- Email: [email protected]
October Consultation #5
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CONSULTATION SECTION
inject some OVD into the anterior chamber but then allow the chamber to shallow slightly due to aqueous egress. I would next slide the cannula underneath the optic while injecting just enough OVD to avoid puncturing the posterior capsule as the tip is advanced. Once the cannula tip is positioned peripherally enough, I would forcefully inject a dispersive OVD along and across the superior capsular bag equator. I would next cross above the optic with the cannula to further expand the superior equator of the bag. I would then locate additional corneal stab incisions superiorly to allow me to progressively viscoexpand the nasal and temporal equator of the bag until it ultimately reopened inferiorly. It is important to repeatedly pause to burp out OVD to avoid overfilling the anterior chamber. I would be surprised if this were not successful because in my experience, the lack of anterior capsule fibrosis is very favorable and much more important than the length of time (5 years) since surgery. After reinflating the capsular bag, dialing the external haptic into the capsular bag should be straightforward. In hypothetical situations in which the bag could not be fully reopened, the IOL could be explanted after amputating the intracapsular haptic at its optic junction if necessary. A replacement 3-piece posterior chamber IOL with rounded anterior optic edges would be implanted in the ciliary sulcus. In the low powers, the Sensar, Clariflex, and Tecnis IOLs (all Abbott Medical Optics) have the longer 13.5 mm overall length. All have rounded anterior optic edges, and power adjustment for sulcus implantation is not necessary for such low dioptric powers. In the unlikely event that the patient refuses surgery, immobilizing the pupil with pilocarpine could be tried. This case emphasizes the desirability of early IOL repositioning in this situation. Performed early, this would have been a simple and safe maneuver that would have spared this patient from years of chronic inflammation and recurrent hemorrhage. David F. Chang, MD Los Altos, California, USA Dr. Chang's consulting fees from Abbott Medical Optics and Alcon are donated to the Himalayan Cataract Project and to Project Vision. REFERENCES 1. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 2. Toma HS, DiBernardo C, Schein OD, Adams NA. Recurrent vitreous hemorrhage secondary to haptic-induced chafing. Can J Ophthalmol 2007; 42:312–313. Available at: http://www.eyesite. ca/CJO/4202/i07-018.pdf. Accessed July 24, 2012
3. Wintle R, Austin M. Pigment dispersion with elevated intraocular pressure after AcrySof intraocular lens implantation in the ciliary sulcus. J Cataract Refract Surg 2001; 27:642–644 4. Chang SHL, Lim G. Secondary pigmentary glaucoma associated with piggyback intraocular lens implantation. J Cataract Refract Surg 2004; 30:2219–2222 5. Iwase T, Tanaka N. Elevated intraocular pressure in secondary piggyback intraocular lens implantation. J Cataract Refract Surg 2005; 31:1821–1823 6. Masket S, ed. Consultation section. Cataract surgical problem. J Cataract Refract Surg 2005; 31:2247–2253 7. Chang WH, Werner L, Fry LL, Johnson JT, Kamae K, Mamalis N. Pigmentary dispersion syndrome with a secondary piggyback 3-piece hydrophobic acrylic lens; case report with clinicopathological correlation. J Cataract Refract Surg 2007; 33:1106–1109 8. Chang DF, Masket S, Miller KM, Braga-Mele R, Little BC, Mamalis N, Oetting TA, Packer M, for the ASCRS Cataract Clinical Committee. Complications of sulcus placement of single-piece acrylic intraocular lenses; recommendations for backup IOL implantation following posterior capsule rupture. J Cataract Refract Surg 2009; 35:1445–1458
