ARTICLE

Late dislocation of in-the-bag and out-of-the bag

intraocular lenses: Ocular and surgical
characteristics and time to lens repositioning
Gunnar Jakobsson, MD, Madeleine Zetterberg, MD, PhD, Mats Lundström, MD, PhD,
Ulf Stenevi, MD, PhD, Richard Grenmark, MD, Karin Sundelin, MD, PhD

PURPOSE: To characterize patients with late intraocular lens (IOL) dislocation to evaluate possible
risk factors, determine the time between cataract surgery and IOL repositioning, describe the
surgical management, and estimate the incidence.
SETTING: Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden.
DESIGN: Case series.
METHODS: Medical records from the cataract surgery and IOL repositioning were reviewed.
RESULTS: The study enrolled 84 eyes, 63 with in-the-bag IOL dislocation and 21 with out-of-the-
bag IOL dislocation. The prevalence of pseudoexfoliation (PXF) was 60% and of glaucoma, 36%.
A high proportion of eyes with IOL dislocation (37%) had zonular dehiscence at cataract
surgery. The median time from cataract surgery to IOL repositioning surgery was significantly
shorter in eyes with out-of-the-bag IOL dislocation (3.2 years) than in eyes with in-the-bag IOL
dislocation (6.7 years) (P Z .029). The interval was also significantly shorter in eyes with
zonular dehiscence. Using data from the National Cataract Register, the calculated incidence of
IOL repositioning surgery per pseudophakic individuals in western Sweden was 0.050%.
CONCLUSIONS: The possible major predisposing factors for late IOL dislocation were PXF, glau-
coma, and cataract surgery complicated by zonular dehiscence. Primary placement of the IOL in
the ciliary sulcus was associated with earlier IOL dislocation. Intraocular lens repositioning surgery
using a posterior or anterior approach was successful in many cases.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2010; 36:1637–1644 Q 2010 ASCRS and ESCRS

Although late dislocation of intraocular lenses (IOLs)
is a rare complication of cataract surgery, the problem
is well known to cataract surgeons and several cases
have been reported in the past 30 years.1–7 The pseudo-
phakic population in the Western world has increased
rapidly during the past 2 decades as a result of
expanded indications for cataract surgery and a longer
lifespan; therefore, the incidence of late IOL disloca-
tion may increase.
There are several reports of series of patients with
spontaneous late IOL dislocation.8–12 The present
study is a retrospective evaluation of patients who
had secondary IOL fixation surgery during a 3-year
period (2004 through 2006) at our clinic. The aims of
the study were to evaluate ocular and surgical
characteristics; that is, the possible risk factors for
late IOL dislocation. The time between the cataract
extraction and IOL repositioning and the surgical tech-
niques for IOL repositioning were also analyzed. We
believe this study is the first to estimate the incidence
of late IOL dislocation in a pseudophakic population.
PATIENTS AND METHODS
This retrospective study reviewed the medical records of all
patients with a diagnosis of late IOL dislocation who had
surgery with secondary IOL fixation from January 1, 2004,
to December 31, 2006, at the Department of Ophthalmology,
Sahlgrenska University Hospital, Mölndal, Sweden. There
are approximately 1.53 million inhabitants in western
Sweden, and the clinic is the region’s referral center for

