- Email: [email protected]
October Consultation #4
CONSULTATION SECTION
It is important to evaluate the integrity of the haptics when the capsular bag is opened. Usually, the haptics appear adequate to simply reposition the IOL in the capsular bag. If severe distortion is present, an IOL exchange may be necessary. Alternatively, an emergency maneuver would be to tuck the haptic into a small capsule puncture or to capture the optic within an opening made in the fused anterior and posterior capsules. At the same time, it may also be possible to remove cortical material, polish an intact capsule, repair damaged iris, or reduce preexisting astigmatism. In other words, the surgeon should take advantage of this opportunity and try to leave the patient with an improved surgical result. In this case, the least aggressive approach is appropriate given the extreme myopia, which carries a slightly greater risk for retinal tear/detachment. Once endocapsular fixation is achieved, the posterior UGH syndrome will disappear. Robert H. Osher, MD Cincinnati, Ohio, USA
REFERENCES 1. Pazandak B, Johnson S, Kratz R, Faulkner GD. Recurrent intraocular hemorrhage associated with posterior chamber lens implantation. Am Intra-Ocular Implant Soc J 1983; 9:327–329 2. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256
OTHER CITED MATERIAL A. Osher RH, "Late Reopening of the Capsular Bag; Surgical Technique," Audiovisual J Cataract Implant Surg 1993; Vol IX, Issue 1
- From Figure 1, it can be concluded that (1) the superior half of the anterior capsule is positioned anteriorly to the optic of the IOL, (2) the inferior part of the anterior capsule is located posteriorly to the IOL optic, (3) the inferior part of the anterior capsulorrhexis is adherent to the posterior capsule, and (4) the inferior part of the IOL optic is tilted anteriorly. Because of the specific shape of the 3-piece sharp-edged IOL that was implanted, the optic border causes shaving of the posterior iris, resulting in pigment dispersion and inflammation. This is beautifully illustrated by the inferior iris transilluminance. Lens epithelial growth on the posterior capsule is progressing to the visual axis from the 3 o'clock and 9 o'clock positions starting from the space created by the partial optic buttonholing within the anterior capsulorrhexis. To repair this situation, the surgeon is best seated at the temporal position. After a 1.0 mm corneoscleral incision is created, the anterior chamber should be filled with an OVD. The anterior capsule located on the surgeon's left can be lifted with a small blunt needle mounted on the OVD syringe. The OVD can then be
1869
injected behind the anterior capsule in an attempt to fill the capsular bag and separate the anterior capsule from the posterior capsule. This maneuver will separate both capsules in 2 quadrants. With a curved needle mounted on the same OVD syringe, the anterior capsule at the 12 o'clock surgeon position can be viscodissected further toward the 9 o'clock surgeon position. The inferior capsulorrhexis can be progressively separated from the posterior capsule by inserting the curved needle under the inferior IOL optic and introducing it into the capsular bag. Care should be taken at the surgeon's 9 o'clock position, where transformed lens epithelial cells (LECs) have contracted the posterior capsule, causing folds. At this area, the adhesion between both capsules may be very strong and the risk for capsule tear is real. I would therefore recommend continuing the separation of the 2 capsules using a bimanual technique (eg, 1 capsule forceps in both hands). Once the inferior part of the anterior capsule is completely detached, the IOL can be mobilized in the capsular bag and dialed into position with both haptics in the capsular bag. If this maneuver is successful, the LECs can be cleaned from the posterior capsule; if the surgeon is familiar with performing a posterior capsulorrhexis, it can also be done at this stage. If the refractive outcome was not achieved as expected by the patient after the first surgery, the IOL can be easily exchanged and a more precise IOL power can be implanted. If the anterior capsulorrhexis approximates the same size, a 5.0 mm posterior capsulorrhexis can be created, allowing an exchange for a bag-in-the-lens IOL, which will increase the possibility that the eye will remain free of posterior capsule opacification. Marie-Jose Tassignon, MD Antwerp, Belgium
