- Email: [email protected]
Management of a dislocated intraocular lens with a suction-based grasping tool
TECHNIQUE
Management of a dislocated intraocular lens with a suction-based grasping tool Jeffrey L. Olson, MD, Raul Velez-Montoya, MD, Michael Erlanger, MD, Douglas Mackenzie, MD
Spontaneous late subluxation of an intraocular lens (IOL) is a rare but serious complication of cataract surgery, often associated with poor zonular support. The management of this complication with a conventional forceps is difficult because the forceps often cannot adequately grasp the optic or haptic to fixate the IOL to the sclera or iris or remove it. The new suction-based grasping tool has a suction cup at the end. The combination of a suction vector and the use of a set of specially designed suction tips allow grasping and stabilization of the subluxated IOL. The properties of the suction-based grasping tool provide better control of the subluxated IOL, simplifying the management of these challenging cases. Financial Disclosure: Drs. Olson and Mackenzie have a patent application pending for the disclosed device. No other author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2013; 39:154–157 Q 2013 ASCRS and ESCRS Online Video
Cataract surgery is the most common medical procedure in the United States, and there are more than 6 million patients already aphakic or pseudophakic.1 Since the introduction of the phacoemulsification technique, the incidence of cataract surgery has increased five-fold, primarily because of the excellent results and low incidence of complications.2,3 Spontaneous late subluxation of an intraocular lens (IOL) or partial or total dislocation of the IOL–capsular bag complex into the posterior segment is a rare but serious complication of cataract surgery4 and poses a challenging scenario to even experienced surgeons whatever the surgical technique. Spontaneous late subluxation is often associated with poor zonular support
Submitted: August 9, 2012. Final revision submitted: September 25, 2012. Accepted: September 26, 2012. From the Department of Ophthalmology, University of Colorado School of Medicine, Rocky Mountain Lions Eye Institute, Anschutz Medical Campus, Aurora, Colorado, USA. Presented as a video at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Chicago, Illinois, USA, April 2012. Corresponding author: Jeffrey L. Olson, MD, 1675 Aurora Court, Aurora, Colorado 80045, USA. E-mail: [email protected].
154
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
(pseudoexfoliation syndrome, Marfan syndrome, Weill-Marchesani syndrome, intraocular neoplasia, aniridia, microspherophakia).5–7 Blunt, penetrating, or surgical trauma is another cause of direct damage to the zonule and IOL subluxation.5,8 The incidence of spontaneous late subluxation of an IOL ranges from 0.2% to 3.0% and has been reported to occur as early as 3 months and as late as 25 years after surgery.9–11 Whereas most complications associated with cataract surgery have been decreasing, the incidence of spontaneous late IOL subluxation has been increasing in recent years.9,12 Associated conditions include pseudoexfoliation, prior vitreoretinal surgery, high myopia, retinitis pigmentosa, uveitis, and history of trauma.9,13 Whatever the reason, the surgical management of subluxation or dislocation of the IOL–capsular bag complex is technically demanding and time consuming. The most complicated cases will also require a retinal surgeon to assess and resolve concomitant sight-threatening conditions (giant retinal tear, retinal detachment, vitreous hemorrhages, epiretinal membranes).4,14 In this paper, we describe a minimally invasive instrument that can be used to grasp and control an IOL or IOL–capsular bag complex. The ability to control the IOL within the eye increases the safety and simplifies the options of scleral or iris fixation or IOL removal. 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.12.004
TECHNIQUE: CONTROLLING A SUBLUXATED IOL
155
Figure 1. A: Three-dimensional representation of the suction-based grasping tool. B: Set of custom-made suction tips for different surgical purposes. C: Suction tip attached to a cannula (real scale).
