CaseWise 4 -Ab-interno fixation of Subluxated in the bag IOL

Dr. Shreya Jaiswal, Dr. Sarang Lambat, Dr. Vinay Nangia
Suraj Eye Institute, Nagpur, India

Introduction

Davison was the first to report spontaneous subluxation of in-the-bag-intraocular lens (IOL) as a result of capsular contraction syndrome.1 Some degree of capsular contraction is common after cataract surgery, but profound capsule shrinkage has been described in cases with pseudoexfoliation, diabetes mellitus, uveitis, pigmentary retinal degeneration and myotonic dystrophy. Almost 90% of the reviewed cases of in-the-bag-IOL subluxation had one of these associated predisposing conditions.2 Several techniques for preventing and managing this complication have been described in literature. Though the management of these cases is difficult, the surgical outcome and visual prognosis is generally good.

Case report

A male, 52 years of age, came with the complaints of intermittent fluctuation in vision in right eye since 1 month. He was a diagnosed case of retinitis pigmentosa and had a history of cataract extraction, IOL with endocapsular ring (ECR) implantation done in right eye. On examination his best corrected visual acuity (BCVA) in right eye was 6/24, N12 and in left eye was 6/18, N36. Anterior segment examination showed an inferiorly subluxated in-the-bag IOL in right eye and aphakia in left eye. Fundus examination of both eyes showed optic disc pallor, arteriolar attenuation and bony spicules in mid periphery, which was suggestive of retinitis pigmentosa.

Management

Patient underwent ab-interno fixation of the in-the-bag-IOL  with the help of two endocapsular segments. Corneo-scleral pockets were created at 3 and 9 O’ clock.  4 clear corneal stab incisions were made and iris hooks were inserted. Capsular bag was stabilised with the  iris hooks. Two capsular segments were inserted at 3 and 9 O’ clock. The capsular segments were engaged by railroading technique. Fixation of the capsular segments under the corneo-scleral pockets. The suture ends were cut and embedded under the pockets. The post operative unaided visual acuity was 6/12 in right eye with a well centered and stable IOL.

Discussion
Dislocation of in-the-bag IOL can be managed either by retrieval and internal fixation of the IOL or by explantation with secondary IOL implantation. In this case we did ab-interno fixation of the in-the-bag IOL with the help of two endocapsular segments and were able to achieve satisfactory visual outcome and IOL stability. The advantages of repositioning and ab-interno fixation of the IOL is that it is a relatively safe and effective technique and causes  minimal vitreous disturbance. It can be accomplished without a large limbal incision reducing the chances of post surgical astigmatism, endophthalmitis and also the intraocular complications especially damage to corneal endothelium.3 Though explantation of in-the-bag IOL with secondary IOL implantation is a less challenging approach, it can lead to above complications especially increased chances of vitreous disturbance and possible subsequent risk of retinal detachment.

References

1.Davison JA. Capsule contraction syndrome. Journal of Cataract & Refractive Surgery. 1993 Sep 1;19(5):582-9. https://doi.org/10.1016/S0886-3350(13)80004-1

2.Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens dislocation: incidence, prevention, and management. Journal of Cataract & Refractive Surgery. 2005 Nov 1;31(11):2193-204. https://doi.org/10.1016/j.jcrs.2005.06.053

3.Gunenc U, Kocak N, Ozturk AT, Arikan G. Surgical management of spontaneous in-the-bag intraocular lens and capsular tension ring complex dislocation. Indian journal of ophthalmology. 2014 Aug;62(8):876. doi: 10.4103/0301-4738.116451

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