- Email: [email protected]
November consultation #4
CONSULTATION SECTION
3. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912 ~e s J, Ferna ndez-Hortelano A, Caire J. Bilateral 4. Moreno-Montan intraocular lens subluxation secondary to haptic angulation. J Cataract Refract Surg 2008; 34:700–702
- First, one should confirm that the IOL–CTR– capsular bag complex stays accessible with the patient supine; if not, it would demand a vitreoretinal approach, which is unlikely because his supine vision improved. The preoperative informed consent requires thorough risk–benefit counseling. Under peribulbar anesthesia, I would use Condon's modified ab externo technique to lasso the IOL–CTR– capsular bag complex and fixate it to the sclera with 9-0 polypropylene sutures. The tension ring portion of the iris shield device allows fixation on either side of the tinted poly(methyl methacrylate) (PMMA) shield (which itself is impenetrable to needles) without regard to the haptic location, all of which is performed with a formed chamber and small incisions. With an intact globe, under a nasal fornix-based flap, two 2.0 mm long grooves are created to a depth of 250 mm with a guarded diamond blade 1.5 mm posterior to the limbus on either side of the coloboma shield. Cautery is avoided and time allowed for clotting instead. Iris hooks are then inserted through small limbal stab incisions to adequately expose the subluxated complex. An inferior 23-gauge paracentesis allows intraocular forceps entry. Minimal dispersive ophthalmic viscosurgical device (OVD) is instilled to maintain the chamber and protect the endothelium. Then, a long curved needle armed with 9-0 polypropylene is introduced perpendicular to the sclera at 1 end of 1 of the grooves to enter below the bag complex while an intraocular forceps introduced through the paracentesis exerts counterpressure, helping the needle pass from under the bag, through the bag, and into the anterior chamber to exit through clear cornea temporally, thereby incorporating the CTR in the bite. The needle is then cut off. A small stab wound is fashioned with a 0.3 to 0.5 mm diamond blade through the sclera at the other extreme end of the groove containing the suture entry, allowing a Condon snare or Bonn hook to retrieve the suture's corneal end. This results in a lasso around the bag that exits the groove, preventing the complex from descending. Before the suture is tightened, dilute triamcinolone acetonide is instilled into the anterior chamber to identify vitreous anterior to the bag complex. If necessary, another anterior paracentesis or a pars plana trocar entry is created for a 23-gauge vitrector with biaxial irrigation
1783
through the inferior paracentesis to remove prolapsed vitreous. Then, the bag complex is centered by adequate tension on the 2 suture ends. Overstressing the contralateral zonules by overtightening is avoided. In pseudoexfoliation, a second point of fixation 180 degrees opposite is invariably needed, while trauma cases without global zonulopathy may only require fixation in the meridian of traumatic zonulysis. In this case, due to the presence of the aniridia shield, I would use the groove on the other side of the shield, repeating the same steps to prevent tilting the stiff bag. The knots are buried by rotating them through the stab wound in the groove, and the fornix-based flap is sutured with 8-0 polyglactin. After the chamber is reformed, triamcinolone acetonide is reinstilled to confirm the absence of residual vitreous prolapse. The iris hooks are removed, and intracameral antibiotic instilled (off label). Vigilant postoperative pressure and inflammation management promotes excellent visual recovery. Lisa B. Arbisser, MD Bettendorf, Iowa, USA
- The primary choice of many surgeons is to remove an unstable malpositioned IOL and replace it with an alternative IOL. However, in the present case, vision is relatively good (0.8, J1), IOL power calculation is correct (spherical equivalent almost emmetropia), and the pressure and fundus are normal in the better eye of an 80-year-old patient. Removal of the IOL requires complex surgery, especially because the fibrosed capsule equator is supported by an endocapsular ring. This may require a very large (w10.0 mm) corneoscleral incision. An alternative IOL, an anterior chamber IOL or, alternatively, an iris- or scleralfixated posterior chamber IOL will not provide better vision. The current malpositioned IOL is optically good. The problem is the malposition; therefore, my definite choice would be to treat this patient by repositioning the same IOL and fixating it to the scleral wall. This can be effectively done using 10-0 or 9-0 polypropylene suture with a straight or curved long (16.0 mm) needle. My preferred technique is the following: The needle is inserted through the exposed sclera behind the haptic–ring complex, penetrates the capsule, and is externalized through a paracentesis on the opposite side using a 27-gauge needle as a guide. The needle is then rotated 180 degrees and reinserted through the same side-port incision, whereas the 27-gauge needle is inserted through the sclera close to the initial penetration point and directed in front of the lens
