Several surgical options for managing this case exist.1,2 One is IOL explantation and followed by implantation of a retropupillary iris-fixated Verisyse IOL for aphakia. Explantation of the IOL would likely be difficult. An incision width of approximately 6.5 mm would be necessary, resulting in surgically induced astigmatism.
Second, another attempt at transscleral fixation could be performed. However, given that the IOL has dislocated twice after transscleral fixation, the danger of redislocation is evident.
Therefore, I would choose a third surgical option: Suturing the IOL haptics to the iris.3,4 The technique would be as follows: Miochol is injected through the paracentesis to constrict the pupil. The anterior chamber is filled with an OVD. The IOL optic is then dislocated in the anterior chamber and stabilized via the pupil using a Sinskey hook. Both haptics are projected through the pupil while the optic is held above the iris plane. Four clear corneal paracentesis stab incisions are placed along the path of the needle's entry and exit. For haptic fixation to the midperipheral iris stroma, the edge of the IOL optic is tilted upward with a hook to provide better visualization of the haptic. This tenting of the iris reduces the amount of iris tissue. A 10-0 polypropylene suture on a long, curved needle (Ethicon CIF-4) is passed through the paracentesis perpendicular to the orientation of the peripheral haptic. The needle tip is passed through midperipheral iris, behind the haptic, and out through the iris and peripheral cornea. The CIF-4 needle is threaded into the lumen of the OVD cannula, which was introduced through the second opposite paracentesis. After the needle is cut off, the Siepser slipknot technique for McCannel iris suturing5 is used to successfully fixate the IOL to the iris. The second haptic fixation is done in the same manner. After haptic fixation, the IOL optic is relocated into the posterior chamber. The OVD is removed by bimanual irrigation/aspiration.
1. Mohr A, Hengerer F, Eckardt C. Retropupillary fixation of the iris claw lens in aphakia; 1 year outcome of a new implantation techniques. Ophthalmologe 2002; 99:580-583
2. Dick HB, Augustin AJ. Lens implant selection with absence of capsular support. Curr Opin Ophthalmol 2001; 12:47-57
3. Zeh WG, Price FW Jr. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg 2000; 26:1028-1034
4. Condon GP. Simplified small-incision peripheral iris fixation of an AcrySof intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1663-1667
5. Chang DF. Siepser slipknot for McCannel iris-suture fixation of subluxated intraocular lenses. J Cataract Refract Surg 2004; 30:1170-1176