- This patient has reasonably good vision in the right eye with recurring bleeding in anterior chamber and vitreous cavity as a result of iris chafing. The following can be seen in Figure 1: (1) One IOL haptic is in the capsular bag and the temporal one is in the sulcus. The superior optic edge is in the bag, and the inferior optic edge (which could be tilted anteriorly) is in the sulcus. The iris chafing is the result of the inferior optic edge. (2) The inferior anterior capsule and the posterior capsule are fused and fibrosed at the 6 o'clock position. (3) The IOL is well centered and the posterior capsule is intact. In view of the good vision in this eye with inferior and anterior–posterior capsule fibrosis and that it is highly myopic, minimal treatment should be performed. One might confirm the iris–IOL optic relationship by requesting ultrasound biomicroscopy with an undilated pupil. Also, it might be useful to see the extent of the inferior capsular bag fusion and fibrosis to help in the direction of management. The ideal correction of this problem would be to place the temporal haptic and the inferior optic in the capsular bag and separate the inferior optic from the iris by placing the inferior part of the anterior capsule anterior to the inferior optic edge. I would start with an attempt to keep the IOL optic away from the iris by pushing the inferior optic posteriorly, preferably in the capsular bag. This would be done by opening the capsular bag with an OVD and releasing the inferior and anterior–posterior capsule adhesion at 6 o'clock, although this may be unsuccessful and compromise the posterior capsule. If this approach is successful, the temporal haptic can be placed in the capsular bag. The other alternative is to open the posterior capsule parallel, but more central, to the edge of the inferior optic and place the inferior optic posterior to the
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
CONSULTATION SECTION
posterior capsule, separating the iris from the optic. One must keep in mind the extra risk of opening the posterior capsule in this myopic eye. The temporal haptic can be left in place because the fibrosis might keep the IOL in central position and stabilize it. Ali Al-Rajhi, MD, FRCOphth Riyadh, Saudi Arabia
- The pigment dispersion, inflammation, and recurrent hyphema in this case are directly caused by chafing of the inferior optic edge on the posterior pigment epithelium of the iris. I believe the best solution is to reposition the inferior optic beneath the anterior capsule by reopening the fibrosed capsular bag. Should damage occur to the capsule or to the zonular fibers during the procedure that prohibits repositioning the IOL, I would first consider IOL exchange with placement of a large, round-edged, 3-piece IOL in the sulcus. The last option would be to resort to an anterior chamber IOL. To reopen the fibrosed lens capsule, I begin with two 1.4 mm trapezoidal clear corneal incisions, 1 in the superior temporal quadrant and 1 in the inferior temporal quadrant. After instillation of preservative-free lidocaine, I coat the corneal endothelium with a dispersive OVD on a standard cannula. I then replace the cannula with a 30-gauge hypodermic needle and insinuate the tip of the needle between the anterior capsule and the IOL optic. In this case, this maneuver would be performed in the 2 o'clock region, where it appears the edge of the capsulotomy is slightly elevated above the optic. Once the tip of the needle is beneath the anterior capsule, I inject OVD to force apart the capsule and the optic. A wave of OVD moves peripherally from the injection site, dissecting apart the capsule and the optic. Once this potential space has been opened, I replace the needle with the original cannula and continue the viscodissection. The anterior and posterior capsule separate as the wave of OVD proceeds around the optic. In this case, it is important to ensure that the anterior and posterior capsule leaflets are completely separated inferiorly. It is often surprising to what a great extent the capsule can be opened. This technique is equally applicable in cases of planned IOL exchange. In these cases, the next step is to gently free the haptics from the equatorial capsule with a hook or microforceps and rotate the IOL out of the bag. In this case, all that may be necessary is to tuck the inferior optic beneath the anterior capsule. If there is adequate covering of the optic by the capsule, the chafing will no longer occur. However, if there is doubt that the IOL optic will remain positioned within the capsule, I would also reposition the temporal haptic inside the bag. This maneuver is accomplished as in
1871
a planned IOL exchange by rotating the IOL, but in this case rotating the temporal haptic posteriorly into the bag. The case would be concluded with bimanual irrigation/aspiration of the OVD, instillation of a miotic and moxifloxacin, and stromal hydration to ensure a watertight seal of both incisions. Although some variations to this technique are necessary when repositioning or exchanging specific IOLs (such as 1-piece acrylic IOLs with expanded haptic tips), in general the approach is widely applicable and uniformly successful. Mark Packer, MD Eugene, Oregon, USA