J CATARACT REFRACT SURG - VOL 39, NOVEMBER 2013
1784
CONSULTATION SECTION
capsule. The suture is externalized through the 27gauge needle to create a ring suture around the haptic–endocapsular ring. The knot is buried in the scleral tissue; therefore, there is no need for a scleral flap. The same is performed on the opposite side because the wobbling motion of the IOL indicates that all the zonular fibers are weakened, not only the inferonasal ones. If needed, a third or more sutures can be placed to maintain a stable central IOL position and prevent IOL tilting. The presence of an endocapsular ring thus turns out to be an advantage because the sutures can be located almost anywhere around the equator (except for the location of the iris shield). I would recommend inserting all sutures before closing the knots to allow controlled, balanced pulling of the sutures and positioning of the capsulorhexis behind the displaced pupil. The entire procedure is performed in a relatively closed system and usually requires only 2 side-port incisions and 4 needle holes. This is a relatively simple and very rewarding procedure, and long-term experience has shown its clinical applicability and efficacy. Ehud I. Assia, MD Kfar-Saba, Israel - This late IOL–capsular bag subluxation due to traumatic zonulopathy is likely to worsen over time because the patient's normal ocular saccades will shear the remaining zonular attachments. Eventually, total posterior dislocation of the IOL–capsular bag complex will occur. Surgical extraction of the entire complex through the pupil would be difficult because of the intracapsular coloboma ring, which is much more rigid and brittle than a conventional CTR. Attempting this would almost certainly necessitate an anterior vitrectomy and would also leave the sector defect unblocked. Therefore, scleral suture fixation of the black intracapsular coloboma ring should be attempted. A variety of techniques are used for scleral suture fixation of an intracapsular CTR. My plan in this case would be to make a half-thickness scleral groove approximately 1.5 mm posterior to the limbus at the desired site for each scleral suture. One scleral suture should be located at the 7 o'clock position in this left eye, at the inferior edge of the large sector defect and alongside the smaller peripheral coloboma. The second scleral suture should be located 180 degrees opposite the first. I would align a quartet of iris retractors so they provide maximum peripheral visualization near these suture sites (1 at the 7 o'clock position and 1 at the 1 o'clock position). Through a paracentesis created over the large defect (8:30 position), I would inject a dispersive OVD behind the IOL–capsular bag complex to
push back the anterior hyaloid face. I would then use a Lester hook to recenter and reposition the coloboma ring so the black plate was realigned with the sector defect. The first scleral suture would be placed at the 7 o'clock position, with the goal of it catching the ring just adjacent to the black plate. A 25-gauge disposable guide needle would be introduced ab externo through the base of the half-thickness scleral groove. The guide needle would be passed through the ciliary sulcus, behind the iris, beneath the CTR, and through the peripheral capsular bag before reaching the pupillary space. Approaching from an oppositely located paracentesis, a straight, doublearmed 9-0 polypropylene suture needle would be docked into the guide-needle lumen so it can be backed out externally through the base of the scleral groove. The same steps would be repeated with the second polypropylene needle, except this time the guide needle would pass above the CTR. The second of the double-armed polypropylene needles would be similarly guided out through the base of the scleral groove so it exits approximately 1.0 mm from the first needle. The smaller peripheral coloboma inferiorly would facilitate visualization of these maneuvers. Once tied, the trimmed knot would lie within the half-thickness scleral groove so it would not erode through the overlying conjunctiva. This same set of steps would be repeated to place the second scleral suture around the CTR at a location 180 degrees away. Figure 3 shows these steps used to scleral suture fixate a CTR after late IOL–capsular bag subluxation in a patient with pseudoexfoliation. David F. Chang, MD Los Altos, California, USA
- The indication for a CTR was correct here because traumatic zonular damage usually leaves a large part of the zonules intact and there is low risk for eventual CTR–IOL complex dislocation. However, now that this has happened, the patient requires further surgery. Because the refractive defect is low and the patient has been satisfied with his IOL, there is no need for IOL exchange. In addition, because vision in supine position is good, we can expect little posterior CTR– IOL displacement at surgery. Therefore, ab externo scleral fixation of the CTR in a closed eye seems to be the best approach.1 General anesthesia would be better because of the length of the procedure, which may last up to
