- Email: [email protected]
November consultation #5
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CONSULTATION SECTION: CATARACT
OTHER CITED MATERIAL A. Neuhann T. Die einfache Alternative zur Sklerafixation [The simple alternative to scleral fixation]. Ophthalmologische Nachrichten March 2007, Special page 9 B. Spandau U. Retropupillary IOL implantation for subluxated intraocular lenses cristalline & artificial without capsular support. Available at: https://youtu.be/5W57Wwtaa2A. Accessed August 12, 2016 C. Mohr A. Retropupillar fixation. Development of technology, rationale, and broad uses. Available on Eye Tube at: http://eyetube. net/series/ophtec-retrieval/episode-6-retropupillary-iris-clawlens-implantation/. Accessed August 12, 2016
- This is a case of UGH syndrome, which is typically associated with pressure from anterior chamber IOL (AC IOL) footplates in the anterior chamber angle–iris root area. It has also been recognized with errant posterior chamber IOL (PC IOL) haptics in the ciliary sulcus, especially if it is a 1-piece IOL (which should be in the bag) that has been placed there. A ultrasound biomicroscopy (UBM) examination before surgery to confirm the exact status of the haptic would be prudent. This case shows the latter; there is haptic–iris root contact posteriorly that resulted in iris chafing, recurrent hyphema, and a secondary rise in IOP. In Figure 1, the haptic appears to be exposed; however, the case description suggests the haptic is still in the bag. If so, it would be highly unusual that the IOL could exert enough contact force with the posterior iris root to cause the UGH syndrome. The only scenario in which this could feasibly happen is if there were significant loss of zonular support in 1 sector and some capsule contraction diametrically opposite, resulting in displacement of the whole IOL–capsular bag complex peripherally and anteriorly as in this case. The second possible scenario is that there was an undetected peripheral posterior capsule tear or zonular dehiscence at the time of surgery and that over time, capsule contraction displaced the haptic into the sulcus. The recurrent hyphema and secondary IOP rise necessitate surgical intervention even though the CDVA is still good. The first surgical step would be to use iris retractors to clearly expose the relationship between the IOL and the capsular bag. Should the bag be completely intact and merely displaced, as in the first scenario, it would be worth excising any fibrotic capsular bands that are dragging the IOL and then recentering the capsular bag complex, using either Assia anchors or capsular tension segments on the opposite side. This would have the effect of pulling the offending haptic away from the iris root. It would be prudent to use triamcinolone to check for the presence of vitreous contributing to the displacement and then perform a vitrectomy (anterior or posterior) if indicated. However, if the peripheral capsular bag appears to be defective peripherally, it would be challenging to replace the haptic in the bag and ensure it stays there.
I would then remove the IOL–capsular bag complex and implant a new IOL. There are numerous options today, such as iris fixation of a 3-piece IOL, retropupillary iris enclavation of an Artisan lens, and the various forms of scleral fixation, ranging from the glued IOL technique popularized by Agarwal et al.1 to the newest iteration by Yamane,A which uses an innovative 30-gauge intrascleral fixation technique. The general principle would be to prevent further trauma to the ciliary sulcus area; therefore, I would veer toward 1 of the iris-fixation techniques. Ronald Yeoh, FRCS, FRCOphth, DO, FAMS Singapore, Singapore REFERENCE 1. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg 2008; 34:1433–1438
OTHER CITED MATERIAL A. Yamane S, “Transconjunctival Intrascleral IOL Fixation With Double-Needle Technique,” film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016 and the 29th annual meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons, Bali, Indonesia, July 2016
- The patient has recurrent bleeding with high IOP threatening vision, although the CDVA is excellent. The decentered IOL with phacodonesis indicates a zonulysis and a probable cut through the capsular bag equator. The iris chafing with a window defect suggests the IOL haptic is rubbing against the iris or ciliary body, which explains the recurrent hyphema. After excluding other causes of late postoperative recurrent hyphema, such as subincisional vascular tuft that bleeds in response to minor trauma or angle neovascularization, the solution would be to remove the IOL that is causing the problem. The challenges include the poorly dilating pupil, the displaced IOL–capsular bag complex with a contracted anterior capsulorhexis, and the zonulysis and subluxation of the capsular bag. Planning for the surgery should include an evaluation of the corneal endothelium because of the patient's age, and because he has a pseudophakic eye and has had recurrent bouts of secondary glaucoma. I would explant the IOL and reimplant a new PC IOL in the sulcus while protecting the corneal endothelium and preserving the integrity of the capsule. The surgical procedure would begin with paracenteses at 12 o'clock and 2 o'clock. Then, I would inject a dispersive OVD followed by a cohesive OVD to protect the endothelium, deepen the anterior chamber, and dilate the pupil. With a push–pull spatula, I would inspect the
