Mastering IOL Exchange

As cataract surgery becomes more and more a branch of refractive surgery, pseudophakic patients are increasingly asking for their intraocular lens to be replaced due to higher expectations and a lack of satisfaction. IOL exchange, however, is usually performed only for specific reasons. According to Mirko Jankov MD, PhD, it is mainly dissatisfaction with the refractive outcomes that pushes patients to drive a hard bargain.

“Of my last 15 cases of IOL exchange, I had to exchange the lenses not because of misplacement, dislocation, inflammation, or opacification of the IOL or the posterior capsule, but because the patient was highly dissatisfied,” he said. “This was especially common in patients with multifocal IOLs.”

Professor Jankov explained how lens exchange can be challenging even in the simplest cases, where the posterior capsule, the whole anatomy of the bag, and the zonules are intact. However, even in this easy scenario, the lack of proper instrumentation can make everything difficult, so ensuring the correct hooks, the microforceps, and strong enough scissors are available is still extremely important. He further emphasised the endothelium needs protection from being touched during the procedure by any means necessary.

Regarding the incision site, Prof Jankov suggested making the process easier by going for an incision that is too small: a 2.5–3.0 mm incision is better to avoid both complications without incurring a longer recovery time. When dealing with rigid IOLs, however, a larger incision may still be required.

If it is not possible to dissect the original incision, targeting the temporal approach is suggested to reduce the risk of induced astigmatism. Any of the available techniques for IOL exchange start with a good viscodissection, he observed. It is very important to start the viscodissection from the posterior part—failing to do this first will make it difficult to move the lens soon after, he added.

Moreover, during the cutting phase, some parts of the IOL can become a potential danger not only for the endothelium but the integrity of the capsular bag, emphasising the need for caution.

Amongst the different IOL extraction techniques, such as the classic cut, the Pacman, the FLAIR, and the cartridge pull-through, Prof Jankov chose the ‘twist and out’ as his preferred approach. This technique allows twisting the lens and folding it inside the anterior chamber while a spatula protects the endothelium. Describing it as a very elegant technique, he said another version uses a cannula shaft to give the surgeon complete use of both hands.

The technique choice, however, is not only driven by the surgeon’s preference, Prof Jankov observed, but the IOL material, its location, the presence of fibrosis, and other anatomical variables that make some techniques more suitable than others. Especially important is the presence of a capsular bag already treated with YAG capsulotomy, which can make things much more difficult.

“Master the technique and have the right instruments,” he said. “And always be aware that damaging the endothelium, the capsule, or the zonules can lead to undesired complications.”

Prof Jankov spoke during the 2025 ESCRS Winter Meeting in Athens.

Mirko Jankov MD, PhD is clinical director at the LaserFocus Clinic of Belgrade, Serbia; Sarajevo, Bosnia and Herzegovina; and Budva, Montenegro. mirko.jankov@laserfocus.eu