Incidence of Dislocation of Intraocular Lenses and Pseudophakodonesis 10 Years after Cataract Surgery

Eva I. Mönestam, MD, PhD
Purpose: To estimate the incidence of early and late intraocular lens (IOL) dislocation and the frequency of pseudophakodonesis in a population-based cohort of cataract surgery cases. The patients were followed up from before to 10 years after surgery. Design: Cohort study. Participants: Eight hundred ten cataract surgery patients. Methods: A prospective population-based cohort of 810 cataract surgery patients with presenile or senile cataracts was examined before surgery. Ten years later, 289 (73%) of 395 survivors agreed to participate in an eye examination. In addition to a routine eye examination of the anterior and posterior segment, all eyes were assessed for pseudophakodonesis and significant dislocation of the IOL. The medical records were studied and information concerning previous postoperative surgical interventions such as IOL exchange or repositioning was noted. This information was also obtained from the records of the deceased patients and those unable or unwilling to participate. The material was analyzed statistically. Main Outcome Measures: Previous IOL exchange or repositioning surgery, significant IOL dislocation, and degree of pseudophakodonesis. Results: Most patients (n 795/810; 98%) underwent sutureless clear corneal phacoemulsification surgery with a 3.2-mm temporal incision. A foldable IOL was implanted, 95% of which were an Alcon MA60BM AcrySof (Alcon Inc, Fort Worth, TX). Approximately 40% of the patients had pseudoexfoliations (PEX). After a 10-year follow-up, 5 (0.6%) of the 800 patients at risk required surgery for a dislocated IOL. All of these patients were male, and in all cases, the dislocation was late and within the capsular bag. The cumulative incidence over 10 years was 1%. At the examination 10 years after surgery, 2 (0.7%) of 287 patients at risk had pronounced pseudophakodonesis and 4 (1.4%) had moderate pseudophakodonesis. Conclusions: The 10-year cumulative incidence of dislocated IOLs needing surgical attention was low in this population-based cohort with a high frequency of PEX. Early dislocation did not occur in any of the patients. The risk of this complication in an individual patient seems to be low. Because of the large number of people with previous cataract surgery, dislocated IOLs may cause a relatively large public health care burden. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2009;116:2315–2320 © 2009 by the American Academy of Ophthalmology.

Posterior chamber intraocular lens (IOL) dislocation or decentration is a well-known complication of cataract surgery, but the exact incidence is not known.1 A retrospective survey published in 2005 indicated that approximately 0.3% required subsequent IOL exchange resulting from IOL dislocation.2 Most cases of early IOL dislocation occur in the first week after cataract surgery.1 In these cases, the major cause is inadequate support for the IOL resulting from zonular or capsular damage, rupture, or both.3,4 Late IOL dislocation is defined as occurring 3 months or more after cataract surgery and has been reported with increasing frequency in recent years.1,5 Both the relatively long time frame for the presentation of this complication and the large number of people who have undergone cataract surgery have led to concerns of an impending epidemic of IOL dislocations.6 – 8 Late dislocations are associated with trauma9 or silicone plate IOLs passing through capsular defects, or as a result of progressive zonular dehiscence caused by contraction
© 2009 by the American Academy of Ophthalmology Published by Elsevier Inc.

of the capsular bag6 many years after an uneventful surgery. The risk for capsule contraction syndrome and zonular weakness seems to be greater in elderly patients.10 Other predisposing factors include pseudoexfoliation syndrome (PEX),7,11,12 high myopia, retinitis pigmentosa,11 myotonic dystrophy, certain connective tissue disorders (i.e., Marfan’s syndrome), homocystinuria, hyperlysinemia, Ehlers-Danlos syndrome, scleroderma, Weill-Marchesani’s syndrome, and previous vitreoretinal surgery.11,13,14 A dislocated IOL often requires explantation or repositioning because of potential complications such as retinal tears, rhegmatogenous retinal detachment, and vitreous hemorrhage.1,14 The purpose of this study was to estimate the cumulative incidence of IOL dislocation, the rate of pseudophakodonesis, and significant IOL decentration in a population-based cohort of cataract surgery cases, of which 95% received implantation of a 3-piece hydrophobic acrylic IOL. The patients were followed up from before to 10 years after surgery.
