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October Consultation #6
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
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