Recovering from a misloaded IOL


August 18, 2021

3 min read

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Decades ago, foldable IOLs allowed us to advance cataract surgery to smaller incisions that were about 3 mm to 4 mm in width. An IOL with a 6-mm optic could be folded in half and then inserted with forceps.

We then moved to injectable IOLs in which the optic could be rolled and placed into a cartridge that would allow incisions under 3 mm wide. When inserting these IOLs into the injector cartridges, we must follow the manufacturer’s specific instructions in order to avoid damaging the IOL.

Uday Devgan
Uday Devgan

In the case presented here, the IOL was incorrectly loaded, and upon injection into the anterior segment of the eye, it was noted to be upside down with a bent haptic (Figure 1). The orientation matters because this IOL is posteriorly vaulted with the haptics positioned 10° angulated with respect to the optic plane. We can tell the IOL is upside down because the haptics are in the “S” orientation. We can explant the IOL and then try again with a new IOL, or we can recover by flipping the IOL over and restoring the haptic to its original shape.

misloaded IOL
Figure 1. The IOL was misloaded by the scrub tech, and when it was injected into the anterior segment, it was noted to be upside down with a bent leading haptic.

Source: Uday Devgan, MD

This IOL is a special-order model of low dioptric power for this highly myopic eye. While we do have a back-up IOL available, the safest and least traumatic option is to reorient the IOL and straighten the haptic. If the IOL had sustained damage to the optic, then the best move would be to perform an IOL exchange.

When flipping this IOL over, we need to protect the capsular bag and the corneal endothelium by injecting more viscoelastic, which also helps to create space. Using a chopper or other second instrument, the optic can be tilted to the vertical position and then pushed over into the correct orientation. It is also helpful to leave one haptic outside of the incision, which can be held with forceps to further assist (Figure 2). With the IOL now in the correct orientation, we can address the distorted haptic.

IOL is flipped
Figure 2. After placing more viscoelastic in the eye to create space, the IOL is carefully flipped over without damaging the capsule or the corneal endothelium.

The bent haptic needs to be brought outside of the eye through the phaco incision. The IOL is rotated until the bent haptic is near the incision, and then forceps can be used to externalize it. Using two forceps, we can straighten the bent part of the haptic and restore the normal shape and curvature (Figure 3). This is done gently so as to not cause the haptic to break.

externalize bent haptic
Figure 3. The IOL is rotated so the bent haptic can be externalized. Then, two tying forceps are used to restore the haptic shape.

At this point, the IOL is now in the correct orientation, and the haptics are of the normal curvature. The IOL is dialed into the capsular bag where it centers precisely and is securely held by the 5-mm capsulorrhexis (Figure 4). There is a 360° overlap of the capsulorrhexis on top of the 6-mm optic for great long-term stability. The patient had a normal postoperative course and achieved excellent vision.

implant IOL
Figure 4. Now the fixed IOL can be dialed into the capsular bag where it centers precisely, and it is held securely by the overlapping capsulorrhexis.

Most manufacturers are now upgrading to preloaded IOL designs in which there is minimal manipulation required. By avoiding direct contact of the IOL by the surgical scrub technician, there is a lower risk of a misloaded or damaged IOL.

Although the error in this case was in the hands of the scrub tech, ultimately the responsibility of the surgery rests on the shoulders of the surgeon. The ability to handle complications such as this misloaded IOL is an important skill that the surgeon learns over the course of many years. We cannot always predict complications, but we can recover from them and provide our patients with their desired visual outcome.

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Elena Johaness

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