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Clinical science
examination included the BCVA, central macular thickness on anteriorly, just behind the iris. The IOL was grasped by the end
optical coherence tomography, IOP, and anterior and posterior opening forceps introduced from the corneal incision under
segment inammation, fundus biomicroscopy, lens positioning direct visualisation through the microscope; the suction was
and complications. turned off and the extrusion cannula was then removed as the
forceps grasped the IOL (gure 1D). The surgeon then proceeds
to remove, reposition or exchange the IOL, depending on the
SURGICAL TECHNIQUE status of the capsulorhexis rim and the type of IOL in each indi-
All the surgeries were performed with constellation machine vidual case (web only video le). The retinal periphery was
from Alcon and local anaesthesia was used comprising a peribul- checked 360 with scleral indentation to rule out any retinal
bar injection of a mixture of lidocaine 1%, bupivacaine 0.5% breaks.
and hyaluronidase. Standard 23-gauge 3-port pars plana vitrec-
tomy incisions were framed and the initial step was complete
removal of the vitreous to prevent traction on the retina from RESULTS
subsequent manoeuvres. All the vitreo-lenticular adhesions were Data were entered in a Microsoft Excel sheet (Microsoft Corp,
gently released from the retinal surface using the vitrectomy Redmond, Washington, USA) and analysed using SPSS V.16.1
probe. A complete vitrectomy with careful separation and (SPSS Inc, Chicago, Illinois, USA). The change in the mean pre-
removal of the posterior hyaloid face was performed prior to operative and postoperative visual acuity was analysed using the
lifting the IOL. Once the lens implant was freed from such Wilcoxon signed-rank test. Differences were considered statistic-
attachments (gure 1A), it gently oated to the posterior pole ally signicant at p value <0.05.
of the eye. Care was taken to shave the vitreous as close to the Of 15 identied cases, complete case notes were available for
surface of the peripheral retina and pars plana. 10 eyes whose database was evaluated. The study included 10
The sleeveless-extrusion cannula was connected to the vitreo- eyes of 10 patients (seven men, three women; mean age of 57.1
tome aspiration and the vacuum was set to 300 mm Hg, with 4.58 years; range 5163 years) with a mean follow-up of
the cutting function turned off. Occluding the IOL before com- 36 weeks. The dislocation involved a 3-piece foldable IOL in six
pleting the vitrectomy was avoided to minimise the risk of per- cases, 1-piece foldable IOL in three cases and a plate haptic IOL
ipheral retinal breaks due to trapping of the vitreous in the in one case. Intraoperatively, suction loss and a subsequent IOL
lumen of the cannula. dislocation while levitating the IOL from the surface of retina
As the IOL rested at on the retina, the sleeveless-extrusion were seen in 1 (10%) eye and a second attempt was made to
cannula was placed in contact with the centre of the optic and create an effective suction. No intraoperative or any post-
suction was initiated to allow a rm grasp (gure 1B). operative complication was observed in this case in the entire
Addressing the IOL with extrusion cannula without sleeves gives follow-up. Intraoperative corneal oedema was seen in 1 (10%)
a larger surface area to be adhered to the IOL. The suction can eye which resolved in the immediate postoperative period. On
be dynamically controlled with the foot pedal. The IOL was the rst postoperative day, pigment dispersion was observed in 1
lifted from the surface of the retina (gure 1C) and was brought (10%) eye and grade 2 anterior chamber cellular reaction was
Figure 1 Levitation of dislocated posterior chamber intraocular lens (IOL). (A) Vitrectomy is done to clear all vitreo-lenticular adhesions. (B)
Sleeveless-extrusion cannula is placed close to the anterior surface of the optic of the IOL; vacuum is initiated and occlusion is achieved. (C) IOL is
lifted from the surface of retina. (D) The IOL is lifted, brought in to the mid-pupillary plane and is grasped by an end opening forceps.
