What is the management of an intraocular lens (IOL) drop?

Management of IOL Dislocation

Surgical intervention is the definitive management for visually significant IOL dislocation, with the choice between IOL repositioning (with or without scleral fixation), IOL exchange, or leaving the eye aphakic depending on the timing, type of dislocation, and IOL characteristics. 1, 2

Initial Assessment and Decision-Making

Determine the type and timing of dislocation:

• In-the-bag dislocations typically occur late (mean 132 months post-cataract surgery) and are associated with pseudoexfoliation syndrome (40-57% of cases), high myopia (40%), previous vitrectomy (38%), or Marfan syndrome 3, 2
• Out-of-the-bag dislocations occur much earlier (mean 3.8 months) and result from capsular rupture or zonular dehiscence during complicated cataract surgery 2
• Most dislocations (80%) occur spontaneously without a triggering event 2

Surgical Approach Selection

Choose between anterior versus posterior approach based on the clinical scenario:

Posterior Approach (Pars Plana)

• Preferred in 76% of cases and involves pars plana vitrectomy with IOL repositioning using scleral sutures 3
• This approach is particularly effective for complete posterior segment dislocations 1, 3
• Results in significant IOP reduction (mean 3.0 mm Hg) in glaucoma patients 3

Anterior Approach (Limbal)

• Used in 67% of cases in some series, particularly for partial dislocations or when posterior segment complications are less likely 2
• May be combined with limbal-pars plana approach depending on IOL position 4

Surgical Management Options

Select the specific surgical technique:

IOL Repositioning with Scleral Fixation

• Performed in 94% of cases using scleral sutures to secure the existing IOL 3
• For single-piece acrylic IOLs, the "punch and rescue" technique creates anchor points at the optic-haptic junction using an IOL punch instrument, allowing precise scleral fixation without explantation 5
• This approach maintains or recovers previous uncorrected visual acuity while being less invasive 5

IOL Exchange

• Required in 47% of cases when the existing IOL cannot be safely repositioned 2
• Consider when IOL is damaged, incorrect power, or unsuitable for refixation 1, 2

Aphakia

• Left aphakic in 25% of cases when neither repositioning nor exchange is feasible or safe 2
• This may be necessary due to severe complications or patient factors 2

Expected Outcomes and Complications

Visual outcomes:

• 59% of eyes achieve Snellen CDVA of 0.5 (20/40) or better at follow-up 3
• 50% achieve 20/50 or better in combined series 4
• 23% may have worse CDVA than preoperatively due to preexisting conditions or complications 3

Common complications to monitor:

• Cystoid macular edema is the most frequent complication (10% of cases) 1
• Retinal detachment occurs in 3-4% of cases after IOL dislocation management 1, 3
• Recurrent dislocation or decentration occurs in 6-10% of cases, requiring reoperation in 6% 1
• Additional surgical procedures needed in 13-18% of eyes 3

Critical Pitfalls to Avoid

• Do not delay surgery when dislocation is visually significant, though timing does not appear to affect visual outcome in non-randomized observations 4
• Recognize that foldable IOLs (3-piece silicone 50%, one-piece foldable 28%) are now more commonly involved than rigid IOLs 2
• Screen for pseudoexfoliation as it significantly increases risk of in-the-bag dislocation 3, 2
• Monitor IOP closely in glaucoma patients, as repositioning surgery may improve IOP regulation 3