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Pressurized anterior chamber approach to in-the-bag posterior chamber lens insertion
Pressurized anterior chamber approach to in-the-bag posterior chamber lens insertion Klaus D. Teichmann, M.D.
Table 1. Advantages of in-the-bag IOL implantation. l. Good optical cent ration
Avoids sunset, sunrise, wind-shield-wiper syndromes, lens tilt 2. Posterior position Avoids endothelial contact, subluxation, pupillary block, pupillary capture, posterior synechias, iris chafing, vitreous prolapse after caps ulotomy, capsule opacification (barrier effect) 3. Fixation by avascular structures
AB TR T . n \\ approa h to in-th -bag in -rtion i dcribed. It combin -I m nt\ of previ u I) u,ed tc hniqu' and in 'Iud a 0- haped ap .. ulotom}, a po terior hamb r intra ular len, with p()I.pr p)1 ne I p. and ne ntrol tip a ill'll.: '} re\ I' e \iultzman, or . imilar h k, and a len loop injector (a implified v r ion of the Bail y len h ter).
Ke) W rd
'ap Ill. I' hag fi ation. do .. ·d <:hamh'r t dllliqll', in-th ,-h
A few years ago Shearing l expressed his opinion about the ciliary-sulcus versus in-the-bag fixation controversy: "I do not think a surgeon should pay any special price for achieving one or the other." In the meantime, despite lack of a controlled clinical study, there is mounting evidence that the site of Ridley's first lens is the most desirable one. 2 - 9 The advantages (Table 1) seem to outweigh the disadvantages (Table 2). It may be time for the surgeon to pay a small price for "getting it in the bag." I recently modified Bailey's lens shooter.lO The device (Figures 1 and 2), which I call a lens loop injector, consists of a 23-gauge blunt-tipped cannula with a 0.35 mm diameter stylet, all made of stainless steel. It is fully sterilizable, less bulky than Bailey's model and, omitting the unnecessary outer irrigating Prototype of the lens loop injector was manufactured by Ian Sharp, Department of Bio-Engineering, Armed Forces Hospital, Riyadh. Figures 3 to 8 were drawn by Amanda German, Department of Medical Illustrations, Armed Forces Hospital, Riyadh. Reprint requests to Klaus D. Teichmann, M.D., Riyadh Armed Forces Hospital, P.o. Box 7897, Riyadh, 11159, Kingdom of Saudi Arabia.
J CATARACT REFRACT
Avoids disturbance of blood-aqueous barrier, microhyphema white out syndrome, pigment dispersion - grey iris syndrome, pigmentary glaucoma, polypropylene biodegradation, complement activation by polypropylene, ciliary body damage, difficult IOL removal
Table 2. Disadvantages of in-the-bag IOL implantation. 1. Difficult surgical technique Causes risk of endothelial, capsular, zonular damage, prolonged duration of surgery, need for special equipment and Healon® 2. Large anterior capsular Haps necessary May cause secondary cataracts 3. Risk of decentration Because of one loop only in the bag (sunrise syndrome), zonular rupture, late traction by capsular fibrosis 4. Difficulty in performing YAG laser capsulotomy Because of close apposition of lens and posterior capsule
cannula, avoids misfeeding the lens loop into the wrong ostium. This instrument is ideally suited for in-the-bag insertion. To achieve this reliably, even in cases with positive vitreous pressure, I recommend a simple procedure using a closed chamber technique, which gives the surgeon almost total control. The procedure requires aD-shaped caps ulotomy, an intraocular lens (IOL) with polypropylene or poly methyl methacrylate loops and one control tip, a Sinskey, Osher-Fenzl, or reverse Maltzman hook,l1 and the lens loop injector. Balanced salt solution and air can be used to fill the anterior chamber; sodium hyaluronate (Healon®) facilitates the procedure but is not routinely required. After standard extracapsular or phacoemulsification surgery, the IOL is introduced into the anterior chamber with the control loop in the 6-0' clock position and anterior to the iris, unless it slips easily into the capsular bag. The second loop remains outside the eye. The wound is tightly sutured with the surgeon's preferred technique (Figure 3). The anterior chamber is deepened until the posterior capsule becomes level or concave. Assuming the inferior loop did not slide into the bag by itself, a Sinskey (Osher-Fenzl, reverse Maltzman) hook is introduced and the control SURG-VOL 14, MAY 1988
331
~-
Fig. 1.