J CATARACT REFRACT SURG - VOL 42, NOVEMBER 2016
CONSULTATION SECTION: CATARACT
area behind the iris inferotemporally to check for possible zonulysis and capsular bag dehiscence. With the help of capsular traction hooks at 12 o'clock and 2 o'clock, the capsule would be stabilized and pulled back into position, after which pupil dilation in that area would be gained. Next, I would create a temporal 3.0 mm clear corneal incision and slowly inject a dispersive OVD into the capsular bag to separate it from the optic of the IOL. Silicone IOLs do not adhere to the capsule and are easily separated from it. Therefore, I would carefully rotate the IOL clockwise because the inferior haptic might be entangled in the capsule. If there were resistance, I would stop and concentrate on freeing the optic edge. I would then reinflate the anterior chamber with a cohesive OVD and with the help of fine Vannas scissors and a push–pull hook engaging the opposite edge of the IOL optic for counter traction, I would cut the IOL optic in 2 halves. I would pull each half out with rotation to dislodge and remove the haptics safely. I would then remove the capsular tension hooks and check for capsular bag dehiscence and the zonular fibers for defects. I would perform a capsule flush with a balanced salt solution, using a 27-gauge cannula to wash the epithelial cells from the posterior capsule. Then, I would implant a 3-piece hydrophobic acrylic IOL with a 13.0 mm overall diameter in the sulcus. The haptic orientation would be placed 90 degrees from the area of zonulysis. If the IOL optic were decentered, I would use a double-armed 9-0 polypropylene suture mounted on a long, curved needle to pass 1 in front and the other behind the superior haptic to fixate it to the sclera and I would bury the knot under a scleral flap or corneoscleral pocket. Yehia Salah Mostafa, PhD, MD Cairo, Egypt - This case presents many challenges and shows how difficult it can sometimes be to make the right decision about surgical management. First, I would consider the zero option of masterly inactivity because any surgical intervention will require relatively major surgery, including removal of the IOL–capsular bag complex in view of its instability and decentration. The natural history of recurrent bleeds from focal erosion or irritation can be variable; however, this patient has had episodes of progressively increasing severity resulting in secondary glaucoma from outflow obstruction. Therefore, the case for intervention in this instance is fairly compelling. Surgery would necessitate removal of the IOL and bag and then a decision regarding visual rehabilitation. I would first create a 3.0 mm limbal-based incision. This
1689
would avoid wound and corneal distortion that can result during extraction of the IOL fragments. I would use iris hooks in a diamond configuration with the incisions placed posteriorly in the sclera, approximately 1.0 mm back from the limbus. This would give much better pupil dilation as well as minimum forward tenting of the iris and, therefore, easier instrument access without repeated iris trauma. An anterior chamber flush with triamcinolone at this stage would likely confirm the absence of vitreous; however, it is worth performing because peripheral prolapse through zonular defects might be present. I would inflate the anterior chamber with a cohesive OVD and then lift and cut open the edge of the capsulorhexis to facilitate IOL removal. These 3-piece silicone IOLs are relatively easily prolapsed out of the bag with a combination of viscoexpression from behind and circumferential dialing. The Packer-Chang IOL cutters (Microsurgical Technology) are the best scissors I have used for cutting IOL optics in half, and using a chopper for counterpressure on the opposite edge of the optic to the scissors works best in my experience. The bag is probably hanging by only a few remaining zonular fibers and is best removed in view of the axial folds and lens pearls. It will most likely deliver quite easily. Although, the anterior hyaloid face can surprisingly sometimes remain intact, a flush with triamconolone would be wise at this stage. You cannot see what you cannot see! The choice of which type of IOL to use is fairly personal, and I think it will stimulate the most debate regarding this case. The first option is to leave the eye aphakic and use a contact lens, although this is not ideal if a better option is available. Moreover, because the patient has secondary glaucoma and the meshwork is compromised by the recurrent hemorrhages, an angle supported AC IOL is contraindicated. Another option would be a sclerally tunneled or glued IOL; however, this is not an easy surgical procedure and would require an extensive anterior vitrectomy to avoid vitreoretinal traction. Similarly, a scleral-sutured IOL would also raise the issue of suture longevity. On balance, I would favor an iris-claw or Artisan IOL located in the posterior chamber and enclavated from in front. Brian Little, FRCOphth London, United Kingdom
- This patient is experiencing typical UGH syndrome from haptic–iris chafe. To cause the iris transillumination defect shown in the clinical photograph, the inferotemporal haptic has to be rubbing directly against
