This patient had excellent acuity at the targeted vision because the optic was in the capsular bag. Now that the optic is anterior to the bag, the visual acuity has changed with induced myopia from the more forward placement of the optic. In addition, there is some induced astigmatism associated with pseudophakodonesis, indicating that the lens is not stable in the ciliary sulcus. The opening in the anterior capsule appears centered, with the optic in front of it. The haptics appear to be partially compressed and fixed in that position.
The first step would be to attempt to replace the optic in the capsular bag. From the photographic appearance of the eye, it appears that a simple stab incision would be followed by placement of a needle that would tuck the optic behind the anterior capsule leaflets. It does not appear that vitreous is present but if so, a small vitrectomy could be performed. Once the optic is behind the anterior capsule leaflets, the lens should be fixed and secured, the pseudophakodonesis resolved, the astigmatism eliminated, and the spherical component back to normal.
If it is not possible to fixate the optic behind the capsule, it becomes necessary to fixate the entire lens. I would use a double-armed suture across the anterior chamber, with 1 passing above and 1 below the haptic of the IOL, suturing it to the sulcus. Hanemoto and coauthors1 describe another technique that uses a loop suture on a single needle that can be “cowhitched” to the haptic before it is sutured in the sulcus.
Regardless of which technique is used to secure the lens in the sulcus, the IOL will become secure and stable and the pseudophakodonesis and the astigmatism should pass. However, the patient will still be more myopic than anticipated.
If the myopia is a problem, a 4.5 mm temporal corneal incision can be fashioned. The IOL can be removed through that incision without being cut. A new lens with a power of about 1 diopter less could then be injected into the ciliary sulcus for placement there. The lens would have full-length haptics and not require suture fixation.
Finally, there is always the possibility of correcting the refractive change via corneal refractive surgery. However, in this case, the pathology is based on the lens and I think that the first attempt should secure the lens. Corneal refractive surgery should be considered only after the lenses are stable and in the best position possible.
1. Hanemoto T, Ideta H, Kawasaki T. Dislocated intraocular lens fixation using intraocular cowhitch knot. Am J Ophthalmol 2001; 131:265-267