▪ This malpositioned lens needs to be surgically corrected since leaving a decentered lens, fixed dilated pupil, and eroding sutures is quite intolerable.
The IOL can be either replaced or repositioned and fixated to the adjacent structures. There seems to be no more capsular support (Figure 2). The lenses used 15 years ago were usually 13.0 mm and longer (since in 70% at least 1 loop was out of the bag), and still it was not enough for a stable fixation. Therefore, sulcus fixation alone is out of question.
Anterior chamber IOL is a reasonable option, especially the Artisan lens. However, pupilloplasty needs to be done first to ensure stable fixation and avoid diplopia.
My preference is to reposition and refixate the same IOL with minimal surgical intervention. This eye had a suprachoroidal hemorrhage in the past, probably as a result of a prolonged hypotony during the scleral fixation procedure. It is, therefore, at high risk to develop a second event if the eye is opened again. A closed system procedure will maintain a stable pressure and reduce the risk of this potentially blinding complication. To fixate the IOL, I usually prefer iris fixation over scleral fixation, if possible. The iris tolerates the IOL surprisingly well, and in most cases there is no chronic inflammation, chafing, pigment dispersion, or microhyphema, which may theoretically occur. The eyes are quiet, the lenses can be easily centered, and there are no external suture endings that may erode and cause intolerable pain and irritation.
The procedure that I would do is the following: The anterior chamber is filled with highly viscous viscoelastic substance without pupil dilation. It is very important not to dilate the pupil because it interferes with IOL centration and suture position. The IOL is then centered, assuming that at least 1 of the sutures is broken (otherwise the IOL would not decenter). If the sutures are still there, I would cut the 2 sutures of the loops and leave only the loose suture that passes through the positioning hold (Figure 2) as a safety suture. I would then elevate the optic of the IOL to the anterior chamber to create iris capture for 3 reasons: (1) The IOL is thus best centered relative to the visual axis; (2) it prevents the IOL from falling backward during the procedure; and (3) it creates indentation of the IOL loops behind the iris, facilitating passage of the needle behind the haptics. I usually use the W1713 polypropylene (Prolene®) 10-0 suture (16.0 mm long straight needle) for the procedure. I do not think Prolene is the ideal material, but it the best on the market. The modified McCannel suture is done by passing the needle through the cornea, through the iris, under the IOL loop, and again through the iris and cornea. The suture is then externalized through a paracentesis, tied tightly, cut, and inserted into the anterior chamber. An alternative technique was introduced by Siepser (“slipping knot technique”) and is equally effective. Passing the needle at the superotemporal pupillary margin may achieve both loop fixation and effective pupilloplasty by the same suture, or pupilloplasty with the same needle can be done as a separate procedure. To reduce the risk for recurrent lens subluxation, I would make two iris sutures on each side. The eroding scleral suture can then be covered with preserved scleral patch, but I would prefer to remove it. The patient should be treated with topical steroids for 1 month because the uveal tissue was manipulated and to reduce the local inflammation at the area of the eroding sutures.
I have a good number of patients with iris fixation only, and my feeling is that these eyes do better than eyes with scleral-fixated IOLs.