cochrane Library Central database identified 1 randomized clinical trial, 1 prospective case series, 2 prospective cohort studies, and 36 retrospective studies of this condition, which showed that the cumulative incidence was 0.5% to 3%, it occurred on average 6 to 12 years after cataract surgery, and mean patient age was 65 to 85 years. Pseudoexfoliation syndrome, myopia, and previous vitreoretinal surgery were the most common predisposing conditions. Studies indicated that IOL repositioning and IOL exchange provided similar visual outcomes and were equally safe. The long-term visual outcome seemed satisfactory. However, the quality of evidence regarding treatment was in general quite low. More studies of late in-the-bag IOL dislocation are needed, and in particular, different surgical techniques should be included in high-quality clinical trials.

Late Dislocation of In-the-Bag Intraocular Lens in Three Patients with Multiple Chorioretinal Atrophy Associated with Sarcoidosis

PurposeA late dislocation of an in-the-bag intraocular lens (IOL) is strongly associated with pseudoexfoliation and less with retinitis pigmentosa, prior vitreoretinal surgery, and uveitis. We present our findings of late in-the-bag IOL dislocation in three patients with multiple chorioretinal atrophy associated with sarcoidosis.MethodsObservational study of three elderly female Japanese patients with a history of uveitis from sarcoidosis who presented with a late dislocation of an in-the-bag IOL.ResultsThe late in-the-bag IOL dislocation occurred in the convalescent/quiescent stage of the sarcoidosis. Peripheral multifocal chorioretinal atrophy was the main manifestation in all patients who were diagnosed with definite or presumed sarcoidosis. The dislocated IOLs were successfully removed and new IOLs were implanted with scleral suture fixation followed by no remarkable active uveitis.ConclusionClinicians should be aware that patients with peripheral multifocal chorioretinal atrophy associated with sarcoidosis can have a late in-the-bag IOL dislocation.

Long-term myofibroblast persistence in the capsular bag contributes to the late spontaneous in-the-bag intraocular lens dislocation

Late spontaneous in-the-bag intraocular lens (IOL) dislocation is a complication presenting 6 months or later after cataract surgery. We aimed to characterize the cells in the lens capsules (LCs) of 18 patients with spontaneous late in-the-bag IOL dislocation. Patients' average age was 82.6 ± 1.5 years (range 72–98), and most of them had pseudoexfoliation syndrome (PEX). Cells from the LCs were positive for myofibroblast (αSMA), proliferation (Ki-67, PCNA), early lens development/lens progenitor (SOX2, PAX6), chemokine receptor (CXCR4), and transmembrane (N-cadherin) markers, while negative for epithelial (E-cadherin) marker. Moreover, the cells produced abundant fibronectin, type I and type V collagen in the nearby extracellular matrix (ECM). During ex vivo cultivation of dislocated IOL-LCs in toto, the cells proliferated and likely migrated onto the IOL’s anterior side. EdU proliferation assay confirmed the proliferation potential of the myofibroblasts (MFBs) in dislocated IOL-LCs. Primary cultured lens epithelial cells/MFBs isolated from the LC of dislocated IOLs could induce collagen matrix contraction and continuously proliferated, migrated, and induced ECM remodeling. Taken together, this indicates that long-lived MFBs of dislocated IOLs might contribute to the pathogenic mechanisms in late in-the-bag IOL dislocation.

Cost-effectiveness analysis in a randomized trial of late in-the-bag intraocular lens dislocation surgery: repositioning versus exchange.

To compare the cost-effectiveness of two operation methods for late in-the-bag intraocular lens (IOL) dislocation. In this randomized clinical trial, 104 patients were randomly assigned to IOL repositioning by scleral suturing (n=54) or IOL exchange with a retropupillary iris-claw lens (n=50). A cost-effectiveness analysis (CEA) was performed in conjunction with previously published 6-month efficacy and safety results. An incremental cost-effectiveness ratio was calculated as the cost difference between the operation groups relative to their difference in postoperative corrected distance visual acuity (CDVA) (mean and 95% confidence interval: minimum and maximum), reported as the cost difference in United States Dollars ($) per logMAR difference. Exchange surgery was $281.20±17.66 more expensive than repositioning, mainly explained by the new IOL and the frequent use of anterior vitrectomy. A previous trial publication revealed no significant difference in the 6-month postoperative CDVA between the groups. In the CEA, the mean group difference yielded an incremental cost-effectiveness ratio of -$281.20 per -0.11 logMAR (-$1108/QALY) in favour of repositioning, ranging from -$281.20 per -0.29 logMAR (-$406/QALY) in favour of repositioning to +$281.20 per -0.08 logMAR (+$1522/QALY) in favour of exchange. The CEA did not include the mean 9.5min shorter operation time for exchange. Repositioning tended to be more cost-effective than exchange; however, this is modified if also considering the operation time. Overall, it seems the cost-effectiveness is not alone sufficiently different to recommend one of the operation methods over the other for late in-the-bag IOL dislocation.