Q 2010 ASCRS and ESCRS 0886-3350/$dsee front matter 1637

Published by Elsevier Inc. doi:10.1016/j.jcrs.2010.04.042
1638 LATE IOL DISLOCATION
most secondary IOL fixation procedures. The study was ap-
proved by the Regional Ethics Committee in Gothenburg,
Västra Götaland County, Sweden, and performed in agree-
ment with the Declaration of Helsinki.
Late IOL dislocation was defined as any case requiring
IOL repositioning surgery that occurred after primary cata-
ract surgery in which the initial postoperative IOL position
had been noted as good, thus excluding dislocations occur-
ring during cataract surgery or detected at the first postoper-
ative visit. Indications for repositioning surgery were IOL
dislocation causing visual symptoms or rapid and distinct
dislocation. Cases of IOL dislocation from ocular trauma
were excluded.
Medical records of the patients were analyzed using
a standardized case report form designed for the study.
Data on age, sex, coexisting eye disease, type of cataract,
and presence of phacodonesis or pseudoexfoliation (PXF),
and date of cataract surgery were collected. Other data in-
cluded type of cataract surgery, preoperative complications
(eg, capsule rupture, zonular dehiscence), use of mechanical
pupil dilation or a capsular tension ring (CTR), type of IOL,
and whether the IOL was placed in the capsular bag or in the
ciliary sulcus. Data collected after cataract surgery included
complications (eg, high intraocular pressure) and additional
surgeries, including neodymium:YAG (Nd:YAG) laser treat-
ment for posterior capsule opacification. Finally, the time
between the cataract surgery and IOL repositioning surgery
and the techniques used for repositioning were noted.
Snellen visual acuity was measured between 2 and
12 months postoperatively. Although it was not the primary
objective of this study to describe follow-up data but rather
to evaluate possible predisposing factors for late IOL disloca-
tion, most patient records included postoperative visual
acuity; thus, it is reported here.
The incidence of late IOL dislocation was calculated based
on the estimated number of pseudophakic eyes during each
year between 2004 and 2006 in western Sweden and the
number of surgeries for late IOL dislocation during the
same years. The pseudophakic prevalence was calculated
using data from the Swedish National Cataract Register
Submitted: March 2, 2010.
Final revision submitted: April 4, 2010.
Accepted: April 15, 2010.
From the Institute of Neuroscience and Physiology (Jakobsson,
Zetterberg, Stenevi, Grenmark, Sundelin), Section of Clinical Neu-
roscience and Rehabilitation/Ophthalmology, Sahlgrenska Acad-
emy, University of Gothenburg, Mölndal, and EyeNet Sweden
(Lundström), Blekinge Hospital, Karlskrona, Sweden.
Supported by the Swedish Research Council, Sahlgrenska Univer-
sity Hospital, Gothenburg Medical Society, and Kronprinsessan
Margaretas Arbetsnämnd för Synskadade.
Presented in part at the XXVI Congress of the European Society of
Cataract & Refractive Surgeons, Berlin, Germany, September 2008.
Corresponding author: Gunnar Jakobsson, MD, Institute of Neuro-
science and Physiology, Department of Clinical Neuroscience and
Rehabilitation/Ophthalmology, Sahlgrenska Academy at University
of Gothenburg, Sahlgrenska University Hospital, SE-431 80 Möln-
dal, Sweden. E-mail: gunnar.jakobsson@vgregion.se.
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
(NCR), which contains data on 98% of all cataract surgeries
performed in Sweden, and statistics from population
records.13
Statistical Analysis
Statistical analysis was performed to compare the time be-
tween cataract extraction and IOL repositioning between the
in-the-bag group and the out-of-the-bag group using the
Mann-Whitney U test. Further analyses compared the inter-
val between these 2 surgical events and possible predispos-
ing factors for IOL dislocation. Only in-the-bag cases were
considered in the latter analysis because out-of-the-bag cases
constituted a small proportion of all IOL dislocations and the
mechanisms behind in-the-bag IOL dislocation and out-of-
the bag IOL dislocation are likely different, with in-the-bag
cases representing a more ‘‘pure’’ and initially less
complicated group of patients.
Statical analysis was performed using SPSS for Mac soft-
ware (version 16.0, SPSS, Inc.). To estimate whether there
was an increase in the incidence of late IOL dislocation, the
incidences in 2004, 2005, and 2006 were compared using
the Fisher exact test. A P value less than 0.05 was considered
statistically significant.
RESULTS
Eighty-four patients fulfilled the criteria of late dislo-
cated IOL and were enrolled in the study; 23 patients
were enrolled in 2004, 29 in 2005, and 32 in 2006. Coex-
isting eye disease was diagnosed in 47 patients at the
time of IOL repositioning surgery, with the most prev-
alent being primary open-angle glaucoma. A signifi-
cant number of patients with glaucoma had PXF and
were thus classified as having pseudoexfoliative glau-
coma. Table 1 shows the patients’ demographics and
preoperative variables overall and in the in-the-bag
IOL dislocation and out-of-the-bag IOL dislocation
groups. Table 2 shows the perioperative events at
cataract surgery.
The overall median time between cataract surgery
and IOL dislocation surgery was 6.5 years (range 1
month to 26 years; 25th to 75th percentile, 3.8 to
9.5 years). Eight patients (10%) had IOL dislocation
surgery within 1 year of cataract surgery; the interval
between the 2 surgical procedures was 10 years or
more in 24 cases (29%). The time between cataract sur-
gery and IOL dislocation surgery was statistically sig-
nificantly shorter in the out-of-the-bag group (median
38 months; 25th to 75th percentile, 6 to 94 months) than
in the in-the-bag group (median 80 months; 25th to
75th percentile, 62 to 111 months) (P Z .029, Mann-
Whitney U test). Figure 1 shows the distribution of
the interval between cataract surgery and the reposi-
tioning surgery in the in-the-bag group.
Table 3 shows the results of statistical analysis per-
formed to determine whether there was an association
between a predisposing factor for IOL dislocation and
the time between initial cataract surgery and IOL
 LATE IOL DISLOCATION 1639

Table 1. Demographics and preoperative variables.

