How should a dislocated intraocular lens be managed, including urgent referral, intra‑ocular pressure control, anti‑inflammatory and cycloplegic therapy, and surgical options?

Management of Dislocated Intraocular Lens

A dislocated intraocular lens requires urgent ophthalmology referral within 24 hours, immediate IOP control if elevated, and surgical repositioning or exchange as definitive treatment, with the specific surgical approach determined by capsular support and lens type. 1

Immediate Assessment and Stabilization

Urgent Referral

• All patients with suspected IOL dislocation require ophthalmology evaluation within 24 hours to assess the degree of dislocation, rule out serious complications (endophthalmitis, retinal detachment, malignant glaucoma), and determine surgical candidacy 1, 2
• Document visual acuity with and without pinhole testing to assess visual potential and guide urgency of intervention 1

IOP Management

• Measure IOP using Goldmann applanation tonometry or alternative methods (pneumotonometer, rebound tonometer) if corneal abnormalities are present 1
• Initiate ocular hypotensive therapy immediately if IOP is elevated, as dislocated IOLs can cause acute angle-closure glaucoma or pigmentary glaucoma 1
• Monitor for pupillary block, particularly with anterior chamber or iris-fixated phakic IOLs 1

Anti-inflammatory and Cycloplegic Therapy

• Start topical corticosteroids (prednisolone acetate 1% or loteprednol) to control inflammation and prevent iritis, which occurs as a complication in dislocated IOL cases 1
• Use preservative-free formulations if available to minimize additional ocular surface complications 2
• Apply cycloplegic agents (cyclopentolate 1% or atropine 1%) to reduce ciliary spasm, stabilize the blood-aqueous barrier, and prevent posterior synechiae formation 1

Comprehensive Slit-Lamp Examination

Perform detailed biomicroscopy to determine:

• Degree of dislocation: complete luxation into vitreous cavity versus subluxation with partial capsular support 3, 4
• IOL type: 3-piece versus 1-piece design, as 3-piece IOLs are more amenable to repositioning techniques 3
• Capsular bag integrity and zonular support: adequate capsular support allows sulcus repositioning, while absent support requires alternative fixation 5, 6
• Associated complications: corneal edema, cystoid macular edema, retinal detachment, vitreous hemorrhage 1
• Presence of peripheral anterior synechiae, iris capture, or pupil distortion 1

Surgical Management Algorithm

For IOLs with Adequate Capsular Support

• Repositioning in ciliary sulcus is the preferred approach when sufficient capsular bag remnant exists, using 23-gauge transconjunctival sutureless pars plana vitrectomy to retrieve and reposition the IOL 7
• This technique provides benefits of sutureless surgery with faster recovery and reduced astigmatism 7
• Visual outcomes of 20/50 or better are achieved in approximately 50% of cases regardless of surgical technique 5

For IOLs without Capsular Support

• Iris suture fixation is recommended for dislocated 3-piece acrylic IOLs, allowing the same IOL to be used in closed-eye surgery with long-term stability 3

• The technique involves 3-port 23-gauge PPV, placing the optic anterior to iris with haptics sutured to iris, then repositioning optics behind iris plane 3

• Mean visual improvement of 4.08 ± 5.33 logMAR lines is achieved with this approach 3

• IOL exchange with anterior chamber IOL is a viable alternative when capsular support is absent, particularly for posteriorly dislocated IOLs 6

• This approach achieves 20/30 or better vision in the majority of cases with similar complication rates to scleral suture techniques 6

• Requires limbal incision but avoids long-term suture-related complications (hemorrhage, endophthalmitis through suture tract) 6

• Scleral-sutured posterior chamber IOL remains an option but carries risks of hemorrhage, cystoid macular edema, retinal detachment, and endophthalmitis, with sutures that must last the patient's lifetime 6, 4

Special Considerations for Phakic IOLs

• Phakic IOL dislocation requires repositioning, exchange, or removal depending on the clinical scenario 1
• Care must be taken when dilating eyes with phakic IOLs in place due to increased risk of lens dislocation 1
• Iris-fixated phakic IOLs may cause transient IOP elevation, particularly when the crystalline lens apex is anterior to the iris plane 1

Postoperative Management

• Follow standard post-cataract surgery protocols with visits at Day 1, Weeks 1-2,1 month, 2 months, and 3-6 months 2
• Monitor for late complications including macular edema (occurs in approximately 1% of cases), retinal detachment (2% of cases), and IOL re-dislocation 3
• Continue topical corticosteroids with gradual taper over 4-6 weeks, monitoring for steroid-induced IOP elevation 1
• Assess for corneal endothelial compromise, particularly in cases requiring anterior chamber manipulation 1

Common Pitfalls

• Delaying surgical intervention in symptomatic patients can lead to irreversible complications including retinal detachment, chronic inflammation, and corneal decompensation 1, 5
• Attempting to reposition 1-piece IOLs in the sulcus is contraindicated; these require exchange or alternative fixation 3
• Failing to perform complete vitrectomy during repositioning increases risk of subsequent retinal complications 7, 3
• Overlooking predisposing conditions such as pseudoexfoliation, uveitis, or high myopia that increase risk of recurrent dislocation 4