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Technique for Fixating a Subluxated Posterior Chamber Lens
5. Taylor DM, Dalburg LA, Consentino RT, Khaliq A: Intraocular lenses: 500 consecutive intracapsular cataract extractions with lens implantation compared with 500 intracapsular extractions -observations and comments. Ophthalmic Surg 9(1):29-55, 1978 6. Worthen DM, Boucher JA, Buxton JN, Hayreh SS, et al: Interim FDA report on intraocular lenses. Ophthalmology 87: 267-271, 1980 7. Moretsky SL: Suture fixation technique for subluxated posterior chamber IOL through stab wound incision. Am IntraOcular Implant Soc J 10:477-480, 1984 8. Stark WJ, Bruner WE, Martin NF: Management of subluxed posterior chamber intraocular lenses. Ophthalmic Surg 13(2): 130-133, 1982 9. Jaffe MS: Consultation section. Am Intra-Ocular Implant Soc J 5:358, 1979 10. Clayman HM, Jaffe NS, Galin MA: Intraocular Lens Implantation: Techniques and Complications, St Louis, CV Mosby Co, 1983, p 245 11. Murphy GE: A technique for suturing the Shearing posterior chamber implant to the iris. Am Intra-Ocular Implant Soc J 7:167-169, 1981 12. McCannel M: A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 7(2):98-103, 1976 13. Kraff MC, Sanders DR, Lieberman HL: The results of posterior chamber lens implantation. Am Intra-Ocular Implant Soc] 9:148-150, 1983 14. Pallin SL, Walman GB: Posterior chamber intraocular lens implant centration: In or out of "the bag." Am Intra-Ocular Implant Soc] 8:254-257, 1982 15. Sciarrino JF: Successful removal and exchange of a chronically decentrating Harris-Arnott posterior chamber intraocular lens. Am Intra-Ocular Implant Soc] 10:71-74, 1984 16. Sternberg P, Michels RG: Treatment of dislocated posterior chamber intraocular lenses. Arch Ophthalmol104: 1391-1393, 1986 17. Jacobi KW, Krey H: Surgical management of intraocular lens dislocation into the vitreous: Case report. Am Intra-Ocular Implant Soc] 9:58-59, 1983
PREOPERATIVE SCLERAL RUPTURE To the Editor: On April 12, 1988, after completing a surgical case, I was called by the anesthesiologist to reinspect the left eye of an 84-year-old patient upon whom I had performed a retrobulbar block 20 to 30 minutes earlier. The anesthetist had applied digital pressure and Super Pinky after the regional anesthetic injection in a routine manner but had noted that the eye was "super soft." Upon inspection, a large subconjunctival hemorrhage overhanging the peripheral cornea and encompassing the nasal quadrant of the eye was seen. The pupil was smaller than when the regional anesthesia had been administered. The patient was taken to the operating room and the conjunctiva was reflected from the cornea from the 7 o'clock to the 11 o'clock meridian, exposing a crescent-shaped scleral rupture parallel to and 2 mm to 3 mm from the limbus, which extended from the 8:30 to the 10:00 o'clock meridian. The iris, which was protruding through the wound, was reposited and the wound was closed with six interrupted 10-0 polypropylene sutures (Figure 1). 688
J CATARACT REFRACT
Fig. 1.
(Hall) Placement of sutures to close the scleral rupture.
The anterior chamber was well formed and the pupil round and the wound watertight at completion. The sclera was thoroughly inspected and thought to be no thinner than that seen in the patient's age group. The axial length of this eye was 22.6 mm. The patient's cataract was removed by the extracapsular method and a posterior chamber polymethylmethacrylate intraocular lens was implanted under general anesthesia one week later. Her early postoperative course was complicated by mild central corneal edema which cleared. She was corrected to 20/40 visual acuity in this eye at eight weeks postoperatively. It has been my adamant belief for many years that a soft eye is an important key to successful cataract surgery and, to that aim, following retrobulbar regional block, pressure is applied to eyes digitally by the anesthetist or anesthesiologist while the patient is recovering from intravenous methohexital (Brevital®) and subsequently by a self-maintained apparatus, the Super Pinky. To my knowledge, this is the first reported case of preoperative scleral rupture. Donald L. Hall, M.D.