J CATARACT REFRACT SURG - VOL 39, NOVEMBER 2013
3. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912 ~e s J, Ferna ndez-Hortelano A, Caire J. Bilateral 4. Moreno-Montan intraocular lens subluxation secondary to haptic angulation. J Cataract Refract Surg 2008; 34:700–702
- First, one should confirm that the IOL–CTR– capsular bag complex stays accessible with the patient supine; if not, it would demand a vitreoretinal approach, which is unlikely because his supine vision improved. The preoperative informed consent requires thorough risk–benefit counseling. Under peribulbar anesthesia, I would use Condon's modified ab externo technique to lasso the IOL–CTR– capsular bag complex and fixate it to the sclera with 9-0 polypropylene sutures. The tension ring portion of the iris shield device allows fixation on either side of the tinted poly(methyl methacrylate) (PMMA) shield (which itself is impenetrable to needles) without regard to the haptic location, all of which is performed with a formed chamber and small incisions. With an intact globe, under a nasal fornix-based flap, two 2.0 mm long grooves are created to a depth of 250 mm with a guarded diamond blade 1.5 mm posterior to the limbus on either side of the coloboma shield. Cautery is avoided and time allowed for clotting instead. Iris hooks are then inserted through small limbal stab incisions to adequately expose the subluxated complex. An inferior 23-gauge paracentesis allows intraocular forceps entry. Minimal dispersive ophthalmic viscosurgical device (OVD) is instilled to maintain the chamber and protect the endothelium. Then, a long curved needle armed with 9-0 polypropylene is introduced perpendicular to the sclera at 1 end of 1 of the grooves to enter below the bag complex while an intraocular forceps introduced through the paracentesis exerts counterpressure, helping the needle pass from under the bag, through the bag, and into the anterior chamber to exit through clear cornea temporally, thereby incorporating the CTR in the bite. The needle is then cut off. A small stab wound is fashioned with a 0.3 to 0.5 mm diamond blade through the sclera at the other extreme end of the groove containing the suture entry, allowing a Condon snare or Bonn hook to retrieve the suture's corneal end. This results in a lasso around the bag that exits the groove, preventing the complex from descending. Before the suture is tightened, dilute triamcinolone acetonide is instilled into the anterior chamber to identify vitreous anterior to the bag complex. If necessary, another anterior paracentesis or a pars plana trocar entry is created for a 23-gauge vitrector with biaxial irrigation
1783
through the inferior paracentesis to remove prolapsed vitreous. Then, the bag complex is centered by adequate tension on the 2 suture ends. Overstressing the contralateral zonules by overtightening is avoided. In pseudoexfoliation, a second point of fixation 180 degrees opposite is invariably needed, while trauma cases without global zonulopathy may only require fixation in the meridian of traumatic zonulysis. In this case, due to the presence of the aniridia shield, I would use the groove on the other side of the shield, repeating the same steps to prevent tilting the stiff bag. The knots are buried by rotating them through the stab wound in the groove, and the fornix-based flap is sutured with 8-0 polyglactin. After the chamber is reformed, triamcinolone acetonide is reinstilled to confirm the absence of residual vitreous prolapse. The iris hooks are removed, and intracameral antibiotic instilled (off label). Vigilant postoperative pressure and inflammation management promotes excellent visual recovery. Lisa B. Arbisser, MD Bettendorf, Iowa, USA
- The primary choice of many surgeons is to remove an unstable malpositioned IOL and replace it with an alternative IOL. However, in the present case, vision is relatively good (0.8, J1), IOL power calculation is correct (spherical equivalent almost emmetropia), and the pressure and fundus are normal in the better eye of an 80-year-old patient. Removal of the IOL requires complex surgery, especially because the fibrosed capsule equator is supported by an endocapsular ring. This may require a very large (w10.0 mm) corneoscleral incision. An alternative IOL, an anterior chamber IOL or, alternatively, an iris- or scleralfixated posterior chamber IOL will not provide better vision. The current malpositioned IOL is optically good. The problem is the malposition; therefore, my definite choice would be to treat this patient by repositioning the same IOL and fixating it to the scleral wall. This can be effectively done using 10-0 or 9-0 polypropylene suture with a straight or curved long (16.0 mm) needle. My preferred technique is the following: The needle is inserted through the exposed sclera behind the haptic–ring complex, penetrates the capsule, and is externalized through a paracentesis on the opposite side using a 27-gauge needle as a guide. The needle is then rotated 180 degrees and reinserted through the same side-port incision, whereas the 27-gauge needle is inserted through the sclera close to the initial penetration point and directed in front of the lens