- The posterior iris-chafing syndrome resulting from sulcus placement of IOLs was first defined more than two decades ago.1 In addition to UGH syndrome, it can result in recurrent vitreous hemorrhage,2 as in this case. This suggests that a breach of the zonular barrier is present. Although it is most commonly noted with 1-piece acrylic IOLs in the ciliary sulcus, pigment dispersion has also been reported with square-edged 3-piece hydrophobic acrylic IOLs that have been placed in the sulcus.3–8 In this eye, the capsular bag is quite clean and without fibrosis, and I would expect that it could be completely reopened with a dispersive OVD. For the right eye, I would sit temporally and introduce the cannula through a 7:30 paracentesis. I would
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
1870
CONSULTATION SECTION
inject some OVD into the anterior chamber but then allow the chamber to shallow slightly due to aqueous egress. I would next slide the cannula underneath the optic while injecting just enough OVD to avoid puncturing the posterior capsule as the tip is advanced. Once the cannula tip is positioned peripherally enough, I would forcefully inject a dispersive OVD along and across the superior capsular bag equator. I would next cross above the optic with the cannula to further expand the superior equator of the bag. I would then locate additional corneal stab incisions superiorly to allow me to progressively viscoexpand the nasal and temporal equator of the bag until it ultimately reopened inferiorly. It is important to repeatedly pause to burp out OVD to avoid overfilling the anterior chamber. I would be surprised if this were not successful because in my experience, the lack of anterior capsule fibrosis is very favorable and much more important than the length of time (5 years) since surgery. After reinflating the capsular bag, dialing the external haptic into the capsular bag should be straightforward. In hypothetical situations in which the bag could not be fully reopened, the IOL could be explanted after amputating the intracapsular haptic at its optic junction if necessary. A replacement 3-piece posterior chamber IOL with rounded anterior optic edges would be implanted in the ciliary sulcus. In the low powers, the Sensar, Clariflex, and Tecnis IOLs (all Abbott Medical Optics) have the longer 13.5 mm overall length. All have rounded anterior optic edges, and power adjustment for sulcus implantation is not necessary for such low dioptric powers. In the unlikely event that the patient refuses surgery, immobilizing the pupil with pilocarpine could be tried. This case emphasizes the desirability of early IOL repositioning in this situation. Performed early, this would have been a simple and safe maneuver that would have spared this patient from years of chronic inflammation and recurrent hemorrhage. David F. Chang, MD Los Altos, California, USA Dr. Chang's consulting fees from Abbott Medical Optics and Alcon are donated to the Himalayan Cataract Project and to Project Vision. REFERENCES 1. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 2. Toma HS, DiBernardo C, Schein OD, Adams NA. Recurrent vitreous hemorrhage secondary to haptic-induced chafing. Can J Ophthalmol 2007; 42:312–313. Available at: http://www.eyesite. ca/CJO/4202/i07-018.pdf. Accessed July 24, 2012
3. Wintle R, Austin M. Pigment dispersion with elevated intraocular pressure after AcrySof intraocular lens implantation in the ciliary sulcus. J Cataract Refract Surg 2001; 27:642–644 4. Chang SHL, Lim G. Secondary pigmentary glaucoma associated with piggyback intraocular lens implantation. J Cataract Refract Surg 2004; 30:2219–2222 5. Iwase T, Tanaka N. Elevated intraocular pressure in secondary piggyback intraocular lens implantation. J Cataract Refract Surg 2005; 31:1821–1823 6. Masket S, ed. Consultation section. Cataract surgical problem. J Cataract Refract Surg 2005; 31:2247–2253 7. Chang WH, Werner L, Fry LL, Johnson JT, Kamae K, Mamalis N. Pigmentary dispersion syndrome with a secondary piggyback 3-piece hydrophobic acrylic lens; case report with clinicopathological correlation. J Cataract Refract Surg 2007; 33:1106–1109 8. Chang DF, Masket S, Miller KM, Braga-Mele R, Little BC, Mamalis N, Oetting TA, Packer M, for the ASCRS Cataract Clinical Committee. Complications of sulcus placement of single-piece acrylic intraocular lenses; recommendations for backup IOL implantation following posterior capsule rupture. J Cataract Refract Surg 2009; 35:1445–1458
