Eyeworld

EW FEATURE 44 by Maxine Lipner EyeWorld Senior Contributing Writer Gone lens fishing Easing into IOL explantation W hile implanting a lens during cataract surgery has become routine, explanting it can be another story, according to Lisa Park, MD, clinical associate professor, New York Uni- versity School of Medicine, New York. This can be anything but a day at the beach, beginning with the incision through which the lens must be removed, since this is smaller than the lens itself. The fact is, when the lens is first implanted it is usually rolled or curled up, like a cigar, and then after insertion it unfolds like the petals of a flower. "In order to get that out you have to either fold the lens again, which can be challenging, or most people like to cut the lens," Dr. Park said. 'Casting' techniques Many simply cut the lens in half be- fore removing it. Dr. Park prefers to make a cut about halfway through the circular part of the implant, re- move this section, and then spin the lens out. "That way you don't have to enlarge your wound and you can manipulate the lens out of a small incision." Likewise, Richard Hoffman, MD, clinical associate professor of ophthalmology, Oregon Health & Science University, Portland, avoids refolding the lens inside the eye. "I think that it's safer to cut it in half and take each half out," Dr. Hoffman said. "Another approach is to cut a quarter pie (slice) out of the optic. That leaves a lens that has a diameter that is no greater than 3 mm, so you can work that lens out of a 3-mm incision." One trick to enhance safety is to insert a new lens prior to attempting to cut the old one, Dr. Hoffman observed. "That gives surgeons an added layer of safety shielding the posterior capsule from the blade." Dr. Park agreed that such a ma- neuver may be helpful. "It protects your capsular bag before removing the lens that will be explanted—it's an extra layer of protection under- neath," she said. When explanting a lens, Dr. Park usually proceeds in a stepwise fashion. She stressed the need for viscoelastic use here. "It is impor- tant to use viscoelastic in order to isolate the implant and get it out of whatever location it's in, in the sulcus or the capsular bag, and then to protect your endothelium. You don't want that lens coming up and scraping against the cornea." She prefers a cohesive viscoelastic here. "I use Healon [Abbott Medical Optics, Santa Ana, Calif.]," she said. "I feel that it creates space, and it allows me to manipulate the tissues easily." Some of the instrumentation that Dr. Park finds helpful includes IOL cutting scissors and forceps. "I like to use an IOL cutting scissor; it actually has teeth on it," she said. She finds these helpful for making a Pseudophakic dysphotopsia April 2014 T he topic of the April Monthly Pulse survey was "Pseudophakic dysphotopsia." When asked about positive dysphotopsias (glare, halos, photophobia) after cataract surgery, the majority (77%) of respondents said this occurs in less than 10% of their patients. Similarly, when asked about negative dysphotopsias (dark shadow in temporal periphery), the majority (71%) of respondents said this occurs in less than 10% of their patients. When asked which dysphotopsia is more problematic for patients, positive dysphotopsia and negative dysphotopsia were just about tied. When asked what negative dysphotopsias are from, the majority answered "Not sure," with "IOL square edge design" as the second most popular answer. Monthly Pulse Keeping a Pulse on Ophthalmology Subluxation is one of the most common reasons for explanting a lens within the capsular bag. AT A GLANCE • In explanting a lens, many prefer to cut rather than fold the IOL to get it through the small incision. • Implanting a new lens before explanting the old can serve as a shield to protect the bag from accidental puncture. • Experts agree that it's easiest to remove a lens early on, but even many years later this can be done.

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