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Video Report

Suture of a Subluxated Posterior Chamber Lens within the Capsular Bag

Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA

Correspondence: Dr KD Solomon
Email: solomonk{at}musc.edu
Tel: +1 843 792-8854
Fax: +1 843 792-6347

Date of acceptance: 3rd June 2005

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Introduction

Intraocular lens (IOL) dislocation is an uncommon complication of cataract surgery with an incidence between 0.2% and 2.8%.[1] Late dislocations, those occurring 3 months or more after cataract extraction, have been associated with either trauma, rupture of the zonules as a result of contracture of the capsular bag, or as a long term consequence of pseudoexfoliation. In some circumstances these processes may cause the entire capsular bag containing the IOL to separate from the ciliary processes.

Multiple techniques for transscleral suture fixation have been described for repositioning a dislocated posterior chamber IOL. However, in cases of a dislocated capsular bag containing the IOL, manipulation can cause unwanted traction of the vitreous and may induce peripheral retinal breaks. We illustrate a technique for fixation of a dislocated capsular bag containing the IOL which can reduce unnecessary manipulation.

Technique

After surgical preparation, a corneal stab wound was made on the opposite side of the desired scleral fixation site after dissection of the limbal conjunctiva. A viscoelastic material was then injected into the anterior chamber through the corneal incision. A 26-gauge needle was then introduced 1.0 mm posterior to the limbus, entering the anterior chamber posterior to the iris as a guide wire. The 26-gauge needle was aimed to be placed below the haptic and above the optic. Through the opposite corneal incision, one end of a double-armed 10-0 polypropylene suture on a straight needle was introduced. As it was being introduced, the polypropylene suture was observed to ensure that it did not capture corneal tissue. The tips of the 26-gauge and the suture needle were then aligned so the 26-gauge needle captured the polypropylene suture needle. The 26-gauge needle holding the 10-0 suture was retracted from the scleral puncture site leaving one suture below the haptic.

Then the 26-gauge needle was reintroduced 1.0 mm adjacent and at the same level to the first entry site. For the second pass, the needle was aimed to be placed above the haptic. The other end of the suture was reintroduced through the corneal stab wound and captured. As the 26-gauge needle was retracted, a suture loop was formed around the haptic. When both ends of the suture were pulled the dislocated IOL was placed in a stable position and the ends of the sutures were then tied.

Once the IOL was in a stable position the other haptic was situated and fixed in a similar manner, without the use of the 26-gauge needle. A Lindstrom manipulator was used to assist the suture of the capsular bag. The 10-0 polypropylene suture ends were cut, trimmed, and left long to minimize erosion. Through the corneal stab wound the viscoelastic material was aspirated with an irrigation/aspiration unit. Finally, the conjunctiva was closed with 10-0 nylon.

Comment

Lens dislocation is a well-known complication that can lead to severe complications and visual loss.[2] It may occur spontaneously or intraoperatively during cataract surgery. Cases of intermediate postoperative dislocation and late decentration of IOLs placed within the capsular bag have also been reported.[1]

Surgical management for IOL malposition includes IOL exchange, haptic rotation, and suturing the haptics to the iris or ciliary sulcus. Manipulation of the IOL and removal of the capsule from the end of the haptic in some scleral fixation techniques is difficult and may induce peripheral retinal breaks. With this procedure the suture can be placed with slight manipulation. The 26-gauge needle has to be inserted through the opposite side of the corneal incision, preferably close to the optic-haptic junction. Depending on the stability of the IOL and the areas of remaining capsular support the surgeon can decide the number of point-fixation required.

Koh and colleagues[3] described this technique; however, it required a bent 26-gauge needle. Similar to our findings the procedure provided optimal stability. We believe this technique is a simple way to reposition a dislocated capsular bag containing the IOL.

Acknowledgements

The authors thank James P. Byrnes, Storm Eye Institute, MUSC, for his expert contribution in the video editing of this case.

Conflict of Interest Statement

Supported in part by NIH/NEI EY-014793 and an unrestricted grant to MUSC-SEI from Research to Prevent Blindness, New York, NY, USA.
None of the authors have a proprietary interest in any product mentioned.

References

• Gross JG, Kokame GT, Wingberg DV, et al. In-the-bag Intraocular Lens Dislocation. Am J Ophthalmol 2004;137:630-635.
• Sternberg P Jr. Michels RG. Treatment of dislocated posterior chamber intraocular lenses. Arch Ophthalmol 1986;104:1391-1393.
• Koh HJ, Kim CY, Lim SJ, Kwon OW. Scleral fixation technique using 2 corneal tunnels for a dislocated intraocular lens. J Cataract Refract Surg 2000;26:1439-1441.