SURGICAL TECHNIQUE The suction-based grasping tool is a multipurpose surgical device that has a suction cup at its terminal end. The suction cup, made of silicon and nitrile, has a 3.0 mm diameter, which enables it to be used through a typical clear corneal wound (Figure 1). The distal suction cup can be used on a standard stainless steel cannula or on the tip of a vitrectomy probe, which allows both suction and cutting capabilities (Figure 2). The ability to cut the surrounding vitreous allows safe engagement and movement of the subluxated IOL. The suction is applied by the surgeon and dynamically controlled intraoperatively. The suction can be applied manually by a syringesuction device or mechanically by hooking the device to a vitrectomy or phaco machine (Figure 3). Once the IOL is engaged by suction, the suction line can be
clamped, allowing the surgeon to control the IOL while performing bimanual techniques for refixation. Alternatively, the IOL can be removed from the eye with the suction-based grasping tool to allow exchange with another posterior chamber IOL or an anterior chamber IOL. Initial laboratory testing of the device was aimed at demonstrating the suction force. In this experiment, an IOL was engaged by the device under air and a balanced salt solution. A traction force was then applied in the direction opposite to the suction vector. Data from the magnitude of force needed to break the seal between the IOL and the device were collected and plotted (Extech Instruments Corp.). The results of the test showed that the device can exert a suction force of up to 40 mN (enough force to hold and lift an entire enucleated globe) before breaking the seal. The results
Figure 2. Suction-based grasping tool suction cup adapted for a 23-gauge vitrectomy probe.
Figure 3. Suction-based grasping tool manual syringe/suction device prototype.
J CATARACT REFRACT SURG - VOL 39, FEBRUARY 2013
156
TECHNIQUE: CONTROLLING A SUBLUXATED IOL
Figure 4. Graphic representation of a force test. The arrow to the left represents the point at which the object was engaged and the suction started. The arrow to the right indicates the point at which the seal between the object and the suction-based grasping tool was broken due to the force applied in the direction opposite the suction vector.
were reproduced with the same result under balanced salt solution, perfluorocarbon liquids, and air (Figure 4). To test the device’s ability to grasp and stabilize a dislocated IOL in a surgical setting, the crystalline lens of an enucleated porcine eye was removed using a conventional phaco technique. A break was created in the posterior capsule, and an IOL was intentionally dislocated into the vitreous cavity. A pars plana infusion line or an anterior chamber maintainer was placed to maintain infusion during recovery of the IOL. The principal port of the phacoemulsification was enlarged to 3.2 mm using a disposable surgical blade, and the anterior chamber was refilled with a dispersive ophthalmic viscosurgical device. The suction-based grasping tool was inserted through the clear corneal phaco incision. Suction was applied and control of the IOL obtained (Video, available at http://jcrsjournal.org). It was then possible to manipulate the IOL and suture the haptics to the iris or to remove the IOL from the eye through the 3.2 mm incision. DISCUSSION Approximately 20.5 million people in the U.S. have a cataract in one eye (prevalence of 17.2%), and this number is expected to rise to 30.1 million by the year 2020.1 With an average of 3 million cataract surgeries each year and a prevalence ranging from 0.2% to 3.0% (mean 2.0%), there are approximately 60 000 new cases of spontaneous late subluxation or dislocation of an IOL into the vitreous cavity, a number that also seems to be increasing.9–11 Managing subluxated IOLs with poor capsule support from an anterior chamber approach is technically challenging and has a risk for giant retinal tear, retinal detachment, IOL damage, or posterior dislocation and migration of the IOL.15 To safely reposition or remove the IOL in most cases, an anterior or pars plana vitrectomy is needed to free the IOL from vitreous attachments.4,5 The device and technique described above offer a new approach to the surgical resolution of these
complicated cases. This device provides the surgeon with a way of grasping the IOL while performing concurrent vitrectomy with a single tool. The ability to clamp the aspiration line once suction is obtained enables the surgeon to perform bimanual techniques while controlling the IOL. In summary, the suction-based grasping tool provides a safe and effective way to gain control and manipulate a subluxated or dislocated IOL–capsular bag complex. We believe the device improves safety and simplifies the management of a subluxated or dislocated IOL–capsular bag complex. Further studies are needed to determine the clinical use of the device. WHAT WAS KNOWN Subluxation or dislocation of the IOL–capsular bag complex is a challenging surgical scenario that requires manipulation of the IOL for repositioning or exchange. WHAT THIS PAPER ADDS The suction-based grasping tool is a minimally invasive device that uses suction to allow better grasping, stabilization, and manipulation of the subluxated IOL. The suction-based grasping tool simplifies and improves the safety of surgically managing the subluxation or dislocation of the IOL–capsular bag complex and provides the technical advantage of controlling and manipulating the IOL while performing bimanual maneuvers.
