NEWS & OPINION 64 EWAP MARCH 2022 by Andres Parra, MD Contact information Parra: ASParra@mednet.ucla.edu Pineles: pineles@jsei.ucla.edu Review of ‘Repositioning surgery of different intraocular lens designs in eyes with late in-the-bag intraocular lens dislocation’ Following cataract extraction with IOL implantation, late inthe-bag IOL dislocation is a known phenomenon with an estimated incidence of 0.5–1%.1,2 This type of IOL dislocation occurs on average 6–12 years after otherwise uneventful cataract surgery, and risk factors include pseudoexfoliation, trauma, high myopia, vitreoretinal surgery, and uveitis.1–4 The decision to pursue surgery to address this dislocation is based off a myriad of factors including whether the patient experiences visual symptoms subjectively, the degree of dislocation of the IOL, as well as presumed risk of further dislocation.5 Surgical approaches can include IOL repositioning by various techniques or IOL exchange. Existing literature raises concerns regarding the suitability of using 1-piece IOLs in repositioning, primarily due to potential for uveitisglaucoma-hyphema (UGH) syndrome due to iris chafing.6,7 However, the authors of this study hypothesized that if IOL dislocation occurs in the bag and repositioning surgery techniques maintain the IOL in the bag, there should be a similar safety profile for the 1-piece IOL when compared to the 3-piece IOL design. Design and methods This prospective cohort study aimed to evaluate the long-term efficacy and safety following IOL repositioning of varying IOL designs for late in-the-bag dislocations. The IOL designs included 1-piece foldable (n=17), 3-piece foldable (n=28), plate haptic (n=8), and 1-piece rigid (n=1). The surgical technique employed scleral suturing via anterior approach using an ab externo suture loop technique with two scleral fixation points 180 degrees apart and placed approximately 1.8–2.0 mm behind the limbus using two 10-0 polypropylene sutures. All surgeries were performed by one surgeon. Extensive preop screening took place to ensure all dislocations were exclusively in the bag and no dislocation was found to be out of the bag. Patients were examined postop as well as at the 6-month, 1-year, and 2-year postop marks by the same ophthalmologists. The primary outcome of safety was determined as the absence of postop UGH syndrome or redislocation, however, the examination also tracked other complications such as iritis, IOP changes, and clinically relevant IOL decentration. The other primary outcome was efficacy in terms of postop corrected distance visual acuity (CDVA) and postop change in spherical equivalent. Postop spherical equivalent was compared to habitual refraction prior to IOL dislocation to determine the change in spherical equivalent. Predisposing risk factors in the population included pseudoexfoliation in 42 eyes (78%), myopia in 10 eyes (19%), previous vitreoretinal surgery in 5 eyes (9%), blunt trauma in 4 eyes (7%), and history of uveitis in 3 eyes (6%), with overlap of risk factors in some eyes and no predisposing risk factors in three eyes (6%). Summary of results The main analysis compared repositioning of the two most common IOL designs, the 1-piece and the 3-piece IOL, accounting for uncertainty due to attrition in long-term followup using intention-to-treat analysis. There were no instances of UGH in either of the two groups. The 3-piece IOL group had one case of mild iritis with history of chronic ocular inflammation prior to cataract surgery, one case of redislocation with a broken haptic discovered intraoperatively during repositioning, and one case of corneal decompensation. No serious complications occurred. Clinical decentration was noted in 2 eyes in the 1-piece group and 5 eyes in the 3-piece group, none of which were found to be symptomatic. Postop mean CD6A at final observation was similar between the 1-piece IOL at 0.36 logMAR (0.14 to 0.59) and the 3-piece IOL at 0.29 logMAR (0.12 This article originally appeared in the December 2021 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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