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March 2012 EW NEWS & OPINION 17 tors and anterior chamber main- tainer in place." Dr. Hart, on the other hand, would have avoided the YAG proce- dure here. His preference was for scleral fixation of this implant. "When I am considering an IOL fixation/reposition I would not per- form a YAG capsulotomy first. … Given that he is complaining about a sudden decrease in vision and you can see that the inferior haptic and optic is tilted posteriorly, I would consider surgical intervention. Why wait until the suture supporting the superior haptic breaks? If the IOL is tilting posteriorly and suspended by a single suture superiorly, the risk of suture breakage or of the superior haptic slipping out of the suture ap- pears great. I would recommend scleral fixation of both haptics. The superior haptic has been held in place by the suture you placed 5 years ago. Nothing lasts forever so if I were to operate, I would place an- other suture fixating the superior haptic to the sclera. Since he has a trabeculectomy in that area I would use a Hoffman scleral pocket tech- nique to avoid conjunctival dissec- tion that could result in trab failure. For the inferior haptic the technique for scleral fixation would not be as critical. I would use 9-0 prolene sutures. … Also consider re- moving the capsular remnants since they are free-floating in the visual axis and no longer providing sup- port for the IOL. This could be per- formed with a bimanual vitrectomy at the time of IOL fixation." Dr. Lewis also prefers scleral fix- ation, but he would consider an IOL exchange in this case. His focus is on removing the opacity. "Any solution to this problem should involve the complete removal of the residual capsule with the best possible vitrec- tomy a surgeon can perform. These patients, in my experience over the last 20 years, do best with double transscleral sulcus fixation of a CZ70BD using 10-0 polypropylene (Alcon or Ethicon [Somerville, N.J.])." Like Dr. Lewis, I have been a big fan over the years of treating IOL dislocations with lens exchange using a scleral-fixated, single-piece PCIOL with eyelets in the haptic. This has been a "fastball" procedure for me to fix a wide variety of IOL problems once and for all. In this case, however, I wanted to minimize the patient's risk from a glaucoma standpoint and keep the surgery as simple as possible. Dr. Brown, the glaucoma spe- cialist on my panel, was naturally concerned about this patient's glau- coma. He immediately asked me to provide VF and optic nerve imaging information prior to considering further options. After reviewing this data, Dr. Brown commented, "Any surgery is going to risk the bleb, and he would need to have a tube-shunt—a whole new set of serious risks. So doing nothing is my top choice if he's OK with that course. As long as the IOP is good, there is no imperative to move quickly with further surgery. "If he wants something done, I would approach in a step-wise fash- ion. First, you might try pilocarpine to see if a small pupil would reduce the symptoms of lens/capsule mo- tion. This is probably futile, and with his limited VF he may hate the small pupil, although that is unpre- dictable. Step two would be consid- eration of YAG laser to the capsule— although any YAG Rx may destabi- lize the lens since the capsule is probably providing A-P stability. However, you could theoretically imagine that if the capsule was hanging down low enough, you could laser the superior bag just below the zonule and let it fall back while the inferior and more intact zonule kept the inferior lens haptic in place. He certainly doesn't dilate well so you would probably need a gonio lens to see under the iris. But that's probably fantasy, and laser treatment probably isn't going to be possible or helpful. "The next step would be sewing the inferior haptic to the sclera and then doing pars plana vitrectomy and removing the capsule, too. You would probably need hooks to move the iris out of the way to visualize the lens haptic, but this would fixate the lens without requiring capsule support. Since the fixation would be inferior, you would not be going into the trab area. Despite that, the trab would probably be toast, and he would eventually need a tube-shunt. That is probably where this case is going." 0.06% TRYPAN BLUE OPHTHALMIC SOLUTION VisionBlueTM is indicated for use as an aid in ophthalmic surgery by staining the anterior capsule of the lens.1 VisionBlueTM is intended to be applied directly on the anterior lens capsule, staining any portion of the capsule which comes in contact with the dye. It is recommended that after injection all excess VisionBlueTM be immediately removed from the eye by thorough irrigation of the anterior chamber. The dye does not penetrate the capsule, permitting visualization of the anterior capsule in contrast to the non stained lens cortex and inner lens material.1 VisionBlueTM is contraindicated Rx Only Please see adjacent page for brief prescribing information. when a non-hydrated (dry state), hydrophilic acrylic intraocular lens (IOL) is planned to be inserted into the eye because the dye may be absorbed by the IOL and stain the IOL. Adverse reactions reported following use of VisionBlueTM include D.O.R.C. International B.V. Scheijdelveweg 2 3214 VN Zuidland The Netherlands Phone: +31 181 45 80 80 Fax: +31 181 45 80 90 E-mail: sales@dorc.nl inadvertent staining of the posterior lens capsule or vitreous face. Staining of the posterior lens capsule or vitreous face is generally self limited, lasting up to one week. ORDER INFORMATION VisionBlueTM of 10 syringes of 0.5ml/box Dutch Ophthalmic USA 10 Continental Drive Bldg 1, Exeter, NH 03833, U.S.A. Phone: +1 800-75-DUTCH or +1 603-778-6929 Fax: +1 603-778-0911 E-mail: sales@dutchophthalmicusa.com Call: (800) 75-DUTCH or (603) 778-6929 E-mail: sales@dutchophthalmicusa.com 1 Melles GJR, de Waard PWT, Pameyer JH, Houdijn Beekhuis W, Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refractive Surgery 1999; 25:7-9 is available in sterile packs Treatment When I decided to surgically inter- vene in this case, my goals were to remove the capsular bag and its con- tents (as I thought this was the pri- mary impediment to the patient's vi- sion) and to stabilize the patient's implant in the least invasive manner continued on page 18