Shreveport, Louisiana
TECHNIQUE FOR FIXATING A SUBLUXATED POSTERIOR CHAMBER LENS To the Editor: I read the excellent technique, "Scleral Fixation of a Subluxated Posterior Chamber Intraocular Lens," by Girard et al. in the May 1988 issue (pages 326-327). It is obvious that as we gain more experience with implant surgery, other similar techniques will be developed, making it easier for the surgeon to handle such complications. Recently I devised a technique to fixate a subluxated posterior chamber lens. This technique is different from others as the suturing needle has an eye on the
SURG-VOL 14, NOVEMBER 1988
sharp end. This makes it possible for the lens to be repositioned and sutured in position with minimal trauma. The principle is the same as a sewing machine or shoe repair. Figures 1 to 8 describe the two different techniques for fixation of subluxated posterior chamber lenses. The technique can be used to fixate a posterior chamber lens in the absence of a posterior capsule as a
primary or secondary procedure (Figures 9 to ll). It can be used to fixate an ante rior chamber lens (Figure 12). The technique may also have application in other conditions, such as large retinal tears (Figures 13 to 15) and subluxated lenses (F igure 16). Jaswant Singh Pannu , M .D. Fort Lauderdale, Florida
Fig. 1.
(Pannu) The Sharpoint needle is passed through clear cornea under the lens loop, behind the iris and out of the sclera and conjunctiva. The eye of the needle is then threaded with a 9-0 polypropylene suture . (The needle can be prethreaded.)
Fig. 3 .
(Pannu) The needle is advanced over the lens loop and back out through the sclera and conjunctiva.
Fig. 4.
(Pannu) The suture is tied. A second suture can b e used around the othe r loop.
Fig . 6 .
(P annu) The needle is passed through the pars plana under and over the loop.
Fig. 7.
(Pannu) The suture is threaded and pulled back out of the eye. (Again , the needle can be pre-threaded. )
Fig. 2.
(Pannu) The needle is retracted until it is beyond the lens loop.
J CATARACT REFRACT SURG- VOL
Fig. 5.
(Pannu) Final position of the lens. Notice no posterior capsule is necessary to secure the lens in position.
Fig. 8 .
(P annu) The suture is tighte ned which pulls the implant in position so it hangs by the sutures like a medallion.
14, NOVEMBER 1988
689
Fig. 9.
Fig. 12.
(Pannu) Suturing a lens in the posterior chamber in the absence of th e posterior capsule combined with a corneal transplant. The needle passes behind the iris in the ciliary sulcus area. No needle holder is necessary. A very short portion of the needle has to pene trate the globe to thread the suture .
Fig. 10.
(Pannu) Suturing a len s in th e anterior chamber is also possible with this technique , preventing its rotation or wobbling.
Fig. 15. Fig. 14.
690
(Pann u) Implant positioned and secured in the posterior chamber.
(Pan nu) The needle is pulled back into the eye and advanced again through the retina a:nd pars plana area.
Fig. 11.
(Pan nu) Implantation of a lens in the posterior chamber with intracapsular cataract extraction or secondary implantation in the absence of the posterior capsule. The position of the sutures and path of the needle prior to IOL insertion are illustrated. The suhIres are tightened and the IOL is suspended in th e posterior chamber as shown in Figure 5.
Fig. 13.
(Pann u) The needle is directed so it will flatten the retina as it is pushed toward the scle ra. After coming through the sclera, the needle is threaded.
Fig. 16.
(Pannu) Securing a subluxated lens with a net of sutures befc)re opening the eye makes it easy to handle the lens. The suture can be pulled as tight as desired to secure and bring the lens into the iris plane.
(Pannu) After several repetitions of this maneuver, the retina is secu r e d in place . The insert shows the external 'a ppearance of the eye.
J CATARACT REFRACT
SURG-VOL
}4,
NOVEMBER 1988
PREOPERATIVE SCLERAL RUPTURE To the Editor: On April 12, 1988, after completing a surgical case, I was called by the anesthesiologist to reinspect the left eye of an 84-year-old patient upon whom I had performed a retrobulbar block 20 to 30 minutes earlier. The anesthetist had applied digital pressure and Super Pinky after the regional anesthetic injection in a routine manner but had noted that the eye was "super soft." Upon inspection, a large subconjunctival hemorrhage overhanging the peripheral cornea and encompassing the nasal quadrant of the eye was seen. The pupil was smaller than when the regional anesthesia had been administered. The patient was taken to the operating room and the conjunctiva was reflected from the cornea from the 7 o'clock to the 11 o'clock meridian, exposing a crescent-shaped scleral rupture parallel to and 2 mm to 3 mm from the limbus, which extended from the 8:30 to the 10:00 o'clock meridian. The iris, which was protruding through the wound, was reposited and the wound was closed with six interrupted 10-0 polypropylene sutures (Figure 1). 688
J CATARACT REFRACT
Fig. 1.
(Hall) Placement of sutures to close the scleral rupture.
