For qualified healthcare professionals. It does not replace national guidance, device labelling, institutional protocols or individual clinical judgement.
Anatomy and complications determine management
Define IOL position, capsular and zonular support, vitreous prolapse, corneal and iris status, macula and retina.
Stable, asymptomatic decentration with preserved visual function warrants observation; progression, visual symptoms or complications change the threshold.
Randomised data do not show a universal long-term visual-acuity advantage of one strategy over the other. [7] [8]
With sufficient capsular support, preserving and repositioning the existing IOL may be appropriate. With major capsular/zonular failure, fixation outside the bag or IOL exchange is considered, incorporating corneal, iris, IOP, vitreous and retinal status.
Describe dislocation in a way that informs surgery
Early dislocation usually reflects perioperative capsular-zonular damage; late dislocation often develops years later and may involve the entire IOL–capsular bag complex.
Determine whether the whole complex has shifted or the IOL has displaced relative to the capsule.
Record optic tilt, pupil-edge relationship, movement with gaze and dynamic instability.
Anterior displacement threatens the endothelium, iris and aqueous outflow; posterior displacement may require vitreoretinal access.
Late dislocation usually reflects progressive zonular failure
- Pseudoexfoliation syndrome is one of the most consistently reproduced risk factors for late in-the-bag IOL dislocation. [5] [6]
- High myopia, trauma, previous vitrectomy and selected ocular procedures have observational associations with late dislocation. [6]
- Capsular phimosis can increase centripetal stress on an already compromised zonular apparatus.
- Other ocular disorders should be interpreted in their anatomical context rather than used alone to select a secondary IOL fixation method.
Document function and anatomy
Uncorrected and best-corrected visual acuity, refraction, monocular diplopia, glare and fluctuation.
Optic and haptic position, anterior chamber, endothelium, iris, capsular bag and inflammation.
Measure intraocular pressure and assess the angle when clinically relevant.
Dilated retinal examination and macular OCT when vision is reduced or macular oedema is suspected.
Minimum diagnostic work-up
| Test | Clinical question |
|---|---|
| Dilated slit-lamp examination | Optic/haptic position, capsular support and dynamic IOL–bag instability. |
| Tonometry | Secondary ocular hypertension or glaucoma decompensation. |
| Macular OCT | Macular oedema and alternative causes of reduced vision. |
| UBM / anterior-segment OCT | Haptic position and relationship to iris/ciliary sulcus. |
| B-scan ultrasound | IOL and posterior-segment status when fundus view is inadequate. |
| Specular microscopy | Selected cases at risk of endothelial decompensation. |
Situations in which delay may increase risk
- IOL dislocation into the anterior chamber or contact with the corneal endothelium.
- Pupillary capture with significant iris distortion, pain, inflammation or acute IOP elevation.
- Pupillary block or other IOL-related acute IOP rise.
- Mechanical iris chafing with recurrent hyphema and inflammation.
- Complete posterior IOL dislocation into the vitreous cavity, especially with retinal tear/detachment concern.
- Progressive visual loss with macular oedema when a mechanical IOL factor persists.
Symptoms, progression and complications set the threshold
Stable small decentration, acceptable vision and no progressive instability, inflammation, IOP problem or corneal/retinal threat.
Reduced best-corrected visual acuity, monocular diplopia, significant tilt/decentration, optic edge in the pupil, progression or recurrent mechanical complications.
Preserve the IOL when doing so is anatomically rational
If the IOL–bag complex can be stabilised reliably, consider repositioning.
Damage, unsuitable design or inability to achieve safe fixation favours IOL exchange.
Posterior displacement or vitreous prolapse may require an anterior or pars plana vitrectomy component.
No single method is universally best
Appropriate when the IOL and bag are suitable for preservation and stable fixation is feasible.
Sutured or sutureless strategies; choice depends on IOL design, sclera, conjunctiva, glaucoma surgery and surgeon expertise.
Requires adequate iris anatomy and awareness of inflammation, pupil distortion and pigment dispersion.
Reserved for selected eyes after endothelial, angle and iris assessment.
Its haptic/optic design increases the risk of iris chafing, pigment dispersion, inflammation, hyphema and secondary glaucoma. [14]
When a vitreoretinal component is required
- Complete or substantial posterior IOL dislocation into the vitreous cavity.
- Vitreous prolapse into the anterior chamber or surgical wounds.
- Need to free the IOL safely from vitreous before repositioning or removal.
- Concurrent retinal pathology requiring vitreoretinal treatment.
When vitreous prolapse is present, identify and remove vitreous from the manipulation zone before moving the IOL. Traction transmitted through residual vitreous may increase the risk of peripheral retinal tears.
Coexisting anatomy changes the plan
Expect generalised zonular weakness and possible progression beyond the currently visible defect.
Altered posterior-segment support affects access, IOL behaviour and fixation planning.
Account for filtering blebs, drainage devices, conjunctival availability, angle anatomy and target IOP.
Assess inflammatory activity, iris/scleral integrity and retinal risk before selecting fixation.