Clinical science
seen in two eyes which resolved with topical medication. Late have been described.614 Retinal forceps have been described to
postoperative complication included macular oedema in 1 lift the IOL, although they run a risk of damaging the retina dir-
(10%) eye which resolved considerably with medical line of ectly or indirectly;14 the IOL is often sneaky, slippery, difcult to
management but eventually led to a compromised vision of 0.6 grasp and manipulate. By lifting the IOL from the retinal surface
Snellens decimal equivalent in that eye. The mean central with an illuminated pick or hook, the IOL optic can be grasped
macular thickness at 9 months was 181.99.39 mm. None of with serrated or diamond-dusted forceps.14 Olson et al13 devised
the eyes had postoperative vitreous or retinal haemorrhage, a suction-based grasping tool that has a suction cup at its terminal
retinal break or retinal detachment (table 1). end for lifting the dislocated IOLs. But it necessitates the use of
The mean BCVA was 0.960.1 (table 1). The mean post- specially designed suction tips to allow grasping and stabilisation
operative IOP as measured with non-contact tonometer was of the IOL. The fragmatome tip has been described to manipu-
13.21.8 mm Hg and there was no statistically signicant late the posteriorly dislocated IOLs by applying adequate suction
change in the IOP at 9 months follow-up ( p=0.32). to the centre of the anterior surface of the IOL optics.15
In all, out of 10 eyes, eight eyes with inadequate sulcus support However, the device requires a conjunctival peritomy, which
underwent glued intrascleral xation of an IOL and two eyes can cause conjunctival oedema, and also necessitates a 20-gauge
underwent sulcus implantation of an IOL. Out of three eyes sclerotomy wound. Moreover, its availability and accessibility may
which had intraoperative dislocation, repositioning in the sulcus be an issue to many surgeons and it is also comparatively bulky to
was done in one eye and the remaining two eyes underwent hold as compared with a 23-gauge extrusion cannula.
glued intrascleral xation of an IOL. The IOL remained well Perurocarbon liquids (PFCL) have also been used to prevent the
positioned throughout the follow-up interval and no recurrence adjacent retina from damage16 and to facilitate the anterior dis-
of IOL dislocation was reported. The nal vision and symptoms location of luxated IOL. They have high density and low viscosity
were stable in nine eyes and improved considerably in one eye and it is these characteristics that allow easy aspiration and injec-
which developed macular oedema out of the total 10 patients. tion of PFCL in a 23-gauge vitrectomy system where it can be
Repeat surgery was not required in any of the eyes. injected to levitate the IOL in the pupillary plane. However,
ocular toxicity due to retained PFCL, including uncontrolled
DISCUSSION IOP,17 corneal epithelial toxicity18 and decreased focal sensitivity
Since the inception of the rst intraocular implant in 1949 by of the retina,19 has been reported. An in vitro study showed that
Dr Harold Ridley, IOL dislocation has been recognised as an PFCL is directly toxic to human retinal pigment epithelial cells
important complication of cataract surgery. Perspex lens had to when exposed to the cells for 7 days.20 Retinal forceps are often
be abandoned as a 13% rate of IOL dislocation5 was reported. used to manipulate dropped IOLs and are usually the standard
Improvements in IOL design have decreased the reported inci- mainstay of treatment in vitreo-retinal surgery. Accidental pinching
dence of dislocation of rigid posterior chamber IOLs from 0.2% and creation of an iatrogenic retinal tear while lifting an IOL from
to 2%.6 7 Phacoemulsication with implantation of various fold- the surface of the retina is always a possibility with its use. Often
able IOL designs has become the established cataract surgery the IOLs are sneaky, slippery and difcult to grasp14 especially in
technique8 and, consequently, the incidence of dislocation of cases of plate haptic IOLs.
foldable IOLs has increased.9 Extrusion cannula is used primarily for internal drainage of
Inadequate capsular support is the most common cause of IOL subretinal uid in eyes with rhegmatogenous retinal detach-
dislocation and most commonly manifests in the early post- ments. It is also used to remove haemorrhage, gas or silicone oil
operative period,4 but late, in-the-bag dislocation of IOLs in the subretinal space along with removal of surface retinal
owing to progressive zonular dehiscence has been increasingly haemorrhage. The exible silicon sleeve ts snugly within the
reported. Dislocation of a posterior chamber IOL into the vitre- rigid outer shaft of the instrument to prevent an air or uid
ous cavity is an uncommon but serious complication. Numerous leakage around the outside of the cannula and provides better
techniques for the management of posteriorly dislocated IOLs access due to its exibility into the subretinal space.21 Santos
Table 1 Demographics of eyes with sleeveless-extrusion cannula-based suction levitation of dislocated posterior chamber IOL (vision in
Snellens decimal equivalent)
Age/ Type of IOL BCVA BCVA IOP mm Hg Intraoperative/postoperative IOL repositioning/IOL
Case sex levitated (preoperative) (9 months) (9 months) dislocation (1 week) exchange
Clinical science
and Roig-Melo22 proposed lifting the IOL by the optic with a grasp with a retinal forceps, and no difculty was encountered
silicone-tip aspiration cannula connected to the vacuum of the in the levitation process. Another advantage is that no additional
vitrectome. Removal of the silicon sleeve gives a wider access of device is required and inaccessibility or unavailability of the
the bore of the cannula to create an effective suction around the device will not be an issue.
