Eyeworld

41 EW REFRACTIVE August 2018 trauma). 3 For refractive fine-tun- ing, corneal laser refractive surgery could be used. "In recent years, we started to implant intrascleral sin- gle-piece multifocal IOLs (MFIOL), using a slight modification of the technique," he explained. "For the limbus parallel intrascleral tunnel, instead of a 23-gauge cannula, we create a small pocket with a 20-gauge cannula to fit the AcrySof single-piece IOLs [Alcon, Fort Worth, Texas], which have a thicker haptic than a three-piece IOL. Unfortu- nately, three-piece multifocals are no longer available so we had to use a modern single-piece MFIOL and this is, to my knowledge, the first PanOptix lens [Alcon] fixated in- trasclerally using this technique. We achieved excellent long-term results with the use of this standardized technique." EW References 1. Gabor SG, Pavlidis MM. Sutureless intras- cleral posterior chamber intraocular lens fixa- tion. J Cataract Refract Surg. 2007;33:1851–4 2. Scharioth GB, et al. Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2010;36:254–9. 3. Pavlidis M, et al. Bioptics in sutureless intrascleral multifocal posterior chamber intraocular lens fixation. J Refract Surg. 2011;27:386–8 Editors' note: Dr. Scharioth has finan- cial interests with DORC and Alcon. Contact information Scharioth: Gabor.scharioth@augenzentrum.org Tough situation: Subluxated lens Dr. Scharioth presented a variety of tricky clinical scenarios in which, by implementing his specialized technique, he was able to reliably fixate IOLs, including eyes with no viable capsule, traumatic aniridia and aphakia, and eyes with sublux- ated lenses that underwent phaco during cataract surgery. The surgical technique is standardized, with no need to change any of the steps to achieve IOL centration. Despite the standardized im- plantation technique, surgeons need to be aware of difficult situations. Dr. Scharioth showed a case of an eye with a high degree of zonular di- alysis and a highly mobile lens that required extra cautionary measures. "The lens can easily subluxate when the zonular fibers are weak. Make sure that you have a good capsulor- hexis in these eyes and use a second instrument to stabilize the lens during these maneuvers," he said. "I like to use an endoforceps, which I can insert through the paracentesis. This also ensures that I do not lose viscoelastic material, which might occur when going through the main incision with a capsulorhexis forceps. In this severely subluxated lens case, I injected a high viscosity OVD through the pars plana behind the lens that pushed it a little bit forward. It also stabilized the lens and formed a pillow behind it. If you have a capsule rupture in the late stages of the surgery, there is less risk that the pieces are going to fall down into the vitreous by doing this step. Make sure there is no vitre- ous in the anterior chamber. If you don't see the vitreous well then use triamcinolone staining or perform a vitrectomy without triamcinolone." Dr. Scharioth used hooks to sta- bilize the lens during phacoemulsifi- cation due to the precarious position of the subluxated lens. He placed his paracentesis slightly posteriorly to the usual spot, nearer to the lim- bus. When doing phaco, he tried to minimize the stress on the capsule. "Be prepared for these cases to end badly. Things can look fine until you come to the end of the surgery and suddenly you lose the whole capsular bag during phaco," he said. "You need a strategy for how to fixate the IOL. A capsular tension ring [CTR] can be helpful to prevent this in severe cases, but sometimes in subluxated cases, I find a CTR is worse because when you have a cap- sule break and the CTR needs to be explanted because it is useless in the situation, it can expand the capsule break. Put your CTR in as late as possible in the surgery." Dr. Scharioth performed an anterior vitrectomy to remove the small pieces of remaining capsule. Then, as the patient was not in drop anesthesia, he could continue with the immediate intrascleral fixation of the IOL, as described. He em- phasized that the use of peribulbar anesthesia or even general anesthe- sia is a better choice in complicated cases than topical, particularly if the surgeon expects a long surgery. In special cases, Dr. Scharioth has used three-piece multifocal IOLs (e.g., in young patients with Mar- fan syndrome or lens luxation after Figure 3. MFIOL with intrascleral haptic fixation; patient had severe blunt trauma with luxation of crystalline lens, lensectomy and pars plana vitrectomy performed elsewhere; note ciliary sulcus sclerotomies at 5.30 and 11.30 Source: Gabor Scharioth, MD Update on FDA regulations of contact lenses Bennie Jeng, MD, discusses FDA regulations of contact lenses, with the goal of reducing infectious keratitis.

• Cover