In late in-the-bag intraocular lens dislocation, what becomes displaced?

The intraocular lens together with the whole capsular bag The implant stays inside the capsular bag, but the bag and its zonular attachments come loose, so the whole complex may sublux inferiorly or fall into the vitreous.

Only one haptic, which slips out of the bag

The optic alone, with the haptics left in place

The posterior capsule, with the lens staying fixed

What distinguishes late in-the-bag dislocation from early intraocular lens dislocation?

Early cases arise from an intraoperative placement problem Early dislocation reflects an intraoperative problem, with the lens placed outside the bag or a haptic slipping out, whereas late in-the-bag dislocation follows slow zonular failure years later.

Late cases always involve an anterior chamber lens

Early cases are characteristically bilateral

Late cases follow laser capsulotomy rather than surgery

Which condition is the commonest association of late in-the-bag IOL dislocation?

Pseudoexfoliation Pseudoexfoliation is by far the commonest association; trauma, high axial myopia, previous vitreoretinal surgery, retinitis pigmentosa, uveitis and Marfan syndrome are other risk factors.

What cumulative incidence of late IOL dislocation is reported 25 years after cataract surgery?

About 1.7 percent Population-based work found a cumulative incidence of roughly 0.1 percent at five years, rising to about 1.7 percent at twenty-five years, so risk accumulates with time since surgery.

Which capsular change adds stress to already weakened zonules after cataract surgery?

Contraction of the capsular bag, or phimosis Zonules degrade slowly in conditions that weaken them, and contraction of the capsular bag adds a mechanical stress that contributes to eventual dislocation.

Elschnig pearl formation on the capsule

Thinning of the anterior capsule rim

Calcification of the posterior capsule

Which symptom pattern suggests late in-the-bag IOL dislocation?

Monocular diplopia with vision changing on lying down Presentation includes blur with a refractive change, monocular diplopia, a visible lens edge in the pupil, glare, and positional change in vision when the lens falls back on lying down.

A painful red eye with photophobia alone

Slowly progressive peripheral field loss

Night blindness with a ring scotoma

Which slit-lamp findings are typical in late in-the-bag IOL dislocation?

Phacodonesis and iridodonesis with a displaced bag With the pupil dilated, the bag and lens are seen displaced, leaving a clear zone where the bag used to sit, and phacodonesis and iridodonesis are common.

Keratic precipitates with a layered hyphema

A vertical spindle of endothelial pigment

A fixed dilated pupil with iris atrophy

When is observation a reasonable option in late in-the-bag IOL dislocation?

When the lens is slightly decentered and vision is good Observation suits an eye where the lens is only slightly decentered and vision remains good; repositioning, lens exchange or pars plana vitrectomy are used as displacement increases.

When the lens has fallen into the vitreous

When the intraocular pressure is raised

When monocular diplopia has recently begun

Which step at the original cataract operation may reduce the risk of late dislocation?

Placing a capsular tension ring when zonules are weak Surgeons who recognise weak zonules during the original cataract operation can place a capsular tension ring, which may reduce the later risk of in-the-bag dislocation.

Implanting a multifocal intraocular lens

Using an anterior chamber lens routinely

Performing a primary posterior capsulotomy

Which complication of suture fixation can allow the lens to dislocate again?

Suture exposure or breakage Known complications include retinal detachment, vitreous haemorrhage, cystoid macular edema, glaucoma, endophthalmitis, and suture exposure or breakage leading to re-dislocation.

Posterior capsule opacification

Late IOL Dislocation: Causes and Management

A cataract operation is expected to last a lifetime, and for most people it does.

In a small proportion of eyes, though, the capsular bag containing the lens implant slowly drifts out of position, years or even decades after surgery, because the zonules supporting it have failed.

This is late in-the-bag intraocular lens dislocation, and it has become the leading cause of late IOL dislocation in many reports.

What actually happens

In late in-the-bag dislocation, the IOL stays inside the capsular bag, but the whole bag, along with its zonular attachments, comes loose.

The bag may sublux inferiorly, or it may fall into the vitreous.

The lens optic is displaced, causing blur or double vision.

This is different from early dislocation, caused by an intraoperative problem, where the IOL is placed outside the bag or the haptic slips out.

The zonules degrade slowly with time in conditions that weaken them, and the contraction of the capsular bag (phimosis) adds a stress.

Who is at risk

Pseudoexfoliation, by far the commonest association (see pseudoexfoliation syndrome)
Prior trauma
High axial myopia and previous vitreoretinal surgery
Retinitis pigmentosa
Uveitis
Connective tissue disorders such as Marfan syndrome
Long time since surgery. Population-based work found a cumulative incidence of roughly 0.1 percent at 5 years, rising to about 1.7 percent at 25 years

Surgeons who recognize weak zonules at the time of the original surgery can place a capsular tension ring, which may reduce the risk (see capsular tension ring indications and zonular dehiscence in cataract surgery).

Test your knowledge 10 questions from this article

How it presents

Gradual or sudden blur, often with a change in refraction
Monocular diplopia, or a visible edge of the lens in the pupil
Glare, if the lens edge crosses the visual axis
Positional changes in vision when lying down, if the lens falls back
Pain and redness if raised pressure or uveitis develop

Examination at the slit lamp, with a dilated pupil, will show the bag and lens displaced, with a clear zone where the bag used to be.

