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October Consultation #8
1872
CONSULTATION SECTION
a +2.00 hyperopic shift that may be easily tolerated with spectacle correction. Again, I do not favor this approach because there is a hypothetical and practical advantage to pseudophakia over aphakia in cases of high axial myopia to minimize ophthalmodonesis, which can lead to unnecessary vitreous tractional forces on the anterior retina. So, the preferred approach is to rotate the entire IOL into the bag. Sadeer B. Hannush, MD Philadelphia, Pennsylvania, USA - The classic UGH syndrome is as common as ever in my opinion. The most common cause recently for us has been 1-piece acrylic intraocular lenses (IOLs) placed in the sulcus; however, this syndrome is associated with other types of IOLs in the sulcus, anterior chamber and, rarely, in-the-bag IOLs with loose zonules. The mission in this case is to get this IOL, at least the optic, into the bag. First, I would use a dispersive OVD to open the space beyond the optic. I would approach inferiorly, just under the optic. Then I would reach the cannula around the optic and free the anterior edge of the superior portion of the capsular bag. When the optic is free of adhesion to the capsule, I would try to open the bag with an OVD and get the bag open in the area under the optic. Then, I would open the bag under the sulcus-based haptic and use a Sinskey hook to place the haptic into the bag. Get the optic under the anterior capsule, and you are done. However, it may be hard to open the bag 5 years after surgery. One might be able to eliminate the IOL tilt (and UGH) by simply cutting off the sulcus-based haptic at the optic and then tucking the optic in the bag. The IOL will most likely stay centered and will no longer tilt, likely resolving the UGH syndrome If that does not work, one should explant the IOL. I would consider leaving the patient aphakic. One could also place an IOL in the sulcus, using a large IOL such as the AQ5010 (Staar). Thomas A. Oetting, MS, MD Iowa City, Iowa, USA
- This complication of posterior chamber IOLs was recognized and described in the early 1980s.1,2 This case, presented in 2012, shows that Solomon was correct when he wrote, “What has been will be again, what has been done will be done again; there is nothing new under the sun” (Ecclesiastes 1:9, NIV). Asymmetric haptic and optic placement do not typically tilt an optic anteriorly enough to contact the iris. It may be that a meniscus-type optic responds differently
to asymmetric capsule forces or that the shape or location of a haptic is the cause of the problem. The optic– iris contact must be eliminated to fix the problem. Preoperatively, the discussion and consent should include IOL repositioning or exchange. Intraoperatively, note the amount of separation between the posterior capsule surface and the inferior edge of the optic. Make 2 small stab incisions at 3 o'clock and 9 o'clock and replace the aqueous with a cohesive OVD. Using a 30-gauge cannula on the OVD syringe, perform blunt dissection and viscodissection to free the superior optic edge from its capsular entrapment and lay the optic on the anterior capsule. If the superior and inferior rims of the optic lie reasonably flat against the capsule, the case is over. If the inferior edge of the optic remains tilted anteriorly, the shape and location of both haptics have to be visually assessed. The temporal inferior haptic can be swept into the anterior chamber by placing the 30gauge cannula through the temporal incision, beneath the haptic and optic, elevating them both while a manipulating hook through the nasal incision is swept along the outer edge of the haptic, bending the haptic centrally enough to clear the pupillary margin so that it can be released to lie on top of the iris. The haptic should have normal shape and 5 degrees of angulation. If it does not, the IOL will have to be exchanged. This IOL has linearly smooth haptics, so it may be possible to dial the superior nasal haptic out of its capsule ensheathment and into the anterior chamber by gently rotating the optic while watching for undue stress on the zonules. Before the optic is rotated, an attempt to viscodissect and expand the capsule containing the superior nasal haptic can be made by using a 27-gauge cannula on an OVD syringe with a small cannula tip placed through an additional stab incision near 6 o'clock. If this haptic is normal as well, the IOL could be repositioned in the sulcus. If the haptic cannot be easily withdrawn, it will have to be cut and left in place. A superior keratome incision would permit cutting the haptic and the optic, withdrawing the pieces, and inserting an IOL of the same style and power in the sulcus. The optic should lie flat against the posterior capsule whether the IOL is repositioned or exchanged. Stephen H. Johnson, MD Newport Beach, California, USA
REFERENCES 1. Johnson SH, Kratz RP, Olson PF. Iris transillumination defect and microhyphema syndrome. Am Intra-Ocular Implant Soc J 1984; 10:425–428 2. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