ISSN 0161-6420/09/$–see front matter doi:10.1016/j.ophtha.2009.05.015

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The study followed the tenets of the Declaration of Helsinki and was approved by the local ethics committee. all patients underwent a routine eye examination with dilation. The Distribution of the Intraocular Lenses Implanted Type of Intraocular Lens Alcon MA60BM (AcrySof)( )* Alcon MA30BA* Alcon LX90BD* Pharmacia 757C† Pharmacia 911A† Pharmacia 812A† Pharmacia 722A† Pharmacia 812C† Pharmacia 352C (anterior chamber lens)† Corneal ACR6D‡ Storz H50M§ Alcon CZ70BD (sutured) No IOL Missing data Total No.5 to 6 mm (PMMA IOL) Phacoemulsification surgery converted to ECCE Sclerally sutured IOL because of insufficient capsular support ICCE with no IOL ICCE anterior chamber IOL ECCE anterior chamber IOL Total No. i. A chi-square test for trends was used to assess gender-related differences in the degree of pseudophakodonesis. the number of residents who underwent surgery in other districts was negligible. Approximately 1 month after surgery. Therefore. Austria.1 0. Seventeen patients who died before the first follow-up at approximately 1 month after surgery and 1 patient scheduled before surgery for cataract surgery without IOL implantation also were excluded. Eleven (1. PMMA polymethyl methacrylate (rigid IOL). A life table calculation was made to estimate the 10-year cumulative incidence of IOL dislocation requiring surgical attention.2-mm temporal incision and a foldable IOL As above but with an incision of 5. Santa Ana. 1997.1 0.1 0. Pseudophakodonesis was assessed by 1 surgeon (EIM) as none.25 100 Patients underwent the same eye examination as that performed 10 years previously.5 0.2 1.4%) of the 790 patients who had undergone sutureless clear corneal phacoemulsification and had a foldable IOL implanted also had a capsular tension ring (CTR) implanted. A decentration of at least 2 mm in any direction was classified as significant. the eye examination was repeated. Sweden. CA.25 0. 1998.Ophthalmology Volume 116. and 11 (3%) could not be located. the study included a total of 810 patients. at Norrlands University Hospital in Umeå. ICCE intracapsular cataract extraction.5 0. Germany.e. Forty-one were unable to participate because of dementia (10%). Chroma Pharma GmbH.1 0. All survivors (n 395) were offered an eye examination and 289 (73%) participated. 2316 . the centration of the IOL was assessed and graded using the pupil as a reference. Number 12. of Patients 771 1 1 6 2 1 1 1 4 5 4 4 2 7 810 % 95.25 0.2 0.25 0. to wait 5 seconds.8 0. because there are no other public or private eye clinics performing cataract surgery in the area..1 0. Thirty-two patients were lost to follow-up or declined to participate. TX. In addition. Results Type of Surgery and Intraocular Lens Implanted The type of cataract surgery performed is shown in Table 1. All cataract surgeries in the study population were performed at the university clinic. Statistical Methods Independent sample t tests were used to compare age-differences between groups. Heidelberg.0 100 Preoperative and Postoperative Examination A few weeks before surgery. and then to gaze downward quickly to induce movements of the IOL. or pronounced (looks like it will immediately drop into the vitreous). Data Collected 10 Years after Surgery Ten years after surgery. The Type of Cataract Surgery Performed and Intraocular Lens Implanted at Surgery Type of Surgery Sutureless clear corneal phacoemulsification with 3. Because of the Swedish Social Security regulations. Four different surgeons performed all the operations. Therefore. Korneuburg. ‡ Corneal Laboratories Paris. Informed consent was obtained from all patients. and data from only the first surgery were included in the analysis. If there were no obvious signs of pseudophakodonesis. Fort Worth.5 1 0. Patients who underwent cataract surgery for reasons other than restoring vision or who had surgery combined with other types of ocular surgery were excluded (n 38). Chicago. *Alcon. Statistical analyses were performed using SPSS software version 17. The Fisher exact test was used to analyze the 2-by-2 and 2-by-4 tables regarding the frequency of PEX and need for additional surgery as determined by a surgeon. IOL intraocular lens. Inc.5 0. The presence of any ocular comorbidity or past surgery was recorded. slight or minor (barely discernible). ECCE extracapsular cataract extraction. The records of all 810 patients were checked to determine if any IOL exchange or repositioning surgery had been performed in the 10 years since the surgery.2 0. † Abbott Medical Optics Inc.6 0.0 (SPSS. IL). December 2009 Table 1. moderate (obvious).5 0. Storz Ophthalmics Inc. IOL intraocular lens. of Patients 790 8 2 4 2 2 2 810 % 97. Methods Patient Cohort 1997–1998 A total of 898 patients with presenile and senile cataracts who underwent cataract surgery between June 1. § Bausch & Lomb. Patients who had undergone surgery in both eyes during the period studied were included as 1 cataract patient. Inc. the patients were asked to gaze upward quickly. and May 31. The CTR implantation was performed routinely when judged necessary by the surgeon. were registered prospectively. 415 (51%) of the 810 patients were deceased. for intraoperative zonular weakness or zonular rupture to such a degree that the future stability of the IOL was believed Table 2.. 54 (14%) declined participation. patients seldom crossed county borders to obtain treatment during the study period.