-
-
-
(Teichmann) Lens loop injector with one polypropylene haptic of an IOL inserted into the cannula and the stylet appropriately withdrawn.
loop at 6 o'clock is engaged and manipulated under the visible inferior capsular ledge (Figure 4). This step is absolutely critical as the position of the inferior loop determines where the lens will be located. The extraocular superior loop is now threaded into the lens loop injector as far as possible (Figure 5). The tip of this device is inserted into the anterior chamber and placed near the pupillary margin at 3 o c' lock (Figure 6). During this maneuver the surgeon must make sure that the lens optic and the shoulder of the superior loop slide underneath the edge of the anterior capsule (Figure 7). Ideally, the tip will point slightly posteriorly and be directed toward the posterior capsule. The loop is now injected. This exerts a tangential force on the lens optic, which rotates about 90 degrees from a near vertical to a horizontally oblique position (Figure 8).
Fig. 3.
332
(Teichmann) Intraocular lens inserted into the anterior chamber. Wound is permanently closed with part of the superior loop still outside the eye.
J CATARACT
Fig. 2.
(Teichmann) Close-up of the tip of the lens loop injector in Figure 1.
Little displacement of the lens optic is experienced and minimal stress is exerted on the lens capsule or zonules. The lens will invariably be within the bag. A Sinskey hook can be reintroduced to center the lens optic, as even in-the-bag placement does not guarantee self-centering. If Healon® has been used, it can be removed with a Simcoe cannula or similar device. This method is easy, particularly the initial introduction of the IOL into the anterior chamber, as the inferior loop may be deliberately placed anterior to the iris. Later, engaging the control loop and sliding it
Fig. 4. (Teichmann) The hook is introduced . Control eyelet is engaged and inferior loop manipulated into the bag.
REFRACT SURG-VOL 14, MAY 1988
Fig. 5.
(Teichmann) Inferior loop of the IOL is in the bag. The external part of the superior loop has been inserted into the lens loop injedor.
Fig. 7.
Fig. 6.
(Teichmann) Lens loop injector is insinuated into the anterior chamber.
Fig. 8. (Teichmann) Lens optic and shoulder of the superior loop glide underneath the anterior capsule shortly after beginning of injection.
(Teichmann) After completing injection of the superior loop, the lens loop injector has been withdrawn. Intraocular lens has rotated 90 degrees and lies completely within the bag.
underneath the anterior capsule is not difficult as there is no protrusion of the posterior capsule from vitreous bulging. However, feeding the superior, external loop into the cannula of the lens loop injector may require a little practice, as will introducing the tip of the instrument into the anterior chamber through the tightly sutured wound. The injection itself happens almost automatically by pushing the stylet into the cannula.
Another advantage is that positive pressure can no longer spoil an otherwise successful operation. In patients with positive vitreous pressure, I have occasionally had a lens pop out of the bag immediately after insertion despite the use of Healon®. With a wellsutured wound, however, almost any degree of positive pressure can be neutralized. The procedure promises to be of particular value in young adults or children in whom in-the-bag insertion is highly desirable.
