Eyeworld

SEPTEMBER 2020 | EYEWORLD | 27 C be to perform a posterior continuous curvilin- ear capsulorhexis to turn the tear into a stable round hole, which is unlikely to tear out," Dr. Kim said. Dr. Davidson said he prefers to align hap- tics 90 degrees away from anterior capsule tear because putting the haptic at the tear may cause undue stress at the equator that could cause the tear to run to the posterior capsule. If there's a posterior capsular tear that's somewhat linear, you can still get a one-piece lens in the bag most of the time, as long as the haptics are 90 degrees to the tear, Dr. Davidson said. If there is an anterior capsule tear, Dr. Vann uses a single-piece IOL, injecting into the anterior chamber and trying to depress the optic underneath the capsular bag, tucking the haptic with the second instrument. Strategy for removing OVD from behind the IOL? Dr. Davidson usually manipulates and rotates the IOL with the I/A handpiece. He continues to deliver the posterior trailing haptics with the I/A handpiece and does not use a second instrument through the sideport. "I'm already evacuating the viscoelastic before the lens is fully unfolded," he said. "I don't have to inten- tionally lift the edge of the IOL to evacuate the OVD from behind it because the OVD is gone before the lens is unfolded." Dr. Kim said he does not advise relying on indirect means to remove OVD from behind the IOL. You don't want to leave OVD in- side the bag because it can cause capsular bag distention syndrome and a myopic refractive surprise from the anteriorly displaced IOL. The best way to remove OVD is to get it directly by going behind the IOL and remov- ing it from within the bag. This way you have no doubt that all the OVD is out of the bag. Single-piece acrylic IOLs are malleable and easy to tilt to go under the optic with the I/A tip. His technique is to go under the IOL, then tilt and rotate 90 degrees. Tilting the optic allows you to get into the bag without putting stress on the zonules and rotating it helps to ensure both haptics are within the bag. Contact Davidson: doctorjohn@johndavidsonmd.com Kim: kim@professionaleye.com Vann: Robin.Vann@duke.edu Relevant disclosures Davidson: Alcon Kim: None Vann: Alcon Where should you direct the IOL when inserting? The initial step with IOL insertion is complete expansion of the capsular bag with OVD, Dr. Kim said. As the cartridge is inserted, the single-piece acrylic IOL should be angled toward the capsular bag with the leading haptic injected into the bag while the remainder of the IOL is left in the anterior chamber, he said. The surgeon can then elect to use a second instrument to position the remainder of the IOL in the bag. "I prefer to use the I/A handpiece to manipulate the IOL into the bag because 1.) I need to irrigate the OVD out anyway, and 2.) I can take ad- vantage of the irrigating fluid to inflate the capsular bag, which creates more room for me to position the IOL in the bag," Dr. Kim said. "This stepwise approach also enables me to carefully inspect the IOL for scratches or defects, ensures the IOL is oriented properly (leading haptic points left), and allows me the time to ensure both haptics are released from the optic before the entire IOL is inserted within the bag." To liberate a stuck haptic, apply centrifugal pressure in the X-Y plane of the optic to the back of the haptic tip with the I/A needle tip. Source: John Davidson, MD

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