005. The cumulative incidence over 10 years was estimated to be 1% (Fig 2). Fisher exact test). There was no significant difference between the 4 surgeons in the number of patients needing additional surgery (P 0. ACL anterior chamber lens. The mean age of the patients with an in-the-bag dislocation (74.82). ICCE intracapsular cataract extraction.9% and 2. data not shown).7 years. Flowchart showing the longitudinal 10-year outcome regarding intraocular lens (IOL) dislocation and pseudophakodonesis.77. Of the 800 patients at risk. Details of the demographic and clinical patient data for those having surgery for IOL dislocation are shown in Table 3. Additional surgery refers to all types of IOL suturing and repositioning. None of the patients had a history of ocular trauma before or after surgery.6 %) had a late IOL dislocation that required surgical attention at some point after the initial surgery. The IOL was repositioned with scleral fixation in 1 eye. 76 months). Postoperative best-corrected visual acuity ranged from 20/33 to 20/21.4 years) was not significantly different from that of the total group of patients (74. 39%. The complication rates of posterior capsule rupture and vitreous loss were 4.7%. The time lapse from cataract surgery to the date of IOL exchange or repositioning ranged from 36 to 108 months (mean. The presence of PEX was more common. IOL intraocular lens. the IOL had dislocated into the vitreous cavity and was replaced with a sclerally fixated posterior chamber IOL. P 0. respectively. Most of the patients (95%) were implanted with a 3-piece Alcon MA60BM AcrySof IOL (Table 2). The size of the capsular opening was not measured during or after surgery. One patient with late dislocation had a CTR implanted during the primary surgery. P 0.5%) had an anterior chamber lens implanted. Incidence of Intraocular Lens Dislocation Figure 1 shows a flow chart of the longitudinal 10-year outcome regarding IOL dislocation and pseudophakodonesis. CTR capsular tension ring. One patient (patient 3) had an in-the-bag IOL dislocation of to be at risk. 2317 . All of Figure 1. a significantly higher percentage than the 39% of the total group (P 0.Mönestam Dislocation of IOLs 10 Years after Surgery these dislocations were within the capsular bag. Nine (82%) of these 11 patients had PEX. but the difference was not significant (80% vs. In 4 eyes. 5 (0.08). ECCE extracapsular cataract extraction. but none of the patients examined at 10 years had capsular contraction syndrome to such a degree that radial yttrium–aluminum– garnet laser anterior capsulotomy was indicated (an opening of 4 mm). Four patients (0.

