There are a few ways to manage the right eye. First, I would review previous operative reports, specifically looking for IOL type and whether a CTR was used. Obtaining specular microscopy to determine endothelial health might also be beneficial. I would perform an examination with the patient supine to gain a better idea of what might be encountered intraoperatively.
The patient is symptomatic because of the IOL subluxation; thus, surgical repositioning or exchange in combination with a filtering procedure is reasonable. I tend to favor tube-shunt placement in these cases because it lends itself to a larger peritomy and I can be less concerned about the additional tissue manipulation that might be required when addressing the IOL. In addition, should further IOL stabilization become necessary in the future, there might be less effect on the filter function.
My approach to surgery would begin with a large peritomy in the superotemporal quadrant. Dissection should be carried posterior and the plate would be sutured to the sclera, taking advantage of a pressurized globe. I would make 2 paracenteses, and instill a dispersive OVD. On examination, zonular fiber weakness was evident superiorly. I would attempt to suture the IOL complex to the sclera, if possible. Iris hooks could be placed to better visualize the zonular status and haptic location. I would use an additional OVD and blunt dissection to separate capsule fibrosis surrounding the haptic to allow placement of an Ahmed capsular tension segment, which can be sutured to the sclera to recenter the IOL. This far out from surgery, there might be too much fibrosis to introduce the segment. If this were the case, or if minimal zonular support remains, I would favor removal of the entire complex and proceed with placement of an AC IOL. (A scleral or iris-sutured 3-piece IOL might also be a consideration.) In this case, a scleral tunnel should be created superiorly and the existing IOL and capsule material should be removed under protection from an OVD. I would perform a subtotal vitrectomy before inserting the IOL. Triescence can help ensure complete removal of vitreous from the anterior chamber. After the IOL is placed and the scleral incision is closed, the tube should be trimmed and positioned anterior to the IOL. A patch graft would be placed and then the conjunctiva closed in the usual fashion.
Regarding management of the left eye, the patient’s IOP is controlled and she is asymptomatic. I would continue to observe at this point. Should visual symptoms develop, the aforementioned approach could be performed. However, even in the setting of medically controlled IOP, it would be reasonable to place a tube in anticipation of IOP elevation related to the IOL exchange. A neodymium:YAG capsulotomy could also be considered to clear the visual axis if the patient prefers a more conservative approach. Should uncontrolled IOP develop in the absence of visual symptoms, I would favor a lower risk laser trabeculoplasty before incisional surgery. For older patients, I review all options, from the least invasive and potentially least efficacious to the more definitive, which might carry more risk. Life expectancy and quality are also taken into account.