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February 2012 EW NEWS & OPINION 15 lotomy here as a first option under certain circumstances: "My first question to the patient would be if he was happy with his vision after surgery, at least for the first few months. I'd be trying to establish if the tilt and the edge effect of the IOL or spherical error of the lens is bothersome to him or whether it is the PCO that is bothering him. "If the complaint of visual dis- turbance is more recent, suggesting PCO as the cause of his unhappi- ness, then I might consider doing a YAG capsulotomy. If there is clinical suspicion that the tilt and error is contributing to the patient's symp- toms, then I would plan to do a repositioning. With the lens par- tially in the bag, it would be reason- able to assume that one could reinflate the bag and reposition the IOL in the bag. If for whatever rea- son the bag cannot be reinflated, my fallback position would be to ampu- tate the haptics, explant the optic, and place a Sensar lens [Abbott Medical Optics, AMO, Santa Ana, Calif.] in the sulcus. In both of these scenarios, I would perform a YAG capsulotomy after a minimum of 1 month after surgery." Finally Dr. Goldberg felt (as I did) that a YAG capsulotomy would likely not be enough to solve this patient's problems. "This excep- tional gentleman will not be satis- fied with a simple YAG capsulotomy and fortunately has a healthy ocular surface, cornea, and retina, so he is an excellent candidate to repair the superiorly subluxed PCIOL. The IOL appears to be in the bag, and it ap- pears that the anterior capsulotomy ring is reasonably centered and could serve as a good scaffold for reverse optic capture. A secondary benefit would be reduced hyperopia from a more anterior optic." Treatment At the time I saw this patient I con- sidered a few different surgical op- tions, but ultimately chose the option that I felt would give me the best chance to correct all the pa- tient's complaints with one proce- dure. I felt that a YAG capsulotomy would still leave this patient hyper- opic and coping with issues related to edge glare and could make future surgical intervention more compli- cated. I was nervous about reposi- tioning this particular implant be- cause I did not know if the haptics were kinked or damaged (as I could- n't visualize them completely). I decided to replace this lens for another implant of greater power, a three-piece Tecnis Acrylic (AMO) in the capsular bag. View a video of the surgery at youtu.be/qA19XQoOOzk. In this case I used a 26-gauge spatula-tipped LASIK cannula to enter the anterior capsule and inject viscoelastic to reopen the capsular bag. This is an ideal instrument for this because of its blunt, flat tip. You may note at 4:51 in the video there is what looks like a pos- terior capsule tear, but it's actually the ring of fibrosis that was fusing the capsule together between 4:00 and 8:00 that has been pulled off the rim of the anterior capsule and is now floating free like a ring of scotch tape. In Figure 2, you can see the ring of fibrosis that was apparent on the video now extending from the cap- sule and wrapping around behind the implant. If I had been a little more aggressive at the time of sur- gery this ring of fibrosis most likely could have been removed entirely. A YAG capsulotomy was never needed in this case. This case demonstrates that be- neath the LEC (lens epithelial cell) proliferation and its associated fibro- sis an elastic, clear capsular bag may be found even in an 85-year-old years after his initial surgery. The capsule itself isn't what becomes stiff and fibrotic; it is the LEC metaplas- tic transformation into myofibrob- lasts laying down collagen and connective tissue with contractile properties that transform a clear and elastic capsule into something with a substance like stucco or rubber ce- ment layered on it. If you can strip that off you may find a virgin elastic capsule underneath. This demonstrates the impor- tance of meticulous LEC removal at the time of cataract surgery. It also illustrates that creating a perfect rhexis (as was clearly present in this case) is secondary to removing these LECs if one is to avoid the issues of capsular phimosis, fibrosis, and con- traction that will lead to problems with implant tilt and centration and to achieve predictable outcomes with current and future accommo- dating IOL designs. Dr. Goldberg made the excellent suggestion of reverse optic capture, which I feel is very reasonable and something I did not consider at the time. After viewing the video of the surgery, Dr. Condon agreed: "It's also interesting how the existing IOL seemed to center nicely once you re- leased some of the cap fibrosis. Re- verse optic capturing at that point might have secured centration and induced enough myopic shift to help the hyperopia. Just a thought." I did this case 3.5 years ago and reverse optic capture was not some- thing yet popularized as a treatment for negative dysphotopsia (by Samuel Masket, M.D.), so it wasn't on my radar screen. Traditional optic capture in the bag with haptics in the sulcus was considered, but ul- timately I felt that exchanging this lens for the exact IOL I wanted would give me a chance to correct the refractive outcome, clean out the bag, obtain the advantage of an as- pheric implant, and avoid any possi- ble problems related to a damaged haptic. It worked out well in this case with a 20/20 uncorrected visual outcome and relief of all negative visual symptoms. Depending on the desired refractive outcome, anterior optic capture or even optic capture through a posterior capsulorhexis could be considered along with other options for cases that present like this in the future. EW Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Safran: safran12@comcast.net Sunday, May 27, 2012 Saint Petersburg, Russia www.eyeworld.ru Russian Society of Cataract and Refractive Surgeons Meeting