REFERENCES 1. The Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004; 122:487–494. Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/9922/ EEB30088.pdf. Accessed October 20, 2012 2. Erie JC, Baratz KH, Hodge DO, Schleck CD, Burke JP. Incidence of cataract surgery from 1980 through 2004: 25-year population-based study. J Cataract Refract Surg 2007; 33:1273–1277 3. Fong CS-u, Mitchell P, de Loryn T, Rochtchina E, Hong T, Cugati S, Wang JJ. Long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants in an Australian cohort. Clin Exp Ophthalmol 2012; 40:597–603 4. Vanner EA, Stewart MW. Vitrectomy timing for retained lens fragments after surgery for age-related cataracts: a systematic review and meta-analysis. Am J Ophthalmol 2011; 152:345–357.e3 5. Salehi-Had H, Turalba A. Management of traumatic crystalline lens subluxation and dislocation. Int Ophthalmol Clin 2010; 50(1):167–179 6. Blecher MH, Kirk MR. Surgical strategies for the management of zonular compromise. Curr Opin Ophthalmol 2008; 19:31–35 7. Groessl SA, Anderson CJ. Capsular tension ring in a patient with Weill-Marchesani syndrome. J Cataract Refract Surg 1998; 24:1164–1165
J CATARACT REFRACT SURG - VOL 39, FEBRUARY 2013
TECHNIQUE: CONTROLLING A SUBLUXATED IOL
8. Vela JI, Andreu D, Dıaz-Cascajosa J, Buil JA. Intraocular lens dislocation after whole-body vibration. J Cataract Refract Surg 2010; 36:1790–1791 9. Werner L, Zaugg B, Neuhann T, Burrow M, Tetz M. In-the-bag capsular tension ring and intraocular lens subluxation or dislocation; a series of 23 cases. Ophthalmology 2012; 119:266–271 10. Pueringer SL, Hodge DO, Erie JC. Risk of late intraocular lens dislocation after cataract surgery, 1980–2009: a populationbased study. Am J Ophthalmol 2011; 152:618–623 11. Lorente R, de Rojas V, Vazquez de Parga P, Moreno C, Landaluce ML, Domınguez R, Lorente B. Management of late spontaneous in-the-bag intraocular lens dislocation: retrospective analysis of 45 cases. J Cataract Refract Surg 2010; 36:1270–1282
157
12. Clark A, Morlet N, Ng JQ, Preen DB, Semmens JB. Whole population trends in complications of cataract surgery over 22 years in Western Australia. Ophthalmology 2011; 118:1055–1061 13. Lam HH, Visvaraja S. Spontaneous dislocation of intraocular lens as a late complication of uncomplicated cataract surgery: a case series. Clin Exp Optom 2012; 95:99–102 14. Zhang HJ, Dong JY, Jin K, Wang GH, Xu da L, Huo M. [Efficacy of removing dislocated lens using intravitreal phacoemulsification] [Chinese]. Yan Ke Xue Bao 2012; 27:34–36 W. 15. Hirashima DE, Soriano ES, Meirelles RL, Alberti GN, Nose Outcomes of iris-claw anterior chamber versus iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome. Ophthalmology 2010; 117:1479–1485
J CATARACT REFRACT SURG - VOL 39, FEBRUARY 2013
Management of a dislocated intraocular lens with a suction-based grasping tool Jeffrey L. Olson, MD, Raul Velez-Montoya, MD, Michael Erlanger, MD, Douglas Mackenzie, MD
Spontaneous late subluxation of an intraocular lens (IOL) is a rare but serious complication of cataract surgery, often associated with poor zonular support. The management of this complication with a conventional forceps is difficult because the forceps often cannot adequately grasp the optic or haptic to fixate the IOL to the sclera or iris or remove it. The new suction-based grasping tool has a suction cup at the end. The combination of a suction vector and the use of a set of specially designed suction tips allow grasping and stabilization of the subluxated IOL. The properties of the suction-based grasping tool provide better control of the subluxated IOL, simplifying the management of these challenging cases. Financial Disclosure: Drs. Olson and Mackenzie have a patent application pending for the disclosed device. No other author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2013; 39:154–157 Q 2013 ASCRS and ESCRS Online Video
