▪ This is a very unfortunate case because this 48-year-old man would be expected to have a long life expectancy of over 20 years. The probability of future suture breakage of any fixation Prolene sutures needs to be discussed with him because Prolene may well degrade in the eye over a period of time. Any further surgery in his eye would definitely increase the chance of difficulties with his retina, inflammation that can lead to cystoid macular edema (CME), and possibly further problems with suprachoroidal hemorrhages or effusions. One of the first things I would do is specular microscopy to evaluate the health of his endothelium. If he has a very good cell count of over 1500 or 2000 cells/mm2, one could consider doing further surgery to reposition this IOL or replace it with another one. If the cell count is low, one wants to minimize any further trauma to the cornea. It appears that the eroded fixation sutures will have to be removed and, in doing so, it can be assumed that the implant will dislocate even further. Therefore, a decision has to be made to either refixate the IOL with different sutures, to exchange it with some type of other implant, or to merely remove it. If the patient has a very long axial length and he would have a relatively emmetropic refraction by merely removing the IOL, that would be my first suggestion to him. I think that has to be considered because the patient has only this 1 eye and it would minimize further risk to the eye.
If it is decided to leave the lens in place, perhaps a more efficient way to fixate the lens would be to use a McCannel-type suture to fixate the 2 haptics. Once the lens is positioned, a similar suture can be placed by any variety of methods to close the side of the pupil that is distended toward the limbus. I would utilize 9-0 Prolene sutures for all of these maneuvers for a longer lasting suture fixation. Considering the history that he has in the other eye and that he has already had a history of a suprachoroidal hemorrhage in this eye, in reconstructing the pupil, I would try to leave at least a 4.0 or 5.0 mm pupil to facilitate better examination of his retina.
If the patient had 2 eyes, I would consider exchanging his IOL with an artificial iris implant, which would be scleral fixated with 9-0 Prolene sutures. However, with his history of a suprachoroidal hemorrhage in this eye and this being his only eye, I do not believe that would be an appropriate alternative for him. I have seen patients develop suprachoroidal hemorrhages for a second time when they have undergone surgery years after a previous suprachoroidal hemorrhage, and I do not think that is an appropriate risk to take in this case.