Eyeworld

JUNE 2022 | EYEWORLD | 67 C Contact Al-Mohtaseb: zaina1225@gmail.com Behshad: soroosh.behshad@emory.edu Venkateswaran: nandini_venkateswaran@ meei.harvard.edu Relevant disclosures Al-Mohtaseb: None Behshad: None Venkateswaran: None scenario to provide further IOL stability, but if the anterior capsulotomy is too small or large, it may not be possible in all cases." He said that if the PCR occurs after place- ment of a one-piece in the capsular bag, and the posterior rent or tear is stable with an intact anterior capsule, optic capture with the ante- rior capsule can be performed. Care and time should be taken to ensure that the IOL is stable in this configuration. "If there is any concern for stability, the one-piece IOL should be removed and a three-piece placed in the ciliary sulcus," he said. "It is never OK to place a one-piece IOL in the ciliary sulcus, as this will lead to UGH syndrome." Placement of an ACIOL has been shown to lead to complications down the line, including glaucoma and corneal decompensation. There- fore, it may not be the best long-term option for patients, Dr. Behshad said, adding that other IOL placement techniques are dependent on sur- geon skills. These techniques include suturing a three-piece IOL to the iris, suturing a three-piece IOL or PMMA IOL to the sclera, or intrascleral IOL fixation using a three-piece IOL with haptics made of polyvinylidene fluoride, such as the CT LUCIA 602 (Carl Zeiss Meditec). Following IOL placement, care should be taken to do a complete anterior vitrectomy to ensure all prolapsed vitreous is removed from the anterior chamber, Dr. Behshad said. Dilute triamcinolone or acetylcholine should be consid- ered to help identifying prolapsed vitreous, and the surgical approach, whether anterior or pos- terior, should be based on surgeon experience. Dr. Al-Mohtaseb also highlighted lens options that are available if a posterior capsular tear or rupture does occur. Typically, if there is a small, circular tear that is centrally located, the surgeon could still do a one-piece in the bag, but for most posterior capsular tears, you typically want to put a three-piece lens in the sulcus. "I'm a firm believer that you need to also optic capture that three-piece lens to avoid decentration in the future and UGH syndrome, especially in patients with long axial lengths," Dr. Al-Mohtaseb said. "I don't like putting three-piece lenses in the sulcus without optic capture." Another benefit of doing optic capture is the surgeon doesn't have to change the power of the IOL because the position of the IOL is theoretically the same as if they'd put a one- piece lens in. Additionally, if the anterior capsule is too large or the surgeon can't get a good optic cap- ture, Dr. Al-Mohtaseb said she likes to make the posterior capsular tear round and circular and capture the lens into the posterior capsulotomy. In a complex case where there is a large posterior capsular tear, zonular loss, etc., Dr. Al-Mohtaseb said surgeons might want to choose another technique, like getting rid of the capsule altogether and doing Yamane intrascler- al fixation. Dr. Behshad added that in cases where the surgeon is planning for astigmatism manage- ment with a toric IOL, there currently are no toric IOL options FDA approved for placement in the ciliary sulcus. There has been some move- ment in developing a toric IOL that is stable in the sulcus and not a one-piece IOL, but cur- rently none are available in the U.S., he said, adding that astigmatism management can be completed with placement of corneal LRIs or subsequent laser vision correction. Both Drs. Al-Mohtaseb and Behshad again stressed the importance of early recognition of PCR and having a plan in place if it occurs. They said to not chase lens material that falls posteriorly. Dr. Al-Mohtaseb said that this can potentially cause traction or retinal tears. Dr. Behshad added that in this case, risks increase exponentially for retinal damage that can lead to permanent vision loss. Remove as much of the cataract that is present anteriorly and complete a thorough vitrectomy, he said. If possible, place a three-piece IOL in the sulcus, and if there are retina services available, consid- er same-day lens fragment removal by a retina colleague. Otherwise, plan to involve retina early in the postop course.

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