Dislocation

Parameter All Patients* (N Z 84) In Bag (n Z 63) Out of Bag (n Z 16)

Age (y)
At cataract surgery
Mean 72.2 72.0 72.8
Range 39–91 39–91 51–87
At IOL repositioning
Mean 78.9 78.8 77.3
Range 42–97 42–97 57–88
Male sex, n (%) 35 (41.7) 28 (44.4) 6 (37.5)
Pseudoexfoliation (n Z 78*), n (%) 47 (60.3) 38 (60.3) 7 (43.8)
Phacodonesis (n Z 75*), n (%) 9 (12.0) 7 (11.1) 1 (6.2)
Vitreoretinal surgery before cataract surgery, n (%) 7 (8.3) 7 (11.1) 0
Ocular comorbidity at IOL repositioning, n (%) 47 (56.0) 36 (57.1) 10 (62.5)
Glaucoma† 30 (35.7) 17 (27.0) 5 (31.2)
AMD 14 (16.7) 11 (17.5) 3 (18.8)
Uveitis 2 (2.4) 1 (1.6) 1 (6.2)
Otherz 6 (7.1) 5 (7.9) 1 (6.2)
Type of cataract (n Z 76*), n (%)t
Nuclear 19 (25.0) 16 (25.4) 2 (12.5)
Mixed{ 34 (44.7) 25 (39.7) 8 (50.0)
Subcapsular 5 (6.6) 4 (6.3) 1 (6.2)
Mature 18 (23.7) 14 (22.2) 3 (18.8)

AMD Z age-related macular degeneration; IOL Z intraocular lens

*In 5 cases, not known whether IOL implanted in or out of bag
†
Included 22 patients with pseudoexfoliative glaucoma and 1 with closed-angle glaucoma
z
Single cases of branch vein occlusion, macular pucker, retinal detachment, chorioretinitis, and corneal dystrophia
{
Cortical cataract with nuclear and/or subcapsular opacities

repositioning. The amount of time to IOL reposition-
ing had a significant negative correlation with patient
age; that is, the younger the patient, the longer the in-
terval. There was a strong association in the in-the-bag
group between zonular dehiscence at cataract surgery
and a shorter time to repositioning surgery (P Z .009).
Table 4 shows the techniques used for surgical man-
agement of the dislocated IOLs. A posterior approach
with pars plana vitrectomy (PPV) was used in 50 cases
(60%) and an anterior approach with or without ante-
rior vitrectomy in 34 cases (41%). In almost half the
cases managed by the posterior approach, the IOL

Table 2. Perioperative events at cataract surgery.

Cases, n (%)

Parameter All Patients* (N Z 84) In Bag IOL (n Z 63) Out of Bag IOL (n Z 16)

Cataract surgery type (n Z 78†)

Phacoemulsification 64 (82.1) 49 (77.8) 13 (81.2)
Extracapsular 14 (18.0) 9 (14.3) 3 (18.8)
Capsule rupturez 13 (16.5) 1 (1.6) 12 (75.0)
Zonular dehiscencez 29 (36.7) 24 (38.1) 5 (31.2)
Mechanical pupil dilation 13 (16.5) 10 (15.9) 3 (18.8)
Capsular tension ring 21 (26.6) 17 (27.0) 4 (25.0)
Postop IOP R40 mm Hg 13 (16.5) 10 (15.9) 3 (18.8)

IOL Z intraocular lens; IOP Z intraocular pressure

*No data were available for perioperative events in 5 cases
†
Surgery type could not be determined in 6 cases
z
Four eyes had both a capsule rupture and zonular dehiscence

J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010

1640 LATE IOL DISLOCATION

Table 3. Possible risk factors for late IOL dislocation and inter-
val between cataract extraction and surgical IOL repositioning.
Only in-the-bag dislocations (n Z 63) are included.

