Where should the IOL go when it does not go where it should?

hroughout the latter half of the twentieth century, a series of disruptive innovations and hotly debated issues resulted in general consensus for standard cataract surgery and agreement on the ideal anatomic location for intraocular lenses (IOL); namely, within the capsular bag. Sir Harold Ridley envisioned this outcome from the inception of the IOL, stating “...the site for the prosthesis should be, if possible, just where nature had placed a biconvex lens throughout the animal kingdom.”1 Now, in-the-bag implantation is not only standard practice but also a necessity for many monofocal and premium IOL styles, including one-piece acrylic, plate haptic, and toric IOLs. In striving for maximum achievable refractive outcomes from cataract surgery, we are beginning to inspect the impact of the most subtle aspects of “effective lens position.” Evidence is mounting regarding the effect of absolute capsular stability and IOL positioning issues within the bag, including IOL centration and tilt, on fi nal visual outcomes, especially with toric and multifocal IOLs. In this issue, Kránitz and colleagues2 provide further evidence on the importance of capsulorrhexis parameters on ultimate IOL centration and tilt, demonstrating subtle differences with femtosecond laser capsulotomies in both of these positional parameters. These fi ndings support the authors’ previous work regarding minimal IOL decentration with femtosecond laser capsulotomy3 and the utility of this device in otherwise challenging cases where traditional capsulotomy approaches may have resulted in loss of capsular integrity necessitating alternate IOL placement location.4 Alió and colleagues have reported the effi cacy of a novel rotationally asymmetric multifocal IOL,5 and in this month’s issue, provide intriguing data that suggest capsular tension ring (CTR) placement, even in seemingly normal capsules, improves outcomes with this IOL.6 These results may stimulate a new fi eld of study evaluating IOL stability and function with routine CTR placement. Whether surgeons will adopt this strategy of CTR placement in “normal” capsules remains to be seen. Even in cases with anatomically well-centered IOLs, functional decentration may occur with regard to IOL centration relative to pupillary position. Although this has minimal impact for most monofocal and toric IOLs, this can cause signifi cant deterioration of visual quality and patient satisfaction with multifocal IOLs. Solomon and colleagues7 describe a relatively straightforward technique to improve relative pupil and multifocal IOL centration using argon laser pupilloplasty to functionally shift and center the pupil over the multifocal optic. This technique may signifi cantly improve symptoms in select patients and thereby reduce the incidence of multifocal IOL exchange in these potentially challenging cases.8 In more challenging surgical cases, with insuffi cient capsular support for in-the-bag IOL placement due to a variety of mechanisms, where should the IOL be placed? What is the optimal strategy for IOL placement and fi xation in these cases, and what IOLs can be safely positioned outside of the capsular bag? Furthermore, what if an IOL is initially placed within the capsule but becomes functionally decentered or otherwise unstable? Recent studies challenge current thinking on IOL positioning in these unique situations and may expand our treatment options, some with controversial techniques. Sutured scleral IOL fi xation has been a useful technique for many years; however, signifi cant complications may arise, including late dislocation. In recent years, fi brin glue–assisted scleral IOL fi xation has been evaluated,9 and Ganekal and colleagues10 report similar visual outcomes with signifi cantly less postoperative complications with the fi brin glue technique. Another novel approach to this situation is the nontraditional use of retro-iris fi xation of a hyperopic phakic iris claw IOL, as reported by Hara et al.11 Ease and reproducibility of surgiT