Questions that should be answered before surgery
- What is best-corrected visual acuity and is the IOL responsible for the functional loss?
- Where are the optic and both haptics? Is the IOL in the bag?
- How much capsular and zonular support is truly present?
- Is there vitreous prolapse?
- What are the IOP, corneal, iris, macular and peripheral retinal findings?
- Can the existing IOL be preserved safely, or is exchange preferable?
- Is vitreoretinal support required and what is the backup fixation plan?
Common ways to make surgery less controllable
- Nd:YAG capsulotomy before assessing IOL–bag stability.
- Moving the IOL while vitreous prolapse remains unaddressed.
- Selecting fixation without considering endothelium, iris, conjunctiva and previous glaucoma surgery.
- Placing a single-piece acrylic IOL in the ciliary sulcus. [14]
- Treating inflammation or IOP alone while persistent mechanical IOL contact remains: medical therapy may reduce manifestations temporarily, but the mechanical cause must be addressed when it persists.
Monitor more than IOL position
Visual acuity, IOP, cornea, IOL position, inflammation, wounds and pupil.
OCT if vision is reduced or cystoid macular oedema is suspected.
Peripheral examination when symptoms or vitreoretinal risk factors are present.
Early recognition protects function
- Recurrent IOL decentration/instability.
- Ocular hypertension or glaucoma decompensation.
- Inflammation and recurrent hyphema from mechanical iris contact.
- Cystoid macular oedema.
- Corneal endothelial decompensation.
- Retinal tears or detachment.
- Endophthalmitis — uncommon but urgent.
Useful information when referring a patient
Include best-corrected visual acuity, IOP, IOL/capsular bag position, presence or absence of vitreous prolapse, macular and retinal status, pseudoexfoliation syndrome, previous vitrectomy, glaucoma and any urgent complication. Attach anterior-segment photography, macular OCT and UBM/anterior-segment OCT when available.
What is relatively robust
Randomised studies support good outcomes with both strategies when anatomy is respected. [7] [8]
Pseudoexfoliation shows one of the most consistent associations; evidence for several other conditions is heterogeneous and largely retrospective. [6]
Meta-analyses show acceptable outcomes with multiple techniques; anatomy and complication profile matter more than a single universal winner. [11] [12]
Many technique-specific studies are retrospective series, so surgeon familiarity must remain bounded by anatomical contraindications and known complications.
Sources
- Russian Ministry of Health. Clinical guideline “Complicated Cataract”. 2025. ID 969_1; ICD-10 T85.2. Official source ↗
- European Society of Cataract and Refractive Surgeons. ESCRS Recommendations for Cataract Surgery.
- Miller KM, Oetting TA, Tweeten JP, et al. Cataract in the Adult Eye Preferred Practice Pattern®. Ophthalmology. 2022;129:P1–P126.
- Khoramnia R, Baur ID, Auffarth GU. Aetiology and Management of IOL Dislocations. Klin Monbl Augenheilkd. 2023;240:971–980. PMID:37494272.
- Kristianslund O, Dalby M, Drolsum L. Late in-the-bag intraocular lens dislocation. J Cataract Refract Surg. 2021;47:942–954.
- Risk and protective factors of late in-the-bag intraocular lens dislocations: systematic review. J Cataract Refract Surg. 2025. PMID:39602350.
- Kristianslund O, Råen M, Østern AE, Drolsum L. Randomized clinical trial comparing lens repositioning and lens exchange. Ophthalmology. 2017;124:151–159.
- Dalby M, Kristianslund O, Drolsum L. Long-Term Outcomes after Surgery for Late In-The-Bag IOL Dislocation. Am J Ophthalmol. 2019;207:184–194.
- Dalby M, Kristianslund O, Østern AE, et al. Longitudinal corneal endothelial cell loss after corrective surgery for late in-the-bag IOL dislocation. J Cataract Refract Surg. 2020;46:1030–1036.
- Medin H, Dalby M, Kure ISH, et al. Intraocular Inflammation in Eyes Operated for Late In-the-bag IOL Dislocation (LION). Am J Ophthalmol. 2022;238:66–74.
- Chang YM, Weng TH, Tai MC, et al. Meta-analysis of sutureless scleral-fixated IOL versus retropupillary iris-claw IOL. Sci Rep. 2024;14:2044.
- Nagino K, Inomata T, Ohta T, et al. Postoperative complications of intrascleral IOL fixation: systematic review and meta-analysis. Surv Ophthalmol. 2025;70:489–498.
- Postoperative complication rates in IOL placement and fixation methods for inadequate capsular support: review and meta-analysis. 2024. PMID:39418054.
- Mehta R, Aref AA. Intraocular Lens Implantation In The Ciliary Sulcus: Challenges And Risks. Clin Ophthalmol. 2019;13:2317–2323.
For colleagues
Refer a patient with IOL dislocation for consultation
For in-person assessment of IOL position, capsular support, anterior/posterior segment status and surgical planning.