EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/387844
EW FEATURE 82 Complex cataract cases October 2014 • Surgeons use different types of sutures depending on the patient's condition; CV-8 Gore-Tex, 9-0 Prolene, and 10-0 Prolene are used often. • When performing a vitrectomy, physicians sometimes perform these on their own and other times consult a retina colleague. • Attending wet labs and courses at meetings can be helpful for the cataract surgeon who is uncomfortable performing secondary IOL implantation. by Ellen Stodola EyeWorld Staff Writer Methods for secondary lens implantation IOL choice For iris or scleral fixation, D . Davidson said he uses the STAAR AQ5010V (STAAR Surgical, Monro- via, Calif.) for low diopter powers or AQ2010V for regular powers. These IOLs are silicone, 3-piece lenses that work well for scleral fixation gluing or with iris fixation, he said Dr. Lee likes the STAAR AQ2010 for iris fixation because it has a large optic and a rounded edge, but it is not always available in his OR. The AcrySof MA60AC (Alcon, Fort Worth, Texas) also tends to work well. "For a scleral sutured IOL, I use the Alcon CZ70BD and go through Surgeons discuss types of secondary IOL implantation, suture use, and postop medication W ith secondary lens implantation it is important to consider specific techniques, the best IOL, sutures, and medication regimens. Richard Davidson, MD, associate professor and vice chair for Quality and Clinical Affairs, University of Colorado, Aurora, Colo.; Natalie Afshari, MD, chief of cornea and refractive surgery, Shiley Eye Center, University of California, San Diego, La Jolla, Calif.; and Bryan S. Lee, MD, assistant professor, Department of Ophthalmology, University of Washington, Seattle, discussed their preferred methods for these procedures. Preferred method It depends on the patient when choosing a method of secondary IOL implantation, Dr. Davidson said. It depends on the patient's anatomy, age, refractive error, if the patient has any comorbidities, and what hardware is in the eye, he said. "But in general, I prefer to either do a Hoffman pocket, which is a way to scleral fixate the IOL, or I'll suture the IOL to the iris." Dr. Lee said that he prefers iris fixation if the iris is able to support the lens, and his second choice is scleral suturing. "Although modern anterior chamber IOLs are good, suturing an IOL to the iris or sclera is still safer for the corneal endothe- lium," he said. Compared to scleral fixation, iris fixation has severa advantages, including that all the sutures are internal, you do not need to worry about doing a very peripheral vitrectomy, you avoid the possibility of a leaking sclerotomy, and there is less risk of a vitreous hemorrhage that can slow down visual recovery, Dr. Lee said. The glued IOL technique is also a possibility. "Although I think it's attractive, I'd like longer-term fol- low-up, plus a lot of the advantages of iris fixation are still applicable," he said. Dr. Afshari said she uses a 3-piece PC-IOL in the sulcus if there is enough anterior capsular support because it is a more natural option. Otherwise, she decides on a case- by-case basis, with other options including a scleral- or iris-sutured PC-IOL or an anterior chamber IOL. "I feel that the new anterior cham- ber IOLs have quite good designs as well," she said. For scleral fixation, Dr. Afshari prefers gluing of the lens because suture failure in the long term can result in lens decentration or subluxation. Monthly Pulse Keeping a Pulse on Ophthalmology T he topic of this Monthly Pulse survey was "Complex cataract cases." We asked what you do in patients with pseudoexfoliation syndrome, and a large majority answered "I place a CTR only when there is evidence of zonular dialysis." For patients with poor pupillary dilation, more than half of respondents prefer to use a pupil expanding ring such as the Malyugin ring. When it comes to dense brunescent cataracts, the majority answered "I phaco them," followed by "It depends on the health of the cornea and other ocular structures." Finally, we present- ed the statement, "In patients with pseudoexfoliation syndrome, I believe it is a contraindication to place any type of premium IOL including a multifocal, accommodating, or toric IOL." The majority of respondents disagree with this statement. AT A GLANCE Dr. Lee demonstrates one technique for iris fixation of an IOL. A spatula supports the IOL while the suture is passed. His first pass uses a Siepser sliding knot and he uses the Condon modification of the Siepser sliding knot which he thinks makes it easier to tie the knot. Source: Bryan S. Lee, MD