Posterior segment Intra-Ocular Implant (IOL) dislocation: Predisposing factors, surgical management, outcome analysis.

PURPOSE: To evaluate the predisposing factors, management and visual prognosis of intraocular Lens (IOL) dislocation into the posterior segment. METHODS: The cases of posterior IOL dislocation from January 2012 to May 2017 at 2 centers were reviewed. Only eyes with dislocations requiring IOL explantation or repositioning were included. Predisposing factors, interval between cataract surgery and IOL dislocation, circumstances of onset, management, and postoperative complications are reported. RESULTS: 72 eyes of 72 patients were included. The mean age was 67.6 years. 47 patients (68%) were men. The mean time interval from cataract surgery to IOL dislocation was significantly shorter in the out-of-the bag group than the in-the-bag IOL dislocation group (3.8 months vs 132 months, P=0.002). Predisposing factors for out-of-the-bag IOL dislocation were mainly capsular rupture and/or zonular dehiscence (83%) after complicated cataract surgery. The predisposing factors for in-the-bag IOL dislocation were high myopia (40%), pseudoexfoliation syndrome (40%), previous vitrectomy (38%), or Marfan syndrome (3%) with uneventful cataract surgery. The type of luxated implant was mainly a 3-piece foldable IOL (50%), followed by foldable one-piece IOL (28%) and a rigid one-piece IOL (17%). Most cases of posterior chamber IOL dislocation occurred spontaneously (80%) without a trigger event. Management consisted of a posterior approach in 24 cases (33%) or an anterior approach in 48 cases (67%), associated with IOL repositioning in 20 eyes (28%), and IOL replacement in 34 eyes (47%). Finally, 18 eyes (25%) were left aphakic. Postoperative complications occurred in 7 cases (9.7%). CONCLUSIONS: Predisposing factors and time from cataract surgery to IOL dislocation were different for out-of-the bag versus in-the-bag IOL dislocation. Management of IOL dislocation varied considerably, depending on surgeon preference and experience. Surgery for IOL dislocation significantly improved best corrected visual acuity and was associated with a low complication rate.

The Aravind Pseudoexfoliation Study: 5-Year Postoperative Results. The Effect of Intraocular Lens Choice and Capsular Tension Rings.

PURPOSE: We compared rates of intraocular lens (IOL) decentration, neodymium-doped yttrium aluminum garnet capsulotomy for posterior capsule opacification (PCO), and visual acuity (VA) in eyes with and without pseudoexfoliation (PEX) 5 years after undergoing cataract surgery. DESIGN: Prospective comparative interventional study. METHODS: This multicenter study population included 1 eye of both 930 cataract patients with and 470 cataract patients without uncomplicated PEX (no small pupils or phacodonesis) all undergoing phacoemulsification by experienced Aravind Eye Care System surgeons. Eyes were randomized to either 1- or 3-piece intraocular lenses (IOLs). PEX eyes were also randomized to either receive or not receive a capsule tension ring. The main outcome measures included IOL decentration and PCO. Secondary outcomes included postoperative best-corrected VA. RESULTS: Follow-up was 86.2% in the PEX group and 86.7% in the control group at 5 years. The PEX group was older (P < .001) and had more men (P = .01). IOL decentration at 5 years was equally prevalent in PEX and control eyes (1.0% vs 1.1%, respectively, P = .8). Neodymium-doped yttrium aluminum garnet posterior capsulotomy rates for PCO were similar in the PEX group when compared with control subejcts (5.3% compared with 3.2%, respectively, P = .07). Best corrected VA was better at baseline and years 2 and 3 in the control group (P = .0001, P = .0005, and P = .02); however, there was no difference in BCVA at years 1, 4, and 5 between the PEX and control groups (P = .09, P = .29, and P = .5). CONCLUSION: In a large-scale, long-term, prospective comparative study of cataract surgery in eyes with uncomplicated PEX, the risks of IOL decentration and PCO were low and comparable to that in control subjects. When approaching cataract surgery in eyes with relatively uncomplicated PEX, neither IOL choice (1- vs 3-piece acrylic IOL) nor the presence/absence of a capsule tension ring affects outcomes at 5 years.

