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May consultation #4
704
CONSULTATION SECTION: CATARACT
To manage this patient’s visual problems, I would prefer a surgical approach to save and relocate the IOL. Different techniques have been described for this purpose. The whole IOL–capsule complex can be sutured to the iris or to the sclera.2,3 In this case, scleral fixation seems to be a more appropriate way to prevent contact with the iris and to prevent CME. With all relocation procedures, sometimes changes have to be made in the technique during surgery; for example, the IOL–capsule complex might have to be removed from the posterior segment of the eye. Therefore, I would plan to perform the reoperation in the hospital and make sure general anesthesia is available to use if necessary. Depending on the direction of the dislocation, I would make 2 opposite side-port incisions and inject an OVD into the anterior chamber. In the same axis, a scleral pocket should be made behind the limbus. I prefer the technique of Hoffman et al.,3 in which the conjunctiva does not have to be dissected. To refixate the IOL, I would use a McCannel suture (polypropylene 10-0). I would pull it through the opposite paracentesis and pass it through the capsule complex under the haptic. The needle can then be docked inside a 27-gauge cannula that penetrated the scleral pocket and the sclera 1.0 mm behind the limbus. As the needle is quite flexible, it follows the direction of the cannula and can be led out of the eye very gently. In some cases, it helps to use iris retraction hooks for better visualization. The second needle should be pulled through the same way; however, it should be passed above the capsule being docked into a 27-gauge cannula and led out just beside the first one. The McCannel needles should be cut off and the thread ends pulled out of the scleral pocket with a small iris spatula. After the knots are tightened, I would slip them into the scleral pocket. No suture of the sclera or the conjunctiva is necessary. If the other haptic of the IOL appears unstable as well, the technique can be repeated the same way on the opposite side. Finally, the OVD can be removed by simple irrigation or using a bimanual irrigation/aspiration system. REFERENCES
1. Dabrowska-Kloda K, Kloda T, Boudiaf S, Jakobsson G, Stenevi U. Incidence and risk factors of late in-the-bag intraocular lens dislocation: evaluation of 140 eyes between 1992 and 2012. J Cataract Refract Surg 2015; 14:1376–1382 2. Siegel MJ, Condon GP. Single suture iris-to-capsulorhexis fixation for in-thebag intraocular lens subluxation. J Cataract Refract Surg 2015; 41:2347– 2352. Available at: http://www.jcrsjournal.org/article/S0886-3350(15)01164-5/ pdf. Accessed January 23, 2017 3. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www. finemd.com/reprints/Scleral%20Fixation%20Without%20Conjunctival% 20Dissection.pdf. Accessed January 23, 2017
would require a larger corneal incision. In case of IOL subluxation within the capsular bag, my preferred technique is to fixate the IOL to the sclera. I like to use the technique described by Hoffman et al.1 Briefly, the first step would be to create 2 partial-thickness clear corneal incisions followed by scleral pockets at the area of the IOL haptics, 180 degrees apart. Then, I would create the paracenteses from each corneal incision into the anterior chamber and place a cohesive OVD in the anterior chamber. A bent 27-gauge needle should be passed through the conjunctiva and the sclera 1.0 mm posterior to the limbus close to 1 edge of the scleral pocket (within the pocket area), adjacent to the IOL haptic that is seen in the pupil. Next, the needle should be passed posterior to the iris and the IOL haptic, then between the haptic and the optic component, anterior to the IOL optic (perforating the capsule), and into the anterior chamber thorough the pupil. Insert a double-arm 10-0 polypropylene (Prolene) suture on a long needle through the opposite paracentesis and into the 27-gauge needle and remove both outside the eye. The 27-gauge needle should be passed again 1.0 mm to 2.0 mm adjacent to the first pass (inside the pocket area), posterior to the iris; however, this time it should be passed above and anterior to the IOL haptic and optic through the pupil into the anterior chamber. Pass the second needle of the 10-0 polypropylene suture through the same opposite paracentesis (taking care not to grasp any corneal stroma) into the 27-gauge needle and outside the eye. The procedure should be repeated in the same manner on the opposite side. The needles should be cut and removed and the sutures pulled from the scleral pockets and tied gently under the scleral pocket, taking care to ensure the IOL is well centered. The OVD should be removed from the anterior chamber and the paracenteses should be hydrated with a balanced salt solution. Place an intracameral antibiotic in the anterior chamber as the last step of the procedure. An alternative to creating scleral pockets would be to perform a peritomy on each side, with horizontal partialthickness scleral incisions approximately 1.0 mm posterior to the scleral spur and then, repeat the procedure through the partial-thickness scleral incisions. The polypropylene suture can be replaced with a polytetrafluoroethylene (Gore-Tex) suture, which is believed to be more durable. REFERENCE
1. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www. finemd.com/reprints/Scleral%20Fixation%20Without%20Conjunctival% 20Dissection.pdf. Accessed March 29, 2017
Guy Kleinmann, MD Rehovot, Israel
Christoph Kranemann, MD, FRCS, DABO North York, Ontario, Canada
Assuming that the IOL performed well before it subluxated and that it had the correct optical power, I would try to fixate the same IOL rather than exchange it because that
The incidence of late in-the-bag dislocations of PC IOLs has been increasing. The average onset is approximately 10 years after the original cataract surgery as in the case at hand.