J CATARACT REFRACT
SURG-VOL 14, MAY 1988
333
If the surgeon prefers to insert the lens in the sulcus, he or she can use this technique with advantage. Inadvertent insertion of the inferior loop in the bag can be safely avoided as long as the anterior capsule can be visualized. The rotational insertion with the lens loop injector works as well in front of the anterior lens capsule as it does within the bag. Inserting an IOL with this method adds only five minutes to the total surgical time of a standard extracapsular cataract extraction once the surgeon is familiar with the technique. REFERENCES 1. Shearing S: Technique for Shearing lens insertion. In: Emery JM, Jacobson AC, eds, Current Concepts in Cataract Surgery; Selected Proceedings of the Eighth Biennial Cataract Surgical Congress. Norwalk, Conn, Appleton-Century-Crofts, 1984, pp 62-63 2. Apple DJ, Reidy JJ, Googe JM, Mamalis N, et al: A comparison of ciliary sulcus and capsular bag fixation of posterior chamber intraocular lenses. Am Intra-Ocular Implant Soc] 11:44-63, 1985 3. Johnson SH, Kratz RP, Olson PF: Iris transillumination defect and microhyphema syndrome. Am Intra-Ocular Implant Soc] 10:425-428, 1984 4. Woodhams JT, Lester JC: Pigmentary dispersion glaucoma secondary to posterior chamber intra-ocular lenses. Ann Ophthalmol 16:852-855, 1984 5. Lieppman ME: Intermittent visual "white out"; a new intraocular lens complication. Ophthalmology 89:109-112, 1982 6. Smith JP: Pigmentary open-angle glaucoma secondary to posterior chamber intraocular lens implantation and erosion of the iris pigment epithelium. Am Intra-Ocular Implant Soc] 11:174-176, 1985 7. Huber C: The gray iris syndrome; an iatrogenic form of pigmentary glaucoma. Arch Ophthalmol 102:397-398, 1984 8. Miyake K, Asakura M, Kobayashi H: Effect of intraocular lens fixation on the blood-aqueous barrier. Am ] Ophthalmol 98:451-455, 1984 9. Masket S: Pseudophakic posterior iris chafing syndrome. ] Cataract Refract Surg 12:252-256, 1986 10. Bailey PF: An irrigating instrument for inserting Simcoe and Binkhorst retropupillary lenses. Am Intra-Ocular Implant Soc ] 11:187-188, 1985 11. Maltzman BA, Cinotti DJ, Rocco P: A modified hook for posterior chamber intraocular lens positioning. Am IntraOcular Implant Soc] 11:607-608, 1985
Investigation of unwanted images caused by intraocular lenses PaulO. Burk, Ph.D.
B TR.\ T
A widel)' circulat d paper b> 10L.\B orporation d, cl'ihin~ u","ant 'd ima~' inad" 'rtentl pre~ 'nt 'd ~ari()lI" ima~ that 'Ollld not ',i t with a c 'nt 'r ,d intraocular I 'no a \\a laim 'd in th' tud). I I'CP 'at 'd th' 10 B p rimenh and found that at,tifact.. \\ ithin til, Gull trand ) 'I, "hi h wa u d in til 10 B .. tud, w re th ' cam' ofth' 'ima~c . I also found that a m)opic '. ' \" ill .. " a ollimat 'd Ii~ht or point .. ur 'a a mottled clu tcr of hri~ht I)ot whicl, can b, imulat'd, in an '>' mod ,I b)~, ft' . ,t 'd corn 'al I 'n ... From this ob 'rvation I I 'am d that p opl' ~ 11 Ii' th 'ii' ()\\Il cataract.. \\ h 'n I()okin~ at a di tant
moo
li~ht.
'.
Kc) Word . <:ollilllat
h,.,('r ridg( \ hioll t') t' lllu
In March 1986, IOLAB Corporation published a paper entitled "Unwanted Optical Images Created by Posterior Chamber Intraocular Lenses." The study was suggested by Robert M. Sinskey, M. D., as part of his effort to eliminate the Hare and glare that his patients complained of. Sinskey presented photographs from this study in a paper he delivered the next month ("Postoperative IOL Glare-Its Cause and Cure," Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, April 1986). A summary of the study was also reported (Ocular Surgery News, June 1,1986, pI). I did not feel that the photographs properly represented an on-axis and off-axis collimated source image when seen through a "centered intraocular lens (IOL)." Furthermore, the photographs represented a small portion of the approximately 90 by 170 degree field of view of the eye. The photographs suggested that the entire retina was Hooded with Hare and glare, whereas the photographs probably displayed no more than a Reprint requests to PaulO. Burk, Ph.D., 1352 Hidden Springs Lane, Glendora, California 91740.