J CATARACT REFRACT SURG - VOL 42, NOVEMBER 2016
CONSULTATION SECTION: CATARACT
OTHER CITED MATERIAL A. Neuhann T. Die einfache Alternative zur Sklerafixation [The simple alternative to scleral fixation]. Ophthalmologische Nachrichten March 2007, Special page 9 B. Spandau U. Retropupillary IOL implantation for subluxated intraocular lenses cristalline & artificial without capsular support. Available at: https://youtu.be/5W57Wwtaa2A. Accessed August 12, 2016 C. Mohr A. Retropupillar fixation. Development of technology, rationale, and broad uses. Available on Eye Tube at: http://eyetube. net/series/ophtec-retrieval/episode-6-retropupillary-iris-clawlens-implantation/. Accessed August 12, 2016
- This is a case of UGH syndrome, which is typically associated with pressure from anterior chamber IOL (AC IOL) footplates in the anterior chamber angle–iris root area. It has also been recognized with errant posterior chamber IOL (PC IOL) haptics in the ciliary sulcus, especially if it is a 1-piece IOL (which should be in the bag) that has been placed there. A ultrasound biomicroscopy (UBM) examination before surgery to confirm the exact status of the haptic would be prudent. This case shows the latter; there is haptic–iris root contact posteriorly that resulted in iris chafing, recurrent hyphema, and a secondary rise in IOP. In Figure 1, the haptic appears to be exposed; however, the case description suggests the haptic is still in the bag. If so, it would be highly unusual that the IOL could exert enough contact force with the posterior iris root to cause the UGH syndrome. The only scenario in which this could feasibly happen is if there were significant loss of zonular support in 1 sector and some capsule contraction diametrically opposite, resulting in displacement of the whole IOL–capsular bag complex peripherally and anteriorly as in this case. The second possible scenario is that there was an undetected peripheral posterior capsule tear or zonular dehiscence at the time of surgery and that over time, capsule contraction displaced the haptic into the sulcus. The recurrent hyphema and secondary IOP rise necessitate surgical intervention even though the CDVA is still good. The first surgical step would be to use iris retractors to clearly expose the relationship between the IOL and the capsular bag. Should the bag be completely intact and merely displaced, as in the first scenario, it would be worth excising any fibrotic capsular bands that are dragging the IOL and then recentering the capsular bag complex, using either Assia anchors or capsular tension segments on the opposite side. This would have the effect of pulling the offending haptic away from the iris root. It would be prudent to use triamcinolone to check for the presence of vitreous contributing to the displacement and then perform a vitrectomy (anterior or posterior) if indicated. However, if the peripheral capsular bag appears to be defective peripherally, it would be challenging to replace the haptic in the bag and ensure it stays there.
I would then remove the IOL–capsular bag complex and implant a new IOL. There are numerous options today, such as iris fixation of a 3-piece IOL, retropupillary iris enclavation of an Artisan lens, and the various forms of scleral fixation, ranging from the glued IOL technique popularized by Agarwal et al.1 to the newest iteration by Yamane,A which uses an innovative 30-gauge intrascleral fixation technique. The general principle would be to prevent further trauma to the ciliary sulcus area; therefore, I would veer toward 1 of the iris-fixation techniques. Ronald Yeoh, FRCS, FRCOphth, DO, FAMS Singapore, Singapore REFERENCE 1. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg 2008; 34:1433–1438
OTHER CITED MATERIAL A. Yamane S, “Transconjunctival Intrascleral IOL Fixation With Double-Needle Technique,” film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016 and the 29th annual meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons, Bali, Indonesia, July 2016
- The patient has recurrent bleeding with high IOP threatening vision, although the CDVA is excellent. The decentered IOL with phacodonesis indicates a zonulysis and a probable cut through the capsular bag equator. The iris chafing with a window defect suggests the IOL haptic is rubbing against the iris or ciliary body, which explains the recurrent hyphema. After excluding other causes of late postoperative recurrent hyphema, such as subincisional vascular tuft that bleeds in response to minor trauma or angle neovascularization, the solution would be to remove the IOL that is causing the problem. The challenges include the poorly dilating pupil, the displaced IOL–capsular bag complex with a contracted anterior capsulorhexis, and the zonulysis and subluxation of the capsular bag. Planning for the surgery should include an evaluation of the corneal endothelium because of the patient's age, and because he has a pseudophakic eye and has had recurrent bouts of secondary glaucoma. I would explant the IOL and reimplant a new PC IOL in the sulcus while protecting the corneal endothelium and preserving the integrity of the capsule. The surgical procedure would begin with paracenteses at 12 o'clock and 2 o'clock. Then, I would inject a dispersive OVD followed by a cohesive OVD to protect the endothelium, deepen the anterior chamber, and dilate the pupil. With a push–pull spatula, I would inspect the