Risk Factors for Intraocular Lens Dislocation After Phacoemulsification: A Nationwide Population-Based Cohort Study.

PURPOSE: Few studies have measured the incidence and risk factors of intraocular lens (IOL) dislocation in the total population. We investigate the risk factors for IOL dislocation in a nationwide Korean cohort. DESIGN: Retrospective cohort study. METHODS: National data on 2,162,191 subjects who underwent cataract surgery were collected from the Health Insurance Review and Assessment service database of health claims from 2009 to 2016. The Health Insurance Review and Assessment database was used to identify potential risk factors for IOL dislocation, including age, sex, and various pre- and postoperative ophthalmic conditions. The hazard ratios (HRs) and confidence intervals (CIs) of these risk factors were assessed with a multivariable-adjusted Cox regression model. RESULTS: IOL dislocation occurred in 15,170 patients (0.7%) in the cataract surgery cohort (2,162,191 patients). The incidence rate of IOL dislocation peaked at 40-50 years of age, although the mean age of IOL dislocation was 65.25 ± 10.81 years. The average male:female ratio was 1.8. The adjusted HR for IOL dislocation in patients with partial vitrectomy was 11.93 (95% CI 10.95-12.99; P < .0001). Posterior capsulotomy performed within 1 year after the cataract surgery significantly decreased IOL dislocation, with an adjusted HR of 0.48 (95% CI 0.44-0.51; P < .0001). CONCLUSIONS: IOL dislocation tended to occur in young males. Anterior vitrectomy was a significant risk factor for IOL dislocation, while posterior capsulotomy after surgery was associated with a decreased risk of IOL dislocation.

Comparison of incidence of repositioning surgery to correct misalignment with three toric intraocular lenses.

PURPOSE: To compare the incidence of re-orientating surgery to improve misalignment of three models of acrylic toric intraocular lenses: AcrySof toric intraocular lens (Alcon Laboratories, Inc.), TECNIS toric intraocular lens (Johnson & Johnson Vision, Inc.) and HOYA 355 toric intraocular lens (HOYA). METHODS: In this retrospective, multicenter case series, medical charts were reviewed for collecting data on realignment surgery of toric intraocular lenses at 10 ophthalmic surgical sites in Japan. RESULTS: Over all, intraocular lens repositioning surgery was conducted in 89 of 9430 eyes (0.944%) at an average of 10.5 ± 9.7 days after the initial cataract surgery. The incidence was 0.213% (11/5155), 1.797% (62/3451) and 1.942% (16/824) with AcrySof, TECNIS and HOYA toric intraocular lenses, respectively. The incidence was significantly lower with AcrySof than with other two brands of toric intraocular lenses (p < 0.0001). In those eyes which underwent reorientation surgery, the amount of misalignment was 26.4 ± 21.9°, 29.7 ± 15.4° and 28.1 ± 20.7° with AcrySof, TECNIS and HOYA toric intraocular lenses, respectively; there was no significant difference among groups (p = 0.821). The repositioning surgery significantly reduced misalignment in all three groups. CONCLUSION: The rotational stability was considerably different among toric intraocular lenses of different manufacturers. The incidence of repositioning surgery was significantly lower with AcrySof than with TECNIS and HOYA toric intraocular lenses.

Frequency of Intraocular Lens Dislocation and Pseudophacodonesis, 20 Years After Cataract Surgery - A Prospective Study.

