Although it has been shown that late spontaneous dislocation of the capsular bag/IOL may occur in patients with pseudoexfoliation after routine cataract surgery,1 we think the rate of this complication is extremely low. In a routine cataract patient with pseudoexfoliation, we prefer to place the IOL in the capsular bag when possible.
When evaluating these patients preoperatively, we look closely for signs that may indicate zonular instability. Poor pupil dilation, a shallow anterior chamber, and phakodonesis seen at the slitlamp are possible signs that alternate IOL placement may be necessary. Subtle iridodonesis or phakodonesis, however, may be masked by dilation as cycloplegia often tightens even lax zonules and deepens the anterior chamber from its undilated state.
Intraoperatively, it often becomes obvious on initiation of the capsulorhexis whether zonular instability is present. Phacoemulsification is made more difficult by phakodonesis, and any major zonular weakness is obvious by I/A when the tension on the cortical material is directed against the zonules. Aspiration directed in a tangential fashion rather than perpendicular to the zonules may decrease the incidence of zonular dehiscence. In addition, irrigation of smaller amounts of cortex at any given time may produce less zonular stress by transmitting less tension to the capsule.
If the cataract extraction is uneventful with minimal zonular instability, we place the IOL in the bag. If more significant zonular weakness is present, we consider fixation of the lens with a McCannel-type suture in the bag or perform sulcus placement.
A CTR may be helpful in these situations, but it is unclear whether its use will reduce the incidence of late dislocation of the capsular bag/IOL. If there is minimal capsule support, we place a transsclerally sutured IOL. Complete absence of capsule support necessitates an anterior chamber IOL.
With this approach, the overwhelming majority of our patients do well and never require a second intervention for a dislocated or displaced IOL. In the few who may develop visually significant decentration or dislocation, we recenter and fixate the lens with a McCannel suture or do an IOL exchange with an anterior chamber or transsclerally sutured IOL.
1. Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology 2001; 108:1727-1731