- To start, one would have to assume that the patient is symptomatic in the right eye. Otherwise, a strong argument may be made for conservative management. The nonsurgical approach would consist of longterm cycloplegia and a short course of topical corticosteroids. If the patient can tolerate the symptoms associated with dilation, cycloplegia may limit the friction between the inferior aspect of the IOL and the iris pigment epithelium, the resultant chafing, and the secondary inflammation and hemorrhage. In the surgical approach, the goal would be to eliminate the contact between the IOL and the iris. As such, tucking the optic into the capsular bag may be very helpful. Even 5 years after the initial surgery, this could be accomplished by gentle dissection of the anterior leaflet of the capsular bag off the posterior capsule inferiorly with a 30-gauge needle followed by inflation of the bag with a dispersive OVD. This will allow the optic to be positioned entirely inside the capsular bag, as is the case in the left eye. Because 1 haptic is outside the bag, simply positioning the optic in the bag at the time of the surgical intervention may not be long lived. An effort should be made to reposition the temporal haptic inside the bag as well. This may require inflation of the entire bag with the dispersive OVD followed by rotation of the IOL into the bag. If there is significant anatomic resistance to accomplishing this goal, an argument can be made for amputating the temporal haptic flush with the optic (to avoid a barb). I do not favor this approach because the asymmetric force exerted by the nasal haptic may spring the IOL out of the bag again. If amputation is to be considered, which should not be the first approach, it may be prudent to remove both haptics and tuck the optic in the bag inferiorly. Unfortunately, retained capsular memory may again spring the inferior aspect of the optic out of the bag. Finally, an argument can be made for removing the entire +3.00 diopter IOL from the eye, resulting in
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
CONSULTATION SECTION
inject some OVD into the anterior chamber but then allow the chamber to shallow slightly due to aqueous egress. I would next slide the cannula underneath the optic while injecting just enough OVD to avoid puncturing the posterior capsule as the tip is advanced. Once the cannula tip is positioned peripherally enough, I would forcefully inject a dispersive OVD along and across the superior capsular bag equator. I would next cross above the optic with the cannula to further expand the superior equator of the bag. I would then locate additional corneal stab incisions superiorly to allow me to progressively viscoexpand the nasal and temporal equator of the bag until it ultimately reopened inferiorly. It is important to repeatedly pause to burp out OVD to avoid overfilling the anterior chamber. I would be surprised if this were not successful because in my experience, the lack of anterior capsule fibrosis is very favorable and much more important than the length of time (5 years) since surgery. After reinflating the capsular bag, dialing the external haptic into the capsular bag should be straightforward. In hypothetical situations in which the bag could not be fully reopened, the IOL could be explanted after amputating the intracapsular haptic at its optic junction if necessary. A replacement 3-piece posterior chamber IOL with rounded anterior optic edges would be implanted in the ciliary sulcus. In the low powers, the Sensar, Clariflex, and Tecnis IOLs (all Abbott Medical Optics) have the longer 13.5 mm overall length. All have rounded anterior optic edges, and power adjustment for sulcus implantation is not necessary for such low dioptric powers. In the unlikely event that the patient refuses surgery, immobilizing the pupil with pilocarpine could be tried. This case emphasizes the desirability of early IOL repositioning in this situation. Performed early, this would have been a simple and safe maneuver that would have spared this patient from years of chronic inflammation and recurrent hemorrhage. David F. Chang, MD Los Altos, California, USA Dr. Chang's consulting fees from Abbott Medical Optics and Alcon are donated to the Himalayan Cataract Project and to Project Vision. REFERENCES 1. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 2. Toma HS, DiBernardo C, Schein OD, Adams NA. Recurrent vitreous hemorrhage secondary to haptic-induced chafing. Can J Ophthalmol 2007; 42:312–313. Available at: http://www.eyesite. ca/CJO/4202/i07-018.pdf. Accessed July 24, 2012
