Eyeworld

EW FEATURE 45 nice cut through the lens. To grab the lens, Dr. Park recommends IOL- grabbing forceps with paddles on the ends. "If you have paddle-like forceps, you can also get a better grip on the IOL in order to remove it," she said. Dr. Hoffman prefers graspers and scissors from MicroSurgical Technology (Redmond, Wash.). "The grasper can be used through a 1-mm incision," he said. "You can go through a paracentesis, hold the lens, and cut the lens in half with lens-cutting scissors." He uses the dispersive viscoelastic Viscoat (Alcon, Fort Worth, Texas) to vis- codissect the bag open. However, this is something on which surgeons have differing opinions. "I've heard of some surgeons using Healon 5 [Abbott Medical Optics] and others saying they prefer a cohesive, but I think the dispersive ones open the bags up easier," he said. "I tend to use that so if there is some remain- ing viscoelastic in the eye at the end of the procedure, you're less likely to get a pressure spike." Snarls in the line There can be a variety of complica- tions with explantation, Dr. Hoffman cautioned. In cases of an open posterior capsule, the most common one is vitreous loss. To avoid this, Dr. Hoffman recom- mends trying to viscodissect as much of the lens out of the bag as possible, while placing a lot of viscoelastic behind the lens and remaining aware of the possibility of vitreous loss. When the capsule is intact, Dr. Hoffman finds that it's rare to get complications, other than possibly not getting the lens out of the bag in one piece. "There are rare occasions where you might not be able to get the lens out and you might have to abort depending on the reason that you're taking the lens out," Dr. Hoffman said. "You may have to cut the haptics from the lens and leave these behind, which is not a problem." Dr. Hoffman recalled one recent case involving a patient who had "Z syndrome" from an accommodating lens. The surgeon on the case couldn't get the lens out and had to improvise. "They cut the haptic optic junction to take the optic out and then put another accommodat- ing lens in the bag 90 degrees from where the haptics were," Dr. Hoffman said, adding that unfortu- nately, they had the same problem with the second lens. "It was one of those situations where they should have cut their losses and put a standard monofocal lens in." Meanwhile, Dr. Park pointed out that explanting a lens and removing it from the bag can disrupt the posterior structures, which are very important in order to maintain sup- port. One has to be very careful to avoid penetrating the capsular bag, she warned. The general rule here is to use a lot of viscoelastic to vis- codissect the implant free. "If it's in the bag I'm going to try to use the cannula and the viscoelastic or even sometimes a 30-gauge needle so I can get under there and free up the tissues," Dr. Park said. In addition, it's important to protect the cornea when lifting the lens up and out, making sure you're not scraping against the endothe- lium and losing endothelial cells or causing a Descemet's tear, she stressed. The key here is having the correct instrumentation in order to prevent the lens from tilting and touching the cornea, as well as plenty of viscoelastic protection. Timing when to remove the lens can also factor in. In Dr. Park's view, April 2014 Poll size: 258 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a four-question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Copyright EyeWorld 2014 An explantation case involving a single-piece lens that was put in the sulcus and is causing dispersion syndrome continued on page 46

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