Eyeworld

46 | EYEWORLD | JULY 2023 ATARACT C Contact Micheletti: morgan.micheletti@gmail.com Schockman: sschockman@cvphealth.com Teichman: josh.teichman@gmail.com For example, she said placing an IOL in the bag is optimal, but sometimes it is not a viable option, and the surgeon should have different IOLs available to them for these scenarios. "It's most important to ensure the patient's primary problem with the IOL is addressed," Dr. Micheletti said. "If the problem is a refractive miss, it's straightforward. If the issue lies with the characteristics of the lens, then it's a more complex discussion with the patient to deter- mine the next best IOL for them. For example, one could change from a continuous range of vision multifocal to a segmented bifocal or to a non-diffractive EDOF or small aperture optic or, as a final fallback, to a monofocal IOL. The Light Adjustable Lens [LAL, RxSight] is also a good option. The adjustability of the LAL is beneficial in nailing the outcome and because the LAL is a 3-piece IOL, you can place it in the sulcus and optic capture in cases where the posterior capsule is already open. That does commit the patient to having to return more fre- quently for postop adjustments, so it's import- ant to discuss this possibility with the patient if the LAL is used as a backup intraoperatively for an unexpected capsular break." Final best practices Dr. Micheletti mentioned the IOL calculators on ASCRS.org. "There are some calculators that can be used given the patient's postop refraction and biometry to say what the power and orien- tation of the new lens should be," he said. Dr. Schockman said her additional best practices for IOL exchange include obtaining an endothelial cell count (ECC) and a macular OCT. The ECC, she said, helps determine if an AC IOL is a reasonable option, if needed, and it allows for better counseling if there might be a future need for keratoplasty due to reduced endothelial function. Dr. Schockman also said that it might be necessary to remove an IOL and leave the patient aphakic. "IOL exchanges can be challenging, and surgeons should optimize their chances at success by taking their time, improving visual- ization whenever possible, and having several backup plans at their disposal. The use of iris hooks for direct visualization can be invalu- able," Dr. Schockman said. Depending on the IOL material, the first IOL can be folded, cut, or removed whole, Dr. Schockman said, also mentioning the Pac- Man technique. Both Dr. Schockman and Dr. Micheletti discussed inserting the second IOL posterior to the original to act as a scaffold, pro- tecting the capsule. Dr. Schockman also gave the tip of using enough viscoelastic to protect the corneal endothelium while cutting or folding the original IOL. "A second instrument, such as a Kuglen hook or spatula, can be used to keep the IOL away from the cornea while it is removed," she said. Dr. Micheletti recently published about the "modified twist and out" technique. 1 With this method, once the IOL is in the anterior chamber with one haptic externalized, an additional paracentesis is made 180 degrees away from a side port and "the shaft of a 25- or 27-gauge cannula is threaded across the AC to connect these incisions." According to the paper, this technique "frees both hands to use forceps within the incision, grasp the IOL, and rotate it around the forceps." The technique allows for "smaller, more controlled movement than the large, 1-handed pronation" originally described. The technique is completed by withdrawing the forceps-lens complex "with one efficient movement." What to exchange for The second IOL for replacement depends on the reason for the original IOL's removal as well as the patient's age, other ocular comorbidities, the patient's goals, and the patient's anatomy, Dr. Schockman said. If the reason for exchange is a refractive miss, Dr. Teichman said he'll exchange for the same IOL with the correct spherical power/toricity. "If the patient is having an IOL exchange to replace a multifocal for a monofocal IOL due to visual disturbances, it may be a straightfor- ward in-the-bag IOL exchange. In such a case, the most important aspect of the IOL exchange is to set realistic patient expectations prior to surgery," Dr. Schockman said, adding later, "The decision on what IOL to insert is directly dependent on the best intraocular placement for a stable IOL. It is a good idea to have multiple types of IOLs available prior to surgery to allow for different scenarios." continued from page 45

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