Characteristic Result P Value

Age at cataract surgery .013

Regression coefficient 1.40
Intercept 184
Correlation coefficient 0.312
Sex .79
Male (n Z 28)
Figure 1. Interval between cataract surgery and IOL surgery in 63 Median time interval (mo) 77
cases of in-the-bag IOL dislocation. 25th–75th percentiles 34–123
Female (n Z 35)
was repositioned with scleral sutures of the haptics un- Median time interval (mo) 82
der triangular scleral flaps just peripheral to the cor- 25th–75th percentiles 67–106
neal limbus. Pseudoexfoliation* .127
Corrected distance visual acuity was measured in 75 Yes (n Z 38)
eyes (89%) after the IOL was repositioned. Table 5 Median time interval (mo) 84
shows the results. 25th–75th percentiles 68–104
The estimated prevalence of pseudophakic patients No (n Z 22)
Median time interval (mo) 65
in 2005 was 58 300 (3.8%); 57.7% had bilateral surgery.
25th–75th percentiles 18–126
Thus, the incidence of surgery for late dislocated IOL
Mature cataract† .97
in 2005 was 0.050% (29 of 58 300 patients), or 0.032% Yes (n Z 14)
when considering the total number of operated eyes. Median time interval (mo) 83
In 2004 and 2006, the incidence of surgery for late dis- 25th–75th percentiles 55–133
located IOL in the pseudophakic population in the No (n Z 45)
region was 0.042% and 0.052%, respectively, corre- Median time interval (mo) 80
sponding to 0.027% in 2004 and 0.033% in 2006 in rela- 25th–75th percentiles 64–113
tion to the number of pseudophakic eyes. The slight Glaucoma
increase in the incidence during these 3 years was Yes (n Z 24) .78
Median time interval (mo) 81
not statistically significant (P Z .588, Fisher exact
25th–75th percentiles 63–100
test comparing incidences in pseudophakic eyes in
No (n Z 39)
2004 and 2006). Median time interval (mo) 80
25th–75th percentiles 47–126
DISCUSSION Capsule rupture .153
Yes (n Z 1)
Late IOL dislocation is an unusual complication of Median time interval (mo) 1
cataract surgery. This is reflected in the literature, in 25th–75th percentiles d
which many studies include few cases. The lack of No (n Z 62)
data makes conclusions unreliable. Also, several pre- Median time interval (mo) 80
vious reports are outdated, describing patients who 25th–75th percentiles 61–107
had cataract extraction with surgical techniques that Zonular dehiscence .009
are no longer in use. Wider indications for cataract sur- Yes (n Z 24)
gery along with increased lifespan may result in an Median time interval (mo)
increased incidence of late IOL dislocations. However, 25th–75th percentiles 70
No (n Z 39) 47–83
the current incidence in the pseudophakic population
Median time interval (mo) 93
has not been described. The present study comprised
25th–75th percentiles 67–128
84 patients, most of who had in-the-bag IOL disloca-
tions; this makes our study of this cataract surgery *Data missing in 2 cases
†
Data missing in 4 cases
complication one of the largest. z
Mann-Whitney U test except age, which was by linear regression analysis
We assessed the possible factors predisposing to late
IOL dislocation. Between 2004 and 2006, the mean age
of patients having cataract surgery in Sweden was The sex distribution of cataract surgery patients in
75.5 years, only slightly older than the patients in Sweden between 2004 and 2006 was 36.7% men and
our study at the time of cataract surgery (72.2 years). 63.3% women, which is very similar to the percentages