5 mm because he needed a lens power of 8.29%) of IOL exchange caused by decentration or dislocation in a total of 6630 cataract surgeries between 1998 and 2004.5 Previously. minor. PMMA polymethyl methacrylate. Of 287 patients at risk. PEX pseudoexfoliation. *At the time of cataract surgery. Number 12. 11 men and 22 women). Minor pseudophakodonesis was observed in 12% (33/287. 2318 . 86%) of the patients had no sign of pseudophakodonesis at the examination 10 years after surgery (Fig 1). both were women) had pronounced pseudophakodonesis. chi-square for trend) if the analysis included those with no. The higher rate found in the present study may be explained by the longer follow-up time of 10 years and the addition of cases requiring IOL repositioning. which is consistent with the observation that it now seems to be more common for the IOL to dislocate within an intact capsular bag. IOL dislocation typically occurred after decentration and migration of the lens through a rupture of the equatorial capsule or posterior capsulotomy. December 2009 Discussion Population-based studies with a 10-year follow-up are comparatively easy to perform in the Swedish health care system. All patients except case 1 underwent small-incision phacoemulsification (3. M male. 4 (1. Most previous estimations of the incidence ranged between 0. IOL intraocular lens. In studies to estimate the frequency of complications with a low incidence.3%.2 All patients included had at least a 3-month follow-up.1.16 The major cause of early IOL dislocation currently is thought to be zonular rupture during surgery.2% and 3%.7%. F female. 65 months). not only IOL exchange.2 mm) with implantation of a foldable IOL. bilateral case None known PEX Neodymium: Yttrium– Aluminum–Garnet Posterior Capsulotomy No Yes No Intraocular Lens Type/Capsular Tension Ring? 1-piece PMMA Pharmacia 812A 3-piece Alcon MA60BM 3-piece Alcon MA60BM CTR Model x14 Morcher† 3-piece Alcon MA60BM 3-piece Alcon MA60BM Final Visual Acuity 20/32 20/28 20/21 Surgical Intervention IOL exchange to sclerally sutured IOL IOL exchange to sclerally sutured IOL IOL exchange to sclerally sutured IOL vitrectomy IOL exchange to sclerally sutured IOL Reposition and suture of the original IOL 4 5 73 72 M M 6 yrs 3 mos 8 yrs 6 mos No No 20/33 20/24 CTR capsular tension ring. 1 2 3 Age (yrs)* 80 75 72 Time from Surgery to Gender Dislocation M M M 9 yrs 2 mos 3 yrs 9 mos 4 yrs Predisposing Conditions (Diagnosis/Associated presentation) Myopia gravis (axial length.5. 28. it is important to obtain low numbers of dropouts to reduce the selection bias and to increase the validity of the results. Pseudophakodonesis Observed 10 Years after Surgery Most (248/287. Graph showing the cumulative (Cum) 10-year odds of not needing surgical attention because of dislocation of the intraocular lens. that is. there was no significant decentration. and the time lapse from the initial implantation to IOL exchange was 1 to 180 months (mean. † Morcher GmbH. the risk of cataract patients being operated on outside of county borders was negligible.15–17 A more recent retrospective study reported 19 cases (0. both eyes. Demographic and Clinical Data of the Patients with In-the-Bag Intraocular Lens Dislocation Case No. moderate. Germany. Case 1 had his incision enlarged to 5.12 None of the patients experienced an early dislocation.Ophthalmology Volume 116. At the time of the study. 2 men and 2 women) had moderate and 2 (0. Significant decentration ( 2 mm) of the IOL was observed in 1% of the patients (4/287). which is consistent with previous studies. The visual outcome after the second surgical procedure generally was good. Stuttgart. There was no significant difference in degree of pseudophakodonesis or dislocation between men and women (P 0. or pronounced pseudophakodonesis and the 2 patients examined who underwent additional surgery (Fig 1). which at the clinic at that time only was available in PMMA IOLs. In 283 (99%) of 287 patients. when a different cataract extraction technique was used. but most studies were published in 1995 or earlier.9 This trend Figure 2. Table 3. The incidence of IOL exchange or repositioning as a result of dislocation or decentration 10 years after surgery was low in this population-based cohort with a high frequency of PEX.63 mm) PEX PEX PEX asteroid hyalosis dislocated with CTR.28.