- This patient has reasonably good vision in the right eye with recurring bleeding in anterior chamber and vitreous cavity as a result of iris chafing. The following can be seen in Figure 1: (1) One IOL haptic is in the capsular bag and the temporal one is in the sulcus. The superior optic edge is in the bag, and the inferior optic edge (which could be tilted anteriorly) is in the sulcus. The iris chafing is the result of the inferior optic edge. (2) The inferior anterior capsule and the posterior capsule are fused and fibrosed at the 6 o'clock position. (3) The IOL is well centered and the posterior capsule is intact. In view of the good vision in this eye with inferior and anterior–posterior capsule fibrosis and that it is highly myopic, minimal treatment should be performed. One might confirm the iris–IOL optic relationship by requesting ultrasound biomicroscopy with an undilated pupil. Also, it might be useful to see the extent of the inferior capsular bag fusion and fibrosis to help in the direction of management. The ideal correction of this problem would be to place the temporal haptic and the inferior optic in the capsular bag and separate the inferior optic from the iris by placing the inferior part of the anterior capsule anterior to the inferior optic edge. I would start with an attempt to keep the IOL optic away from the iris by pushing the inferior optic posteriorly, preferably in the capsular bag. This would be done by opening the capsular bag with an OVD and releasing the inferior and anterior–posterior capsule adhesion at 6 o'clock, although this may be unsuccessful and compromise the posterior capsule. If this approach is successful, the temporal haptic can be placed in the capsular bag. The other alternative is to open the posterior capsule parallel, but more central, to the edge of the inferior optic and place the inferior optic posterior to the
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
It is important to evaluate the integrity of the haptics when the capsular bag is opened. Usually, the haptics appear adequate to simply reposition the IOL in the capsular bag. If severe distortion is present, an IOL exchange may be necessary. Alternatively, an emergency maneuver would be to tuck the haptic into a small capsule puncture or to capture the optic within an opening made in the fused anterior and posterior capsules. At the same time, it may also be possible to remove cortical material, polish an intact capsule, repair damaged iris, or reduce preexisting astigmatism. In other words, the surgeon should take advantage of this opportunity and try to leave the patient with an improved surgical result. In this case, the least aggressive approach is appropriate given the extreme myopia, which carries a slightly greater risk for retinal tear/detachment. Once endocapsular fixation is achieved, the posterior UGH syndrome will disappear. Robert H. Osher, MD Cincinnati, Ohio, USA
REFERENCES 1. Pazandak B, Johnson S, Kratz R, Faulkner GD. Recurrent intraocular hemorrhage associated with posterior chamber lens implantation. Am Intra-Ocular Implant Soc J 1983; 9:327–329 2. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256
OTHER CITED MATERIAL A. Osher RH, "Late Reopening of the Capsular Bag; Surgical Technique," Audiovisual J Cataract Implant Surg 1993; Vol IX, Issue 1
- From Figure 1, it can be concluded that (1) the superior half of the anterior capsule is positioned anteriorly to the optic of the IOL, (2) the inferior part of the anterior capsule is located posteriorly to the IOL optic, (3) the inferior part of the anterior capsulorrhexis is adherent to the posterior capsule, and (4) the inferior part of the IOL optic is tilted anteriorly. Because of the specific shape of the 3-piece sharp-edged IOL that was implanted, the optic border causes shaving of the posterior iris, resulting in pigment dispersion and inflammation. This is beautifully illustrated by the inferior iris transilluminance. Lens epithelial growth on the posterior capsule is progressing to the visual axis from the 3 o'clock and 9 o'clock positions starting from the space created by the partial optic buttonholing within the anterior capsulorrhexis. To repair this situation, the surgeon is best seated at the temporal position. After a 1.0 mm corneoscleral incision is created, the anterior chamber should be filled with an OVD. The anterior capsule located on the surgeon's left can be lifted with a small blunt needle mounted on the OVD syringe. The OVD can then be