3. Wintle R, Austin M. Pigment dispersion with elevated intraocular pressure after AcrySof intraocular lens implantation in the ciliary sulcus. J Cataract Refract Surg 2001; 27:642–644 4. Chang SHL, Lim G. Secondary pigmentary glaucoma associated with piggyback intraocular lens implantation. J Cataract Refract Surg 2004; 30:2219–2222 5. Iwase T, Tanaka N. Elevated intraocular pressure in secondary piggyback intraocular lens implantation. J Cataract Refract Surg 2005; 31:1821–1823 6. Masket S, ed. Consultation section. Cataract surgical problem. J Cataract Refract Surg 2005; 31:2247–2253 7. Chang WH, Werner L, Fry LL, Johnson JT, Kamae K, Mamalis N. Pigmentary dispersion syndrome with a secondary piggyback 3-piece hydrophobic acrylic lens; case report with clinicopathological correlation. J Cataract Refract Surg 2007; 33:1106–1109 8. Chang DF, Masket S, Miller KM, Braga-Mele R, Little BC, Mamalis N, Oetting TA, Packer M, for the ASCRS Cataract Clinical Committee. Complications of sulcus placement of single-piece acrylic intraocular lenses; recommendations for backup IOL implantation following posterior capsule rupture. J Cataract Refract Surg 2009; 35:1445–1458
- This patient has reasonably good vision in the right eye with recurring bleeding in anterior chamber and vitreous cavity as a result of iris chafing. The following can be seen in Figure 1: (1) One IOL haptic is in the capsular bag and the temporal one is in the sulcus. The superior optic edge is in the bag, and the inferior optic edge (which could be tilted anteriorly) is in the sulcus. The iris chafing is the result of the inferior optic edge. (2) The inferior anterior capsule and the posterior capsule are fused and fibrosed at the 6 o'clock position. (3) The IOL is well centered and the posterior capsule is intact. In view of the good vision in this eye with inferior and anterior–posterior capsule fibrosis and that it is highly myopic, minimal treatment should be performed. One might confirm the iris–IOL optic relationship by requesting ultrasound biomicroscopy with an undilated pupil. Also, it might be useful to see the extent of the inferior capsular bag fusion and fibrosis to help in the direction of management. The ideal correction of this problem would be to place the temporal haptic and the inferior optic in the capsular bag and separate the inferior optic from the iris by placing the inferior part of the anterior capsule anterior to the inferior optic edge. I would start with an attempt to keep the IOL optic away from the iris by pushing the inferior optic posteriorly, preferably in the capsular bag. This would be done by opening the capsular bag with an OVD and releasing the inferior and anterior–posterior capsule adhesion at 6 o'clock, although this may be unsuccessful and compromise the posterior capsule. If this approach is successful, the temporal haptic can be placed in the capsular bag. The other alternative is to open the posterior capsule parallel, but more central, to the edge of the inferior optic and place the inferior optic posterior to the
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
CONSULTATION SECTION
posterior capsule, separating the iris from the optic. One must keep in mind the extra risk of opening the posterior capsule in this myopic eye. The temporal haptic can be left in place because the fibrosis might keep the IOL in central position and stabilize it. Ali Al-Rajhi, MD, FRCOphth Riyadh, Saudi Arabia
