Eyeworld

I CHALLENGING CATARACT CASES N FOCUS 64 | EYEWORLD | SEPTEMBER 2019 by Chiles Aedam Samaniego EyeWorld Contributing Writer be repositioned or refixated," said Richard Hoffman, MD. "Single-piece IOLs that are not in the capsular bag will usually need to be removed and exchanged. Three-piece IOLs that are decentered and in the ciliary sulcus can be either scleral fixated or iris fixated if there is still vitreous present in the posterior segment or if there is some capsule support behind the IOL to help reduce pseudophakodonesis." "The key question to ask the patient is if they were happy with the vision prior to sublux- ation," said Nicole Fram, MD. If yes, keeping the IOL is appropriate; otherwise or if there is A n IOL that isn't where it should be after surgery is a serious complica- tion, but not the end of the world. In these cases, the surgeon may have the option to either refixate or exchange the lens. EyeWorld corre- sponded with five experts about this. Fix or exchange? "I prefer to refixate an already present IOL whenever possible since this typically requires fewer steps and is less invasive for the eye," said Samantha Schockman, MD. "I generally plan on an IOL exchange with scleral fixation when there is a one-piece acrylic IOL or when the capsular bag does not allow for safe fixation. A thick capsular bag with a large Soemmering's ring can potentially push the iris forward and create angle closure while an unusually friable capsule may not be strong enough for a stable fixation. One-piece acrylic IOLs are rather short and quite flexible, so loop fixation of the haptics can be challenged by tilt, torque, or degloving of the capsule off the haptics if tied too tight. If tied too loose, the complex can trampoline against the iris with eye movement or rubbing. There are rare anecdotal reports of in-the-bag UGH [uveitis-glaucoma-hyphema syndrome]." Sumitra Khandelwal, MD, prefers reposi- tioning and refixation, but said it "only works if the current lens is the correct type of lens and the power is correct." Repositioning a rotat- ed but correctly powered toric IOL is a good example of this. A dislocated one-piece lens, however, might best be exchanged for a three-piece for more options for fixation and less iris chafing, she said. "In general, if a patient was happy with their vision previously and the lens is amenable to repositioning, I will do so," said Sumit "Sam" Garg, MD. He noted a wide range of factors go into this decision: lens status, degree of dislo- cation, lens type, patient age, capsule status, iris state, cornea status, and patient expectations. In terms of feasibility, "if an IOL is acces- sible from an anterior approach it can usually Guide to refixation and exchange Intraoperative photo of iris suture fixation Method of loading suture for fixating Source (all): Nicole Fram, MD At a glance • In general, refixation is pref- erable when the correct IOL power and refixable IOL type was in place with a satisfied patient prior to subluxation, the IOL is accessible anteriorly, and safe fixation is possible with the existing capsule, iris or sclera; otherwise, replace. • For repositioning and refixa- tion, the IOL, haptic, and bag positions should be evaluated with direct examination using techniques to maximize visu- alization, with pharmaceutical or mechanical dilation and/or biomicroscopy if necessary. • In terms of fixation, whether for refixation or IOL exchange with a compromised bag, scleral fixation is generally preferred. • Indications for IOL exchange include: decentration without bag support, damage to the IOL, patient dissatisfaction with vision or residual refrac- tive error uncorrectable by cor- nea surgery or repositioning, iris optic capture, iris chafing, dislocation into the vitreous cavity, and other conditions such as UGH syndrome.

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