Surgical Management of IOL Subluxation

The debate over which subspecialist—an anterior segment surgeon or a vitreoretinal surgeon—should operate in cases of intraocular lens (IOL) subluxation represents an outdated model, asserted Francesco Boscia MD at a recent conference.

He emphasised that, instead of being a competition, emerging best practice should reflect a collaborative model that leverages the unique and indispensable skill set of each subspecialist.

Presenting a patient-centric algorithm, Professor Boscia said, “This type of unified algorithm of care is the hallmark of a mature surgical community that prioritises patient-centred care above subspecialty silos.”

Surgical decisions

In cases of IOL subluxation, the underlying cause of the dislocation is fundamental to determining surgical management. Other major issues to consider include ensuring retinal safety, determining the presence of concurrent retina pathology, and evaluating whether the risks associated with an anterior versus posterior approach are more acceptable for a given patient’s ocular history.

“An anterior segment procedure has the advantage of being less invasive and likely having a shorter operative time, and it avoids the risks associated with pars plana vitrectomy (PPV),” Prof Boscia said. “An anterior approach, however, can lead to corneal endothelial damage, pupil ovalisation, uveitis/glaucoma/hyphaema syndrome, and haemorrhages. As for its most critical limitation, it does not permit comprehensive examination of the posterior segment or PPV when it is indicated.”

The patient-centric algorithm divides cases of IOL subluxation into four groups described by clinical presentation and provides recommendations on the primary surgeon and surgical options for each group, taking the above-mentioned concerns into account. The algorithm recommends that cases of mild IOL subluxation in which the anterior chamber is the site of IOL subluxation and vitreous-free should be managed by an anterior segment surgeon using either an iris-fixated or anterior scleral-fixated technique for repositioning or exchanging the IOL.

According to the algorithm, a vitreoretinal surgeon should be the primary surgeon in cases of complete posterior IOL luxation (a ‘dropped’ IOL) where PPV is required for safe retrieval of the implant and assessment of the retina. In such cases, the algorithm suggests performing PPV and then implanting a secondary IOL with a Yamane or scleral-sutured fixation technique.

“Even if an eye had previous vitrectomy, the surgeon may not have completely cleaned the vitreous base,” Prof Boscia said. “A meticulous peripheral PPV will eliminate all vitreous traction on the IOL and retina and thereby minimise the risk of iatrogenic peripheral retinal tears during IOL manipulation.”

A comprehensive approach addressing both the IOL and retinal pathology with combined PPV and IOL fixation/exchange is also needed in eyes with retinal disease, such as diabetic retinopathy, epiretinal membrane, or history of retinal detachment. Here again the algorithm identifies the posterior segment surgeon as the preferred operator.

The fourth group of eyes described in the algorithm is defined by those with a complex anterior presentation in which there is extensive vitreous in the anterior chamber. In this situation, definitive vitreous management with PPV is needed to prevent future complications. A posterior segment surgeon working alone or collaboratively with an anterior segment surgeon are the primary surgeon recommendations.

Prof Boscia spoke at an EURETINA/ESCRS joint symposium at Euretina 2025 in Paris, France.

Francesco Boscia MD is a professor at the Ophthalmology Institute of the University of Bari, Italy. francesco.boscia@uniba.it