334
J CATARACT
REFRACT SURG-VOL 14, MAY 1988
Table 1. Advantages of in-the-bag IOL implantation. l. Good optical cent ration
Avoids sunset, sunrise, wind-shield-wiper syndromes, lens tilt 2. Posterior position Avoids endothelial contact, subluxation, pupillary block, pupillary capture, posterior synechias, iris chafing, vitreous prolapse after caps ulotomy, capsule opacification (barrier effect) 3. Fixation by avascular structures
AB TR T . n \\ approa h to in-th -bag in -rtion i dcribed. It combin -I m nt\ of previ u I) u,ed tc hniqu' and in 'Iud a 0- haped ap .. ulotom}, a po terior hamb r intra ular len, with p()I.pr p)1 ne I p. and ne ntrol tip a ill'll.: '} re\ I' e \iultzman, or . imilar h k, and a len loop injector (a implified v r ion of the Bail y len h ter).
Ke) W rd
'ap Ill. I' hag fi ation. do .. ·d <:hamh'r t dllliqll', in-th ,-h
A few years ago Shearing l expressed his opinion about the ciliary-sulcus versus in-the-bag fixation controversy: "I do not think a surgeon should pay any special price for achieving one or the other." In the meantime, despite lack of a controlled clinical study, there is mounting evidence that the site of Ridley's first lens is the most desirable one. 2 - 9 The advantages (Table 1) seem to outweigh the disadvantages (Table 2). It may be time for the surgeon to pay a small price for "getting it in the bag." I recently modified Bailey's lens shooter.lO The device (Figures 1 and 2), which I call a lens loop injector, consists of a 23-gauge blunt-tipped cannula with a 0.35 mm diameter stylet, all made of stainless steel. It is fully sterilizable, less bulky than Bailey's model and, omitting the unnecessary outer irrigating Prototype of the lens loop injector was manufactured by Ian Sharp, Department of Bio-Engineering, Armed Forces Hospital, Riyadh. Figures 3 to 8 were drawn by Amanda German, Department of Medical Illustrations, Armed Forces Hospital, Riyadh. Reprint requests to Klaus D. Teichmann, M.D., Riyadh Armed Forces Hospital, P.o. Box 7897, Riyadh, 11159, Kingdom of Saudi Arabia.
J CATARACT REFRACT
Avoids disturbance of blood-aqueous barrier, microhyphema white out syndrome, pigment dispersion - grey iris syndrome, pigmentary glaucoma, polypropylene biodegradation, complement activation by polypropylene, ciliary body damage, difficult IOL removal
Table 2. Disadvantages of in-the-bag IOL implantation. 1. Difficult surgical technique Causes risk of endothelial, capsular, zonular damage, prolonged duration of surgery, need for special equipment and Healon® 2. Large anterior capsular Haps necessary May cause secondary cataracts 3. Risk of decentration Because of one loop only in the bag (sunrise syndrome), zonular rupture, late traction by capsular fibrosis 4. Difficulty in performing YAG laser capsulotomy Because of close apposition of lens and posterior capsule
cannula, avoids misfeeding the lens loop into the wrong ostium. This instrument is ideally suited for in-the-bag insertion. To achieve this reliably, even in cases with positive vitreous pressure, I recommend a simple procedure using a closed chamber technique, which gives the surgeon almost total control. The procedure requires aD-shaped caps ulotomy, an intraocular lens (IOL) with polypropylene or poly methyl methacrylate loops and one control tip, a Sinskey, Osher-Fenzl, or reverse Maltzman hook,l1 and the lens loop injector. Balanced salt solution and air can be used to fill the anterior chamber; sodium hyaluronate (Healon®) facilitates the procedure but is not routinely required. After standard extracapsular or phacoemulsification surgery, the IOL is introduced into the anterior chamber with the control loop in the 6-0' clock position and anterior to the iris, unless it slips easily into the capsular bag. The second loop remains outside the eye. The wound is tightly sutured with the surgeon's preferred technique (Figure 3). The anterior chamber is deepened until the posterior capsule becomes level or concave. Assuming the inferior loop did not slide into the bag by itself, a Sinskey (Osher-Fenzl, reverse Maltzman) hook is introduced and the control SURG-VOL 14, MAY 1988
331
~-
Fig. 1.