IOL. The authors conceptualise that the vacuum created by the In conclusion, in this retrospective analysis, it seems that
sleeveless-extrusion cannula is strong enough to hold the optic short-term outcomes of suction-based levitation of posterior
of an IOL in the vitreous cavity. Since a complete pars plana chamber dislocated IOLs in eyes are encouraging. The results
vitrectomy seems mandatory to avoid retinal traction with a presented here must be interpreted with caution for a number
high risk of retinal breaks, triamcinolone can be used to increase of reasons. First, this is a retrospective study with a relatively
the visibility of the vitreous adhesions in the posterior chamber small number of subjects. Therefore, only large differences in
before any anterior IOL dislocation. Care is taken that the visual acuity or in the number of complications might be recog-
lumen of the cannula faces the at surface of the optic of IOL nised as signicant by the statistical tests used, thereby making
and that it completely apposes and occludes the IOL optic, more subtle differences difcult to ascertain. Moreover, ethical
thereby, creating an effective active suction to grasp and lift the implications would preclude a prospective study and also it is
IOL. Meanwhile, no pressure is exerted on the IOL while trying difcult to ascertain as to which patients will need this surgical
to occlude and create suction and no passive suction ow to procedure. Second, the mean follow-up period of 9 months is
move the IOL is attempted either. This prevents any uncon- relatively short as compared with many of the previous reports
trolled movement of the IOL that could be detrimental for the on the management of dislocated IOLs. Despite the limitations
retina. The linear control of the foot pedal helps to increase the of this study, it does provide information regarding the tech-
vacuum as and when needed during the levitation of IOL. Loss nique and postoperative outcome of levitation and subsequent
of vacuum while holding and lifting the IOL was reported in IOL implantation in these eyes and indicates the need for
one case and a second attempt had to be made to lift the IOL. further prospective trials with longer follow-up. Adequate
The loss of vacuum control was probably due to ineffective follow-up and study sample size remain critical issues with any
apposition of the lumen of the cannula to the surface of the new approach in technique or technology.
IOL optic.
A dislocated IOL can cause complications such as decreased Contributors All authors included on this paper full the criteria of authorship. In
addition, there is no one else who fulls the criteria but has not been included as
vision, monocular diplopia, glare, hyphaema, iritis, secondary an author. Study plan, conception and design: PN, AmA and AsA. Data acquisition:
glaucoma, corneal decompensation, cystoid macular oedema, DAK and AsA. Drafting article: PN and AmA. Final approval: AmA and PN.
and peripheral retinal traction and subsequent retinal detach- Competing interests None.
ment.23 The complications associated with dislocated IOLs like
Patient consent Obtained.
cystoid macular oedema, corneal oedema, glaucoma and intrao-
cular inammation are often difcult to differentiate from con- Ethics approval Local institutional review board.
sequences of the initial complicated cataract surgery. In our Provenance and peer review Not commissioned; externally peer reviewed.
limited series of cases, we did not come across any major com-
plication, probably because the effective time interval between REFERENCES
the original cataract surgery and the dislocated IOL levitation 1 Leaming DV. Practice styles and preferences of ASCRS members1994 survey.
was minimal. This highlights that the levitation technique with J Cataract Refract Surg 1995;21:37885.
sleeveless-extrusion cannula is an effective method although the 2 Pande M, Dabbs TR. Incidence of lens matter dislocation during
phacoemulsication. J Cataract Refract Surg 1996;22:73742.
nal visual outcome can be affected by many variables in a com-
3 Flynn HW Jr, Blumenkranz MS, Parel JM, et al. Cannulated subretinal uid aspirator
plicated cataract surgery. for vitreoretinal microsurgery. Am J Ophthalmol 1987;103:1068.
During surgical intervention, an important consideration is 4 Flynn HW Jr, Lee WG, Parel JM. A simple extrusion needle with exible cannula tip
whether to remove, reposition or exchange the dislocated pos- for vitreoretinal microsurgery. Am J Ophthalmol 1988;105:21516.
terior chamber IOL after performing a pars plana vitrectomy. In 5 Ridley H. Intra-ocular acrylic lensespast, present and future. Trans Ophthalmol
Soc 1964;84:514.
eyes with inadequate capsular support, glue assisted intrascleral 6 Leaming DV. Practice styles and preferences of ASCRS members1998 survey.
sutureless haptic xation is a good surgical option.24 Following J Cataract Refract Surg 1999;25:8519.
a posterior capsule rupture, 3-piece IOLs are the preferred 7 Sternberg P, Michels RG. Treatment of dislocated posterior chamber intraocular
choice for sulcus implantation.25 This is directly reected in our lenses. [case report] Arch Ophthalmol 1986;104:13913.
