A 79-year-old Korean male with complaints of sudden decrease in visual acuity in the right eye was referred to our clinic. He did not present any remarkable medical history except hypertension. Phacoemulsification with capsular bag implantation of a posterior chamber IOL (AQ2003 V, STAAR Surgical Co., Monrovia, CA) was performed in both his eyes, about 10 years ago in a local clinic. Subsequently, Nd:YAG laser posterior capsulotomy was performed in the right eye at a local clinic. On ocular examination, the uncorrected distance visual acuity (UCVA) was 20/400 for the right eye and 20/20 for the left eye. The best-corrected distance visual acuity (BCVA) was 20/20 (x-10.00 Dsph) for the right eye and 20/20 for the left eye. Intraocular pressure (IOP) was 11 mmHg as measured by noncontact tonometer in the right eye. On slit-lamp examination, the cornea and conjunctiva were unremarkable, and there was no evidence of neovascularization in the iris, while dislocated IOL with intact anterior capsulorrhexis margin was observed in the right eye (Fig. ). We removed the dislocated IOL and fixed a 3-piece IOL (Acrysof MN60AC, Alcon Laboratories, Inc) in the ciliary sulcus under retrobulbar anesthesia. During the dislocated IOL removal operation, a fractured distal haptic was observed (Fig. ), and a proximal haptic was broken when held with a pair of smooth forceps (Fig. ). After the operation, the observed UCVA was 20/20 and the measured IOP was 18 mmHg; the IOL was fixed in the ciliary sulcus. The extracted polyimide haptic was fractured in vitro with 13 shots of 5.5 mJ energy (Fig. ). Patient has provided informed consent for publication of the case
A 71-year-old male presented with decreased visual acuity in the left eye for 2-month duration. On ocular examination, the best-corrected visual acuity in the right and left eyes was 20/20 (MR−, +0.50Ds -0.50Dc Ax90) and 20/60 (MR-error), respectively. On slit lamp examination, an empty capsular bag with anterior continuous curvilinear capsulorhexis (CCC) was found in the anterior chamber []. In addition, the slit lamp examination showed downward subluxation of a three-piece IOL and some vitreous strands in the anterior chamber in the mydriasis test []. The medical history of this patient was as follows. In 2009, he was diagnosed with a senile cataract (posterior subcapsular opacity type) in both eyes and underwent cataract surgery on both eyes in our clinic. There was no zonular weakness or pseudoexfoliation in the crystalline lens on the preoperative examination. The cataract surgery consisted of one-stitch, a 2.8-mm temporal clear corneal incision, phacoemulsification, and implantation of a three-piece hydrophobic acrylic IOL (TECNIS ZA9003, Abbott Medical Optics, Santa Ana, CA, USA) in the left eye and a one-piece hydrophobic acrylic IOL (TECNIS ZCB00, Abbott Medical Optics, Santa Ana, CA, USA) in the right eye. He denied accidental trauma before or after the cataract surgery. He also had no hereditary genetic diseases, including Marfan syndrome, homocystinuria, spherophakia, and retinitis pigmentosa. However, he stated that he had a habit of rubbing his eyes.\nThree years postoperatively, he presented with decreased visual acuity in the left eye and anterior dislocation of the capsular bag. The IOL was dislocated into the posterior chamber. We planned to reposition the IOL with scleral fixation of the existing lens. The dislocated capsular bag was extracted from the anterior chamber and spread on the corneal surface, and we observed a partial circumferential laceration along the equator of the capsular bag; that is, at the junction of the anterior and posterior capsular bags. The bag had an intact margin of anterior capsular curvilinear capsulorhexis [Fig. and ]. To reposition the IOL, two partial-thickness, limbal-based scleral flaps were created about 1.5 mm from the limbus, under which sclerotomies were performed. The IOL was repositioned through two 1-mm side punctures made using two 23-gauge end-gripping micro-capsulorhexis forceps (Micro Surgical Technology, Redmond, WA, USA), and both haptics were externalized under the scleral flap with Colibri forceps. The haptic ends were tucked into intralamellar scleral tunnels made with a 26-gauge needle. The scleral flaps and conjunctiva were closed with fibrin glue (Tisseel; Baxter, Deerfield, IL, USA; []). The surgery was completed with an anterior vitrectomy. This method, called a glued intrascleral fixation of the posterior chamber of the IOL, was introduced by Kumar et al.[] The uncorrected visual acuity recovered to 20/30 in the left eye [].