An intraocular lens lies underneath the detached retina: a rare case with surgical management

Intraocular lens (IOL) dislocation into the subretinal space is a rare but vision-threatening complication, particularly when the lens migrates beneath the macula. While surgical retrieval is challenging, the optimal approach remains controversial. Creating a retinotomy for IOL extraction carries additional risks of bleeding, proliferative vitreoretinopathy, and permanent scotoma. This case is reported to highlight a novel surgical strategy that leveraged the pre-existing original retinal break as a natural exit route for IOL extraction, avoiding the need for an additional retinotomy. A 53-year-old Asian male with keratoconus and a history of bilateral cataract surgery performed ten years earlier presented with a ten-day history of decreased vision in the right eye. Examination revealed hand motion vision, intraocular pressure of 3.6 mmHg, and a completely dislocated IOL located beneath the inferiorly detached retina with rhegmatogenous retinal detachment combined with choroidal detachment. During pars plana vitrectomy, the capsular bag–IOL complex unexpectedly migrated under the macula while the patient was in the supine position. Perfluorocarbon liquid (PFCL) was instilled to gently displace the capsular bag–IOL complex from the macula, followed by deliberate globe manipulation to guide the capsular bag–IOL complex toward and through the original retinal break for extraction. No additional retinotomy was performed. Retinal reattachment and laser photocoagulation were completed with silicone oil tamponade. At one month postoperatively, the patient’s best-corrected visual acuity in the right eye improved from hand motion to 20/100. A dislocated IOL beneath the macula, extraction through the pre-existing original retinal break using PFCL and careful globe manipulation is a feasible strategy that avoids the additional retinotomy.