The anterior chamber was well formed and the pupil round and the wound watertight at completion. The sclera was thoroughly inspected and thought to be no thinner than that seen in the patient's age group. The axial length of this eye was 22.6 mm. The patient's cataract was removed by the extracapsular method and a posterior chamber polymethylmethacrylate intraocular lens was implanted under general anesthesia one week later. Her early postoperative course was complicated by mild central corneal edema which cleared. She was corrected to 20/40 visual acuity in this eye at eight weeks postoperatively. It has been my adamant belief for many years that a soft eye is an important key to successful cataract surgery and, to that aim, following retrobulbar regional block, pressure is applied to eyes digitally by the anesthetist or anesthesiologist while the patient is recovering from intravenous methohexital (Brevital®) and subsequently by a self-maintained apparatus, the Super Pinky. To my knowledge, this is the first reported case of preoperative scleral rupture. Donald L. Hall, M.D.
Shreveport, Louisiana
TECHNIQUE FOR FIXATING A SUBLUXATED POSTERIOR CHAMBER LENS To the Editor: I read the excellent technique, "Scleral Fixation of a Subluxated Posterior Chamber Intraocular Lens," by Girard et al. in the May 1988 issue (pages 326-327). It is obvious that as we gain more experience with implant surgery, other similar techniques will be developed, making it easier for the surgeon to handle such complications. Recently I devised a technique to fixate a subluxated posterior chamber lens. This technique is different from others as the suturing needle has an eye on the
SURG-VOL 14, NOVEMBER 1988
sharp end. This makes it possible for the lens to be repositioned and sutured in position with minimal trauma. The principle is the same as a sewing machine or shoe repair. Figures 1 to 8 describe the two different techniques for fixation of subluxated posterior chamber lenses. The technique can be used to fixate a posterior chamber lens in the absence of a posterior capsule as a
primary or secondary procedure (Figures 9 to ll). It can be used to fixate an ante rior chamber lens (Figure 12). The technique may also have application in other conditions, such as large retinal tears (Figures 13 to 15) and subluxated lenses (F igure 16). Jaswant Singh Pannu , M .D. Fort Lauderdale, Florida
Fig. 1.
(Pannu) The Sharpoint needle is passed through clear cornea under the lens loop, behind the iris and out of the sclera and conjunctiva. The eye of the needle is then threaded with a 9-0 polypropylene suture . (The needle can be prethreaded.)
Fig. 3 .
(Pannu) The needle is advanced over the lens loop and back out through the sclera and conjunctiva.
Fig. 4.
(Pannu) The suture is tied. A second suture can b e used around the othe r loop.
Fig . 6 .
(P annu) The needle is passed through the pars plana under and over the loop.
Fig. 7.
(Pannu) The suture is threaded and pulled back out of the eye. (Again , the needle can be pre-threaded. )
Fig. 2.
(Pannu) The needle is retracted until it is beyond the lens loop.
J CATARACT REFRACT SURG- VOL
Fig. 5.
(Pannu) Final position of the lens. Notice no posterior capsule is necessary to secure the lens in position.
Fig. 8 .
(P annu) The suture is tighte ned which pulls the implant in position so it hangs by the sutures like a medallion.
14, NOVEMBER 1988
689
Fig. 9.
Fig. 12.
(Pannu) Suturing a lens in the posterior chamber in the absence of th e posterior capsule combined with a corneal transplant. The needle passes behind the iris in the ciliary sulcus area. No needle holder is necessary. A very short portion of the needle has to pene trate the globe to thread the suture .
Fig. 10.
(Pannu) Suturing a len s in th e anterior chamber is also possible with this technique , preventing its rotation or wobbling.
Fig. 15. Fig. 14.
690
(Pann u) Implant positioned and secured in the posterior chamber.
(Pan nu) The needle is pulled back into the eye and advanced again through the retina a:nd pars plana area.
Fig. 11.
(Pan nu) Implantation of a lens in the posterior chamber with intracapsular cataract extraction or secondary implantation in the absence of the posterior capsule. The position of the sutures and path of the needle prior to IOL insertion are illustrated. The suhIres are tightened and the IOL is suspended in th e posterior chamber as shown in Figure 5.
Fig. 13.
(Pann u) The needle is directed so it will flatten the retina as it is pushed toward the scle ra. After coming through the sclera, the needle is threaded.
Fig. 16.
(Pannu) Securing a subluxated lens with a net of sutures befc)re opening the eye makes it easy to handle the lens. The suture can be pulled as tight as desired to secure and bring the lens into the iris plane.
(Pannu) After several repetitions of this maneuver, the retina is secu r e d in place . The insert shows the external 'a ppearance of the eye.
J CATARACT REFRACT
SURG-VOL
}4,
NOVEMBER 1988