JAN 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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12 EW NEWS & OPINION January 2014 Anterior segment grand rounds The junk ain't in the trunk by Steven G. Safran, MD T his is a patient referred in five months after cataract surgery in his dominant right eye. The referring surgeon thought that he had placed both the CTR and the IOL in the capsular bag and that the whole lens bag complex was dislocated. On evaluation it was clear the implant was actually positioned in the sulcus over the collapsed capsular bag and that there was a large inferior zonular dialysis the implant had dislocated into. Furthermore, the CTR was not positioned completely in the capsular bag but rather only about 75 degrees of the CTR was in the capsular bag from 12 o'clock to 2:30. At 3 o'clock the CTR exits the capsular bag and is lying in the sulcus behind the IOL, which is sitting in front of it. The conundrum in managing this patient is to figure out how to stabilize the IOL given that the capsular bag is collapsed and dehisced, and what to do with the CTR given that it's partially in the sulcus and partially in the capsular bag. Steven G. Safran, MD, ASGR editor clinical.ewreplay.org/ ?v=2949884744001 Watch this video on your smartphone or tablet using your QR code reader. (Scanner available for free at your app store.) I consulted with four colleagues to discuss this case: Sam Masket, MD, David Geffen School of Medicine, UCLA, Jules Stein Eye Institute, Los Angeles; Ed Hedaya, MD, Seashore Surgical Institute, Brick, N.J.; Tal Raviv, MD, New York Eye and Ear Infirmary, New York; and Sadeer Hannush, MD, cornea service, Wills Eye Institute, Philadelphia. Dr. Hannush commented: "In the case you are presenting you give the reader more information than he/she might normally be able to accurately collect … the photos depict the anatomic relationships clearly. In this case I would try to achieve the original goals of the referring surgeon. I would start by trying to inflate the bag with a dispersive device. The CTR may then be fed into the capsular bag as originally intended. I would then gently maneuver the IOL into the capsular bag, ideally directing the haptics from 12 to 6 o'clock. You may be able to stop right there and end the case, since the 6-clock hour zonulopathy is inferior. If the bag is unstable, you can secure the inferior haptic, inferior aspect of the CTR, or both, which are already within the capsular bag, to the sclera … or add an Ahmed ring segment to achieve the same goal. "All the above assumes successful inflation of the bag. Absent thereof, I would do what I do best: Deliver the CTR, IOL and bag out of the eye, perform a generous pars plana anterior vitrectomy, and then secure a three-piece IOL to the sclera." Dr. Hedaya had the following comments. Like Dr. Hannush, he has a primary and a secondary approach depending on how things unfold. "This case highlights the point that you never really know what you've got and what you're going to be able to do until you get inside the eye and see what's going on. It's important to have not only a main plan but also backup plans, which may be required as events unfold. It is important to make sure there is no glaucoma and know what the endothelial count is. This is especially important because the first cataract surgery was a complicated procedure. In a patient with significant low cell counts or glaucoma, I would shy away from using an AC IOL as part of a backup strategy and look to glue or suture a PC IOL in. "It is worth attempting to reopen the capsular bag and reposition the CTR, even though it is likely the bag will be difficult or impossible to reopen in the face of the lack of inferior zonular support. To open the fused anterior and Figure 1: Implant is seen to be dislocated down in the sulcus and lying above the collapsed capsular bag. The edge of the rhexis is clearly visible here and it is "pointing" to 2:30. Figure 2: Here we can see the inferior bag is collapsed and behind the IOL and there is a large zonular dialysis. The edge of the capsular bag is clearly visible. Figure 3: In this gonioscopy image we can see the point at which the CTR comes into and out of the capsular bag. Approximately 7 o'clock on this image corresponds to the 2:30 point in Figure 1, and it is where the CTR can be seen to be exiting from the capsular bag and lying in the sulcus. The edge of the rhexis can be seen in relation to the CTR. Source (all): Steven G. Safran, MD

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