Eyeworld

I CHALLENGING CATARACT CASES N FOCUS 66 | EYEWORLD | SEPTEMBER 2019 If a three-piece IOL is subluxated within the sulcus, with vitreous or posterior capsular sup- port, I currently prefer iris fixation with either 10-0 or 9-0 Prolene." Describing her algorithm for IOL ex- change, Dr. Fram said that she will use anterior or posterior capsule fixation of a three-piece IOL if she can. "This requires intact zonules and appropriately sized capsulotomy openings relative to optic size (1 mm less than optic size ideally)," she said. "I avoid placing three-piece IOLs in the sulcus without iris suture fixation as the IOL can typically move over time. If there is no sulcus support or capsule, then I will choose an intrascleral or Gore-Tex suture fixation technique." Time to exchange? The physicians noted potential indications for IOL exchange including: decentration without bag support, damage to the IOL, patient dissat- isfaction with vision or residual refractive error that cannot be corrected with cornea refractive surgery or lens repositioning, iris optic capture, iris chafing, dislocation into the vitreous cavity, and other conditions such as UGH syndrome. "The level of IOL subluxation as well as the amount of IOL movement during exam is important in deciding when to intervene," Dr. Schockman said. Exchange is reasonable if the Khandelwal said. "There can be a PC tear or an AC tear or both, but the key is to avoid this technique in eyes without any capsule support especially those that are vitrectomized. These eyes tend to get pseudophakodonesis and UGH." "Iris fixation has higher risk of corectopia and CME," Dr. Garg said. "Additionally, iris fixation generally requires Prolene suture. It is known that this suture can degrade with time." He added, "In general, I have gravitated toward intrascleral haptic fixation [ISHF] over iris fixated IOLs. With innovations such as the glued IOL and Yamane ISHF techniques, I find that secondary fixation of IOLs has become fairly straightforward." "In almost all cases, I find scleral fixation superior to iris fixation for both IOL stability and long-term safety," Dr. Schockman said. "Over time, a polypropylene suture encasing both the IOL haptic and iris tissue can result in pressure necrosis or cheese wiring of the iris. This then reduces the friction within the fixated knot and results in haptic movement and IOL instability. Subsequent repeat dislocation or UGH syndrome may then ensue, resulting in increased IOP, hyphema, vitreous hemorrhage, among other complications." "If I was going to exchange the IOL, I would perform sclera fixation," Dr. Hoffman said. "For subluxated capsular bag/IOL com- plexes I prefer sclera fixation with lasso sutures. continued from page 65 continued on page 68 Yamane intrascleral fixation technique Retrieved haptics with heated flange on the ends Source (all): Nicole Fram, MD

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