1869
injected behind the anterior capsule in an attempt to fill the capsular bag and separate the anterior capsule from the posterior capsule. This maneuver will separate both capsules in 2 quadrants. With a curved needle mounted on the same OVD syringe, the anterior capsule at the 12 o'clock surgeon position can be viscodissected further toward the 9 o'clock surgeon position. The inferior capsulorrhexis can be progressively separated from the posterior capsule by inserting the curved needle under the inferior IOL optic and introducing it into the capsular bag. Care should be taken at the surgeon's 9 o'clock position, where transformed lens epithelial cells (LECs) have contracted the posterior capsule, causing folds. At this area, the adhesion between both capsules may be very strong and the risk for capsule tear is real. I would therefore recommend continuing the separation of the 2 capsules using a bimanual technique (eg, 1 capsule forceps in both hands). Once the inferior part of the anterior capsule is completely detached, the IOL can be mobilized in the capsular bag and dialed into position with both haptics in the capsular bag. If this maneuver is successful, the LECs can be cleaned from the posterior capsule; if the surgeon is familiar with performing a posterior capsulorrhexis, it can also be done at this stage. If the refractive outcome was not achieved as expected by the patient after the first surgery, the IOL can be easily exchanged and a more precise IOL power can be implanted. If the anterior capsulorrhexis approximates the same size, a 5.0 mm posterior capsulorrhexis can be created, allowing an exchange for a bag-in-the-lens IOL, which will increase the possibility that the eye will remain free of posterior capsule opacification. Marie-Jose Tassignon, MD Antwerp, Belgium
- The posterior iris-chafing syndrome resulting from sulcus placement of IOLs was first defined more than two decades ago.1 In addition to UGH syndrome, it can result in recurrent vitreous hemorrhage,2 as in this case. This suggests that a breach of the zonular barrier is present. Although it is most commonly noted with 1-piece acrylic IOLs in the ciliary sulcus, pigment dispersion has also been reported with square-edged 3-piece hydrophobic acrylic IOLs that have been placed in the sulcus.3–8 In this eye, the capsular bag is quite clean and without fibrosis, and I would expect that it could be completely reopened with a dispersive OVD. For the right eye, I would sit temporally and introduce the cannula through a 7:30 paracentesis. I would
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
1870
CONSULTATION SECTION
inject some OVD into the anterior chamber but then allow the chamber to shallow slightly due to aqueous egress. I would next slide the cannula underneath the optic while injecting just enough OVD to avoid puncturing the posterior capsule as the tip is advanced. Once the cannula tip is positioned peripherally enough, I would forcefully inject a dispersive OVD along and across the superior capsular bag equator. I would next cross above the optic with the cannula to further expand the superior equator of the bag. I would then locate additional corneal stab incisions superiorly to allow me to progressively viscoexpand the nasal and temporal equator of the bag until it ultimately reopened inferiorly. It is important to repeatedly pause to burp out OVD to avoid overfilling the anterior chamber. I would be surprised if this were not successful because in my experience, the lack of anterior capsule fibrosis is very favorable and much more important than the length of time (5 years) since surgery. After reinflating the capsular bag, dialing the external haptic into the capsular bag should be straightforward. In hypothetical situations in which the bag could not be fully reopened, the IOL could be explanted after amputating the intracapsular haptic at its optic junction