Twist and out intraocular lens removal : Journal of Cataract & Refractive Surgery

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Twist and out intraocular lens removal

Pandit, Rahul T. MD; Devgan, Uday MD; Chapman, Jack M. Jr MD

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Journal of Cataract & Refractive Surgery 46(8):p 1072-1074, August 2020. | DOI: 10.1097/j.jcrs.0000000000000161
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Foldable acrylic posterior chamber intraocular lenses (PC IOLs) are commonly inserted at the time of cataract surgery. Occasionally these IOLs need to be removed due to dislocation, dysphotopsias, various causes of visual distortions including glistenings and surface deposition, incorrect power, or secondary complications, especially from misplaced or sulcus-placed PC IOLs.1,2 The soft nature of the acrylic material lends these IOLs to cutting and folding. Many techniques have been described to remove foldable PC IOLs, including cutting the IOL into 2 or 3 pieces, removing the haptics and pulling out the optic, cutting and removing a wedge of the optic and then rotating the remainder out of an incision as small as 2.2 mm (so-called “Pacman” intraocular lens [IOL] removal); folding the IOL in the anterior chamber with an insertion device with counter-pressure from a straight instrument, and simply retracting the IOL from an incision size of at least 2.75 mm.3–11 Chapman demonstrated success at removing an Acrysof (Alcon) IOL through an incision size varying from 2.0 to 2.4 mm through a twisting maneuver.12,13 The size of the incision required for this technique varies with the different dioptric powers of this IOL, as central thickness can vary; this technique has had variable success with other brands of acrylic PC IOLs. Here we describe a technique for the removal of a foldable acrylic PC IOL through a 2.2 mm incision.


An anterior chamber paracentesis is created followed by injection of intracameral anesthetic and ophthalmic viscosurgical device. A clear corneal incision measuring 2.2 mm is created in either the temporal or superior quadrant depending on surgeon preference. In cases where the IOL exchange is being performed within proximity to the original surgery, the prior incision can be opened using a blunt spatula. The PC IOL is separated from the capsular bag using viscodissection and manipulation with intraocular instruments. If the posterior capsule is not intact, anterior vitrectomy and ophthalmic viscosurgical device tamponade is required to ensure the maneuvers do not result in vitreous traction. In cases where there is significant disruption of the anterior hyaloid or posterior capsule, such as after a large laser capsulotomy, consideration should be given to a joint procedure with a retina surgeon to perform a core posterior vitrectomy. The IOL is then positioned in the anterior chamber and one haptic is brought out through the main incision (Figure 1).

Figure 1.:
Posterior chamber intraocular lens positioned with one haptic exiting the main incision prior to grasping with forceps.

A straight spatula instrument is inserted through the paracentesis and placed above the optic to protect the cornea. Straight forceps are inserted through the main incision to grasp closely to the left edge of the optic for a right-handed surgeon (Figures 2, A and B). The straight forceps is twisted to roll the IOL around the forceps. In the case of a right-handed surgeon, the forceps are inserted while the hand is in the maximal supinated position (Figure 3, A); then after grasping the IOL, the forceps are twisted by pronation (Figures 3, B and C) of the right hand (Video 1; This will allow approximately 360° of twisting, resulting in the IOL nearly completely rolled around the forceps. The IOL can then be pulled straight out of the eye via the main incision (Video 2;

Figure 2.:
A and B: Correct positioning of straight forceps used to grasp the IOL while the second hand holds a spatula between the IOL and cornea (IOL = intraocular lens).
Figure 3.:
A: Right-hand position in full supination prior to insertion of forceps. B: Hand position halfway through the maneuver after 180° of pronation. C: Hand position after full 360° of pronation.


This simple and rapid technique for IOL removal does not require special instruments for cutting an IOL. This technique might work consistently well through a 2.2 mm incision for 1-piece and 3-piece acrylic PC IOLs. The addition of a second instrument provides added protection to the corneal endothelium such that intraocular maneuvers in eyes of varying anterior chamber depths might not cause corneal damage. This twist and out method for removal of a foldable acrylic PC IOL through a standard microincision could be easily reproduced.


  • Removal of posterior chamber intraocular lenses (PC IOLs) has been described with a variety of techniques that either remove the IOL through incision sizes that often measure 2.75 mm or greater, and often larger than the original size required for modern day foldable IOLs, or require cutting of the IOL.


  • This twist and out method for removal of a foldable acrylic PC IOL through a 2.2 mm corneal incision used commonly available instruments without the need for cutting the PC IOL.


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