J CATARACT REFRACT SURG - VOL 42, NOVEMBER 2016
CONSULTATION SECTION: CATARACT
area behind the iris inferotemporally to check for possible zonulysis and capsular bag dehiscence. With the help of capsular traction hooks at 12 o'clock and 2 o'clock, the capsule would be stabilized and pulled back into position, after which pupil dilation in that area would be gained. Next, I would create a temporal 3.0 mm clear corneal incision and slowly inject a dispersive OVD into the capsular bag to separate it from the optic of the IOL. Silicone IOLs do not adhere to the capsule and are easily separated from it. Therefore, I would carefully rotate the IOL clockwise because the inferior haptic might be entangled in the capsule. If there were resistance, I would stop and concentrate on freeing the optic edge. I would then reinflate the anterior chamber with a cohesive OVD and with the help of fine Vannas scissors and a push–pull hook engaging the opposite edge of the IOL optic for counter traction, I would cut the IOL optic in 2 halves. I would pull each half out with rotation to dislodge and remove the haptics safely. I would then remove the capsular tension hooks and check for capsular bag dehiscence and the zonular fibers for defects. I would perform a capsule flush with a balanced salt solution, using a 27-gauge cannula to wash the epithelial cells from the posterior capsule. Then, I would implant a 3-piece hydrophobic acrylic IOL with a 13.0 mm overall diameter in the sulcus. The haptic orientation would be placed 90 degrees from the area of zonulysis. If the IOL optic were decentered, I would use a double-armed 9-0 polypropylene suture mounted on a long, curved needle to pass 1 in front and the other behind the superior haptic to fixate it to the sclera and I would bury the knot under a scleral flap or corneoscleral pocket. Yehia Salah Mostafa, PhD, MD Cairo, Egypt - This case presents many challenges and shows how difficult it can sometimes be to make the right decision about surgical management. First, I would consider the zero option of masterly inactivity because any surgical intervention will require relatively major surgery, including removal of the IOL–capsular bag complex in view of its instability and decentration. The natural history of recurrent bleeds from focal erosion or irritation can be variable; however, this patient has had episodes of progressively increasing severity resulting in secondary glaucoma from outflow obstruction. Therefore, the case for intervention in this instance is fairly compelling. Surgery would necessitate removal of the IOL and bag and then a decision regarding visual rehabilitation. I would first create a 3.0 mm limbal-based incision. This
1689
would avoid wound and corneal distortion that can result during extraction of the IOL fragments. I would use iris hooks in a diamond configuration with the incisions placed posteriorly in the sclera, approximately 1.0 mm back from the limbus. This would give much better pupil dilation as well as minimum forward tenting of the iris and, therefore, easier instrument access without repeated iris trauma. An anterior chamber flush with triamcinolone at this stage would likely confirm the absence of vitreous; however, it is worth performing because peripheral prolapse through zonular defects might be present. I would inflate the anterior chamber with a cohesive OVD and then lift and cut open the edge of the capsulorhexis to facilitate IOL removal. These 3-piece silicone IOLs are relatively easily prolapsed out of the bag with a combination of viscoexpression from behind and circumferential dialing. The Packer-Chang IOL cutters (Microsurgical Technology) are the best scissors I have used for cutting IOL optics in half, and using a chopper for counterpressure on the opposite edge of the optic to the scissors works best in my experience. The bag is probably hanging by only a few remaining zonular fibers and is best removed in view of the axial folds and lens pearls. It will most likely deliver quite easily. Although, the anterior hyaloid face can surprisingly sometimes remain intact, a flush with triamconolone would be wise at this stage. You cannot see what you cannot see! The choice of which type of IOL to use is fairly personal, and I think it will stimulate the most debate regarding this case. The first option is to leave the eye aphakic and use a contact lens, although this is not ideal if a better option is available. Moreover, because the patient has secondary glaucoma and the meshwork is compromised by the recurrent hemorrhages, an angle supported AC IOL is contraindicated. Another option would be a sclerally tunneled or glued IOL; however, this is not an easy surgical procedure and would require an extensive anterior vitrectomy to avoid vitreoretinal traction. Similarly, a scleral-sutured IOL would also raise the issue of suture longevity. On balance, I would favor an iris-claw or Artisan IOL located in the posterior chamber and enclavated from in front. Brian Little, FRCOphth London, United Kingdom
- This patient is experiencing typical UGH syndrome from haptic–iris chafe. To cause the iris transillumination defect shown in the clinical photograph, the inferotemporal haptic has to be rubbing directly against
J CATARACT REFRACT SURG - VOL 42, NOVEMBER 2016