EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/115557
20 EW NEWS & OPINION March 2013 Tools & techniques rePlay online content Simplifying management of the dislocated in-the-bag IOL by Tyler Q. Kirk, M.D., and Garry P. Condon, M.D. L ate IOL-in-the-bag subluxations are presenting with increasing frequency within our practice. Last month I treated three cases, and I believe that we may be seeing just the tip of the iceberg at this time. Pseudoexfoliation is the most common cause for these late subluxations, and I have seen subluxations develop on average 7-10 years after the initial surgery. In most cases there was no evidence of zonular weakness with the original cataract operation, and many of these cases subluxed despite the use of a prophylactic capsular tension ring (CTR). I believe that the easiest method of treating these cases is by fixating the capsular bag to the sclera, using the haptics as anchoring points in order to avoid cheesewiring of the sutures through the capsular bag. When the IOL haptics are oriented in the meridian of decentration, these cases are somewhat routine. When the haptics are oriented 90 degrees from the meridian of decentration, the cases are a little bit more challenging but still possible. When a CTR is placed at the initial cataract operation, the cases are simplified due to the ability to suture the bag and the CTR anywhere along the 360-degree capsular bag fornix, regardless of the orientation of the IOL haptics. It is for this reason that I now routinely place CTRs in all of my pseudoexfoliation patients. In this month's column, Drs. Kirk and Condon share their ab externo approach for sclerally fixating subluxed IOL-in-the-bag complexes. This technique offers us one more unique method for dealing with these challenging but rewarding cases. I have recently acquired Dr. Condon's suture retrieval snare (MST, Redmond, Wash.) and have found it to be an ingenious and simple device for performing Siepser slip knots for iris fixation and pupilloplasties. Thanks, Gary. W e have increasingly witnessed late in-thebag IOL dislocations in patients with significant zonulopathy since the first published management approaches in the late 1990s, whether from pseudoexfoliation, trauma, previous retinal surgery, uveitis, or idiopathic causes. As our armamentarium of instruments and devices continues to grow, patients with cataracts and significant zonulopathy can often be safely and securely managed. However, it is frequently impossible to predict whose zonules will falter with age and whose will maintain their integrity. When a late in-the-bag IOL dislocation is encountered (Figure 1), we now have several techniques that have reported success in recentering the IOL; however, they often require complicated intraocular manipulations, and concerns for late suture breakage or erosion remain. As we recently reported in the Journal of Cataract & Refractive Surgery, a new technique and instrumentation we developed may help ease the difficulty of repairing these late in-the-bag IOL dislocations.1 Comorbidities Pseudoexfoliation syndrome can lead to zonulopathy and IOL-bag complex dislocation. Those patients who experience dislocation secondary to pseudoexfoliation also tend to be at greater risk of developing pseudoexfoliation glaucoma.2 In the three cases published with the original description of our technique for scleral fixation of late in-the-bag IOL dislocation, each patient who required IOL fixation required trabeculectomy to control their significant pseudoexfoliation glaucoma.1 Surgical planning The key to success in cases of late in-the-bag IOL dislocation begins with a careful clinical exam. Pseudophakodonesis may be appreciated by having the patient make swift eye movements while at the slit lamp. Patients should be examined both upright and supine. Ultrasound biomicroscopy can also greatly aid in identifying the true position of the IOL-bag complex and the site of lost zonular integrity. During exam, remain vigilant for the presence of vitreous, which may need to be addressed during the repair. Depending on the severity of the dislocation and position of the IOL-bag complex during exam, the assistance of our vitreoretinal colleagues may be necessary. Figure 1: Dislocated in-the-bag IOL Figure 2: Suture needle pass through optic-haptic junction Surgical management Scleral fixation of a dislocated IOL is best performed under a retrobulbar block. It is important to maintain anterior chamber stability through initial injection of sodium hyaluronate 1.0% (ProVisc, Alcon, Fort Worth, Texas); this also helps keep vitreous posterior during intraocular lens manipulation. Grieshaber iris hooks are necessary, especially when there is poor pupillary dilatation, to visualize the haptics of the dislocated IOL. Figure 3: Suture retrieval with snare instrument continued on page 22 Figure 4: Adjusting slip knot tension to center IOL Richard Hoffman, M.D., Tools & techniques editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Simplified scleral fixation Tyler Q. Kirk, M.D., narrates a case demonstrating the simplified scleral fixation technique for dislocated in-the-bag IOL developed by Garry P. Condon, M.D. Figure 5: IOL in proper position Source (all): Tyler Kirk, M.D.