- The pigment dispersion, inflammation, and recurrent hyphema in this case are directly caused by chafing of the inferior optic edge on the posterior pigment epithelium of the iris. I believe the best solution is to reposition the inferior optic beneath the anterior capsule by reopening the fibrosed capsular bag. Should damage occur to the capsule or to the zonular fibers during the procedure that prohibits repositioning the IOL, I would first consider IOL exchange with placement of a large, round-edged, 3-piece IOL in the sulcus. The last option would be to resort to an anterior chamber IOL. To reopen the fibrosed lens capsule, I begin with two 1.4 mm trapezoidal clear corneal incisions, 1 in the superior temporal quadrant and 1 in the inferior temporal quadrant. After instillation of preservative-free lidocaine, I coat the corneal endothelium with a dispersive OVD on a standard cannula. I then replace the cannula with a 30-gauge hypodermic needle and insinuate the tip of the needle between the anterior capsule and the IOL optic. In this case, this maneuver would be performed in the 2 o'clock region, where it appears the edge of the capsulotomy is slightly elevated above the optic. Once the tip of the needle is beneath the anterior capsule, I inject OVD to force apart the capsule and the optic. A wave of OVD moves peripherally from the injection site, dissecting apart the capsule and the optic. Once this potential space has been opened, I replace the needle with the original cannula and continue the viscodissection. The anterior and posterior capsule separate as the wave of OVD proceeds around the optic. In this case, it is important to ensure that the anterior and posterior capsule leaflets are completely separated inferiorly. It is often surprising to what a great extent the capsule can be opened. This technique is equally applicable in cases of planned IOL exchange. In these cases, the next step is to gently free the haptics from the equatorial capsule with a hook or microforceps and rotate the IOL out of the bag. In this case, all that may be necessary is to tuck the inferior optic beneath the anterior capsule. If there is adequate covering of the optic by the capsule, the chafing will no longer occur. However, if there is doubt that the IOL optic will remain positioned within the capsule, I would also reposition the temporal haptic inside the bag. This maneuver is accomplished as in
1871
a planned IOL exchange by rotating the IOL, but in this case rotating the temporal haptic posteriorly into the bag. The case would be concluded with bimanual irrigation/aspiration of the OVD, instillation of a miotic and moxifloxacin, and stromal hydration to ensure a watertight seal of both incisions. Although some variations to this technique are necessary when repositioning or exchanging specific IOLs (such as 1-piece acrylic IOLs with expanded haptic tips), in general the approach is widely applicable and uniformly successful. Mark Packer, MD Eugene, Oregon, USA
- To start, one would have to assume that the patient is symptomatic in the right eye. Otherwise, a strong argument may be made for conservative management. The nonsurgical approach would consist of longterm cycloplegia and a short course of topical corticosteroids. If the patient can tolerate the symptoms associated with dilation, cycloplegia may limit the friction between the inferior aspect of the IOL and the iris pigment epithelium, the resultant chafing, and the secondary inflammation and hemorrhage. In the surgical approach, the goal would be to eliminate the contact between the IOL and the iris. As such, tucking the optic into the capsular bag may be very helpful. Even 5 years after the initial surgery, this could be accomplished by gentle dissection of the anterior leaflet of the capsular bag off the posterior capsule inferiorly with a 30-gauge needle followed by inflation of the bag with a dispersive OVD. This will allow the optic to be positioned entirely inside the capsular bag, as is the case in the left eye. Because 1 haptic is outside the bag, simply positioning the optic in the bag at the time of the surgical intervention may not be long lived. An effort should be made to reposition the temporal haptic inside the bag as well. This may require inflation of the entire bag with the dispersive OVD followed by rotation of the IOL into the bag. If there is significant anatomic resistance to accomplishing this goal, an argument can be made for amputating the temporal haptic flush with the optic (to avoid a barb). I do not favor this approach because the asymmetric force exerted by the nasal haptic may spring the IOL out of the bag again. If amputation is to be considered, which should not be the first approach, it may be prudent to remove both haptics and tuck the optic in the bag inferiorly. Unfortunately, retained capsular memory may again spring the inferior aspect of the optic out of the bag. Finally, an argument can be made for removing the entire +3.00 diopter IOL from the eye, resulting in
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012