- Email: [email protected]
August Consultation # 8
1360
CONSULTATION SECTION
to cause pigmentary dispersion from the back of the iris and erosion of iris vessels. This is in contrast to the polished haptics in the 3-piece AcrySof MA60 IOL series; these haptics have been regularly implanted in the sulcus. If the anterior and posterior capsules are already fused, it would make repositioning the IOL in the capsular bag difficult. Furthermore, the capsulorhexis is incomplete. I would therefore use an OVD to free this IOL from the bag, rotate it out, cut it in half, and remove it. I would then implant a 3-piece MA60BM AcrySof IOL in the ciliary sulcus, orientating the haptics away from the site of previous chafing. Ronald Yeoh, FRCS, FRCOphth Singapore, Singapore REFERENCES 1. LeBoyer RM, Werner L, Snyder ME, et al. Acute haptic-induced ciliary sulcus irritation associated with single-piece AcrySof intraocular lenses. J Cataract Refract Surg 2005; 31:1421–1427 2. Micheli T, Cheung LM, Sharma S, et al. Acute haptic-induced pigmentary glaucoma with an AcrySof intraocular lens. J Cataract Refract Surg 2002; 28:1869–1872
- This 58-year-old man has UGH syndrome secondary to a displaced 1-piece AcrySof SA60AT IOL. Given the history, it is possible this represents a primary misplacement of the IOL, but more likely it is a secondary partial dislocation associated with capsule fibrosis/ phimosis and incomplete capsulorhexis. The present situation cannot be left untreated, despite medical stabilization of the patient’s findings. This IOL has a double truncated optic–haptic design with the sharp anterior and posterior edges that are destructive to surrounding tissues. Thus, the IOL is only acceptable for in-the-bag placement. The goal of surgery is to remove the IOL from its present orientation; however, a shifting algorithm of choices must be well thought out before the surgical procedure and the appropriate tools at hand. A careful preoperative examination should include assessment of the status of the capsular bag, a peripheral retinal and posterior polar examination, as well as a comparative evaluation of the trabecular meshwork given the pigment dispersion and possible spikes in IOP in the postoperative phase. Information on the existing IOL power and postoperative refraction would be helpful. A preoperative assessment with the IOLMaster (Zeiss) to select the power of a possible replacement IOL, adjusting for capsule or sulcus lens placement, will be necessary. Because of the iris damage and possibility of further bleeding with surgical manipulation, a discussion with the patient’s primary care physician about
withholding the Plavix 7 days before surgery might be considered. The patient would have a preoperative preparation of 3 days of a topical steroid and an antibiotic agent. After informed consent is obtained, a temporal clear corneal surgical approach would be indicated. The technique would include use of topical anesthesia and maximum pupil dilation. My preferred OVD would be Healon5 because of its viscoadaptive properties. It is an effective tool in opening the capsular bag while protecting the surrounding tissues, and yet it is designed for a more complete removal under low-flow irrigation/aspiration given the possibility of pressure spikes postoperatively. Opening a capsular bag becomes progressively more difficult 6 to 9 months after implantation because of the significant fibrous response. It would be essential to first release that portion of the optic and inthe-bag haptic, being careful to maintain the posterior capsule. A modified cannula with a flattened tip, such as the Nichamin 27-gauge hydrodissection cannula, and an iris spatula would allow easier entry to the capsule–IOL interface for viscodissection. If the capsular bag can be fully opened and the capsulorhexis completed so the optic can be covered 360 degrees by the anterior capsule, repositioning the existing IOL in the bag would be possible. This, however, is unlikely, and any concern that the stress forces on the zonules and capsule could compromise the IOL’s long-term stability would dictate that it be floated into the anterior chamber, bisected or folded depending on the surgeon’s preference, and removed. If the IOL cannot be removed from the capsular bag without undue damage to the bag or zonules, amputation of the ‘‘trapped’’ haptic and removal of the remaining lens would be acceptable. At that point, a 3-piece IOL designed for sulcus placement, such as the Clariflex (AMO), could be implanted. If possible, it would be ideal to have sulcus support for the haptics and capsular bag support for the optics if the surgeon were able to free at least the more central portion of the anterior posterior capsule adhesion. Careful and complete removal of the OVD and careful monitoring of postoperative IOP would be important. Donald R. Nixon, MD Barrie, Ontario, Canada
- This 58-year-old man has an excellent IOL that is implanted incorrectly. The AcrySof 1-piece SA60AT is designed for capsular bag insertion only. The SA60AT, SN60AT, and SN60WF IOLs are 13.0 mm in length with zero-degree angulation. If the haptic is in the sulcus instead of the capsular bag, mechanical
