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Choroidal Disorders

Unilateral Intraocular Lens Implant Subluxation in an Adult

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Ophthalmology

Published Online: April 14, 2022

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Ogul E. Uner, MD¹;

Afshan A. Nanji, MD^1,2;

Alison H. Skalet, MD, PhD^1,2,3,4

Author Affiliations

¹Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
²Knight Cancer Institute, Oregon Health & Science University, Portland
³Department of Radiation Medicine, Oregon Health & Science University, Portland
⁴Department of Dermatology, Oregon Health & Science University, Portland

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A middle-aged patient with a remote history of bilateral juvenile cataracts after posterior chamber intraocular lens (PCIOL) placement presented with decreased vision in the right eye for several months. There was no recent ocular trauma or intraocular surgery. At the time of the initial examination, visual acuity was 20/50 in the right eye and 20/20 in the left eye, with a refraction of −1.50 diopters (D) sphere in both eyes. Examination was notable for a superonasal area of pigmentation with elevation of the conjunctiva and an inferotemporally subluxed PCIOL in the right eye. Results of the fundus examination were reported to be normal in both eyes and the anterior examination of the left eye was notable for only a well-positioned PCIOL. The patient was referred to a cornea specialist for further evaluation and treatment.

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Intraocular lens implant subluxation and extrascleral extension secondary to ciliochoroidal melanoma

B. Order ultrasound biomicroscopy

Intraocular lens (IOL) dislocation is an uncommon complication of cataract surgery, estimated to occur after 0.3% to 2.0% of cases.¹^,2 Risk factors for late postoperative IOL dislocation, defined as dislocation 3 or more months following surgery, include etiologies of zonular weakness such as pseudoexfoliation syndrome, retinitis pigmentosa, trauma, high myopia, prior vitreoretinal surgery, and connective tissue diseases.³ Investigations suggest 0.6% of patients with pseudophakia with these risk factors require corrective surgery for dislocations within 10 years of cataract surgery.² Surgery typically is indicated for decreased visual acuity or lens dislocation-induced retinal detachment, glaucoma, or uveitis.⁴ Both IOL exchange and suture fixation are potential treatments.³

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Article Information

Corresponding Author: Alison H. Skalet, MD, PhD, Casey Eye Institute, Oregon Health and Science University, 3375 SW Terwilliger Blvd, Portland, OR 97239 (skalet@ohsu.edu).

Published Online: April 14, 2022. doi:10.1001/jamaophthalmol.2022.0013

Conflict of Interest Disclosures: Dr Skalet reported being a consultant for Castle Biosciences Inc. All authors were supported by grant P30 EY010572 from the National Institutes of Health and unrestricted departmental funding from Research to Prevent Blindness. No other disclosures were reported.

References

Hayashi K , Hirata A , Hayashi H . Possible predisposing factors for in-the-bag and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens exchange surgery. Ophthalmology. 2007;114(5):969-975. doi:10.1016/j.ophtha.2006.09.017 PubMed Google Scholar Crossref

Mönestam EI . Incidence of dislocation of intraocular lenses and pseudophakodonesis 10 years after cataract surgery. Ophthalmology. 2009;116(12):2315-2320. doi:10.1016/j.ophtha.2009.05.015 PubMed Google Scholar Crossref

Yang S , Nie K , Jiang H , Feng L , Fan W . Surgical management of intraocular lens dislocation: a meta-analysis. PLoS One. 2019;14(2):e0211489. doi:10.1371/journal.pone.0211489 PubMed Google Scholar Crossref

Nelson LB , Maumenee IH . Ectopia lentis. Surv Ophthalmol. 1982;27(3):143-160. doi:10.1016/0039-6257(82)90069-8 PubMed Google Scholar Crossref

Dureau P . Pathophysiology of zonular diseases. Curr Opin Ophthalmol. 2008;19(1):27-30. doi:10.1097/ICU.0b013e3282f29f01 PubMed Google Scholar Crossref

Jager MJ , Shields CL , Cebulla CM , et al. Uveal melanoma. Nat Rev Dis Primers. 2020;6(1):24. doi:10.1038/s41572-020-0158-0 PubMed Google Scholar Crossref

National Comprehensive Cancer Network. NCCN guidelines: uveal melanoma, version 2.2021. 2018. Accessed November 30, 2021. https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1488.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.