J CATARACT REFRACT SURG - VOL 39, NOVEMBER 2013
1784
CONSULTATION SECTION
capsule. The suture is externalized through the 27gauge needle to create a ring suture around the haptic–endocapsular ring. The knot is buried in the scleral tissue; therefore, there is no need for a scleral flap. The same is performed on the opposite side because the wobbling motion of the IOL indicates that all the zonular fibers are weakened, not only the inferonasal ones. If needed, a third or more sutures can be placed to maintain a stable central IOL position and prevent IOL tilting. The presence of an endocapsular ring thus turns out to be an advantage because the sutures can be located almost anywhere around the equator (except for the location of the iris shield). I would recommend inserting all sutures before closing the knots to allow controlled, balanced pulling of the sutures and positioning of the capsulorhexis behind the displaced pupil. The entire procedure is performed in a relatively closed system and usually requires only 2 side-port incisions and 4 needle holes. This is a relatively simple and very rewarding procedure, and long-term experience has shown its clinical applicability and efficacy. Ehud I. Assia, MD Kfar-Saba, Israel - This late IOL–capsular bag subluxation due to traumatic zonulopathy is likely to worsen over time because the patient's normal ocular saccades will shear the remaining zonular attachments. Eventually, total posterior dislocation of the IOL–capsular bag complex will occur. Surgical extraction of the entire complex through the pupil would be difficult because of the intracapsular coloboma ring, which is much more rigid and brittle than a conventional CTR. Attempting this would almost certainly necessitate an anterior vitrectomy and would also leave the sector defect unblocked. Therefore, scleral suture fixation of the black intracapsular coloboma ring should be attempted. A variety of techniques are used for scleral suture fixation of an intracapsular CTR. My plan in this case would be to make a half-thickness scleral groove approximately 1.5 mm posterior to the limbus at the desired site for each scleral suture. One scleral suture should be located at the 7 o'clock position in this left eye, at the inferior edge of the large sector defect and alongside the smaller peripheral coloboma. The second scleral suture should be located 180 degrees opposite the first. I would align a quartet of iris retractors so they provide maximum peripheral visualization near these suture sites (1 at the 7 o'clock position and 1 at the 1 o'clock position). Through a paracentesis created over the large defect (8:30 position), I would inject a dispersive OVD behind the IOL–capsular bag complex to
push back the anterior hyaloid face. I would then use a Lester hook to recenter and reposition the coloboma ring so the black plate was realigned with the sector defect. The first scleral suture would be placed at the 7 o'clock position, with the goal of it catching the ring just adjacent to the black plate. A 25-gauge disposable guide needle would be introduced ab externo through the base of the half-thickness scleral groove. The guide needle would be passed through the ciliary sulcus, behind the iris, beneath the CTR, and through the peripheral capsular bag before reaching the pupillary space. Approaching from an oppositely located paracentesis, a straight, doublearmed 9-0 polypropylene suture needle would be docked into the guide-needle lumen so it can be backed out externally through the base of the scleral groove. The same steps would be repeated with the second polypropylene needle, except this time the guide needle would pass above the CTR. The second of the double-armed polypropylene needles would be similarly guided out through the base of the scleral groove so it exits approximately 1.0 mm from the first needle. The smaller peripheral coloboma inferiorly would facilitate visualization of these maneuvers. Once tied, the trimmed knot would lie within the half-thickness scleral groove so it would not erode through the overlying conjunctiva. This same set of steps would be repeated to place the second scleral suture around the CTR at a location 180 degrees away. Figure 3 shows these steps used to scleral suture fixate a CTR after late IOL–capsular bag subluxation in a patient with pseudoexfoliation. David F. Chang, MD Los Altos, California, USA
- The indication for a CTR was correct here because traumatic zonular damage usually leaves a large part of the zonules intact and there is low risk for eventual CTR–IOL complex dislocation. However, now that this has happened, the patient requires further surgery. Because the refractive defect is low and the patient has been satisfied with his IOL, there is no need for IOL exchange. In addition, because vision in supine position is good, we can expect little posterior CTR– IOL displacement at surgery. Therefore, ab externo scleral fixation of the CTR in a closed eye seems to be the best approach.1 General anesthesia would be better because of the length of the procedure, which may last up to
J CATARACT REFRACT SURG - VOL 39, NOVEMBER 2013