PURPOSE: To examine the incidence and trends of late intraocular lens (IOL) dislocation/decentration and the frequency of pseudophakodonesis. DESIGN: Prospective, population-based cohort study. METHODS: A total of 800 patients were examined before cataract surgery in 1997-1998. Twenty years later, 100 of 133 survivors (75%) participated in the follow-up. An eye examination was performed including assessment for pseudophakodonesis and dislocation of the IOL. The medical records of all included patients at baseline were studied. Main outcome measures were previous IOL exchange or repositioning surgery, significant IOL dislocation, degree of pseudophakodonesis, and visual acuity. RESULTS: Twenty years after the original cataract surgery, 10 of the 800 patients at risk (1.2%) had needed dislocation surgery. Before cataract surgery, 39% of all patients had pseudoexfoliations (PXF). Mean time from cataract surgery to dislocation surgery was 12 years 6 months (range 3 years 9 months to 19 years 3 months). The cumulative incidence over 20 years was 6% in patients with PXF and 2% without PXF at surgery (P = .035). Mean age at cataract surgery in the 10 dislocated cases was 68.3 years (range 58-80). Twenty years after surgery, 5 of 98 (5%) patients had moderate/pronounced pseudophakodonesis. CONCLUSIONS: In this population-based cohort, the 20-year cumulative incidence of IOL dislocation needing surgical attention was significantly higher in patients with PXF than without PXF before surgery. The individual patient seems to have a low risk of being affected by this complication, but dislocated IOLs may cause a relatively large public health care burden, because of the large number of people in society with previous cataract surgery.

Assessment of long-term intraocular lens (IOL) decentration and tilt in eyes with pseudoexfoliation syndrome (PES) following cataract surgery.

BACKGROUND: To evaluate long-term intraocular lens (IOL) decentration and tilt in eyes with pseudoexfoliation syndrome (PES) following cataract surgery using Visante anterior segment OCT and iTrace Visual Function Analyzer. METHODS: Sixty-four eyes following cataract surgery from 2009 to 2012 were included, 34 eyes had PES and 30 eyes did not show PES. A standard phacoemulsification procedure followed by IOL implantation was performed and patients were followed 4-6 years after surgery (mean = 69 months). Best-corrected visual acuity (BCVA), capsulorhexis size, and intraocular pressure (IOP) were measured. IOL decentration and IOL tilt were evaluated using Visante Omni anterior segment OCT (Carl Zeiss Jena GmBH, Germany). The iTrace VFA (Visual Function Analyzer, Hoya surgical optics) was used to measure corneal, internal, and total optical aberrations. RESULTS: Measurements with iTrace showed that horizontal coma was significantly different between PES and control eyes (p = 0.037). Horizontal as well as vertical tilt showed a significant difference between PES and control eyes (p = 0.035 and p = 0.039). Tilt correlated with capsulorhexis size in PES patients (p = 0.011). This indicates a forward tilt of the superior edge of the IOL in eyes with PES. CONCLUSIONS: Patients affected by PES seem to have a higher risk for long-term complications and changes in visual perception due to IOL tilt and decentration after cataract surgery.

Population-based Incidence of Intraocular Lens Exchange in Olmsted County, Minnesota.

PURPOSE: To determine the population-based incidence of pseudophakic intraocular lens exchange in Olmsted County, Minnesota. DESIGN: Retrospective review of a population-based cohort. METHODS: Patients undergoing pseudophakic intraocular lens exchange in Olmsted County, Minnesota, between January 1, 1986 and December 31, 2016 were identified from the Rochester Epidemiology Project medical record linkage system. Indications and outcomes were determined, and the incidence rate was calculated as cases per 1 000 000 person-years. Poisson regression analysis was used to assess changes in incidence over time, and the cumulative probability of needing a lens exchange was estimated by Kaplan-Meier analysis. RESULTS: Eighty cases of intraocular lens exchange were identified, yielding an overall age- and sex-adjusted incidence rate of 28.4 per million (confidence interval [CI], 22.1-34.7), which increased over the study period (P = .04). The 30-year cumulative probability of intraocular lens exchange among patients undergoing cataract surgery was 1.5% (CI, 0.6%-2.4%), increasing at a relatively constant rate. Dislocated lenses accounted for 72.5% of lens exchanges. Unplanned refractive outcome of primary cataract surgery and uveitis-glaucoma-hyphema syndrome from squared-edged haptics emerged as newer indications for intraocular lens exchange. CONCLUSIONS: The population-based incidence of pseudophakic intraocular lens exchange has increased over the last 30 years, and can be explained by the increase in incidence rate of cataract surgery over the same period. Surgeons should be aware of emerging indications of intraocular lens exchange, which reflect changes in lens design and increasing expectations of refractive outcomes.

