Pseudoexfoliation and IOL Dislocation

    • CE credits 2 hours
    • COPE code 68631-PO / 120089
    • Available until Jul 8, 2023


Learning Objectives

  • To review the common causes of zonular instability and intraocular lens (IOL) dislocation
  • To describe the management of intraocular lens dislocation
  • To review the types of commonly used IOL


An 80-year-old man underwent successful bilateral cataract extraction and one-piece IOL implantation four years ago with excellent visual outcome. His ocular history is also significant for glaucoma, for which he takes bimatoprost and brimonidine/timolol.

He presents to the Emergency Department with sudden-onset painless vision loss in the right eye. There is no history of trauma, and he is systemically well with no fever, headache, or jaw claudication. His medical history is notable only for dyslipidemia, for which he takes a statin.

On examination, best-corrected visual acuity is CF in the right eye, and 20/25 in the left eye. There is no injection of the conjunctiva, corneas are clear, and the anterior chambers are deep and quiet. An intraocular lens implant is present in both eyes. In the right eye, the edge of the optic is visible within the pupil at the level of the central visual axis and the implant is tilted, with the inferior edge fallen back into the anterior vitreous. The optic nerves show no pallor or edema, the cup-to-disc ratios are 0.75 and 0.60, with inferior thinning bilaterally. The macula, vessels, and periphery are within normal limits.

Fig 1. Anterior segment photograph of the presenting patient.

Quick Question

What is the most common underlying association with late spontaneous “in-the-bag” intraocular lens implantation (“in the bag” refers to the IOL being placed in the capsular bag)?

  • History of uveitis

    Chronic ocular inflammation is a recognized cause of zonulopathy, however it is much less common than pseudoexfoliation syndrome as a cause of late spontaneous IOL dislocation.

  • Pseudoexfoliation syndrome

    Pseudoexfoliation is a systemic condition characterized by proinflammatory deposits of elastotic material throughout the body. Accumulation of pseudoexfoliation material on zonules is the most common identified cause of progressive zonulopathy and late in-the-bag IOL dislocation.

  • History of intravitreal injections

    Intravitreal injections can lead to occult zonular trauma, and a history of multiple previous injections has been linked to an increased risk of intra-operative complications during cataract surgery (Lee et al., 2016). However, this has not been identified as a common cause for late spontaneous IOL dislocation.

  • High hyperopia

    Increased axial length and high myopia, not hyperopia, are risk factors for late in-the-bag IOL dislocation.

  • Pigment dispersion syndrome

    Pigment dispersion has not been reported to be significantly associated with late IOL dislocation. Some of the exam findings—iris transillumination defects, increased angle pigmentation, and Sampaolesi’s line—can appear similar to those in patients with pseudoexfoliation syndrome.

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