Intraocular pressure changes before and after surgery for spontaneous in-the-bag intraocular lens dislocation

To evaluate changes in intraocular pressure (IOP) after surgical correction of spontaneous late in-the-bag intraocular lens (IOL) dislocation. Two tertiary referral hospitals in Spain. Retrospective case series. Cases of in-the-bag IOL dislocation from 2004 to 2014 were included. The IOP and grade of IOL dislocation were correlated before surgery. The IOP and number of drugs to treat glaucoma were compared before and after surgery in cases with more than 6months of follow-up in the whole group and in separate groups according to the technique used to correct IOL position. This study evaluated 134 eyes. The mean IOP at diagnosis decreased significantly as the grade of dislocation increased (P=.012). After surgery, the mean corrected distance visual acuity improved significantly and the mean IOP decreased significantly after surgery in all groups (both P=.000); the IOP decrease was significantly more pronounced in the glaucoma group than in the entire sample (P=.011). No statistically significant differences were detected in preoperative or postoperative IOP between the surgical technique groups. There was no significant increase in the number of drugs to treat glaucoma (P=.064). There was a significant trend toward a decrease in IOP as the grade of IOL dislocation increased. The IOP decreased significantly after surgical management of in-the-bag dislocated IOLs without a significant increase in number of drugs to treat glaucoma. The decrease was independent of the technique used to correct IOL dislocation.

Glaucoma and Intraocular Pressure in Patients Operated for Late In-the-bag Intraocular Lens Dislocation: A Randomized Clinical Trial

To compare intraocular pressure (IOP) and IOP-lowering treatment requirements in patients with late in-the-bag intraocular lens (IOL) dislocation operated with 2 different methods, and to assess whether an IOP decrease after surgery can be expected. Prospective, randomized, parallel-group clinical trial. In our university clinic, 104 patients (eyes) were randomly assigned to IOL repositioning by scleral suturing (n= 54) or IOL exchange with a retropupillar iris-claw lens (n= 50). The main outcome measure was 6-month postoperative IOP change. Overall IOP was 18.0 ± 6.2mm Hg before surgery and 15.7 ± 4.8mm Hg 6months after surgery (P < .001). IOP changed by-1.2 ± 5.8mm Hg (P= .18) in the Repositioning group and-3.8 ± 6.4mm Hg (P < .001) in the Exchange group (group difference: P= .05). Before surgery, 62 patients had either preexisting glaucoma (n= 39) or high IOP (≥22mm Hg) with suspected glaucoma (n= 23), of whom several required preoperative IOP-lowering treatment. In the postoperative period, 28% and 21% of the patients in each operation group, respectively, required IOP-lowering treatment with glaucoma medications added, adjunctive laser trabeculoplasty, cyclodiode laser, or filtering surgery. Only 0 and 3 patients, respectively, discontinued their IOP-lowering medication. This trial showed an IOP decrease after late in-the-bag IOL dislocation surgery that seemed to be more pronounced with IOL exchange. However, associated high IOP was not resolved by dislocation surgery in many patients, and increased IOP-lowering treatment in the postoperative course was commonly required.

Incidence and risk factors of late in-the-bag intraocular lens dislocation: Evaluation of 140 eyes between 1992 and 2012

To identify risk factors for late in-the-bag intraocular lens (IOL) dislocation and estimate the incidence of this condition over a 21-year period. Department of Ophthalmology, County Hospital of Värmland, Karlstad, Sweden. Retrospective cohort study and nested case-control study. The medical records of eyes operated on for late in-the-bag IOL dislocation between 1992 and 2012 were reviewed. The annual incidence and cumulative risk were calculated. Of 140 eyes whose records were reviewed, 123 qualified for comparison (24 variables) with an equal number in a control group. The annual incidence varied between 0.00% and 0.08%. An increasing trend was found (P < .001). The cumulative risk 5, 10, 15, and 20 years after cataract extraction was 0.09%, 0.55%, 1.00%, and 1.00%, respectively, and was significantly higher (P < .001) in eyes that had cataract surgery between 2002 and 2012 than in those operated on between 1992 and 2001 (0.89% versus 0.39% at 10 years postoperatively) (P < .001). Calendar time (date) of dislocation was positively correlated with the duration of preceding pseudophakia (P = .005). Phacoemulsification time was longer in eyes with dislocation than in control eyes (P < .001). Other identified risk factors were pseudoexfoliation, zonular dehiscence, pseudophacodonesis, and increased axial length. The increasing number of late in-the-bag IOL dislocations cannot be explained by the growing pseudophakic population only. The increase in the incidence was due primarily to the longer duration of pseudophakia in the population and to a greater dislocation risk with recent cataract surgery. The increase in life expectancy played a minor role. Long phacoemulsification time was a risk factor for dislocation. No author has a financial or proprietary interest in any material or method mentioned.

Late in-the-bag intraocular lens dislocation in patients with uveitis.

