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IOL exchange shows positive outcomes in patients with opacification, dislocation or decentration

J Cataract Refract Surg. 2009;35(6):1013-1018.

Issue: August 25, 2009

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IOL opacification, decentration and dislocation were the leading indications for IOL exchange.

“In the absence of ocular comorbidity, the visual outcome was very good,” the study authors said. “Dissection of the IOL from the capsular bag and meticulous peeling of the capsule are key to success.”

The prospective study included 128 eyes of 113 patients who underwent IOL exchange between 2002 and 2007. The main indications for IOL exchange were IOL opacification (31%), IOL decentration (19%), IOL dislocation (18%), capsule phimosis (14%), corneal endothelial cell decompensation (8%), IOL miscalculation (6%), damaged IOL (2%) or chronic uveitis (2%).

Viscodissection of the IOL was the most commonly preferred technique for in-the-bag IOLs. Secondary IOLs were placed in the ciliary sulcus or capsular bag; the bag-in-the-lens technique was used whenever possible. Patients underwent postop follow-up examinations at 1 day, 1 and 5 weeks, 6 months and 12 months.

Before IOL exchange, IOLs were capsule-fixated in 82% of eyes, iris-fixated in 4% of eyes and sulcus-fixated in 7% of eyes. After IOL exchange, IOLs were capsule-fixated in 45% of eyes, iris-fixated in 39% of eyes and sulcus-fixated in 15% of eyes.

“In conclusion, IOL exchange was effective in patients with IOL opacification, decentration or dislocation,” the authors said. “Impaired quality of vision due to mild capsule contraction, causing IOL decentration, was particularly evident in patients with multifocal IOLs and accounted for 14% of the IOL exchanges.”

IOL exchange in Europe would appear to be quite different than in the U.S. With many hydrophilic acrylic models popular in Europe, IOL opacification is their No. 1 indication, while incorrect power and dysphotopsia were hardly on their list. In the U.S., patient dissatisfaction and incorrect power are the two top indications. This probably represents different population expectations more than anything else. With a general aversion to hydrophilic acrylic IOLs in the U.S. — not all such IOLs are bad — IOL opacification is barely on the radar screen here. Also surprising is the large number operated for capsular contraction problems. IOL decentration was the No. 2 indication, and capsular contraction was No. 4. My sense is that capsular contraction may be more commonly treated with YAG laser anterior capsular relaxing incisions as a prophylactic treatment in the U.S. before things get really bad. Certainly, neither is a common indication for IOL exchange in the U.S. They do confirm that premium IOL patients are particularly sensitive to decentration.

The rest of the findings are straightforward and not surprising. They, again, support the oft-repeated mantra: If you think the IOL needs out, do not YAG the capsule.

– Randall J. Olson, MD
OSN Cataract Surgery Board Member