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August consultation #3
CONSULTATION SECTION
limbal paracenteses at the 3 o’clock and 9 o’clock positions using a Sinskey hook. Knots are tied in the externalized sutures, creating loops around the haptics in the capsular bag, and then reposited into the anterior chamber. The loops of the polypropylene sutures under the scleral flaps are pulled out, cut, and tied, centering and fixating the IOL. The advantages of this technique, in which the sutures are passed in a posterior to anterior direction, over Oshika’s technique2 include more accurate IOL placement in the ciliary sulcus and easier needle passage through the fibrotic capsule because of iris stabilization of the IOL–capsular bag complex. Holly B. Hindman, MD Rochester, New York, USA REFERENCES 1. Hindman HB, Casparis H, Haller JA, Stark WJ. Sutured sulcus fixation of an anteriorly dislocated endocapsular intraocular lens. Arch Ophthalmol 2008; 126:1567–1570 2. Oshika T. Transscleral suture fixation of a subluxated posterior chamber lens within the capsular bag. J Cataract Refract Surg 1997; 23:1421–1424
- In this challenging case, the safest option might be total removal of the IOL–capsular bag complex, anterior vitrectomy, and placement of a scleral-fixated IOL, with the sutures placed to avoid the superior sclera and conjunctiva. Nevertheless, removing a PMMA IOL requires a large incision. Alternatively, an attempt can be made to recenter and fixate the subluxated IOL. A technique derived from scleral fixation can be used to reach this goal. The patient must be informed of the limited results of surgery because of her preexisting macular atrophy and glaucomatous visual field loss as well as of potential complications, especially hemorrhagic and vitreoretinal. Because of the length of surgery, peribulbar or general anesthesia should be used. First, 2 conjunctival incisions are made at the 2 o’clock and 8 o’clock positions, exposing the sclera from the limbus to 3.0 mm. In these sites, after gentle episcleral coagulation, a 2.0 mm long superficial incision is created parallel to the limbus at 2.0 mm. Using a crescent knife, a tunnel is created mid-scleral thickness from the bottom of the initial incision toward the limbus by 1.0 mm, creating a scleral pocket that will be used later to bury the sutures. Next, iris retractors are placed through the paracentesis at the 3, 6, 9, and 12 o’clock positions. Two 1.0 mm limbal incisions are then created at the 2 o’clock and 8 o’clock positions, and an OVD is injected into the anterior
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chamber. A 10-0 polypropylene suture with a long, curved needle at each end is used. One needle is introduced into the anterior chamber through the 8 o’clock incision and passed through the pupil and under the superior haptic (the haptic visible in Figure 1), thus perforating the peripheral capsule; and exteriorized in the 2 o’clock scleral pocket. The scleral perforation from inside the globe is supposed to be through the sulcus and is the most difficult step of the procedure. The other needle of the doublearmed suture follows the same way with the exception of passing above the haptic; it comes through the sclera in the pocket 1.0 mm from the first needle. As the 2 ends of the suture are pulled, the loop penetrates the anterior chamber, coming around the haptic to secure it to the sclera. The 2 ends are tied together, and the knot is buried in the scleral pocket. The same maneuver can be achieved through the 2 o’clock incision and the 8 o’clock scleral pocket to secure the inferior haptic. If necessary, a vitrectomy can be performed through an additional limbal incision at 11 o’clock with irrigation through 1 of the previous incisions. This can be useful if the capsules are opaque in the visual axis. After this step, the OVD and iris retractors are removed and the conjunctiva is sutured. Pascal Dureau, MD, PhD Paris, France
- Sometimes, an IOL dislocates inferiorly and even disappears from the surgeon’s sight when the patient is supine. In such cases, an anterior approach can be difficult and the patient must be informed before surgery that a posterior approach may be inevitable. However, when an anterior approach is possible, there are 2 methods to manage a dislocated IOL in the bag without removing the capsule or the IOL. In the first method, the IOL is sclerally fixated. In the second method, it is fixated to the iris. The typical scleral fixation method secures the haptic with a suture loop without making a knot1 or, alternatively, uses an internal sliding knot.2 In this case, because the zonules are almost completely damaged, making a loop around the superior haptic might not be sufficient to secure the dislocated IOL in a stable position. Therefore, I would fixate the superior haptic as well as the inferior haptic with an internal sliding knot.2 Because a knot is threaded around the superior haptic, the inferior haptic can be fixated using an open loop. Iris fixation of the haptics is another option if the zonular damage is severe and the capsular bag almost totally dislocated. With this approach, there is no risk of passing the needle through the sclera; therefore, the procedure can be performed quickly. However, if the iris is pliable, an