Incidence and risk factors of late in-the-bag intraocular lens dislocation: evaluation of 140 eyes between 1992 and 2012.

PURPOSE: To identify risk factors for late in-the-bag intraocular lens (IOL) dislocation and estimate the incidence of this condition over a 21-year period. SETTING: Department of Ophthalmology, County Hospital of Värmland, Karlstad, Sweden. DESIGN: Retrospective cohort study and nested case-control study. METHODS: The medical records of eyes operated on for late in-the-bag IOL dislocation between 1992 and 2012 were reviewed. The annual incidence and cumulative risk were calculated. RESULTS: Of 140 eyes whose records were reviewed, 123 qualified for comparison (24 variables) with an equal number in a control group. The annual incidence varied between 0.00% and 0.08%. An increasing trend was found (P < .001). The cumulative risk 5, 10, 15, and 20 years after cataract extraction was 0.09%, 0.55%, 1.00%, and 1.00%, respectively, and was significantly higher (P < .001) in eyes that had cataract surgery between 2002 and 2012 than in those operated on between 1992 and 2001 (0.89% versus 0.39% at 10 years postoperatively) (P < .001). Calendar time (date) of dislocation was positively correlated with the duration of preceding pseudophakia (P = .005). Phacoemulsification time was longer in eyes with dislocation than in control eyes (P < .001). Other identified risk factors were pseudoexfoliation, zonular dehiscence, pseudophacodonesis, and increased axial length. CONCLUSIONS: The increasing number of late in-the-bag IOL dislocations cannot be explained by the growing pseudophakic population only. The increase in the incidence was due primarily to the longer duration of pseudophakia in the population and to a greater dislocation risk with recent cataract surgery. The increase in life expectancy played a minor role. Long phacoemulsification time was a risk factor for dislocation. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Long-term trends and outcomes of anterior vitrectomy in Western Australia.

PURPOSE: To describe trends, risk factors and outcomes of anterior vitrectomy during cataract and intraocular lens (IOL) surgery. METHODS: All patients 16 years and older undergoing cataract and IOL surgery in Western Australia (WA) from January 1980 to December 2001 (n = 115 815) were included. Hospital administrative data were used to identify all cataract and IOL procedures and subsequent admissions for retinal detachment, IOL dislocation, endophthalmitis and pseudophakic corneal oedema. Data were validated with chart review and analysed to identify trends and risk factors for anterior vitrectomy and the risk of subsequent complications. RESULTS: In total, 1390 (1.2%) anterior vitrectomies were performed. The rate increased with change in surgical technique. Significant risk factors for anterior vitrectomy were age <50 years (OR 1.31), male sex (OR 1.23), IOL procedure (OR 11.45) and operations in public hospitals (OR 1.99) or rural/remote (OR 1.40) areas. Anterior vitrectomy was strongly associated with increased risk of retinal detachment (RD) (RR 18.5), endophthalmitis (RR 3.6), IOL dislocation (RR 21.1) and pseudophakic corneal oedema (RR 17.3). Retinal detachments and IOL dislocations occur earlier after anterior vitrectomy. CONCLUSION: Anterior vitrectomy rates have remained stable since the introduction of phacoemulsification. Anterior vitrectomy is a major risk factor for serious complications compared with uncomplicated surgery, particularly RD and IOL dislocation. We identified an increasing trend in anterior vitrectomy being performed during extracapsular and IOL surgery.