Hayashi K.31:2193–204. 5.140:688 –94. currently. may be a result of the modern standard technique for cataract surgery with continuous curvilinear capsulorrhexis and in-the-bag placement of the IOL. Am J Ophthalmol 2005. A CTR probably reduces. or both compared with 1-piece acrylic IOLs. Jones JJ. Ophthalmology 1987. which is a low number considering the high frequency of PEX in the population. should have routine planned insertion of a CTR at surgery. In conclusion. 4 had PEX. none who were examined 10 years after surgery had a capsular opening of less than 4 mm requiring yttrium–aluminum– garnet laser radial anterior capsulotomy.1 Of the 5 cases that needed IOL exchange or repositioning in the present study. Surgical management of posteriorly dislocated silicone plate haptic intraocular lenses.29 but the use of CTRs increases the cost of surgery. Wilson DJ.1 Some surgeons have recommended implanting a CTR in all eyes with PEX. in cases with zonular weakness. 6.12.114:969 –75. Mamalis N. Ophthalmology 2001. Consistent with previous studies. Changing indications for and improving outcomes of intraocular lens exchange.9.1. or both. A limitation of the study is that the size of the capsular opening was not recorded during or after surgery. Smiddy WE. Gimbel HV. The type of posterior chamber IOL may affect the risk for in-the-bag IOL dislocation. the acrylic hydrophobic IOL induces less capsule contraction. Effects of extracapsular cataract extraction on the lens zonules. Jehan F. however. The cumulative incidence of IOL exchange or repositioning was low in this population with a high incidence of PEX and the use of mainly 3-piece hydrophobic acrylic IOLs. 11 (1.12 This is difficult to explain especially because more women than men undergo cataract surgery30 and more women than men have PEX. Crandall AS.19 Among the various types of foldable IOLs. The potential burden to society caused by dislocated IOLs is relatively large. it is unknown whether the cost of implanting a CTR in all at-risk eyes is justified by the potential decrease in incidence of dislocations. However. A 1-piece polymethyl methacrylate IOL with rigid haptics provides better centration in the bag compared with the 3-piece IOLs with flexible haptics. Kohnen T.26 The CTR maintains the circular contour of the capsular bag and distributes forces circumferentially. Am J Ophthalmol 1997. Jaeger MJ. 39% to 42% of cataract surgery cases have PEX.108:1727–31. routine CTR implantation in cases at risk is believed to reduce the incidence of postoperative IOL dislocation. and there was no significant difference between men and women regarding the degree of pseudophakodonesis. but does not prevent or eliminate. Little is known about the differences between moderate pseudophakodonesis and severe phacodonesis with respect to the time course for the progression to obvious dislocation requiring surgical attention. Possible predisposing factors for in-the-bag and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens exchange surgery.20 Most patients in the present study had a 3-piece hydrophobic acrylic IOL implanted (Alcon MA60BM.11.123:629 –35. which may explain the comparatively low number of dislocations. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. which in some cases precedes late IOL dislocation.28.25. 4. Hayashi H. The presence of pseudophakodonesis is an obvious sign of marked zonular degeneration or trauma that precedes IOL dislocation.5. in the absence of obvious intraoperative complications. Johnson MW. Hirata A. There is References 1. the degree of capsule contraction and spontaneous late IOL dislocation within the capsular bag. prevention and management. a male preponderance in cases needing IOL exchange or repositioning was found.27 In the absence of significant zonular dehiscence. It is important to identify those patients with a preoperative risk for compromised zonulae who. it is important to be aware of the possibility of progressive loss of zonular integrity after surgery.Mönestam Dislocation of IOLs 10 Years after Surgery currently no method available to detect past ocular trauma if the patient has entirely forgotten about it. Trauma and PEX are the most frequent predisposing conditions associated with IOL dislocation. A small capsular opening is believed to be a significant factor in the presentation of capsular contraction syndrome. Another cause may be that males are more prone to ocular trauma that might have happened decades earlier and has been forgotten by the time of cataract surgery. Further research in this field clearly is warranted. The percentage of cataract cases with PEX is high in many parts of the world.19. a long axis. the knowledge of the mechanisms and the interest in late IOL dislocation were not as developed as they are now. This cohort of patients mostly received hydrophobic 3-piece acrylic IOLs. there may be a genderrelated difference that results in weaker zonulae in men with PEX. Late in-the-bag intraocular lens dislocation: incidence. Pseudophakodonesis is observed only in eyes in which the IOL is located within the capsular bag. Crandall AS.11 When this study began in 1997. In our population from northern Sweden. Jin GJ. 3. AcrySof). et al. in-the-bag IOL dislocation or decentration is a late complication of cataract surgery that is more likely to happen in certain predisposed eyes.21 In PEX cases. Condon GP. J Cataract Refract Surg 2005. which improves capsule fixation and avoids focal stress on compromised zonulae.32 The number of patients with moderate to severe pseudophakodonesis was low. and there are no signs of ocular trauma noted at the eye examination. 2.31 Thus. however. Schneiderman TE.7 Several reports recommend placing a CTR in the bag together with the IOL. Ophthalmology 2007. offers more resistance to contraction of the bag.1. Green WR.22–24 In the present study. 2319 . because of the large number of people undergoing cataract surgery. et al. with a follow-up time of 10 years.18 One-piece polymethyl methacrylate IOLs also are believed to have greater resistance against the development of postoperative bag shrinkage and subsequent decentration. nothing is found in the records.4%) of 800 patients had a CTR implanted during surgery. Prognosis after treatment generally is good. 94:467–70.

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