8 Chan CK. An improved technique for management of dislocated posterior chamber
study as six cases had a 3-piece dislocated posterior chamber
implants. Ophthalmology 1992;99:517.
IOLs. These IOLs were levitated and as glued intrascleral x- 9 Smiddy WE. Dislocated posterior chamber intraocular lens. A new technique of
ation also necessitates the use of 3-piece IOL, it was not management. [case report] Arch Ophthalmol 1989;107:167880.
removed and the glued procedure was performed in four cases 10 Smiddy WE, Flynn HW. Needle-assisted scleral xation suture technique for
with inadequate sulcus support. The dislocated plate-haptic IOL relocating posteriorly dislocated IOLs. [letter] Arch Ophthalmol 1993;111:1612.
11 Insler MS, Mani H, Peyman GA. A new surgical technique for dislocated posterior
in one case and a 1-piece IOL in three cases were levitated and chamber intraocular lenses. [case report] Ophthalmic Surg 1988;19:4801.
exchanged for a 3-piece acrylic hydrophobic foldable IOL and a 12 Ruiz-Moreno JM. Repositioning dislocated posterior chamber intraocular lenses.
glued procedure was performed. Retina 1998;18:3304.
The advantage with sleeveless-extrusion cannula-based 13 Olson JL, Montoya RV, Erlanger M, et al. Management of a dislocated intraocular
lens with a suction-based grasping tool. J Cataract Refract Surg 2013;39:1547.
suction levitation technique is that it is safe as it does not tend
14 Mello MO Jr, Scott IU, Smiddy WE, et al. Surgical management and outcomes of
to damage the retina while trying to pick and levitate the IOL dislocated intraocular lenses. Ophthalmology 2000;107:627.
unlike a retinal forceps. Reliability and reproducibility are the 15 Jorge R, Siqueira RC, Cardillo JA, et al. Fragmatome lifting: surgical option for
two important parameters for any surgical technique to be intraocular lens and foreign body removal. Ophthalmic Surg Lasers Imaging
effective. This technique was reproducible in all the cases and 2005;36:2614.
16 Lewis H, Sanchez G. The use of perurocarbon liquids in the repositioning of
was reliable too with a favourable complication rate. Moreover, posteriorly dislocated intraocular lenses. Ophthalmology 1993;100:10559.
this technique was effective for dislocation of any type of IOL 17 Foster RE, Smiddy WS, Alfonso EC, et al. Secondary glaucoma associated with
including the plate haptic IOLs which are often difcult to retained peruorophenanthrene. Am J Ophthalmol 1994;118:2535.
Clinical science
18 Ramaesh K, Bhagat S, Wharton SB, et al. Corneal epithelial toxic effects and 22 Santos A, Roig-Melo EA. Management of posteriorly dislocated intraocular lens: a
inammatory response to perurocarbon liquid. Arch Ophthalmol new technique. Ophthalmic Surg Lasers 2001;32:2602.
1999;117:141113. 23 Brod RD, Flynn HW Jr, Clarkson JG, et al. Management options for retinal
19 Tewari A, Eliott D, Singh CN, et al. Changes in retinal sensitivity from retained detachment in the presence of a posteriorly dislocated intraocular lens. Retina
subretinal perurocarbon liquid. Retina 2009;29:24850. 1990;10:506.
20 Inoue M, Iriyama A, Kadonosono K, et al. Effects of perurocarbon liquids and 24 Kumar DA, Agarwal A. Glued intraocular lens: a major review on surgical technique
silicone oil on human retinal pigment epithelial cells and retinal ganglion cells. and results. Curr Opin Ophthalmol 2013;24:219.
Retina 2009;29:67781. 25 Brazitikos DP, Balidis MO, Tranos P, et al. Sulcus implantation of a 3-piece,
21 Flynn HW, Lee WG, Parel JM. Design features and surgical use of a cannulated 6.0 mm optic, hydrophobic foldable acrylic intraocular lens in phacoemulsication
extrusion needle. Graefes Arch Clin Exp Ophthalmol 1989;227:3048. complicated by posterior capsule rupture. J Cataract Refract Surg 2002;28:161822.
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Notes