-
-
-
(Teichmann) Lens loop injector with one polypropylene haptic of an IOL inserted into the cannula and the stylet appropriately withdrawn.
loop at 6 o'clock is engaged and manipulated under the visible inferior capsular ledge (Figure 4). This step is absolutely critical as the position of the inferior loop determines where the lens will be located. The extraocular superior loop is now threaded into the lens loop injector as far as possible (Figure 5). The tip of this device is inserted into the anterior chamber and placed near the pupillary margin at 3 o c' lock (Figure 6). During this maneuver the surgeon must make sure that the lens optic and the shoulder of the superior loop slide underneath the edge of the anterior capsule (Figure 7). Ideally, the tip will point slightly posteriorly and be directed toward the posterior capsule. The loop is now injected. This exerts a tangential force on the lens optic, which rotates about 90 degrees from a near vertical to a horizontally oblique position (Figure 8).
Fig. 3.
332
(Teichmann) Intraocular lens inserted into the anterior chamber. Wound is permanently closed with part of the superior loop still outside the eye.
J CATARACT
Fig. 2.
(Teichmann) Close-up of the tip of the lens loop injector in Figure 1.
Little displacement of the lens optic is experienced and minimal stress is exerted on the lens capsule or zonules. The lens will invariably be within the bag. A Sinskey hook can be reintroduced to center the lens optic, as even in-the-bag placement does not guarantee self-centering. If Healon® has been used, it can be removed with a Simcoe cannula or similar device. This method is easy, particularly the initial introduction of the IOL into the anterior chamber, as the inferior loop may be deliberately placed anterior to the iris. Later, engaging the control loop and sliding it
Fig. 4. (Teichmann) The hook is introduced . Control eyelet is engaged and inferior loop manipulated into the bag.
REFRACT SURG-VOL 14, MAY 1988
Fig. 5.
(Teichmann) Inferior loop of the IOL is in the bag. The external part of the superior loop has been inserted into the lens loop injedor.
Fig. 7.
Fig. 6.
(Teichmann) Lens loop injector is insinuated into the anterior chamber.
Fig. 8. (Teichmann) Lens optic and shoulder of the superior loop glide underneath the anterior capsule shortly after beginning of injection.
(Teichmann) After completing injection of the superior loop, the lens loop injector has been withdrawn. Intraocular lens has rotated 90 degrees and lies completely within the bag.
underneath the anterior capsule is not difficult as there is no protrusion of the posterior capsule from vitreous bulging. However, feeding the superior, external loop into the cannula of the lens loop injector may require a little practice, as will introducing the tip of the instrument into the anterior chamber through the tightly sutured wound. The injection itself happens almost automatically by pushing the stylet into the cannula.
Another advantage is that positive pressure can no longer spoil an otherwise successful operation. In patients with positive vitreous pressure, I have occasionally had a lens pop out of the bag immediately after insertion despite the use of Healon®. With a wellsutured wound, however, almost any degree of positive pressure can be neutralized. The procedure promises to be of particular value in young adults or children in whom in-the-bag insertion is highly desirable.
