An 86-year-old woman with a history of pseudoexfoliation glaucoma was referred for evaluation of sudden visual decline in her left eye. She carried diagnoses of mild pseudoexfoliation glaucoma in the right eye and moderate to severe disease in the left. Her ocular history was notable for pseudophakia in both eyes and prior selective laser trabeculoplasty in the left eye 5 years earlier, which had been ineffective. She was intolerant to multiple topical agents, including latanoprost, brimonidine, timolol, and dorzolamide. The patient underwent trabeculectomy in the left eye 2 years prior after intraocular pressures (IOPs) were documented in the 40s, with excellent postoperative pressure control thereafter. IOP in the left eye had remained consistently between 9 mm Hg and 11 mm Hg without topical therapy, and testing was stable. She presented with an acute decline in visual acuity in the left eye from her baseline of 20/30 to 20/100. On examination, corrected distance visual acuity (CDVA) was 20/40 in the right eye and 20/100 in the left eye. In the right eye, IOP measured 16 mm Hg with slitlamp findings significant for pseudophakia and pseudoexfoliative material at the pupillary margin. The remainder of the anterior segment was within normal limits. Examination of the left eye revealed a diffusely elevated, avascular filtering bleb extending from 10 to 2 o'clock, consistent with a functioning trabeculectomy. A significantly inferiorly subluxed posterior chamber intraocular lens (IOL) was visualized, with the superior haptic bisecting the visual axis. There was complete loss of superior zonular support, and a fluffy residual cortical material was evident within the peripheral capsular bag (Figure 1 JOURNAL/jcrsoc/04.03/02158035-202601000-00019/figure1/v/2026-04-01T201829Z/r/image-tiff ). Posterior segment visualization was limited because of lens displacement; however, the peripheral retina appeared within normal limits. The IOL position was maintained when the patient was examined supine. Given her history of advanced pseudoexfoliation glaucoma, prior trabeculectomy with a functioning bleb, medication intolerance, and now a visually significant IOL dislocation, determining the safest and most effective approach to restoring visual function while preserving long-term bleb integrity poses a complex management challenge. How would you manage the dislocated IOL in this eye with prior trabeculectomy and advanced pseudoexfoliation glaucoma?
Larsen et al. (Thu,) studied this question.