J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010

 LATE IOL DISLOCATION
Table 4. Surgical management of cases with dislocated IOL
(n Z 84).
Type of Surgery Cases, n (%)
Posterior approach with PPV
IOL repositioning with scleral sutures 47 (56.0)
IOL repositioning without sutures 1 (1.2)
IOL removed 1 (1.2)
IOL exchanged 1 (1.2)
Anterior approach with or without AV*
IOL repositioning with scleral sutures 21 (25.0)
IOL repositioning with iris sutures 7 (8.3)
IOL repositioning without sutures 2 (2.4)
IOL exchanged† 4 (4.8)
AV Z anterior vitrectomy; IOL Z intraocular lens; PPV Z pars plana
vitrectomy
*Performed in 14 of 34 anterior approach cases
†
Anterior chamber IOL implanted in 1 case
in our study. However, according to NCR data, the
prevalence of glaucoma in cataract patients in Sweden
was 8.6% in 2005, which is much lower then the fre-
quency (35.7%) in patients with late IOL dislocation
in our study. Most cases of glaucoma in our study
were classified as pseudoexfoliative; therefore, the
presence of PXF rather than other glaucoma-related
factors may be a main risk factor for IOL dislocation.
All previous studies of late IOL dislocation, espe-
cially in-the-bag dislocation, concluded that PXF is
a significant risk factor.8,9,11 This was supported in
our study because the frequency of PXF was substan-
tially higher (60%) than the reported prevalence in
Scandinavian populations, which ranges between
11% and 40% in comparable age groups.14–19
Additional potential risk factors for IOL dislocation
reported in other studies8,9 are previous ocular trauma
and myopia. In our study, a history of ocular trauma
was reported in 3 cases and denied in 5 cases. Previous
surgical trauma, for example pars plana vitreous sur-
gery, was reported in 7 cases. Myopia was reported
in 14 cases. Hence, as is the case with many retrospec-
tive studies, reliable data could not be obtained for all
parameters; for example, we could not accurately
Table 5. Visual acuity after IOL repositioning surgery (median
follow-up 1 to 12 months).
Decimal CDVA Cases, n (%)
!0.1* 3 (3.6)
0.1–0.4 29 (34.5)
0.5–1.0 43 (51.2)
Missing data 9 (10.7)
CDVA Z corrected distance visual acuity
*Includes 3 cases of severe glaucoma and macular degeneration
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
1641
estimate the prevalence of previous ocular trauma or
the axial length.
The overall median time between cataract extraction
and repositioning surgery was 6.5 years in our study.
The median interval in most cases (ie, in-the-bag dislo-
cation) was 6.7 years. These numbers are similar to
those reported in previous studies of late IOL disloca-
tion (eg, 6.8 years11 and 6.9 years9). In a study by Davis
et al.,12 the mean time between the 2 surgeries was 8.5
years in 86 eyes from which the IOL was explanted. It
is reasonable to assume that these factors might induce
a dislocation earlier. To assess the possible risk factors
for IOL dislocation, we analyzed several variables in
the in-the-bag group to determine whether there was
an association between time to IOL repositioning.
Older age at cataract surgery and zonular dehiscence
were significantly associated with shorter intervals.
However, the presence of PXF did not cause IOL dislo-
cation earlier than the absence of PXF, even though the
high prevalence of PXF in our study indicates it might
be a risk factor for IOL dislocation. This is somewhat
surprising because one would expect an eye with an
additional risk factor for zonular weakness, such as
PXF, to develop IOL dislocation sooner. The true im-
portance of PXF as a primary cause of weakening of
the zonular apparatus may become more clear
through studies of late IOL dislocation in populations
in which PXF is rare.20
The time between cataract surgery and IOL
repositioning was considerably shorter in the out-of-
the-bag dislocation group than in the in-the-bag
dislocation group. Thus, zonular dehiscence and
primary placement of the IOL in the sulcus induced
IOL dislocation sooner than in uncomplicated cataract
surgery cases. This is also reflected in the high propor-
tion of patients (38%) with zonular dehiscence at cata-
ract surgery in the in-the-bag dislocation group.
Because cataract surgery complications occur in only
a small percentage of cataract extractions, they seem
to be a greater risk factor for late IOL dislocations
than PXF alone.21
Capsular tension rings are often used when there is
phacodonesis or zonular dehiscence at the cataract
surgery. It has been proposed that a CTR be used
when there are existing risk factors for IOL dislocation,