J CATARACT REFRACT
SURG-VOL 14, MAY 1988
333
If the surgeon prefers to insert the lens in the sulcus, he or she can use this technique with advantage. Inadvertent insertion of the inferior loop in the bag can be safely avoided as long as the anterior capsule can be visualized. The rotational insertion with the lens loop injector works as well in front of the anterior lens capsule as it does within the bag. Inserting an IOL with this method adds only five minutes to the total surgical time of a standard extracapsular cataract extraction once the surgeon is familiar with the technique. REFERENCES 1. Shearing S: Technique for Shearing lens insertion. In: Emery JM, Jacobson AC, eds, Current Concepts in Cataract Surgery; Selected Proceedings of the Eighth Biennial Cataract Surgical Congress. Norwalk, Conn, Appleton-Century-Crofts, 1984, pp 62-63 2. Apple DJ, Reidy JJ, Googe JM, Mamalis N, et al: A comparison of ciliary sulcus and capsular bag fixation of posterior chamber intraocular lenses. Am Intra-Ocular Implant Soc] 11:44-63, 1985 3. Johnson SH, Kratz RP, Olson PF: Iris transillumination defect and microhyphema syndrome. Am Intra-Ocular Implant Soc] 10:425-428, 1984 4. Woodhams JT, Lester JC: Pigmentary dispersion glaucoma secondary to posterior chamber intra-ocular lenses. Ann Ophthalmol 16:852-855, 1984 5. Lieppman ME: Intermittent visual "white out"; a new intraocular lens complication. Ophthalmology 89:109-112, 1982 6. Smith JP: Pigmentary open-angle glaucoma secondary to posterior chamber intraocular lens implantation and erosion of the iris pigment epithelium. Am Intra-Ocular Implant Soc] 11:174-176, 1985 7. Huber C: The gray iris syndrome; an iatrogenic form of pigmentary glaucoma. Arch Ophthalmol 102:397-398, 1984 8. Miyake K, Asakura M, Kobayashi H: Effect of intraocular lens fixation on the blood-aqueous barrier. Am ] Ophthalmol 98:451-455, 1984 9. Masket S: Pseudophakic posterior iris chafing syndrome. ] Cataract Refract Surg 12:252-256, 1986 10. Bailey PF: An irrigating instrument for inserting Simcoe and Binkhorst retropupillary lenses. Am Intra-Ocular Implant Soc ] 11:187-188, 1985 11. Maltzman BA, Cinotti DJ, Rocco P: A modified hook for posterior chamber intraocular lens positioning. Am IntraOcular Implant Soc] 11:607-608, 1985
Investigation of unwanted images caused by intraocular lenses PaulO. Burk, Ph.D.
B TR.\ T
A widel)' circulat d paper b> 10L.\B orporation d, cl'ihin~ u","ant 'd ima~' inad" 'rtentl pre~ 'nt 'd ~ari()lI" ima~ that 'Ollld not ',i t with a c 'nt 'r ,d intraocular I 'no a \\a laim 'd in th' tud). I I'CP 'at 'd th' 10 B p rimenh and found that at,tifact.. \\ ithin til, Gull trand ) 'I, "hi h wa u d in til 10 B .. tud, w re th ' cam' ofth' 'ima~c . I also found that a m)opic '. ' \" ill .. " a ollimat 'd Ii~ht or point .. ur 'a a mottled clu tcr of hri~ht I)ot whicl, can b, imulat'd, in an '>' mod ,I b)~, ft' . ,t 'd corn 'al I 'n ... From this ob 'rvation I I 'am d that p opl' ~ 11 Ii' th 'ii' ()\\Il cataract.. \\ h 'n I()okin~ at a di tant
moo
li~ht.
'.
Kc) Word . <:ollilllat
h,.,('r ridg( \ hioll t') t' lllu
In March 1986, IOLAB Corporation published a paper entitled "Unwanted Optical Images Created by Posterior Chamber Intraocular Lenses." The study was suggested by Robert M. Sinskey, M. D., as part of his effort to eliminate the Hare and glare that his patients complained of. Sinskey presented photographs from this study in a paper he delivered the next month ("Postoperative IOL Glare-Its Cause and Cure," Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, April 1986). A summary of the study was also reported (Ocular Surgery News, June 1,1986, pI). I did not feel that the photographs properly represented an on-axis and off-axis collimated source image when seen through a "centered intraocular lens (IOL)." Furthermore, the photographs represented a small portion of the approximately 90 by 170 degree field of view of the eye. The photographs suggested that the entire retina was Hooded with Hare and glare, whereas the photographs probably displayed no more than a Reprint requests to PaulO. Burk, Ph.D., 1352 Hidden Springs Lane, Glendora, California 91740.
334
J CATARACT
REFRACT SURG-VOL 14, MAY 1988