Intrastromal misplacement of a foldable IOL during phacoemulsification: Intraoperative OCT identification of type-1...

Intrastromal misplacement of a foldable intraocular lens (IOL) during cataract surgery is exceedingly rare. Immediate identification of the separation plane is critical to prevent additional corneal injury.

A 76-year-old woman with bilateral glaucoma underwent routine phacoemulsification. During insertion of a one-piece acrylic IOL, the lens was inadvertently delivered into the corneal stroma. The IOL remained partially unfolded within a stromal pocket. Intraoperative anterior segment optical coherence tomography (AS-OCT; RESCAN 700) clearly demonstrated deep stromal migration of the IOL and a thick, taut, hyperreflective line consistent with a Type-1 separation of Dua's layer adherent to Descemet's membrane. This real-time confirmation enabled controlled removal of the misdirected IOL without Descemet's membrane rupture, followed by successful in-the-bag implantation of a new IOL and intracameral air tamponade. Postoperative AS-OCT showed gradual resolution of the separation without additional intervention. At 6 months, the cornea remained clear with improved visual acuity (0.6 to 0.7; logMAR 0.22 to 0.15) and an endothelial cell density of 1253 cells/mm² (52.8% loss). At 17 months, visual acuity remained 0.7, and endothelial cell density was 1158 cells/mm² (56.4% loss), and corneal clarity was maintained.

Intraoperative AS-OCT provided decisive, real-time visualization of the stromal entry plane and Type-1 Dua's layer separation, allowing safe retrieval of the misdirected IOL and preservation of Descemet's membrane integrity. Recognition of this separation pattern is essential for guiding atraumatic management of this extremely rare complication.