Phacodonesis and iridodonesis are common.

The lens may be tilted, decentered, or fully in the vitreous.

Management options

The right approach depends on the position of the bag, the patient’s vision, and the state of the retina.

Observation if the lens is slightly decentered and vision is good
Repositioning and suturing the bag or haptics to the sclera or iris
IOL exchange, where the dislocated lens is removed and a new lens is placed with scleral or iris fixation, or an anterior chamber lens is used when support is limited (see scleral-fixated intraocular lens)
Pars plana vitrectomy if the lens is in the vitreous, with attention to retinal tears

Whatever the approach, the eye should be assessed for retinal tears, cystoid macular edema, and pressure elevation.

Complications

Retinal detachment, vitreous hemorrhage, cystoid macular edema, glaucoma, suture exposure or breakage with subsequent re-dislocation, and endophthalmitis are known complications.

Patients with pseudoexfoliation need long-term follow-up since the underlying disease continues to progress.

Clinical eye photograph illustrating Late in the Bag Iol Dislocation

What the patient should be told

Patients with pseudoexfoliation, trauma, or high myopia who have had cataract surgery should know that a late change in vision, double vision, or a visible edge of the lens in the pupil needs prompt review. They should avoid heavy blows to the head and be aware of the symptoms. Explain that the problem is the support of the lens and not the lens implant itself, and that repair is possible.

Surgical planning

The surgeon needs to decide whether to reposition the bag with its lens, to remove the bag and lens and replace it, or to leave the lens and observe. Factors include the position of the lens, the state of the zonules, the condition of the cornea, the retina, and the glaucoma status. A careful vitrectomy is needed when the lens is in the vitreous, and the peripheral retina should be examined for tears. The choice of fixation method, with scleral or iris suturing or with glued haptics, depends on the surgeon’s experience and the anatomy.

Follow-up

After surgery, review for pressure rises, macular edema, retinal tears, and suture problems. Long-term follow-up is advisable because the underlying disease, such as pseudoexfoliation, continues to progress.

Prognosis

With appropriate surgery, visual results are good in most cases.

The best defense is early recognition of zonular weakness before the first operation.

References

Pueringer SL, Hodge DO, Erie JC. Risk of late intraocular lens dislocation after cataract surgery, 1980-2009: a population-based study. Am J Ophthalmol. 2011;152:618-623.
Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens dislocation: incidence, prevention, and management. J Cataract Refract Surg. 2005;31:2193-2204.
Davis D, Brubaker J, Espandar L, et al. Late in-the-bag spontaneous intraocular lens dislocation: evaluation of 86 consecutive cases. Ophthalmology. 2009;116:664-670.
Hayashi K, Hirata A, Hayashi H. Possible predisposing factors for in-the-bag and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens exchange surgery. Ophthalmology. 2007;114:969-975.

Test yourself

A few questions straight from this article.

1 / 10 0 correct

In late in-the-bag intraocular lens dislocation, what becomes displaced?
The implant stays inside the capsular bag, but the bag and its zonular attachments come loose, so the whole complex may sublux inferiorly or fall into the vitreous.
What distinguishes late in-the-bag dislocation from early intraocular lens dislocation?
Early dislocation reflects an intraoperative problem, with the lens placed outside the bag or a haptic slipping out, whereas late in-the-bag dislocation follows slow zonular failure years later.
Which condition is the commonest association of late in-the-bag IOL dislocation?
Pseudoexfoliation is by far the commonest association; trauma, high axial myopia, previous vitreoretinal surgery, retinitis pigmentosa, uveitis and Marfan syndrome are other risk factors.
What cumulative incidence of late IOL dislocation is reported 25 years after cataract surgery?
Population-based work found a cumulative incidence of roughly 0.1 percent at five years, rising to about 1.7 percent at twenty-five years, so risk accumulates with time since surgery.
Which capsular change adds stress to already weakened zonules after cataract surgery?
Zonules degrade slowly in conditions that weaken them, and contraction of the capsular bag adds a mechanical stress that contributes to eventual dislocation.
Which symptom pattern suggests late in-the-bag IOL dislocation?
Presentation includes blur with a refractive change, monocular diplopia, a visible lens edge in the pupil, glare, and positional change in vision when the lens falls back on lying down.
Which slit-lamp findings are typical in late in-the-bag IOL dislocation?
With the pupil dilated, the bag and lens are seen displaced, leaving a clear zone where the bag used to sit, and phacodonesis and iridodonesis are common.
When is observation a reasonable option in late in-the-bag IOL dislocation?
Observation suits an eye where the lens is only slightly decentered and vision remains good; repositioning, lens exchange or pars plana vitrectomy are used as displacement increases.
Which step at the original cataract operation may reduce the risk of late dislocation?
Surgeons who recognise weak zonules during the original cataract operation can place a capsular tension ring, which may reduce the later risk of in-the-bag dislocation.
Which complication of suture fixation can allow the lens to dislocate again?
Known complications include retinal detachment, vitreous haemorrhage, cystoid macular edema, glaucoma, endophthalmitis, and suture exposure or breakage leading to re-dislocation.

Ahmed Ophthalmologist

Writes and reviews the clinical articles on Educate. Every post is checked against peer-reviewed sources before it goes live.

Late In-the-Bag Intraocular Lens Dislocation: Why a Lens Implant Can Fall Years After Surgery