Incidence of dislocated and subluxed iris-fixated phakic intraocular lens and outcomes following re-enclavation.

BACKGROUND: The purpose of this study was to establish the incidence of re-enclavation of iris-fixated phakic intraocular lenses in our centre and evaluate outcomes following re-enclavation. DESIGN: Retrospective observational case series. Single surgeon, hospital setting. PARTICIPANTS: Six hundred and nine patients (1218 eyes) implanted with iris-fixated phakic intraocular lenses between 2000 and 2011. METHODS: Eyes requiring re-enclavation were identified, and outcome measures were evaluated 12 months following re-enclavation. MAIN OUTCOME MEASURES: Rate of re-enclavation, uncorrected distance visual acuity and manifest refractive spherical equivalent were measured 12 months following re-enclavation. RESULTS: Twenty-five eyes (2% of eyes overall) of 20 patients required re-enclavation of a dislocated or subluxed phakic intraocular lens. Eight cases (32%) dislocated secondary to trauma and 17 (68%) subluxed spontaneously. No significant difference was detected (P = 0.59) in uncorrected distance visual acuity (logMAR equivalent) 12 months post-re-enclavation (0.18 ± 0.04) compared with that recorded 6 months post-initial uneventful phakic intraocular lens implantation (0.10 ± 0.06). No significant difference was detected (P = 0.95) in mean manifest refractive spherical equivalent 12 months post-re-enclavation (-0.59D ± 0.29D) compared with that recorded 6 months post-initial phakic intraocular lens implantation (-0.57D ± 0.17D). Following re-enclavation, mean endothelial cell count was 2627 ± 101 cells/mm(2) 12 months postoperatively in 16 eyes. This did not differ significantly from that recorded 6 months post-initial phakic intraocular lens implantation in these eyes (P = 1). CONCLUSION: Dislocation and subluxation of iris-fixated phakic intraocular lenses may occur secondary to trauma or spontaneously because of inadequate iris enclavation. Re-enclavation can be carried out successfully with no significant adverse effect on clinical outcomes.

Possible predisposing factors for late intraocular lens dislocation after routine cataract surgery.

OBJECTIVE: The aim of this study was to evaluate possible risk factors for late intraocular lens (IOL) dislocation after routine cataract surgery. MATERIAL AND METHODS: A retrospective analysis of medical records of all the patients who were treated in the university hospital between 2011 and 2012 for late IOL dislocation requiring surgical management after routine cataract surgery was performed. In total, 58 patients (58 eyes) were included into the study. RESULTS: The mean time between cataract surgery and late IOL dislocation was 67.8 months (SD, 34.9). A negative correlation was found between the patient age at cataract surgery and the time between cataract surgery and IOL dislocation (r=-0.29; P=0.042). Late in-the-bag dislocation occurred in 87.9% and late out-of-the-bag dislocation in 12.1% of the cases. Pseudoexfoliation was present in 56.9% and 42.9% of the eyes with in-the-bag and out-of-the-bag dislocation, respectively. The odds ratio for IOL dislocation within 43 months after complicated cataract surgery was 24.0 (95% confidence interval [95% CI] 4.5-127.4; P<0.001) and for in-the-bag IOL dislocation 24.9 (95% CI, 4.2-148.0; P<0.001). The odds ratio for in-the-bag IOL dislocation within 43 months after advanced cataract surgery was 18.8 (95% CI, 2.0-180.0; P=0.011). Moreover, in-the-bag IOL dislocation occurred earlier in the patients with past uveitis (P=0.020) or zonule laxity (P=0.037). CONCLUSIONS: Complicated cataract surgery increased the risk of both late in-the-bag and out-of-the-bag IOL dislocation, and advanced cataract increased the risk of late in-the-bag IOL dislocation. The time to in-the-bag IOL dislocation shortens with pseudoexfoliation syndrome, advanced age, or past uveitis. These factors must be taken into account while planning a postoperative follow-up.