J CATARACT REFRACT SURG - VOL 36, AUGUST 2010
limbal paracenteses at the 3 o’clock and 9 o’clock positions using a Sinskey hook. Knots are tied in the externalized sutures, creating loops around the haptics in the capsular bag, and then reposited into the anterior chamber. The loops of the polypropylene sutures under the scleral flaps are pulled out, cut, and tied, centering and fixating the IOL. The advantages of this technique, in which the sutures are passed in a posterior to anterior direction, over Oshika’s technique2 include more accurate IOL placement in the ciliary sulcus and easier needle passage through the fibrotic capsule because of iris stabilization of the IOL–capsular bag complex. Holly B. Hindman, MD Rochester, New York, USA REFERENCES 1. Hindman HB, Casparis H, Haller JA, Stark WJ. Sutured sulcus fixation of an anteriorly dislocated endocapsular intraocular lens. Arch Ophthalmol 2008; 126:1567–1570 2. Oshika T. Transscleral suture fixation of a subluxated posterior chamber lens within the capsular bag. J Cataract Refract Surg 1997; 23:1421–1424
- In this challenging case, the safest option might be total removal of the IOL–capsular bag complex, anterior vitrectomy, and placement of a scleral-fixated IOL, with the sutures placed to avoid the superior sclera and conjunctiva. Nevertheless, removing a PMMA IOL requires a large incision. Alternatively, an attempt can be made to recenter and fixate the subluxated IOL. A technique derived from scleral fixation can be used to reach this goal. The patient must be informed of the limited results of surgery because of her preexisting macular atrophy and glaucomatous visual field loss as well as of potential complications, especially hemorrhagic and vitreoretinal. Because of the length of surgery, peribulbar or general anesthesia should be used. First, 2 conjunctival incisions are made at the 2 o’clock and 8 o’clock positions, exposing the sclera from the limbus to 3.0 mm. In these sites, after gentle episcleral coagulation, a 2.0 mm long superficial incision is created parallel to the limbus at 2.0 mm. Using a crescent knife, a tunnel is created mid-scleral thickness from the bottom of the initial incision toward the limbus by 1.0 mm, creating a scleral pocket that will be used later to bury the sutures. Next, iris retractors are placed through the paracentesis at the 3, 6, 9, and 12 o’clock positions. Two 1.0 mm limbal incisions are then created at the 2 o’clock and 8 o’clock positions, and an OVD is injected into the anterior
1439
chamber. A 10-0 polypropylene suture with a long, curved needle at each end is used. One needle is introduced into the anterior chamber through the 8 o’clock incision and passed through the pupil and under the superior haptic (the haptic visible in Figure 1), thus perforating the peripheral capsule; and exteriorized in the 2 o’clock scleral pocket. The scleral perforation from inside the globe is supposed to be through the sulcus and is the most difficult step of the procedure. The other needle of the doublearmed suture follows the same way with the exception of passing above the haptic; it comes through the sclera in the pocket 1.0 mm from the first needle. As the 2 ends of the suture are pulled, the loop penetrates the anterior chamber, coming around the haptic to secure it to the sclera. The 2 ends are tied together, and the knot is buried in the scleral pocket. The same maneuver can be achieved through the 2 o’clock incision and the 8 o’clock scleral pocket to secure the inferior haptic. If necessary, a vitrectomy can be performed through an additional limbal incision at 11 o’clock with irrigation through 1 of the previous incisions. This can be useful if the capsules are opaque in the visual axis. After this step, the OVD and iris retractors are removed and the conjunctiva is sutured. Pascal Dureau, MD, PhD Paris, France
- Sometimes, an IOL dislocates inferiorly and even disappears from the surgeon’s sight when the patient is supine. In such cases, an anterior approach can be difficult and the patient must be informed before surgery that a posterior approach may be inevitable. However, when an anterior approach is possible, there are 2 methods to manage a dislocated IOL in the bag without removing the capsule or the IOL. In the first method, the IOL is sclerally fixated. In the second method, it is fixated to the iris. The typical scleral fixation method secures the haptic with a suture loop without making a knot1 or, alternatively, uses an internal sliding knot.2 In this case, because the zonules are almost completely damaged, making a loop around the superior haptic might not be sufficient to secure the dislocated IOL in a stable position. Therefore, I would fixate the superior haptic as well as the inferior haptic with an internal sliding knot.2 Because a knot is threaded around the superior haptic, the inferior haptic can be fixated using an open loop. Iris fixation of the haptics is another option if the zonular damage is severe and the capsular bag almost totally dislocated. With this approach, there is no risk of passing the needle through the sclera; therefore, the procedure can be performed quickly. However, if the iris is pliable, an
J CATARACT REFRACT SURG - VOL 36, AUGUST 2010