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October consultation #8
1800
CONSULTATION SECTION
maintaining devices (eg, Malyugin ring or iris retractors). These cases typically proceed smoothly when an in situ fracture technique with torsional phacoemulsification and a cohesive–dispersive OVD are used. Excellent visualization is of great benefit, and an operating microscope with red-reflex technology for better contrast aides greatly in these complicated cases. Assuming the result of surgery in the left eye is good or in the unlikely event the patient insists on a fourth procedure in the right eye first, I would obtain records of the 2 failed attempts at repositioning the AC IOL. If during those procedures the IOL had been rotated 90 degrees away from the peripheral iridectomy and it had propelled back around into it, a more invasive approach may be required. I believe that less is better and would prefer to simply rotate the haptic out of the peripheral iridectomy and then rotate the IOL 90 degrees past the peripheral iridectomy. This should be relatively simple and much less invasive than IOL exchange. Should these measures fail, a 6.5 mm, or even a 7.0 mm, PC IOL could be sewn into the posterior chamber using scleral fixation. This has long been my last resort because I have had good success with AC IOLs in the rare instances of totally inadequate zonule support. Richard P. Lehmann, MD Nacogdoches, Texas, USA
- The pupil is reasonably centered, and the edge glare from the IOL appears to be principally from IOL decentration. I would approach this patient with the following decision tree: (1) The previous 2 attempts fully resolved symptoms for a while until the haptic migrated back to the peripheral iridectomy, decentering the IOL and restoring edge-glare symptoms. (2) The previous attempts decreased but did not eliminate the symptoms initially. (3) Previous rotations had no positive effect on the patient’s symptoms. In scenario 1, if rotating the IOL in the horizontal axis centered it over the pupil and resolved the symptoms initially, I would make a stab incision at 7 o’clock and rotate the IOL horizontally for the third time. I would then pass 1 throw of 9-0 or 10-0 polypropylene through the same stab incision and suture the temporal haptic to the midperiphery of the iris using a modified Siepser knot. If stability were in question, an additional stab could be made at 5 o’clock and the nasal haptic could also be sutured to the midperiphery of the iris. Working through stab incisions would minimize the impact of the IFIS. In scenario 2, if the temporal iris defect were contributing to some of the edge glare, I would create the same stab incision as in scenario 1 and repair the iris
defect first with 10-0 polypropylene using a modified Siepser knot. I would then rotate the IOL and suture the haptics to the iris, also as in scenario 1. I believe this is the most likely scenario and would probably be the best approach to help the patient. In scenario 3, if there were no improvement after the 2 previous rotations, I would explant the IOL and, using a Sheets glide, take care not to remove the entire iris with the IOL. I would then evaluate the status of the iris and the sclera in this partially vitrectomized eye to determine whether to suture the IOL to the iris or the sclera. Gary J.L. Foster, MD Ft. Collins, Colorado, USA
- This patient requires removal of the AC IOL because of the decreased ECC and requires fixation of an IOL in the absence of capsule support. In addition, there is a defect in the temporal aspect of the pupil margin. I would recommend performing pupil reconstruction using iris sutures and retropupillary inverse implantation of an iris-fixated IOL with vertical orientation. My second option is iris suture fixation of a foldable acrylic PC IOL. The surgical procedure is performed with a sub-Tenon block. A temporal conjunctival flap is made, after which the episcleral vessels are cauterized. An inverse arc-shaped sclerocorneal tunnel incision with a 6.0 mm diameter is created. Before the anterior chamber is entered, 2 paracenteses are created at 2 o’clock and 5 o’clock with a diamond knife (diameter 1.0 mm). After a cohesive OVD (eg, sodium hyaluronate 1.4%) is injected, the AC IOL is removed and an iris-fixated IOL for aphakia placed in the anterior chamber with a special holding forceps and rotated into the vertical axis orientation. After the IOL is moved down behind the iris and while it is being held, acetylcholine chloride is injected into the anterior chamber. With a narrow pupil, midperipheral fixation of the iris-fixated IOL can be ensured. The IOL enclavation begins in the superior position; the paracentesis is entered at 2 o’clock with the enclavation needle and the iris enclavated into the IOL haptic. With the IOL held with a forceps at the optic edge via the sclerocorneal tunnel, the enclavation needle is changed to the 5 o’clock paracentesis and the inferior haptic is fixated. This is followed by pupil reconstruction using multiple iris sutures. The procedure is completed by removing the OVD and placing polyglactin 910 sutures.
