This interesting case is a good depiction of the problems that can arise with sutured IOLs. It is significant that the current sutured IOL is immobile and stable with no movement of the loops and the loops appear intact. If this were not the case, the course of action would differ. Because nonsurgical techniques for management have been exhausted and the patient is symptomatic, the patient requires surgery to reposit the PC IOL. Because the patient is young, I would try to avoid using an anterior chamber (AC) IOL. It is important to have a well-dilated pupil for visualization. This can be achieved by using preoperative mydriatic agents and intraoperative intracameral lidocaine to help paralyze the iris sphincter and assist in pain control. If the pupil is still not well dilated, iris retractors could be used. It is important to “look around” and ensure that the haptics are still well positioned and secured.
The next step is to discern why the optic moved anteriorly and optic capture occurred. One might suspect that vitreous has moved anteriorly. At this point, 0.1 cc preservative-free Kenalog suspension (10 mg/cc triamcinolone acetate) could be used to determine whether vitreous is present in the anterior chamber. Kenalog would coat the surface of vitreous and stain it white, making it visible. If vitreous is present, the first step would be to remove it using a bimanual technique, splitting irrigation and aspiration/cutting. One could use a limbal or pars plana approach; however, the pars plana approach is probably better in this case. For a limbal vitrectomy, one would make 2 side-port incisions and use a 20-gauge cannula in the nondominant hand for irrigation and a vitreous cutter through the second incision. The disadvantage of this technique is it provides poorer access to vitreous under the iris. With the pars plana approach, one could use a 20- or 25-gauge cutter with a smaller sutureless incision placed 3.5 mm behind the limbus. Irrigation would still occur from the limbal site. With either technique, it is important to minimize vacuum and flow rates and maximize the cut rate. Periodic restaining of the vitreous with reinjection of Kenalog is necessary to ensure all vitreous is removed.
Next, the IOL must be repositioned. If any anterior capsule is present, one could partially capture the optic through the capsulotomy. Once the IOL is well centered behind the iris, one could inject acetylcholine chloride (Miochol) or carbachol to help the pupil constrict. A small peripheral iridecomy should be performed to avoid future risk for pupillary block.
Postoperatively, the patient should be placed on a low-dose topical miotic agent to ensure the optic stays posterior to the iris. It is also important that the patient have a thorough retinal examination postoperatively.