such as PXF,8 and in which the cataract surgery is
otherwise uncomplicated. Considering the high prev-
alence of PXF, especially in the Scandinavian countries
(between 11% and 40%),14–19 this proposal would
involve implanting a CTR in a substantial proportion
of patients having cataract surgery,12 most of whom
will never develop IOL dislocation. In our study, 21
eyes (27%) with IOL dislocation had a CTR in place.
In 19 eyes, the indication for the CTR was zonular
dehiscence, which indicates that CTR implantation
1642 LATE IOL DISLOCATION
was performed for the correct indication. There are
several reports of dislocated CTR–IOL complexes
(Figure 2).7,22,23 Evaluation of the role of CTRs in pre-
venting IOL dislocation is not yet complete. However,
the presence of a CTR with an IOL–capsular bag com-
plex often facilitates IOL fixation and repositioning,
a technique described by Chan et al.24 and later mod-
ified by Hoffman et al.25 This procedure requires less
surgical intervention, and even complicated IOL sub-
luxations can be handled with small-incision surgical
intervention.26
Many types of posterior chamber IOLs were used in
the patients in our study, and we found no correlation
between the type of IOL and an increased risk for dis-
location; this corroborates previous findings.12 A
capsulotomy does not seem to create an additional
risk for IOL dislocation.12 This is supported in our
study, in which only 17% of patients required an
Nd:YAG capsulotomy.
The need for IOL repositioning surgery is evident if
the patient has visual symptoms caused by the disloca-
tion or if the progression is obvious and rapid. How-
ever, many eyes with minor IOL dislocation have no
visual symptoms and do not require surgical interven-
tion if the dislocation does not progress during short-
term follow-up examinations.
Several surgical techniques are used to reposition
a dislocated IOL. The choice of technique often
depends on the surgeon’s preferences, which is why ei-
ther an anterior or a posterior approach is used in many
cases. Also, management of the IOL with different su-
turing techniques and whether the IOL is preserved
or exchanged can differ.8 Some prefer replacing the
posterior chamber IOL with an anterior chamber IOL.9
At present, there are no long-term results in larger se-
ries of different repositioning techniques; therefore,
there is no consensus on what technique to use and
Figure 2. Laterally dislocated CTR–IOL complex.
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
several surgical procedures are reported to give good
results.8,9 Our preferred strategy is an anterior
approach with scleral sutures of 1 or both haptics if
the IOL is dislocated along the iris plane only and
some of the optic is visible in the pupil. An anterior vit-
rectomy is performed when there is prolapsed vitreous
gel in front of or around the IOL. However, if the IOL is
dislocated posteriorly in the vitreous cavity or laterally
from the posterior chamber in the vitreous base, we per-
form a PPV and suture the haptics into the ciliary sulcus
under triangular scleral flaps.27,28 A posterior vitrec-
tomy facilitates removal of vitreous strands from the
haptics and capsule remnants, thereby reducing the
risk for peripheral retinal breaks and subsequent retinal
detachment.29 When there is doubt about how the dis-
location is engaging the vitreous, a posterior approach
is often used, which probably explains the relatively
high frequency of PPV repositioning cases (60%) in
our study. Mello et al.29 used a pars plana approach
in 80 of 110 eyes. In a review of 73 cases, Gimbel
et al.8 found that PPV was used in 38 eyes. If the IOL
is exchanged, a combined technique comprising
a pars plana approach and limbal approach must be
used, as in 16 of 25 eyes in a study by Gross et al.9 and
in all 62 eyes in a study by Hayashi et al.10
We agree with the authors of previous studies that it
is desirable to preserve and reposition the existing IOL
if possible.24,25,29 In our series, the IOL was exchanged
or removed in only 6 cases (7%). Although there might
be a slight hyperopic spherical shift when the present
IOL is sutured to the ciliary sulcus, the surgical trauma
is less when no corneal wound is created to exchange
the IOL,30 thereby avoiding a postoperative increase in
refractive astigmatism.10
Today, cases of late IOL dislocation are not rare in
the everyday practice of many ophthalmologists
because of the large and expanding pseudophakic
population. The exact incidence of this complication
is not known, and previous estimations included all
types of dislocations, including many cases of early