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
Jan Venter, MD London, United Kingdom
CONSULTATION SECTION
maintaining devices (eg, Malyugin ring or iris retractors). These cases typically proceed smoothly when an in situ fracture technique with torsional phacoemulsification and a cohesive–dispersive OVD are used. Excellent visualization is of great benefit, and an operating microscope with red-reflex technology for better contrast aides greatly in these complicated cases. Assuming the result of surgery in the left eye is good or in the unlikely event the patient insists on a fourth procedure in the right eye first, I would obtain records of the 2 failed attempts at repositioning the AC IOL. If during those procedures the IOL had been rotated 90 degrees away from the peripheral iridectomy and it had propelled back around into it, a more invasive approach may be required. I believe that less is better and would prefer to simply rotate the haptic out of the peripheral iridectomy and then rotate the IOL 90 degrees past the peripheral iridectomy. This should be relatively simple and much less invasive than IOL exchange. Should these measures fail, a 6.5 mm, or even a 7.0 mm, PC IOL could be sewn into the posterior chamber using scleral fixation. This has long been my last resort because I have had good success with AC IOLs in the rare instances of totally inadequate zonule support. Richard P. Lehmann, MD Nacogdoches, Texas, USA
- The pupil is reasonably centered, and the edge glare from the IOL appears to be principally from IOL decentration. I would approach this patient with the following decision tree: (1) The previous 2 attempts fully resolved symptoms for a while until the haptic migrated back to the peripheral iridectomy, decentering the IOL and restoring edge-glare symptoms. (2) The previous attempts decreased but did not eliminate the symptoms initially. (3) Previous rotations had no positive effect on the patient’s symptoms. In scenario 1, if rotating the IOL in the horizontal axis centered it over the pupil and resolved the symptoms initially, I would make a stab incision at 7 o’clock and rotate the IOL horizontally for the third time. I would then pass 1 throw of 9-0 or 10-0 polypropylene through the same stab incision and suture the temporal haptic to the midperiphery of the iris using a modified Siepser knot. If stability were in question, an additional stab could be made at 5 o’clock and the nasal haptic could also be sutured to the midperiphery of the iris. Working through stab incisions would minimize the impact of the IFIS. In scenario 2, if the temporal iris defect were contributing to some of the edge glare, I would create the same stab incision as in scenario 1 and repair the iris
defect first with 10-0 polypropylene using a modified Siepser knot. I would then rotate the IOL and suture the haptics to the iris, also as in scenario 1. I believe this is the most likely scenario and would probably be the best approach to help the patient. In scenario 3, if there were no improvement after the 2 previous rotations, I would explant the IOL and, using a Sheets glide, take care not to remove the entire iris with the IOL. I would then evaluate the status of the iris and the sclera in this partially vitrectomized eye to determine whether to suture the IOL to the iris or the sclera. Gary J.L. Foster, MD Ft. Collins, Colorado, USA
- This patient requires removal of the AC IOL because of the decreased ECC and requires fixation of an IOL in the absence of capsule support. In addition, there is a defect in the temporal aspect of the pupil margin. I would recommend performing pupil reconstruction using iris sutures and retropupillary inverse implantation of an iris-fixated IOL with vertical orientation. My second option is iris suture fixation of a foldable acrylic PC IOL. The surgical procedure is performed with a sub-Tenon block. A temporal conjunctival flap is made, after which the episcleral vessels are cauterized. An inverse arc-shaped sclerocorneal tunnel incision with a 6.0 mm diameter is created. Before the anterior chamber is entered, 2 paracenteses are created at 2 o’clock and 5 o’clock with a diamond knife (diameter 1.0 mm). After a cohesive OVD (eg, sodium hyaluronate 1.4%) is injected, the AC IOL is removed and an iris-fixated IOL for aphakia placed in the anterior chamber with a special holding forceps and rotated into the vertical axis orientation. After the IOL is moved down behind the iris and while it is being held, acetylcholine chloride is injected into the anterior chamber. With a narrow pupil, midperipheral fixation of the iris-fixated IOL can be ensured. The IOL enclavation begins in the superior position; the paracentesis is entered at 2 o’clock with the enclavation needle and the iris enclavated into the IOL haptic. With the IOL held with a forceps at the optic edge via the sclerocorneal tunnel, the enclavation needle is changed to the 5 o’clock paracentesis and the inferior haptic is fixated. This is followed by pupil reconstruction using multiple iris sutures. The procedure is completed by removing the OVD and placing polyglactin 910 sutures.
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
Jan Venter, MD London, United Kingdom