Volume 43 Issue 5 May 2017
CONSULTATION SECTION: CATARACT
To manage this patient’s visual problems, I would prefer a surgical approach to save and relocate the IOL. Different techniques have been described for this purpose. The whole IOL–capsule complex can be sutured to the iris or to the sclera.2,3 In this case, scleral fixation seems to be a more appropriate way to prevent contact with the iris and to prevent CME. With all relocation procedures, sometimes changes have to be made in the technique during surgery; for example, the IOL–capsule complex might have to be removed from the posterior segment of the eye. Therefore, I would plan to perform the reoperation in the hospital and make sure general anesthesia is available to use if necessary. Depending on the direction of the dislocation, I would make 2 opposite side-port incisions and inject an OVD into the anterior chamber. In the same axis, a scleral pocket should be made behind the limbus. I prefer the technique of Hoffman et al.,3 in which the conjunctiva does not have to be dissected. To refixate the IOL, I would use a McCannel suture (polypropylene 10-0). I would pull it through the opposite paracentesis and pass it through the capsule complex under the haptic. The needle can then be docked inside a 27-gauge cannula that penetrated the scleral pocket and the sclera 1.0 mm behind the limbus. As the needle is quite flexible, it follows the direction of the cannula and can be led out of the eye very gently. In some cases, it helps to use iris retraction hooks for better visualization. The second needle should be pulled through the same way; however, it should be passed above the capsule being docked into a 27-gauge cannula and led out just beside the first one. The McCannel needles should be cut off and the thread ends pulled out of the scleral pocket with a small iris spatula. After the knots are tightened, I would slip them into the scleral pocket. No suture of the sclera or the conjunctiva is necessary. If the other haptic of the IOL appears unstable as well, the technique can be repeated the same way on the opposite side. Finally, the OVD can be removed by simple irrigation or using a bimanual irrigation/aspiration system. REFERENCES
1. Dabrowska-Kloda K, Kloda T, Boudiaf S, Jakobsson G, Stenevi U. Incidence and risk factors of late in-the-bag intraocular lens dislocation: evaluation of 140 eyes between 1992 and 2012. J Cataract Refract Surg 2015; 14:1376–1382 2. Siegel MJ, Condon GP. Single suture iris-to-capsulorhexis fixation for in-thebag intraocular lens subluxation. J Cataract Refract Surg 2015; 41:2347– 2352. Available at: http://www.jcrsjournal.org/article/S0886-3350(15)01164-5/ pdf. Accessed January 23, 2017 3. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www. finemd.com/reprints/Scleral%20Fixation%20Without%20Conjunctival% 20Dissection.pdf. Accessed January 23, 2017
would require a larger corneal incision. In case of IOL subluxation within the capsular bag, my preferred technique is to fixate the IOL to the sclera. I like to use the technique described by Hoffman et al.1 Briefly, the first step would be to create 2 partial-thickness clear corneal incisions followed by scleral pockets at the area of the IOL haptics, 180 degrees apart. Then, I would create the paracenteses from each corneal incision into the anterior chamber and place a cohesive OVD in the anterior chamber. A bent 27-gauge needle should be passed through the conjunctiva and the sclera 1.0 mm posterior to the limbus close to 1 edge of the scleral pocket (within the pocket area), adjacent to the IOL haptic that is seen in the pupil. Next, the needle should be passed posterior to the iris and the IOL haptic, then between the haptic and the optic component, anterior to the IOL optic (perforating the capsule), and into the anterior chamber thorough the pupil. Insert a double-arm 10-0 polypropylene (Prolene) suture on a long needle through the opposite paracentesis and into the 27-gauge needle and remove both outside the eye. The 27-gauge needle should be passed again 1.0 mm to 2.0 mm adjacent to the first pass (inside the pocket area), posterior to the iris; however, this time it should be passed above and anterior to the IOL haptic and optic through the pupil into the anterior chamber. Pass the second needle of the 10-0 polypropylene suture through the same opposite paracentesis (taking care not to grasp any corneal stroma) into the 27-gauge needle and outside the eye. The procedure should be repeated in the same manner on the opposite side. The needles should be cut and removed and the sutures pulled from the scleral pockets and tied gently under the scleral pocket, taking care to ensure the IOL is well centered. The OVD should be removed from the anterior chamber and the paracenteses should be hydrated with a balanced salt solution. Place an intracameral antibiotic in the anterior chamber as the last step of the procedure. An alternative to creating scleral pockets would be to perform a peritomy on each side, with horizontal partialthickness scleral incisions approximately 1.0 mm posterior to the scleral spur and then, repeat the procedure through the partial-thickness scleral incisions. The polypropylene suture can be replaced with a polytetrafluoroethylene (Gore-Tex) suture, which is believed to be more durable. REFERENCE
1. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www. finemd.com/reprints/Scleral%20Fixation%20Without%20Conjunctival% 20Dissection.pdf. Accessed March 29, 2017
Guy Kleinmann, MD Rehovot, Israel
Christoph Kranemann, MD, FRCS, DABO North York, Ontario, Canada
Assuming that the IOL performed well before it subluxated and that it had the correct optical power, I would try to fixate the same IOL rather than exchange it because that
The incidence of late in-the-bag dislocations of PC IOLs has been increasing. The average onset is approximately 10 years after the original cataract surgery as in the case at hand.
Volume 43 Issue 5 May 2017