A novel unimanual pronation-supination (UPS) technique for the safe and efficient removal of posteriorly dislocated intraocular lenses

Background: Intraocular lens (IOL) dislocation into the vitreous cavity is a well-documented complication of cataract surgery, with a reported incidence ranging from 0.2% to 3%. [1,2] Managing posteriorly dislocated IOLs sometimes, pose challenges during retinal surgery. Surgical planning typically involves explanting the dislocated IOL and achieving visual rehabilitation through secondary IOL implantation—either an anterior chamber IOL, an iris-fixated IOL, or a scleral-fixated IOL. In some cases, the same dislocated IOL can be re-fixated using various haptic fixation techniques such as Yamane [3,4] X-NIT, [5] or the Glued IOL technique. [6] Purpose: Traditionally, a bimanual approach is used for removing the dislocated IOL from the posterior segment. However, this method may result in anterior chamber instability due to sudden changes in fluid dynamics, particularly when using IOP-compensated fluid injection vitrectomy systems, which can lead to the IOL dropping back into the vitreous cavity. We describe a Unimanual Pronation-Supination (UPS) technique, which is a minimally invasive approach that ensures a stable, closed anterior chamber transfer, reducing intraocular instability and surgical risks. Synopsis: The surgical plan involves preplacing a scleral tunnel, performing a thorough pars-plana vitrectomy, and preferably placing perfluorocarbon liquid over the posterior pole for macular protection. This video demonstrates a systematic, stepwise unimanual technique for safely explanting posteriorly dislocated IOLs. By following the described steps, surgeons can consistently remove dislocated IOLs while maintaining anterior chamber stability. Highlights: The technique is described under three key headings to enhance understanding and support learning for beginners. IOL Orientation Step: Under wide-angle visualization, the IOL is oriented such that the inferior haptic tip is directed away from the forceps. The IOL’s long axis is positioned perpendicular to the long axis of the forceps. The optic is firmly held with vitreoretinal forceps (Straight/End-Gripping/Eckardt-type ILM forceps/Pick’s forceps), just behind the inferior haptic-optic junction, and is gently lifted anteriorly into the retro-pupillary space. Pronation Step: Under direct microscope visualization, the inferior haptic is brought above the iris by moving the IOL slightly superiorly beneath the iris while pronating the forceps-holding hand. This rotates the IOL along the forceps' long axis, resulting in the inferior haptic entering the inferior anterior chamber through the pupil. Meanwhile, part of the optic and the superior haptic remain behind the superior iris. Supination Step: Without releasing the IOL, the supination step is carried out. The inferior haptic already in the anterior chamber is slightly de-centred inferiorly while supinating the forceps-holding hand. This manoeuvre lifts the superior haptic above the superior iris, bringing the entire IOL into the anterior chamber. This technique allows the entire IOL to be safely and quickly transferred from the posterior vitreous cavity into the anterior segment within a closed-eye system—without requiring a change of hands. With practice, these movements can be executed by simply rotating the forceps along its axis—counterclockwise for pronation and clockwise for supination—using the sclerotomy port as a fulcrum (for a right-handed surgeon). The IOL can then be removed through the pre-placed sclero-corneal tunnel safely and efficiently. Teaching Points: By adhering to the structured sequence described in the UPS technique, surgeons can methodically remove dislocated IOLs from the posterior segment, eliminating intraoperative unpredictability. Precise orientation of the IOL and consistent gripping at the IOL at the same junction prior to lifting help standardize the manoeuvre, reducing variability during transfer. The Unimanual Pronation-Supination (UPS) technique provides a reproducible, reliable, and minimally invasive method for the safe and efficient removal of any type of posteriorly dislocated IOL. Video link: https://youtu.be/12xqaB2Tly8