Eyeworld

NOV 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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16 EW NEWS & OPINION November 2012 Tools & techniques Glued IOL scaffolding: A new technique during nuclear fragment removal by Amar Agarwal, F.R.C.S. T M anagement of nuclear fragments in the presence of a ruptured posterior capsule is perhaps one of the most dreaded and challenging scenarios for the cataract surgeon. If the capsule ruptures after all of the endonu- cleus has been removed, no problem. If the capsule ruptures with much of the endonu- cleus still in the bag … wake me up when it's all over. One of the more useful approaches for preventing nuclear fragments from dislocating into the posterior chamber in the later example is Dr. Agarwal's IOL scaffold technique. Once the fragments have been moved into the anterior cham- ber, a PCIOL placed behind the fragments (either in front of the iris initially or in the sulcus) acts as a barrier for fragment dislocation. Once the mess has been cleaned up, the IOL can then be placed in the sulcus and the retinal surgeon never needs to be contacted. However, with large iris defects or severely dilated pupils with little or no capsular support, the technique becomes much more difficult or impossible. In this month's column, Dr. Agarwal describes his glued IOL technique for creating a scaffold for cases that have ruptured posterior capsules, retained nuclear fragments, and an inability to perform the routine IOL scaffold technique due to iris abnormalities. Let's hope it's a long time before we need to use it. Richard Hoffman, M.D., Tools & techniques editor The IOL scaffold technique2 he first glued posterior chamber IOL (PCIOL) im- plantation in an eye with a deficient capsule was per- formed on Dec. 14, 2007.1 was described by us in 2011, and we used this as a technique to prevent nuclear fragment drop into the vitre- ous cavity in the presence of a poste- rior capsular rupture. But in certain cases with insufficient iris and anterior capsular support for IOL scaffolding, it may not be prudent to implant the IOL and use it as a scaf- fold because of the risk of the IOL dropping into the vitreous cavity secondary to lack of any support. We have been using a technique that we term "glued IOL scaffolding"3 to provide support during nuclear fragment removal in such eyes with insufficient iris support and insuffi- cient capsular support for sulcus placement of an IOL. We combine the glued IOL technique as well as the IOL scaffold technique for glued IOL scaffolding. Concept and indications In the IOL scaffold technique we implant a three-piece foldable IOL above the iris or over the anterior capsule in cases of posterior capsular rupture (PCR). This prevents the nuclear pieces from descending into the vitreous, as the IOL acts as a scaffold or a temporary platform. Once the nucleus is emulsified, the same IOL can then be placed into the sulcus or glued to the sclera, depending on the availability of the anterior capsule. The problem comes in cases in which the iris support is not sufficient and there is no anterior capsular support for the IOL scaffold technique. In such cases, we cannot implant the IOL to support the nu- clear pieces, as the IOL may sink. This can happen in cases like an iris coloboma in which a PCR has oc- curred and there is no capsular sup- port at all. Alternatively, this can happen in cases such as a floppy iris, where the iris is not taut enough to support the IOL, or cases in which the pupil is very dilated and not constricting due to trauma and, once again, there is no capsular support. Figure 1. Phaco in mature cataract with iris coloboma. Note the PCR. After vitrectomy, a glued three-piece foldable IOL implantation is done Figure 2. Both haptics are externalized and tucked inside the Scharioth tunnels. Phaco of the nuclear pieces. Artificial posterior capsule created by the IOL. Note the IOL scaffold and the glued IOL procedure combined to prevent the nucleus from falling down Surgical technique If there is a PCR (Figure 1) in a case, one should stop phacoemulsifica- tion. The remaining nuclear pieces can be brought to the anterior chamber. One should now fix an infusion cannula and create scleral flaps to prepare for glued IOL sur- gery. A 20-g needle then creates a sclerotomy 1 mm behind the limbus under the scleral flaps. A 23-g vitrec- tomy is passed through the sclero- tomy to perform vitrectomy so that there is no traction in the vitreous. Vitrectomy is an essential step in the surgery, as one can otherwise end up

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