14 Malpositioned Intraocular Lens and Capsular Bag: Intraocular Lens Complex Issues Abstract Malpositioned intraocular lens (IOL) with capsular bag–IOL complex requires an immediate attention with necessary surgical intervention that may range from an IOL explantation to repositioning or to a secondary IOL fixation. This chapter highlights the issue of IOL tilt, decentration, and malposition that can lead to suboptimal outcomes. The capsular bag–IOL complex issues will also be covered along with the techniques to realign the IOL and manage the case as per surgical scenario. Keywords: malpositioned IOL, decentration, glued IOL, IOL scaffold, IOL exchange, Subluxation, Repositioning, capsular bag–IOL complex, IOL explant Malpositioning of an intraocular lens (IOL) may range from mild decentration to complete luxation in the posterior segment. Although the frequency of IOL dislocation ranges from 0.2 to 3%,1,2,3,4,5,6,7,8,9 clinically insignificant and significant decentrations are seen in 25% and 3% of the cases, respectively.10,11 Malpositioned IOLs often present with extreme decentration to the extent that the IOL optic covers only a small portion of the pupillary space ( The management of a malpositioned IOL depends on various factors that may range from the timing of onset of dislocation to the etiology and to the extent of dislocation along with the type of the IOL that is malpositioned in the eye. The surgeon needs to make a decision between the surgical repositioning and refixating the same IOL and performing an IOL exchange. In such a situation, the presence of a three-piece IOL in the eye has a distinct advantage as it can be repositioned and placed in the sulcus with or without an optic capture or the haptics of the same IOL can be externalized and tucked into the intrascleral pockets as in a glued intrascleral haptic (glued IOL) fixation12,13,14,15 in cases with inadequate sulcus support ( Repositioning, if possible, has a distinct advantage of closed chamber approach with the appropriate surgical alignment of the IOL. The amount of maneuver needed to reposition the IOL depends on the type of the IOL and the associated condition in the eye. In cases with inappropriately dialed IOL where one haptic lies in the capsular bag and the other haptic is outside the capsular bag, a simple intervention of inflating the capsular bag and the anterior chamber (AC) with an ophthalmic viscosurgical device (OVD) followed by dialing an IOL completely into the capsular bag suffices the need for any further intervention. Fig. 14.1 Significantly decentered plate haptic intraocular lens (IOL) with the optic not visualized in the pupillary zone. Fig. 14.2 Decentered three-piece intraocular lens (IOL) with capsular tension ring (CTR). (a) A decentered three-piece IOL with a CTR and the entire bag is seen. (b) Two partial-thickness scleral flaps are made 180 degrees opposite along with sclerotomy as in a glued IOL procedure. One IOL haptic is grasped and vitrectomy is performed to cut down all vitreous adhesions and capsular fibrosis. (c) Total cortical and capsular cleanup is achieved. Handshake technique is performed wherein the haptic is transferred from one hand to another for easy haptic externalization and the tip of the haptic is grasped. (d) The tip of the haptic is externalized from the respective sclerotomy site. (e) The CTR is grasped and the handshake technique is performed to reach the tip of the CTR. (f) The handshake technique being performed for CTR. Fig. 14.3 Decentered three-piece intraocular lens with capsular tension ring (CTR). (a) The tip of the CTR is grasped for externalization. (b) The CTR is pulled from the corneal incision. (c) The CTR is removed. (d) The externalized haptic is grasped with an end-opening forceps. (e) Both the haptics are externalized. (f) Scleral pockets are created with a 26-gauge needle. Fig. 14.4 Decentered three-piece intraocular lens with capsular tension ring (CTR). (a) Haptic tucked into the scleral pockets. (b) Both haptics are tucked into the scleral pockets. (c) Fibrin glue is applied beneath the flaps. (d) The scleral flaps and the conjunctival incisions are sealed with fibrin glue. The corneal tunnel incision is closed with a 10–0 suture and air bubble is put into the anterior chamber. Decentration may be associated with a posterior capsule rupture (PCR) and in these cases the type of IOL present in the eye plays the key decision maker along with the surgical technique that the surgeon is most comfortable employing in such a demanding condition. In cases with intraoperative PCR, often after vitrectomy in a localized small posterior capsule (PC) tear, surgeons place a one-piece foldable IOL in the capsular bag. Although this suffices the need at that hour, in late postoperative follow-up period decentrations have been reported to occur. An initial attempt at vitrectomy from the pars plana route allows cutting all the vitreous behind the IOL and the capsular bag. Decompressing the posterior chamber helps obviate the push from behind the IOL and helps stabilize the capsular bag. After adequate vitrectomy, the IOL can be dialed again in its position and if possible optic capture can be attempted although it is a bit difficult to capture a one-piece IOL. In cases with massive PCR