Eyeworld

44 | EYEWORLD | DECEMBER 2020 ATARACT C pseudophacodonesis, postoperative inflamma- tion, and pigment dispersion that lasts for 3–4 months regardless of whether the IOL is iris su- tured or enclavated," she said. "For this reason, I prefer intrascleral haptic fixation as the IOL is rock stable during eye movements." Dr. Chee said if an adequate peripheral iridectomy is created, and the IOL is not tilted or decentered, there is little risk of optic capture when the pupil is dilated. Additionally, Dr. Chee said she will stop the anticoagulant to reduce the risk of vitreous hemorrhage and raised IOP when possible. Passing the needle through the iris or sclera can evoke an uncontrolled bleed and raised IOP in these compromised eyes. Dr. Chee said she will proceed without a retina specialist if she can reach the IOL safely with micro-forceps with adequate exposure for things like iris hooks and scleral indentation. She will stain the vitreous with diluted triamcin- olone acetonide to ensure she does not tug on the vitreous and clear the vitreous around the IOL before moving it to the anterior segment. "Have a vitreoretinal colleague in to assist for the less experienced and combine surgery when the IOL is in the posterior vitreous cavity or on the macula," she said. IOL removal considerations Karolinne Maia Rocha, MD, PhD, said there are several reasons an IOL may need to be exchanged. First, she noted significant residual refractive error. This might be a patient who cannot be corrected with refractive surgery. These are the patients who it's clear on postop day 1 have the wrong power IOL. "That's when we really need to exchange that lens, when it's the wrong lens or power or [has a] huge refrac- tive surprise," she said. Another reason for exchange, Dr. Rocha said, is in a patient who has a trifocal or EDOF lens and, despite all correction of residual refractive error and/or dry eye treatment, is having significant dysphotopsia. Lastly, she noted that a lens may need to be removed if it has been dislocated with damage to the IOL, such as in a traumatic accident or pseudoexfoliation syndrome. When performing an IOL exchange in cases where the capsular bag is intact, Dr. Rocha will continued on page 46 The lens-bag complex is dislocated in this eye with a "dead bag." Despite being more than 10 years postop, there is no fibrosis of the capsular bag. The capsule is very thin and diaphanous, and the zonules are almost non-existent. It is not advised to lasso the lens-bag complex in these cases; instead the whole complex was re- moved and replaced with a Yamane intrascleral haptic fixation lens. Source: Steve Safran, MD continued from page 43

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