Late in-the-bag intraocular lens (IOL) dislocation is an unusual complication of cataract surgery, being strongly associated with pseudoexfoliation, less so with previous vitreoretinal surgery, myopia and uveitis. We present the clinical features, management and outcomes of late spontaneous IOL dislocation in a series of patients with uveitis. A retrospective case series of IOL dislocation affecting patients in the Manchester Uveitis Clinic, UK. The uveitis diagnosis, IOL type, presentation and management are discussed. Six patients from out of 1056 undergoing cataract surgery (0.57%) were affected. Uveitis was the only identified risk factor for IOL dislocation, which occurred a mean 10.3 years following uncomplicated cataract surgery by phakoemulsification with endocapsular IOL implantation. The dislocation was in-the-bag in all six cases. Two patients presented with the IOL in the anterior chamber, and required removal of the IOL-bag complex, and are using aphakic refractive correction. Two patients with inferior IOL subluxation have been managed conservatively. Two patients underwent pars plana vitrectomy with sutureless scleral fixation of the existing IOL in one case, and IOL exchange with a scleral sutured IOL in the other. IOL dislocation is an uncommon late complication in patients with uveitis. Conservative management is appropriate in patients with tolerable symptoms, or in those with difficult uveitis. Otherwise, fixation of the existing IOL, or removal and implantation of a secondary IOL, may be necessary. Angle-supported, or iris-enclaved IOLs, are not of proven safety in this patient group; scleral-fixated posterior chamber IOLs are the favoured approach in our service.

Late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes

To study the predisposing factors for late in-the-bag intraocular lens (IOL) dislocation and to analyze the outcomes after explantation surgery. In this retrospective multicentre study, 61 eyes were enrolled. The main inclusion criterion was in-the-bag spontaneous IOL dislocation after uneventful phacoemulsification cataract extraction. Only eyes with serious dislocation that required IOL explantation were eligible. Follow-up after explantation surgery of at least 3 months was required. Exclusion criteria were complicated cataract surgery, out-of-the-bag IOL dislocation, and dislocations that occurred in the first year after the cataract surgery. The main outcome measures were predisposing factors for dislocation, interval between cataract surgery and dislocation, surgical treatment at the time of explantation, preoperative and postoperative corrected distance visual acuity (CDVA), and postoperative complications. High myopia was detected in 12 cases (19.7%) and it was the main predisposing factor. Mean time interval from cataract surgery to dislocation was 7.5 (SD 5.2) years. The dislocated in-the-bag IOL was replaced with a scleral fixated IOL (36.1%), angle-supported anterior chamber IOL (31.1%), sulcus repositioning (18%), or posterior chamber iris sutured IOL (4.9%). Finally, 9.8% of the patients were left aphakic. Mean CDVA improved significantly after surgery (P=0.005). Final CDVA of 20/40 or better was achieved in 29 cases (47.5%). High myopia was the main risk factor for late in-the-bag IOL dislocation. Surgical treatment significantly improved the CDVA in our sample and was associated with a low complication rate.

Simplified ab externo scleral fixation for late in-the-bag intraocular lens dislocation

Many surgical techniques to repair late in-the-bag intraocular lens (IOL) dislocation have been described. We present a modification to ab externo scleral fixation of in-the-bag IOL dislocation that minimizes cumbersome intraocular manipulations. Using an iris hook for intraocular suture retrieval under direct visualization eliminates the need to mate the suture needle with a hypodermic needle, and the site through which the hook is used provides an ideal place for suture knot burial, potentially minimizing late suture erosion or exposure.

Management of late spontaneous in-the-bag intraocular lens dislocation: Retrospective analysis of 45 cases

To evaluate the characteristics of and risk factors for spontaneous late in-the-bag intraocular lens (IOL) dislocation and to analyze the outcomes of surgical correction. Department of Ophthalmology, Complejo Hospitalario Orense, Orense, Spain. In this retrospective single-surgeon interventional case series, the surgical database of a referral center was searched for cases of late spontaneous in-the-bag IOL dislocation between 2005 and 2009. The main outcome measures were interval between surgery and dislocation, dislocation site and grade, IOL type, associated capsular tension ring (CTR), predisposing factors, surgical technique to correct dislocation, preoperative and postoperative corrected distance visual acuity (CDVA), and surgical complications. Pseudoexfoliation was the main risk factor for in-the-bag IOL dislocation (66.66% of 45 cases identified). A CTR was present in the capsular bag in 8 cases. Dislocation was corrected by repositioning using scleral fixation (20 cases) or iris suturing (1 case), IOL exchange for an anterior chamber IOL (AC IOL) (19 cases) or iris-claw IOL (4 cases), or (3) anterior capsulotomy (1 case). The mean CDVA improved significantly postoperatively (P = .0001); it was 20/40 or better in 28 eyes (62.22%) and 20/25 or better in 10 eyes (22.22%). There was no significant difference in postoperative CDVA between scleral-fixated IOLs and AC IOLs (P = .316). Pseudoexfoliation was the main risk factor for in-the-bag IOL dislocation. The presence of a CTR in the bag did not prevent dislocation. Satisfactory results were achieved with a low rate of complications using different surgical techniques to correct IOL position. No author has a financial or proprietary interest in any material or method mentioned.