How to manage an intraocular lens (IOL) drop?

Management of Intraocular Lens (IOL) Drop

Prompt surgical intervention via pars plana vitrectomy is the definitive management for IOL drop, with the choice between IOL repositioning/scleral fixation versus IOL exchange depending on lens integrity and surgeon expertise.

Immediate Assessment and Timing

When an IOL drops into the vitreous cavity, rapid evaluation is critical to determine the optimal surgical approach:

• Assess IOL integrity and position using dilated fundus examination and B-scan ultrasonography if visualization is limited 1, 2
• Evaluate for concurrent retinal complications including retinal tears or detachment, which occur in approximately 4% of cases following IOL dislocation management 2
• Surgery should be performed promptly once the patient is medically stable, as delayed intervention increases risk of chronic inflammation, cystoid macular edema (occurs in 10% of cases), and secondary glaucoma 1, 2

Surgical Management Algorithm

Primary Surgical Technique: Pars Plana Vitrectomy

All cases of IOL drop require pars plana vitrectomy as the foundational procedure 1, 3:

• Perform 23-gauge or 25-gauge three-port PPV with adequate core and peripheral vitrectomy to prevent future traction complications 1, 3
• The inferonasal or inferotemporal pars plana serves as the primary port, with limbal sites from prior cataract surgery utilized as additional ports 1

Decision Point: IOL Salvage vs. Exchange

For 3-piece IOLs that are intact and well-positioned, iris suture fixation or scleral fixation repositioning yields excellent long-term stability with mean visual improvement of 4+ lines 3:

• Iris suture fixation technique: Place the optic anterior to iris initially, suture haptics to iris tissue, then reposition optic behind iris plane - this avoids large corneal incisions and maintains original IOL power 3
• Scleral fixation: Used in 40% of cases when iris support is inadequate or in eyes with pseudoexfoliation syndrome (present in 44% of in-the-bag dislocations) 2, 4

For damaged IOLs, 1-piece acrylic IOLs, or plate haptic designs, IOL exchange is preferred 2, 4:

• Remove the dislocated IOL using intraocular forceps after adequate vitrectomy 1
• Replace with either anterior chamber IOL (used in 60% of exchange cases) or scleral-fixated posterior chamber IOL (40% of cases) 4

Critical Technical Considerations

Nucleus Drop vs. IOL Drop

If nuclear material has also dropped (distinct from IOL drop):

• Impale the nucleus with a micro vitreoretinal blade and bring it into the anterior chamber for removal before addressing the IOL 1
• Adequate vitrectomy must precede all nuclear or IOL manipulation to prevent vitreoretinal traction 1

Avoiding Perfluorocarbon Liquid

Modified vitrectomy techniques without PFCL are effective and avoid potential complications of retained PFCL, achieving 74% of patients reaching 6/18 (20/60) or better vision 1

Postoperative Management and Complications

Expected Visual Outcomes

• Visual acuity of 6/18 (20/60) or better is achieved in 74% of adult cases with prompt surgical management 1
• Mean postoperative visual improvement is approximately 4 lines on the logMAR scale when IOL is successfully repositioned 3

Common Complications to Monitor

Cystoid macular edema is the most frequent complication (10% incidence) and requires aggressive topical NSAID and corticosteroid therapy 2:

• Monitor with OCT at 1 week, 1 month, and 3 months postoperatively
• Treat with topical ketorolac 0.5% four times daily and prednisolone acetate 1% four times daily, tapering based on response

Retinal detachment occurs in 4% of cases following IOL dislocation surgery 2:

• Perform careful peripheral retinal examination at each postoperative visit
• Educate patients on symptoms of flashes, floaters, and visual field defects requiring urgent evaluation 5

IOL redislocation or decentration occurs in 6% of cases but is not related to IOL type or surgical technique 2:

• Iris suture fixation demonstrates excellent long-term stability with no redislocations reported in recent series 3

Special Circumstances

For patients on anticoagulation (as with stroke history), coordinate with primary care or cardiology regarding perioperative management, but do not delay surgery as the visual prognosis worsens with time 5

In eyes with advanced glaucoma, maintain IOP control throughout the perioperative period and consider prophylactic IOP-lowering measures during vitrectomy 5

IOL opacification can occur as a late complication (months to years postoperatively) and requires IOL exchange if vision is significantly affected 5