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November consultation #6
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
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