dislocation or even instant dislocation at the time of
cataract surgery. In a recent study by Mönestam,18
810 cataract patients were followed for 10 years after
surgery with examinations assessing IOL dislocation
and pseudophakodonesis. Five patients required repo-
sitioning surgery for a dislocated IOL during this time,
resulting in a 10-year incidence of 0.6%.
One objective of our study was to compare the inci-
dence of late IOL dislocation between different years
to determine whether it had changed over time. There-
fore, the yearly incidence of surgery for late IOL
dislocation was correlated with an estimation of the
number of pseudophakic people in our region using
NCR data and official statistics on the Swedish popula-
tion. We calculated a rate of 0.05%, which might seem
 LATE IOL DISLOCATION
low compared with other estimations (0.20% to
3.00%.31,32). However, previous estimations included
all types of IOL luxation, cases of very early dislocation,
and clinically insignificant IOL subluxation; were not
based on calculations from a defined population of
pseudophakic patients; and were not calculated on
a yearly basis. To our knowledge, although we could
obtain only approximations of the number of living
pseudophakic patients in our region, this is the first
time the incidence of surgery for late IOL dislocation
has been compared with the estimated number of pseu-
dophakic people in a defined population. Although we
did not find a significantly increased rate in the inci-
dence, the number of surgeries for late IOL dislocation
at our clinic increased over these years, which became
more obvious when we compared data in 2000 (11
eyes) and 2008 (47 eyes). It is not clear whether this is
because the pseudophakic community is growing or
whether the type of cataract surgery technique also
plays a role. This increase in the number of patients
with late IOL dislocation who require repositioning
surgery was noted by Davis et al.,12 who recently re-
ported a ‘‘dramatic increase in the spontaneously dislo-
cated IOLs.’’ The increase was also predicted by other
authors.8,11,33 Whether this will cause a clinical prob-
lem in only a small group of patients or whether it
will develop into a condition of almost epidemic pro-
portions, only the future will tell.
REFERENCES
1. Stark WJ, Michels RG, Bruner WE. Management of posteriorly dis-
located intraocular lenses. Ophthalmic Surg 1980; 11:495–497
2. Moretsky SL. Suture fixation technique for subluxated posterior
chamber IOL through stab wound incision. Am Intra-Ocular
Implant Soc J 1984; 10:477–480
3. Sternberg P Jr, Michels RG. Treatment of dislocated posterior
chamber intraocular lenses. Arch Ophthalmol 1986; 104:
1391–1393
4. Waheed K, Eleftheriadis H, Liu C. Anterior capsular phimosis in
eyes with a capsular tension ring. J Cataract Refract Surg 2001;
27:1688–1690
5. Moreno-Montañés J, Sánchez-Tocino H, Rodriguez-Conde R.
Complete anterior capsule contraction after phacoemulsification
with acrylic intraocular lens and endocapsular ring implantation.
J Cataract Refract Surg 2002; 28:717–719
6. Masket S, Osher RH. Late complications with intraocular lens
dislocation after capsulorhexis in pseudoexfoliation syndrome.
J Cataract Refract Surg 2002; 28:1481–1484
7. Scherer M, Bertelmann E, Rieck P. Late spontaneous in-the-bag
intraocular lens and capsular tension ring dislocation in pseudoex-
foliation syndrome. J Cataract Refract Surg 2006; 32:672–675
8. 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
9. Gross JG, Kokame GT, Weinberg DV. In-the-bag intraocular
lens dislocation; the Dislocated In-the-Bag Intraocular Lens
Study Group. Am J Ophthalmol 2004; 137:630–635
10. Hayashi K, Hirata A, Hayashi H. Possible predisposing factors
for in-the-bag and out-of-the-bag intraocular lens dislocation
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
1643
and outcomes of intraocular lens exchange surgery. Ophthal-
mology 2007; 114:969–975
11. Kim SS, Smiddy WE, Feuer W, Shi W. Management of dislo-
cated intraocular lenses. Ophthalmology 2008; 115:1699–1704
12. Davis D, Brubaker J, Espandar L, Stringham J, Crandall A,
Werner L, Mamalis N. Late in-the-bag spontaneous intraocular
lens dislocation: evaluation of 86 consecutive cases. Ophthal-
mology 2009; 116:664–670
13. Lundström M, Stenevi U, Thorburn W. The Swedish National Cat-
aract Register: a 9-year review. Acta Ophthalmol Scand 2002;
80:248–257. Available at: http://www3.interscience.wiley.com/
cgi-bin/fulltext/118927388/PDFSTART. Accessed June 9, 2010
14. Arnarsson A, Damji KF, Sverrisson T, Sasaki H, Jonasson F.