with decentration of one-piece IOL, the surgeon is left with the only option of IOL explantation. Ideally in cases of PCR, a three-piece IOL should always be placed either in the bag or in the sulcus. Doing so has an added advantage that in cases of decentrations, the IOL can be easily and safely repositioned either in the sulcus or in the bag, thereby minimizing the chances of an IOL exchange ( Decentrations and malpositioned IOLs call for surgical intervention when repositioning does not suffice the need. The type of IOL to be reimplanted in the eye depends on the etiology of the decentration. In cases with either damage to the IOL at the optic haptic junction or with cut haptics, the IOL needs to be explanted and exchanged. An IOL of the same type can be placed in the bag, as the cause of decentration was IOL damage. However, in cases with multifocal IOL intolerance, the multifocal IOL needs to be exchanged for a monofocal IOL. In cases of decentration with associated PCR, the one-piece IOL if present is explanted, followed by placement of a three-piece IOL in the sulcus with/without an optic capture. In this technique,16 the offending IOL is manipulated out of the capsular bag into the AC, and the corrective IOL is inserted into the bag. The offending IOL is levitated from the bag and is brought into the AC. A new corrective IOL is then injected into the AC beneath the offending IOL. The corrective IOL is then dialed into the capsular bag and is placed in position. The anteriorly elevated IOL is transected with the IOL cutting scissors, while the corrective IOL acts as a scaffold for the PC. The offending IOL is cut with IOL cutting scissors and is then explanted out of the AC. The continuous distension of the bag with the presence of the IOL prevents damage to the PC while the IOL is being cut. Through pars plana approach, a limited vitrectomy is performed beneath the capsular opening and the IOL is then levitated into the AC from the limbal approach. A corrective IOL is then dialed into the capsular bag in a way that it plugs the posterior capsular opening altogether and also acts as a barrier to vitreous prolapse in cases of an open PC. This method works effectively in cases with small PC openings only as in cases where a previous yttrium aluminum garnet (Yag) capsulotomy has been performed. The offending IOL is then cut and explanted. The corrective IOL is always a three-piece IOL so that in cases with further issues with decentration, the IOL can be refixated with the glued technique12,13,14,15 or it can be placed in the sulcus if feasible. In cases involving IOL exchange from a capsule fixated IOL many months or years postoperatively, the surgeon should carefully open the capsular bag and successfully use the scaffold technique to protect the PC or avoid vitreous prolapse if the PC is open. Adequate caution should be exercised while dialing the IOL haptic out of the capsular bag to avoid undue stress on the capsule. In cases of complete loss of capsular support along with IOL decentration, the IOL needs to be explanted altogether and secondary IOL implantation is the only choice that the surgeon is left with. A scleral tunnel incision is framed and often the author prefers to adopt the “L”-shaped incision instead of a linear scleral incision as these “L”-shaped incisions are considered to be astigmatically neutral. For creating an “L” tunnel, a 3-mm mark is set on the vernier caliper and the “L”-shaped scleral incision is marked (
14.1 Malpositioned Intraocular Lens
14.1.1 Introduction
Fig. 14.1). Depending on the amount of IOL dislocation, the patient may present with symptoms of decreased vision and associated complications such as cystoid macular edema (CME), vitritis, corneal decompensation, secondary glaucoma, and retinal involvement. IOL malposition or dislocation can occur either in the initial postoperative period or during any phase of the entire postoperative period depending on the causal factor and associated etiology and predisposing factor.
14.1.2 Management
Fig. 14.2, 
Fig. 14.3, 
Fig. 14.4).
14.1.3 Repositioning the Intraocular Lens
Presence of One-Piece Intraocular Lens
Presence of a Three-Piece Intraocular Lens
Fig. 14.2, 
Fig. 14.3, 
Fig. 14.4).
14.1.4 Intraocular Lens Exchange/Explant
Intraocular Lens Scaffold for Intraocular Lens Exchange
With Intact Posterior Capsule
With Broken Posterior Capsule
Fig. 14.5a). The crescent blade is used to make the tunnel along the L-shaped mark and the tunnel is widened anteriorly and to the sides (intrascleral aspect) creating a nearly 6-mm-wide tunnel (
Fig. 14.5b,c,d). An L-shaped incision provides good chamber stability and an equal ease of IOL explantation and insertion from the “L” design incision with the added advantage of a good intrascleral extension of the L-shaped tunnel incision that facilitates the IOL manipulation. A square incision wherein the length and the width of the incision are equal is the most astigmatically stable wound. L-shaped incision has been considered to be superior to the conventional linear incision due to its astigmatic neutral wound architecture. The scar tissue according to Drew’s theory tends to contract along its horizontal axis as much as to its perpendicular axis.
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