CONSULTATION SECTION
a +2.00 hyperopic shift that may be easily tolerated with spectacle correction. Again, I do not favor this approach because there is a hypothetical and practical advantage to pseudophakia over aphakia in cases of high axial myopia to minimize ophthalmodonesis, which can lead to unnecessary vitreous tractional forces on the anterior retina. So, the preferred approach is to rotate the entire IOL into the bag. Sadeer B. Hannush, MD Philadelphia, Pennsylvania, USA - The classic UGH syndrome is as common as ever in my opinion. The most common cause recently for us has been 1-piece acrylic intraocular lenses (IOLs) placed in the sulcus; however, this syndrome is associated with other types of IOLs in the sulcus, anterior chamber and, rarely, in-the-bag IOLs with loose zonules. The mission in this case is to get this IOL, at least the optic, into the bag. First, I would use a dispersive OVD to open the space beyond the optic. I would approach inferiorly, just under the optic. Then I would reach the cannula around the optic and free the anterior edge of the superior portion of the capsular bag. When the optic is free of adhesion to the capsule, I would try to open the bag with an OVD and get the bag open in the area under the optic. Then, I would open the bag under the sulcus-based haptic and use a Sinskey hook to place the haptic into the bag. Get the optic under the anterior capsule, and you are done. However, it may be hard to open the bag 5 years after surgery. One might be able to eliminate the IOL tilt (and UGH) by simply cutting off the sulcus-based haptic at the optic and then tucking the optic in the bag. The IOL will most likely stay centered and will no longer tilt, likely resolving the UGH syndrome If that does not work, one should explant the IOL. I would consider leaving the patient aphakic. One could also place an IOL in the sulcus, using a large IOL such as the AQ5010 (Staar). Thomas A. Oetting, MS, MD Iowa City, Iowa, USA
- This complication of posterior chamber IOLs was recognized and described in the early 1980s.1,2 This case, presented in 2012, shows that Solomon was correct when he wrote, “What has been will be again, what has been done will be done again; there is nothing new under the sun” (Ecclesiastes 1:9, NIV). Asymmetric haptic and optic placement do not typically tilt an optic anteriorly enough to contact the iris. It may be that a meniscus-type optic responds differently
to asymmetric capsule forces or that the shape or location of a haptic is the cause of the problem. The optic– iris contact must be eliminated to fix the problem. Preoperatively, the discussion and consent should include IOL repositioning or exchange. Intraoperatively, note the amount of separation between the posterior capsule surface and the inferior edge of the optic. Make 2 small stab incisions at 3 o'clock and 9 o'clock and replace the aqueous with a cohesive OVD. Using a 30-gauge cannula on the OVD syringe, perform blunt dissection and viscodissection to free the superior optic edge from its capsular entrapment and lay the optic on the anterior capsule. If the superior and inferior rims of the optic lie reasonably flat against the capsule, the case is over. If the inferior edge of the optic remains tilted anteriorly, the shape and location of both haptics have to be visually assessed. The temporal inferior haptic can be swept into the anterior chamber by placing the 30gauge cannula through the temporal incision, beneath the haptic and optic, elevating them both while a manipulating hook through the nasal incision is swept along the outer edge of the haptic, bending the haptic centrally enough to clear the pupillary margin so that it can be released to lie on top of the iris. The haptic should have normal shape and 5 degrees of angulation. If it does not, the IOL will have to be exchanged. This IOL has linearly smooth haptics, so it may be possible to dial the superior nasal haptic out of its capsule ensheathment and into the anterior chamber by gently rotating the optic while watching for undue stress on the zonules. Before the optic is rotated, an attempt to viscodissect and expand the capsule containing the superior nasal haptic can be made by using a 27-gauge cannula on an OVD syringe with a small cannula tip placed through an additional stab incision near 6 o'clock. If this haptic is normal as well, the IOL could be repositioned in the sulcus. If the haptic cannot be easily withdrawn, it will have to be cut and left in place. A superior keratome incision would permit cutting the haptic and the optic, withdrawing the pieces, and inserting an IOL of the same style and power in the sulcus. The optic should lie flat against the posterior capsule whether the IOL is repositioned or exchanged. Stephen H. Johnson, MD Newport Beach, California, USA
REFERENCES 1. Johnson SH, Kratz RP, Olson PF. Iris transillumination defect and microhyphema syndrome. Am Intra-Ocular Implant Soc J 1984; 10:425–428 2. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012