Eyeworld

46 | EYEWORLD | DECEMBER 2020 ATARACT C use dispersive viscoelastic to try to open the capsular bag, especially around the haptics. Then she carefully prolapses the lens into the anterior chamber. She noted that this is general- ly easy with single-piece IOLs; this may be hard- er with a Crystalens (Bausch + Lomb) because of the design of the haptics. Dr. Rocha places the new lens in the bag and cuts the original IOL in the anterior cham- ber; placing the new lens makes it safer to cut the exiting lens. If the capsular bag is not intact, she checks whether the anterior capsule is intact. She said you should try to place the lens in the sulcus. A single-piece IOL should never be in the sulcus because these patients may develop pigment dispersion and UGH syndrome. A three-piece lens can be placed in the sulcus, Dr. Rocha said, noting that she likes the optic capture tech- nique. Dr. Safran said that many times when he is taking out an old lens, it may be scratched or the wrong power or in some cases, he doesn't know the power. Some lens types don't do well over time, he said, noting that he will always remove a hydrophilic acrylic lens with a prob- lem because those tend to calcify if you do a secondary procedure. continued on page 48 continued from page 44 Reference 1. Rocha KM, et al. Combined flanged intrascleral intraocular lens fixation with corneal trans- plant. Am J Ophthalmol Case Rep. 2018;13:1–5. Relevant disclosures Chee: Carl Zeiss Meditec, Johnson & Johnson Vision, Hoya Surgical Optics Rocha: None Safran: Johnson & Johnson Vision, Cynosure Intraoperative photograph showing a suture snare, created by threading a 27-gauge needle with a short length of Gore-Tex 7-0 suture, entering through a Hoffman pocket 1.75 mm posterior to the limbus, piercing the capsular bag and passing posterior to the IOL-capsular tension ring-capsular bag complex. The loop of the suture snare is externalized. Another length of Gore-Tex 7-0 suture is threaded through the extended loop of the suture snare. Withdrawal of the suture snare then delivers the suture to the scleral fixation point. Intraoperative photograph showing the other end of the fixa- tion suture being drawn out through the Hoffman pocket by the pre-threaded extended loop of the suture snare. This suture creates a belt loop around the IOL-capsular tension ring-capsular bag complex, drawing it into position when both Gore-Tex suture ends are withdrawn from the Hoffman pocket and tied. Source (all): Soon Phaik Chee, MD "If the lens is dislocated with no capsule support, I'm going to cut it and take it out [and do a] pars plana vitrectomy and a Yamane tech- nique," he said. It works well to "clear every- thing out," he said, because then you know you have the right power with a fresh lens. When you lasso an old lens-bag complex, it can be full of "junk," Dr. Safran said, like Soemmering's ring material, fibrosis, etc. Additionally, Dr. Safran said that if you have a dead bag, it's important to take this out because the bag is so fragile, and once you start passing sutures, it will likely fall apart. When choosing to remove the IOL, Dr. Chee said she will use only dispersive OVD to main- tain space and protect the endothelium, which is often weak in these complex eyes. "Further- more, some OVD can safely be left in the eye without incurring a pressure spike," she said. When removing an IOL, Dr. Chee said she prefers to cut it rather than refold it inside the eye. She specifically discussed removal of sili- cone IOLs, which can be more slippery. "I grab the haptic or capsule if they are dislocated pos- teriorly to levitate them, rather than attempting to grasp the optic," she said. "I prefer to explant

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