Cataract surgery is the most common medical procedure in the United States, and there are more than 6 million patients already aphakic or pseudophakic.1 Since the introduction of the phacoemulsification technique, the incidence of cataract surgery has increased five-fold, primarily because of the excellent results and low incidence of complications.2,3 Spontaneous late subluxation of an intraocular lens (IOL) or partial or total dislocation of the IOL–capsular bag complex into the posterior segment is a rare but serious complication of cataract surgery4 and poses a challenging scenario to even experienced surgeons whatever the surgical technique. Spontaneous late subluxation is often associated with poor zonular support
Submitted: August 9, 2012. Final revision submitted: September 25, 2012. Accepted: September 26, 2012. From the Department of Ophthalmology, University of Colorado School of Medicine, Rocky Mountain Lions Eye Institute, Anschutz Medical Campus, Aurora, Colorado, USA. Presented as a video at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Chicago, Illinois, USA, April 2012. Corresponding author: Jeffrey L. Olson, MD, 1675 Aurora Court, Aurora, Colorado 80045, USA. E-mail: [email protected].
154
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
(pseudoexfoliation syndrome, Marfan syndrome, Weill-Marchesani syndrome, intraocular neoplasia, aniridia, microspherophakia).5–7 Blunt, penetrating, or surgical trauma is another cause of direct damage to the zonule and IOL subluxation.5,8 The incidence of spontaneous late subluxation of an IOL ranges from 0.2% to 3.0% and has been reported to occur as early as 3 months and as late as 25 years after surgery.9–11 Whereas most complications associated with cataract surgery have been decreasing, the incidence of spontaneous late IOL subluxation has been increasing in recent years.9,12 Associated conditions include pseudoexfoliation, prior vitreoretinal surgery, high myopia, retinitis pigmentosa, uveitis, and history of trauma.9,13 Whatever the reason, the surgical management of subluxation or dislocation of the IOL–capsular bag complex is technically demanding and time consuming. The most complicated cases will also require a retinal surgeon to assess and resolve concomitant sight-threatening conditions (giant retinal tear, retinal detachment, vitreous hemorrhages, epiretinal membranes).4,14 In this paper, we describe a minimally invasive instrument that can be used to grasp and control an IOL or IOL–capsular bag complex. The ability to control the IOL within the eye increases the safety and simplifies the options of scleral or iris fixation or IOL removal. 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.12.004
TECHNIQUE: CONTROLLING A SUBLUXATED IOL
155
Figure 1. A: Three-dimensional representation of the suction-based grasping tool. B: Set of custom-made suction tips for different surgical purposes. C: Suction tip attached to a cannula (real scale).
