Combined BIL and Vitrectomy

  • Tillmann P. EckertEmail author


The “bag in the lens” (BIL) IOL is a very good option in combined phacoemulsification and vitrectomy. Based on the experience of more than 3000 implantations of the BIL since 2009, necessary modifications of the primary posterior continuous curvilinear capsulorhexis (PPCCC) and other critical steps during phacovitrectomy are discussed: In the eyes with a poor or absent red reflex, the PPCCC can be performed with intracameral illumination. During a fluid-air exchange, a marked condensation of water on the posterior surface of the BIL will occur which can be eliminated with hydroxypropylmethylcellulose. Postoperatively, there is a risk of pupillary capture in gas-filled eyes. Mydriatics in the first postoperative days should be avoided. Pupillary capture can be managed easily. The BIL offers excellent intraoperative stability and postoperative centration. Other advantages are the complete absence of posterior capsular opacification or anterior capsule contraction, a good intraoperative and postoperative view on the fundus, and the lack of posterior synechiae even after heavy postoperative inflammation or in uveitis.


Phacovitrectomy Bag in the lens Morcher Type 89F Primary posterior curvilinear capsulorhexis Vitreous hemorrhage Intracameral illumination Pupillary capture Condensation 



anterior chamber


anterior continuous curvilinear capsulorhexis


“bag in the lens” foldable IOL


balanced salt solution


capsular tension ring




irrigation and aspiration


intraocular foreign body, -ies


intraocular lens


ophthalmic viscoelastic device


proliferative diabetic retinopathy


primary posterior continuous curvilinear capsulorhexis


pars plana vitrectomy


proliferative vitreoretinopathy


retinal detachment


Financial Disclosure

The author has no financial interest in any material or method mentioned.

Supplementary material

Video 19.1

Implantation of a capsular tension ring before PPCCC (MP4 122583 kb)

Video 19.2

PCCC in a silicone oil-filled eye before aspiration of the oil via the pars plana (MP4 142343 kb)

Video 19.3

Enlargement of a small PPCCC with end-gripping forceps via the pars plana (MP4 231968 kb)

Video 19.4

Intracameral illumination-assisted PPCCC in an eye with a vitreous hemorrhage in PDR (MP4 299056 kb)

Video 19.5

PPCCC after core vitrectomy in an eye with a vitreous hemorrhage in PDR (MP4 74914 kb)

Video 19.6

Removal of IOFBs through the capsulotomies before implantation (MP4 125607 kb)

Video 19.7

Implantation of a BIL in two eyes with intraoperative posterior capsule rupture (MP4 252976 kb)

Video 19.8

Bimanual technique of implantation of the BIL in eyes with weakened zonules (MP4 387575 kb)

Video 19.9

Reposition of the incarcerated iris in pupillary capture: partial pupillary capture and circumferential pupillary capture (MP4 150644 kb)

Video 19.10

Phacovitrectomy with BIL in retinal detachment. Condensation on posterior surface of BIL can be managed with HPMC (MP4 123502 kb)

Video 19.11

Phacovitrectomy in an eye with syphilitic panuveitis. Pupillary dilation with five iris retractors (MP4 280070 kb)

Video 19.12

BIL in penetrating injury with traumatic cataract (MP4 171849 kb)


