1. An Epidemic of Dislocated IOLs? Garth Stevens Jr. MD Eye Care Center of Virginia Mary Washington Eye Care Center

2. Financial Disclosure The speaker is a paid consultant to Allergan, Inspire, and Abbott Medical Optics

3. Observation »Increased incidence of IOL dislocation the last 5 years

4. Incidence over time l Retina Institute of Virginia (379.39,996.53) »2006: 12 »2007: 17 »2008: 23 »2009: 22 »2010: 23 l Eye Care Center of Virginia »2000 to 2006: 14 »2007: 12 »2008: 15 »2009: 18 »2010: 15

5. Question: is there an increased incidence of dislocated IOLs over the last decade? l Davis et al Ophthalmology 2009, 116, 664-670. l 86 cases in bag pathology specimens »2000-2006: 27 »2006-2008: 59 l Associated diagnosis »Pseudoexfoliation (PXF) 50% »Vitreo-retinal surgery19% »Trauma16% »Unknown 23% »Uveitis2%

6. Incidence of IOL dislocation l Unclear, older reports from 1980s 0.2 to 3%, no good recent data. Certainly less than 1% with modern cataract surgery techniques l Clark.2% 10 y period others 0.6% over 10 y, with 2% with phakodonesis l How many of you have experienced in the bag dislocations, out of bag dislocations??

7. Role of capsular phimosis l Mechanisms »Preop zonules weak, surgery, capsular contraction, post op trauma l Exerts traction on zonules and may be related to dislocations »Should we avoid small capsulorhexis in high risk patients?

8. Capsular phimosis as a cause of dislocation

9. Open questions l Do capsular tension rings decrease the incidence of late dislocation of IOLs in PXF? »Probably yes with the Cionni ring and scleral fixation l Should we ensure that capsulotomy openings are larger in PXF to avoid capsular contraction syndrome?

10. Cofactors in Dislocations EARLY l Capsular rupture l Capsular instability LATE l Pseudo-exfoliation l Vitreoretinal surgery l Trauma l Uveitis l Cataract surgery complications l Yag capsulotomy l Capsular contraction syndrome

11. Dislocated with attached capsule Courtesy J. Astruc

12. Iris sutured IOL 10-0 prolene

14. Primary treatment concerns l When to intervene »Pseudo-phakodonesis »Subluxation »Dislocation l Factors »Age

15. Surgical decisions l Replace or reposition »Replace –Damaged haptic –Opacified optic »One piece PMMA IOL with suturing eyelets in haptics »Scleral fixation with prolene or Gore-Tex sutures l Alternative »AC IOL »In bag suturing to sclera or iris »Fibrin glue to haptics under sclera

16. Steps in reposition with McCannell suture to the iris: All lens types l Position in AC »Vitrectomy, retina back-up l Remove capsule and retained lens material l Decide on replace or reposition l Haptic behind iris with safety suture l Suture 10-0 prolene, CTC 6 needle, into iris, beneath haptic, out iris and tie loosely l Suture second haptic l Check position l Tighten sutures l iridoplasty

17. 90 y o, 20 y after cataract surgery, 3 y after suturing of left eye, 20/400 preop, 20/40 post op, removal retained lens material