Pseudoexfoliation in the Reykjavik eye study: prevalence and re-
lated ophthalmological variables. Acta Ophthalmol Scand 2007;
85:822–827. Available at: http://www3.interscience.wiley.com/
cgi-bin/fulltext/118515719/PDFSTART. Accessed June 9, 2010
15. Linnér E, Popovic V, Gottfries C-G, Jonsson M, Sjögren M,
Wallin A. The exfoliation syndrome in cognitive impairment of ce-
rebrovascular or Alzheimer’s type. Acta Ophthalmol Scand 2001;
79:283–285. Available at: http://www3.interscience.wiley.com/
cgi-bin/fulltext/119025113/PDFSTART. Accessed June 9, 2010
16. Arnarsson A, Damji KF, Sasaki H, Sverrisson T, Jonasson F.
Pseudoexfoliation in the Reykjavik eye study: five-year inci-
dence and changes in related ophthalmologic variables. Am J
Ophthalmol 2009; 148:291–297
17. Ekström C, Alm A. Pseudoexfoliation as a risk factor for prevalent
open-angle glaucoma. Acta Ophthalmol (Oxf) 2008; 86:741–746
18. Mönestam EI. Incidence of dislocation of intraocular lenses and
pseudophakodonesis 10 years after cataract surgery. Ophthal-
mology 2009; 116:2315–2320
19. Ålström S, Lindén C. Incidence and prevalence of pseudoexfoli-
ation and open-angle glaucoma in northern Sweden: I. Baseline
report. Acta Ophthalmol Scand 2007; 85:828–831. Available at:
http://www3.interscience.wiley.com/cgi-bin/fulltext/118515745/
PDFSTART. Accessed June 9, 2010
20. Young AL, Tang WWT, Lam DSC. The prevalence of pseudoex-
foliation syndrome in Chinese people. Br J Ophthalmol 2004;
88:193–195. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1772018/pdf/bjo08800193.pdf. Accessed June 9, 2010
21. Lundström M, Behndig A, Montan P, Arzén D, Jakobsson G,
Johansson B, Thorburn W, Stenevi U. Capsule complication
during cataract surgery: background, study design, and required
additional care; Swedish Capsule Rupture Study Group report 1.
J Cataract Refract Surg 2009; 35:1679–1687
22. Lim MCC, Jap AHE, Wong EYM. Surgical management of late
dislocated lens capsular bag with intraocular lens and endo-
capsular tension ring. J Cataract Refract Surg 2006; 32:
533–535
23. Oner FH, Kocak N, Saatci AO. Dislocation of capsular bag with
intraocular lens and capsular tension ring. J Cataract Refract
Surg 2006; 32:1756–1758
24. Chan CC, Crandall AS, Ahmed K II. Ab externo scleral suture
loop fixation for posterior chamber intraocular lens decentration:
clinical results. J Cataract Refract Surg 2006; 32:121–128
25. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunc-
tival dissection. J Cataract Refract Surg 2006; 32:1907–1912
26. Hoffman RS. Cataract surgical problem. In: Masket S, ed, Con-
sultation section. J Cataract Refract Surg 2009; 35:1837–1838
27. Smiddy WE, Flynn HW Jr. Needle-assisted scleral fixation su-
ture technique for relocating posteriorly dislocated IOLs [letter].
Arch Ophthalmol 1993; 111:161–162
28. Smiddy WE. Modification of scleral suture fixation technique for
dislocated posterior chamber intraocular lens implants [letter].
Arch Ophthalmol 1998; 116:967
1644 LATE IOL DISLOCATION
29. Mello MO Jr, Scott IU, Smiddy WE, Flynn HW Jr, Feuer W. Surgi-
cal management and outcomes of dislocated intraocular lenses.
Ophthalmology 2000; 107:62–67. Available at: http://download.
journals.elsevierhealth.com/pdfs/journals/0161-6420/PIIS01616
42099000172.pdf. Accessed June 9, 2010
30. Hayashi K, Hayashi H, Nakao F, Hayashi F. Intraocular lens tilt
and decentration, anterior chamber depth, and refractive error
after trans-scleral suture fixation surgery. Ophthalmology 1999;
106:878–882. Available at: http://download.journals.elsevier
health.com/pdfs/journals/0161-6420/PIIS0161642099005047.
pdf. Accessed June 9, 2010
31. Kratz RP, Mazzocco TR, Davidson B, Colvard DM. The Shear-
ing intraocular lens: a report of 1,000 cases. Am Intra-Ocular
Implant Soc J 1981; 7:55–57
32. Stark WJ Jr, Maumenee AE, Datiles M, Fagadau W, Baker CC,
Worthen D, Auer C, Klein P, McGhee E, Jacobs ME, Murray G.
Intraocular lenses: complications and visual results. Trans Am
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
Ophthalmol Soc 1983; 81:280–302. Available at: http://www.
ncbi.nlm.nih.gov/pmc/articles/PMC1312455/pdf/taos00018-0306.
pdf. discussion 302–309. Accessed June 9, 2010
33. Drolsum L, Ringvold A, Nicolaissen B. Cataract and glaucoma
surgery in pseudoexfoliation syndrome: a review. Acta Ophthalmol
Scand 2007; 85:810–821. Available at: http://www3.interscience.
wiley.com/cgi-bin/fulltext/118515723/PDFSTART. Accessed June
9, 2010
First author:
Gunnar Jakobsson, MD
Institute of Neuroscience and Physiology,
Department of Ophthalmology,
Sahlgrenska, Mölndal, Molndal, Sweden