J CATARACT REFRACT SURG - VOL 33, AUGUST 2007
CONSULTATION SECTION
to cause pigmentary dispersion from the back of the iris and erosion of iris vessels. This is in contrast to the polished haptics in the 3-piece AcrySof MA60 IOL series; these haptics have been regularly implanted in the sulcus. If the anterior and posterior capsules are already fused, it would make repositioning the IOL in the capsular bag difficult. Furthermore, the capsulorhexis is incomplete. I would therefore use an OVD to free this IOL from the bag, rotate it out, cut it in half, and remove it. I would then implant a 3-piece MA60BM AcrySof IOL in the ciliary sulcus, orientating the haptics away from the site of previous chafing. Ronald Yeoh, FRCS, FRCOphth Singapore, Singapore REFERENCES 1. LeBoyer RM, Werner L, Snyder ME, et al. Acute haptic-induced ciliary sulcus irritation associated with single-piece AcrySof intraocular lenses. J Cataract Refract Surg 2005; 31:1421–1427 2. Micheli T, Cheung LM, Sharma S, et al. Acute haptic-induced pigmentary glaucoma with an AcrySof intraocular lens. J Cataract Refract Surg 2002; 28:1869–1872
- This 58-year-old man has UGH syndrome secondary to a displaced 1-piece AcrySof SA60AT IOL. Given the history, it is possible this represents a primary misplacement of the IOL, but more likely it is a secondary partial dislocation associated with capsule fibrosis/ phimosis and incomplete capsulorhexis. The present situation cannot be left untreated, despite medical stabilization of the patient’s findings. This IOL has a double truncated optic–haptic design with the sharp anterior and posterior edges that are destructive to surrounding tissues. Thus, the IOL is only acceptable for in-the-bag placement. The goal of surgery is to remove the IOL from its present orientation; however, a shifting algorithm of choices must be well thought out before the surgical procedure and the appropriate tools at hand. A careful preoperative examination should include assessment of the status of the capsular bag, a peripheral retinal and posterior polar examination, as well as a comparative evaluation of the trabecular meshwork given the pigment dispersion and possible spikes in IOP in the postoperative phase. Information on the existing IOL power and postoperative refraction would be helpful. A preoperative assessment with the IOLMaster (Zeiss) to select the power of a possible replacement IOL, adjusting for capsule or sulcus lens placement, will be necessary. Because of the iris damage and possibility of further bleeding with surgical manipulation, a discussion with the patient’s primary care physician about
withholding the Plavix 7 days before surgery might be considered. The patient would have a preoperative preparation of 3 days of a topical steroid and an antibiotic agent. After informed consent is obtained, a temporal clear corneal surgical approach would be indicated. The technique would include use of topical anesthesia and maximum pupil dilation. My preferred OVD would be Healon5 because of its viscoadaptive properties. It is an effective tool in opening the capsular bag while protecting the surrounding tissues, and yet it is designed for a more complete removal under low-flow irrigation/aspiration given the possibility of pressure spikes postoperatively. Opening a capsular bag becomes progressively more difficult 6 to 9 months after implantation because of the significant fibrous response. It would be essential to first release that portion of the optic and inthe-bag haptic, being careful to maintain the posterior capsule. A modified cannula with a flattened tip, such as the Nichamin 27-gauge hydrodissection cannula, and an iris spatula would allow easier entry to the capsule–IOL interface for viscodissection. If the capsular bag can be fully opened and the capsulorhexis completed so the optic can be covered 360 degrees by the anterior capsule, repositioning the existing IOL in the bag would be possible. This, however, is unlikely, and any concern that the stress forces on the zonules and capsule could compromise the IOL’s long-term stability would dictate that it be floated into the anterior chamber, bisected or folded depending on the surgeon’s preference, and removed. If the IOL cannot be removed from the capsular bag without undue damage to the bag or zonules, amputation of the ‘‘trapped’’ haptic and removal of the remaining lens would be acceptable. At that point, a 3-piece IOL designed for sulcus placement, such as the Clariflex (AMO), could be implanted. If possible, it would be ideal to have sulcus support for the haptics and capsular bag support for the optics if the surgeon were able to free at least the more central portion of the anterior posterior capsule adhesion. Careful and complete removal of the OVD and careful monitoring of postoperative IOP would be important. Donald R. Nixon, MD Barrie, Ontario, Canada
- This 58-year-old man has an excellent IOL that is implanted incorrectly. The AcrySof 1-piece SA60AT is designed for capsular bag insertion only. The SA60AT, SN60AT, and SN60WF IOLs are 13.0 mm in length with zero-degree angulation. If the haptic is in the sulcus instead of the capsular bag, mechanical
J CATARACT REFRACT SURG - VOL 33, AUGUST 2007