if necessary. A replacement 3-piece posterior chamber IOL with rounded anterior optic edges would be implanted in the ciliary sulcus. In the low powers, the Sensar, Clariflex, and Tecnis IOLs (all Abbott Medical Optics) have the longer 13.5 mm overall length. All have rounded anterior optic edges, and power adjustment for sulcus implantation is not necessary for such low dioptric powers. In the unlikely event that the patient refuses surgery, immobilizing the pupil with pilocarpine could be tried. This case emphasizes the desirability of early IOL repositioning in this situation. Performed early, this would have been a simple and safe maneuver that would have spared this patient from years of chronic inflammation and recurrent hemorrhage. David F. Chang, MD Los Altos, California, USA Dr. Chang's consulting fees from Abbott Medical Optics and Alcon are donated to the Himalayan Cataract Project and to Project Vision. REFERENCES 1. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 2. Toma HS, DiBernardo C, Schein OD, Adams NA. Recurrent vitreous hemorrhage secondary to haptic-induced chafing. Can J Ophthalmol 2007; 42:312–313. Available at: http://www.eyesite. ca/CJO/4202/i07-018.pdf. Accessed July 24, 2012
3. Wintle R, Austin M. Pigment dispersion with elevated intraocular pressure after AcrySof intraocular lens implantation in the ciliary sulcus. J Cataract Refract Surg 2001; 27:642–644 4. Chang SHL, Lim G. Secondary pigmentary glaucoma associated with piggyback intraocular lens implantation. J Cataract Refract Surg 2004; 30:2219–2222 5. Iwase T, Tanaka N. Elevated intraocular pressure in secondary piggyback intraocular lens implantation. J Cataract Refract Surg 2005; 31:1821–1823 6. Masket S, ed. Consultation section. Cataract surgical problem. J Cataract Refract Surg 2005; 31:2247–2253 7. Chang WH, Werner L, Fry LL, Johnson JT, Kamae K, Mamalis N. Pigmentary dispersion syndrome with a secondary piggyback 3-piece hydrophobic acrylic lens; case report with clinicopathological correlation. J Cataract Refract Surg 2007; 33:1106–1109 8. Chang DF, Masket S, Miller KM, Braga-Mele R, Little BC, Mamalis N, Oetting TA, Packer M, for the ASCRS Cataract Clinical Committee. Complications of sulcus placement of single-piece acrylic intraocular lenses; recommendations for backup IOL implantation following posterior capsule rupture. J Cataract Refract Surg 2009; 35:1445–1458
- This patient has reasonably good vision in the right eye with recurring bleeding in anterior chamber and vitreous cavity as a result of iris chafing. The following can be seen in Figure 1: (1) One IOL haptic is in the capsular bag and the temporal one is in the sulcus. The superior optic edge is in the bag, and the inferior optic edge (which could be tilted anteriorly) is in the sulcus. The iris chafing is the result of the inferior optic edge. (2) The inferior anterior capsule and the posterior capsule are fused and fibrosed at the 6 o'clock position. (3) The IOL is well centered and the posterior capsule is intact. In view of the good vision in this eye with inferior and anterior–posterior capsule fibrosis and that it is highly myopic, minimal treatment should be performed. One might confirm the iris–IOL optic relationship by requesting ultrasound biomicroscopy with an undilated pupil. Also, it might be useful to see the extent of the inferior capsular bag fusion and fibrosis to help in the direction of management. The ideal correction of this problem would be to place the temporal haptic and the inferior optic in the capsular bag and separate the inferior optic from the iris by placing the inferior part of the anterior capsule anterior to the inferior optic edge. I would start with an attempt to keep the IOL optic away from the iris by pushing the inferior optic posteriorly, preferably in the capsular bag. This would be done by opening the capsular bag with an OVD and releasing the inferior and anterior–posterior capsule adhesion at 6 o'clock, although this may be unsuccessful and compromise the posterior capsule. If this approach is successful, the temporal haptic can be placed in the capsular bag. The other alternative is to open the posterior capsule parallel, but more central, to the edge of the inferior optic and place the inferior optic posterior to the
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012