Intervention is justified because of this young man's symptoms of glare and reduced vision quality. Wavefront analysis has confirmed that the Snellen acuity test will not demonstrate the reduction in image quality caused by IOL tilt and decentration. Pharmacologic and neodymium:YAG (Nd:YAG) laser methods were unable to reposit this malpositioned IOL. One might try using a Zeiss-style gonio lens to displace the optic posteriorly through a dilated pupil. If these maneuvers fail, surgical repositioning is indicated. With the patient under topical anesthesia, one should easily be able to push the optic back into the posterior chamber with an instrument introduced through a paracentesis. Given all of the preceding complications and problems, I would be wary of attempting to reposition the optic with a paracentesis needle in the office. To prevent a recurrence, I would place the patient on topical brimonidine drops to limit the amount of scotopic pupil dilation.
This case illustrates the potential drawbacks of scleral suture fixation of PC IOLs, particularly in younger patients. With 10-0 polypropylene, the incidence of suture degradation and breakage is rising as follow-up periods approach and pass 10 years. Because 9-0 polypropylene has a much greater cross-sectional diameter than 10-0, it should improve long-term scleral haptic fixation. However, no one knows how much longer 9-0 polypropylene or 8-0 expandable polytetrafluoroethylene (Gore-Tex) sutures will last. By eroding through overlying scleral flaps, exposed polypropylene knots can cause irritation and giant papillary conjunctivitis. If they protrude through conjunctiva, they create a potential entry path for endophthalmitis-causing pathogens. Intraocular lens tilt and decentration are additional concerns and are likely responsible for this patient's need for a fourth operation in the same eye.
Many individual factors must be considered when deciding where and how to best fixate an IOL in the absence of the posterior capsule. Angle, scleral, or iris fixation of the haptics are the usual options. The presence of glaucoma, abnormal angle anatomy, iris tissue deficiency, and excessive pupil diameter complicate AC IOL use. Nevertheless, we know that long-term fixation of a properly sized AC IOL is permanent, secure, and well tolerated. In the absence of other complicating factors, this is my preference for a secondary or backup IOL in younger patients without posterior capsule support.