SURGICAL TECHNIQUE The suction-based grasping tool is a multipurpose surgical device that has a suction cup at its terminal end. The suction cup, made of silicon and nitrile, has a 3.0 mm diameter, which enables it to be used through a typical clear corneal wound (Figure 1). The distal suction cup can be used on a standard stainless steel cannula or on the tip of a vitrectomy probe, which allows both suction and cutting capabilities (Figure 2). The ability to cut the surrounding vitreous allows safe engagement and movement of the subluxated IOL. The suction is applied by the surgeon and dynamically controlled intraoperatively. The suction can be applied manually by a syringesuction device or mechanically by hooking the device to a vitrectomy or phaco machine (Figure 3). Once the IOL is engaged by suction, the suction line can be
clamped, allowing the surgeon to control the IOL while performing bimanual techniques for refixation. Alternatively, the IOL can be removed from the eye with the suction-based grasping tool to allow exchange with another posterior chamber IOL or an anterior chamber IOL. Initial laboratory testing of the device was aimed at demonstrating the suction force. In this experiment, an IOL was engaged by the device under air and a balanced salt solution. A traction force was then applied in the direction opposite to the suction vector. Data from the magnitude of force needed to break the seal between the IOL and the device were collected and plotted (Extech Instruments Corp.). The results of the test showed that the device can exert a suction force of up to 40 mN (enough force to hold and lift an entire enucleated globe) before breaking the seal. The results
Figure 2. Suction-based grasping tool suction cup adapted for a 23-gauge vitrectomy probe.
Figure 3. Suction-based grasping tool manual syringe/suction device prototype.
J CATARACT REFRACT SURG - VOL 39, FEBRUARY 2013
156
TECHNIQUE: CONTROLLING A SUBLUXATED IOL
Figure 4. Graphic representation of a force test. The arrow to the left represents the point at which the object was engaged and the suction started. The arrow to the right indicates the point at which the seal between the object and the suction-based grasping tool was broken due to the force applied in the direction opposite the suction vector.
were reproduced with the same result under balanced salt solution, perfluorocarbon liquids, and air (Figure 4). To test the device’s ability to grasp and stabilize a dislocated IOL in a surgical setting, the crystalline lens of an enucleated porcine eye was removed using a conventional phaco technique. A break was created in the posterior capsule, and an IOL was intentionally dislocated into the vitreous cavity. A pars plana infusion line or an anterior chamber maintainer was placed to maintain infusion during recovery of the IOL. The principal port of the phacoemulsification was enlarged to 3.2 mm using a disposable surgical blade, and the anterior chamber was refilled with a dispersive ophthalmic viscosurgical device. The suction-based grasping tool was inserted through the clear corneal phaco incision. Suction was applied and control of the IOL obtained (Video, available at http://jcrsjournal.org). It was then possible to manipulate the IOL and suture the haptics to the iris or to remove the IOL from the eye through the 3.2 mm incision. DISCUSSION Approximately 20.5 million people in the U.S. have a cataract in one eye (prevalence of 17.2%), and this number is expected to rise to 30.1 million by the year 2020.1 With an average of 3 million cataract surgeries each year and a prevalence ranging from 0.2% to 3.0% (mean 2.0%), there are approximately 60 000 new cases of spontaneous late subluxation or dislocation of an IOL into the vitreous cavity, a number that also seems to be increasing.9–11 Managing subluxated IOLs with poor capsule support from an anterior chamber approach is technically challenging and has a risk for giant retinal tear, retinal detachment, IOL damage, or posterior dislocation and migration of the IOL.15 To safely reposition or remove the IOL in most cases, an anterior or pars plana vitrectomy is needed to free the IOL from vitreous attachments.4,5 The device and technique described above offer a new approach to the surgical resolution of these
complicated cases. This device provides the surgeon with a way of grasping the IOL while performing concurrent vitrectomy with a single tool. The ability to clamp the aspiration line once suction is obtained enables the surgeon to perform bimanual techniques while controlling the IOL. In summary, the suction-based grasping tool provides a safe and effective way to gain control and manipulate a subluxated or dislocated IOL–capsular bag complex. We believe the device improves safety and simplifies the management of a subluxated or dislocated IOL–capsular bag complex. Further studies are needed to determine the clinical use of the device. WHAT WAS KNOWN Subluxation or dislocation of the IOL–capsular bag complex is a challenging surgical scenario that requires manipulation of the IOL for repositioning or exchange. WHAT THIS PAPER ADDS The suction-based grasping tool is a minimally invasive device that uses suction to allow better grasping, stabilization, and manipulation of the subluxated IOL. The suction-based grasping tool simplifies and improves the safety of surgically managing the subluxation or dislocation of the IOL–capsular bag complex and provides the technical advantage of controlling and manipulating the IOL while performing bimanual maneuvers.