  1. 1.
    Steel DHW. Phacovitrectomy: expanding indications. J Cataract Refract Surg. 2007;33(6):933–6. Scholar
  2. 2.
    Ebihara Y, Kato S, Oshika T, et al. Posterior capsule opacification after cataract surgery in patients with diabetes mellitus. J Cataract Refract Surg. 2006;32(7):1184–7. Scholar
  3. 3.
    Kim S-W, Oh J, Song J-S, et al. Risk factors of iris posterior synechia formation after phacovitrectomy with three-piece acrylic IOL or single-piece acrylic IOL. Ophthalmologica. 2009;223(4):222–7. Scholar
  4. 4.
    Makhzoum O, Crosby NJ, Hero M. Secondary angle-closure glaucoma due to posterior synechiae formation following phacovitrectomy. Int Ophthalmol. 2011;31(6):481–2. Scholar
  5. 5.
    Park SP, Ahn JK, Lee GH. Morphologic changes in the anterior segment after phacovitrectomy for proliferative diabetic retinopathy. J Cataract Refract Surg. 2009;35(5):868–73. Scholar
  6. 6.
    Roh JH, Sohn HJ, Lee DY, et al. Comparison of posterior capsular opacification between a combined procedure and a sequential procedure of pars plana vitrectomy and cataract surgery. Ophthalmologica. 2010;224(1):42–6. Scholar
  7. 7.
    Toda J, Kato S, Oshika T, et al. Posterior capsule opacification after combined cataract surgery and vitrectomy. J Cataract Refract Surg. 2007;33(1):104–7. Scholar
  8. 8.
    Tassignon M-JB, de GV, Vrensen GF. Bag-in-the-lens implantation of intraocular lenses. J Cataract Refract Surg. 2002;28(7):1182–8. Scholar
  9. 9.
    Leysen I, Coeckelbergh T, Gobin L, et al. Cumulative neodymium: YAG laser rates after bag-in-the-lens and lens-in-the-bag intraocular lens implantation: comparative study. J Cataract Refract Surg. 2006;32(12):2085–90. Scholar
  10. 10.
    Tassignon M-J, Gobin L, Mathysen D, et al. Clinical outcomes of cataract surgery after bag-in-the-lens intraocular lens implantation following ISO standard 11979-7:2006. J Cataract Refract Surg. 2011;37(12):2120–9. Scholar
  11. 11.
    Verbruggen KHM, Rozema JJ, Gobin L, et al. Intraocular lens centration and visual outcomes after bag-in-the-lens implantation. J Cataract Refract Surg. 2007;33(7):1267–72. Scholar
  12. 12.
    Lee SB, Lee DG, Kwag JY, et al. The effect of mydriatics on posterior synechia after combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation. Retina. 2009;29(8):1150–4. Scholar
  13. 13.
    Eckardt C. Combined phacovitrectomy Retina Today. 2013. (5/6):36–38.Google Scholar
  14. 14.
    Werner L, Tassignon M-J, Zaugg BE, et al. Clinical and histopathologic evaluation of six human eyes implanted with the bag-in-the-lens. Ophthalmology. 2010;117(1):55–62. Scholar
  15. 15.
    Jung Y, Kim IN, Yoon J, et al. Intracameral illuminator-assisted advanced cataract surgery combined with 23-gauge vitrectomy in eyes with poor red reflex. J Cataract Refract Surg. 2013;39(6):845–50. Scholar
  16. 16.
    Kim K-H, Sohn HJ, Song HJ, et al. Surgeon-controlled-endoillumination-guided irrigation and aspiration during combined 23-gauge sutureless vitrectomy and cataract surgery in eyes with poor fundus reflex. J Cataract Refract Surg. 2010;36(12):2028–31. Scholar
  17. 17.
    Park YM, Park JY, Lee JS, et al. Comparative analysis of brilliant blue G and an intracameral illuminator in assisting visualization of the anterior capsule in eyes with vitreous hemorrhage. J Cataract Refract Surg. 2016;42(7):1015–21. Scholar
  18. 18.
    Yamamoto N, Ozaki N, Murakami K. Trypan-blue- and endoillumination-assisted phacoemulsification in eyes with vitreous hemorrhage during combined cataract and vitreous surgery. Ophthalmologica. 2005;219(6):338–44. Scholar
  19. 19.
    Bilgin S, Kayikcioglu O. Chandelier retroillumination-assisted cataract surgery during vitrectomy. Eye (Lond). 2016;30(8):1123–5. Scholar
  20. 20.
    Jang SY, Choi KS, Lee SJ. Chandelier retroillumination-assisted cataract extraction in eyes with vitreous hemorrhage. Arch Ophthalmol. 2010;128(7):911–4. Scholar
  21. 21.
    Furino C, Alessio G, Recchimurzo N, et al. Anterior capsule staining using micronized triamcinolone in the absence of red reflex. J Cataract Refract Surg. 2011;37(6):983–6. Scholar
  22. 22.
    Tanikawa A, Horiguchi M. Intravitreal triamcinolone-illuminated cataract surgery for patients with dense vitreous hemorrhage. JAMA Ophthalmol. 2015;133(1):93–4. Scholar
  23. 23.
    Rudnisky CJ, Cheung J, Nanji JA. Intraocular lens capture in combined cataract extraction and pars plana vitrectomy: Comparison of 1-piece and 3-piece acrylic intraocular lenses. J Cataract Refract Surg. 2010;36(10):1645–9. Scholar
  24. 24.
    Avci R. Cataract surgery and transpupillary silicone oil removal through a single scleral tunnel incision under topical anesthesia; sutureless surgery. Int Ophthalmol. 2001;24(6):337–41.CrossRefGoogle Scholar
  25. 25.
    Boscia F, Recchimurzo N, Cardascia N, et al. Phacoemulsification with transpupillary silicone oil removal and lens implantation through a corneal incision using topical anesthesia. J Cataract Refract Surg. 2003;29(6):1113–9.CrossRefGoogle Scholar
  26. 26.
    Dada VK, Talwar D, Sharma N, et al. Phacoemulsification combined with silicone oil removal through a posterior capsulorhexis. J Cataract Refract Surg. 2001;27(8):1243–7.CrossRefGoogle Scholar
  27. 27.
    Loncar VL, Petric I, Vatavuk Z, et al. Phacoemulsification and silicone oil removal through the planned posterior capsulorhexis. Coll Antropol. 2005;29(Suppl 1):63–6.Google Scholar
  28. 28.
    Boiko EV, Churashov SV, Kulikov AN, et al. Clear corneal phacovitrectomy with posterior capsulorhexis and IOL implantation in management of selective vitreoretinal cases. J Ophthalmol. 2015;2015:474072. Scholar
  29. 29.
    Kunikata H, Uematsu M, Nakazawa T, et al. Successful removal of large intraocular foreign body by 25-gauge microincision vitrectomy surgery. J Ophthalmol. 2011;2011:940323. Scholar
  30. 30.
    Park JH, Lee JH, Shin JP, et al. Intraocular foreign body removal by viscoelastic capture using DisCoVisc during 23-gauge microincision vitrectomy surgery. Retina. 2013;33(5):1070–2. Scholar
  31. 31.
    MORCHER® GmbH (2012) Bag-in-the-lens. IOL and Technique. Accessed 28 May 2017.
  32. 32.
    Walker NJ, Saldanha MJ, Sharp JAH, et al. Calcification of hydrophilic acrylic intraocular lenses in combined phacovitrectomy surgery. J Cataract Refract Surg. 2010;36(8):1427–31. Scholar
  33. 33.
    Ni Dhubhghaill S, van Os L, de Keizer RJW, et al. Intraocular lens exchange technique for an opacified bag-in-the-lens. J Cataract Refract Surg. 2015;41(5):924–8. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Eye Clinic, Klinikum Frankfurt HoechstFrankfurt am MainGermany

Personalised recommendations