Eyeworld

JULY 2023 | EYEWORLD | 45 C Reference 1. Duncan NB, Micheletti JM. Modified adaptation of the twist-and-out technique for intraocular lens exchange. J Cataract Refract Surg. 2022;48:1469–1471. Relevant disclosures Micheletti: None Schockman: None Teichman: Aequus, Alcon, Allergan, Bausch + Lomb, Labtician Thea, Novartis, Santen, Shire, Sun Pharma cut using intraocular IOL cutters. This is best performed with the second hand holding the IOL using micro-instrumentation. I generally completely bisect the IOL, but other techniques exist, including creating a Pac-Man or twist- ing maneuvers. Some surgeons will insert the second IOL posterior to the first, prior to cutting the first, to protect the capsular bag." Dr. Schockman said having a plan and a backup plan (or two) prior to removal is important. "To remove an IOL from within the capsular bag, it's critical to ensure viscoelastic material is used to completely free the haptics. There can be fibrosis and scarring around the haptics, and manipulation of the haptics before they are completely freed can result in zonular dehiscence or capsular rupture," she said. "Gen- tle dissection can be performed, but attempts to rotate the IOL before the haptics are free should be avoided. In some instances, the haptics can- not be freed, and the surgeon may amputate the haptics and remove the optic only. A new IOL can still be placed in the bag 90 degrees away, if a toric IOL is not required." Dr. Micheletti and Dr. Teichman also shared this advice about leaving a haptic, if it cannot be easily freed. Dr. Micheletti noted that some- times cutting at the haptic gives the surgeon more flexibility that could lead to its removal during the case. "I do try to go back in pretty quickly, within the first 2–3 months," he said, noting that some- times it means switching up IOL technology. He noted that the patient must understand what they might be giving up if they opt to exchange an IOL that they're not entirely happy with. "You have to find out what exactly is both- ering the patient and, in the case of a multifo- cal, if they're willing to give up that near vision that they're getting," Dr. Micheletti said. "Some of my patients think about it and say, 'I'm happy with my near vision, I don't want to go back to glasses, I can handle this.' That's a very different conversation from the patient who says, 'I can't live like this, I'm miserable.'" How to exchange Focusing on in-the-bag IOL exchange, Dr. Teich- man shared his usual process. "If the previous surgery was less than 3 months prior, I generally reopen the wound with a Sinskey hook," he said. "If later, I will create a new wound, making sure it will not connect to the previous wound, which can occasionally reopen creating a very large unstable wound. I favor a slightly larg- er incision for IOL removal. The endothelium should be protected with dispersive viscoelastic and space created with a cohesive OVD (using the soft shell technique of Steve Arshinoff, MD). "It is important not to fill the anterior chamber completely as one will require addi- tional OVD to free the IOL in the next steps," he continued. "Next, ideally at the haptic-optic junction, dispersive OVD is injected just under the anterior capsule to begin the separation of the anterior and posterior capsule to open the bag. This can be done with a 30-gauge needle bevel down or a flat LASIK cannula. Once the separation has begun, the usual OVD cannula can be used to propagate this. This step is a combination of viscodissection and gentle man- ual dissection at times. The goal is to open the capsule 360 degrees. The location of the densest adhesions varies by the haptic shape and may be the proximal or distal portion. Once the IOL is partially freed, OVD is inserted posteriorly to protect the posterior capsule. Once the IOL is completely freed, it is brought into the ante- rior chamber, and with good protection of the endothelium and posterior capsule, the IOL is continued on page 46 IOL cut in half in anterior chamber Source: Joshua Teichman, MD, MPH

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