REFERENCES 1. The Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004; 122:487–494. Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/9922/ EEB30088.pdf. Accessed October 20, 2012 2. Erie JC, Baratz KH, Hodge DO, Schleck CD, Burke JP. Incidence of cataract surgery from 1980 through 2004: 25-year population-based study. J Cataract Refract Surg 2007; 33:1273–1277 3. Fong CS-u, Mitchell P, de Loryn T, Rochtchina E, Hong T, Cugati S, Wang JJ. Long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants in an Australian cohort. Clin Exp Ophthalmol 2012; 40:597–603 4. Vanner EA, Stewart MW. Vitrectomy timing for retained lens fragments after surgery for age-related cataracts: a systematic review and meta-analysis. Am J Ophthalmol 2011; 152:345–357.e3 5. Salehi-Had H, Turalba A. Management of traumatic crystalline lens subluxation and dislocation. Int Ophthalmol Clin 2010; 50(1):167–179 6. Blecher MH, Kirk MR. Surgical strategies for the management of zonular compromise. Curr Opin Ophthalmol 2008; 19:31–35 7. Groessl SA, Anderson CJ. Capsular tension ring in a patient with Weill-Marchesani syndrome. J Cataract Refract Surg 1998; 24:1164–1165
J CATARACT REFRACT SURG - VOL 39, FEBRUARY 2013
TECHNIQUE: CONTROLLING A SUBLUXATED IOL
8. Vela JI, Andreu D, Dıaz-Cascajosa J, Buil JA. Intraocular lens dislocation after whole-body vibration. J Cataract Refract Surg 2010; 36:1790–1791 9. Werner L, Zaugg B, Neuhann T, Burrow M, Tetz M. In-the-bag capsular tension ring and intraocular lens subluxation or dislocation; a series of 23 cases. Ophthalmology 2012; 119:266–271 10. Pueringer SL, Hodge DO, Erie JC. Risk of late intraocular lens dislocation after cataract surgery, 1980–2009: a populationbased study. Am J Ophthalmol 2011; 152:618–623 11. Lorente R, de Rojas V, Vazquez de Parga P, Moreno C, Landaluce ML, Domınguez R, Lorente B. Management of late spontaneous in-the-bag intraocular lens dislocation: retrospective analysis of 45 cases. J Cataract Refract Surg 2010; 36:1270–1282
157
12. Clark A, Morlet N, Ng JQ, Preen DB, Semmens JB. Whole population trends in complications of cataract surgery over 22 years in Western Australia. Ophthalmology 2011; 118:1055–1061 13. Lam HH, Visvaraja S. Spontaneous dislocation of intraocular lens as a late complication of uncomplicated cataract surgery: a case series. Clin Exp Optom 2012; 95:99–102 14. Zhang HJ, Dong JY, Jin K, Wang GH, Xu da L, Huo M. [Efficacy of removing dislocated lens using intravitreal phacoemulsification] [Chinese]. Yan Ke Xue Bao 2012; 27:34–36 W. 15. Hirashima DE, Soriano ES, Meirelles RL, Alberti GN, Nose Outcomes of iris-claw anterior chamber versus iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome. Ophthalmology 2010; 117:1479–1485
J CATARACT REFRACT SURG - VOL 39, FEBRUARY 2013