Eyeworld

EW NEWS & OPINION 17 cataract surgery for the symptomatic patient's second eye. Following nu- clear and cortical removal, it is bene- ficial to clean the anterior subcapsular lens epithelial cells meticulously, as fibrotic changes in the bag tend to occur faster and to a greater extent as a result of antero- placing the optic out of the bag. A capsule tension ring may also be beneficial, and we place them rou- tinely in these cases (see video). Next the IOL (a three-piece model is preferred) is implanted into the bag, the optic portion prolapsed anteri- orly with a spatula, and care is taken to remove the OVD from behind the optic. It should be recognized that surgical success in achieving primary or secondary ROC is highly depend- ent on a properly sized and centered anterior capsulorhexis. There seems to be little optical consequence of ROC, as the haptics remain in the bag; theoretically, however, a mod- est myopic shift would be induced, varying directly with the power of the IOL. The other surgical method that has proven successful for patients with symptomatic ND is a "piggy- back" IOL, as first reported by Paul H. Ernest, M.D., associate clinical professor, Kresge Eye Institute, Wayne State University, Detroit. 4 In this method, a second IOL is im- planted in the ciliary sulcus atop the IOL/capsule bag complex. It appears that covering the primary optic/cap- sule junction reduces ND symptoms. However, the original concept was that a piggyback lens was effective because it collapsed the posterior chamber by reducing the distance between the posterior iris and the anterior surface of the IOL. Our studies have determined that the depth of the posterior chamber is unrelated to ND symptoms. 2 Symptomatic patients may be good candidates for a piggyback IOL if they are also ametropic. In order to qualify for a piggyback, the first IOL surgery should be uncompli- cated with a well-centered IOL within the capsule bag. There should be no evidence of zonulopathy and the iris must be free of defects or damage from earlier surgery. Performing the piggyback Although no parameters have been clearly established, we prefer to per- form a UBM to ascertain adequate space between the posterior iris and the existing IOL/bag complex. We prefer use of a three-piece silicone IOL. The AQ 5010V (STAAR Surgical, Monrovia, Calif.) affords a 6.3 mm optic and 14.0 mm polyimide loops; this design is ideal for the sulcus. Unfortunately, it is only available in full one diopter steps from –4.0 D to + 4.0 D; half diopter steps might be more suitable for some cases. Re- garding ametropia, for hyperopic er- rors multiply the spectacle error by 1.5 to determine IOL power, while for myopic errors multiply by 1.2. As an example, in the case of a 2.0 D hyperope, implant a +3.0 D IOL in the ciliary sulcus. We sense better control of the optic during implantation with the use of folding forceps rather than a "shooter." Generally the IOL can be implanted through a 3.0-mm inci- sion. Varying with conditions, one may reopen the original incision or create one in another quadrant. A cohesive OVD should be employed to cushion the anterior segment structures as the optic opens. The leading loop is placed under the dis- tal iris, the optic rotated and opened, and the trailing loop is di- aled into the ciliary sulcus. Care is taken to avoid damage to the cap- sule or iris. A miotic is instilled to prevent pupil capture of the optic edge. The pupil is not dilated in the early post-op period unless man- dated by symptoms (see video). EW References 1. Davison JA. Positive and negative dyspho- topsia in patients with acrylic intraocular lenses. J Cataract Refract Surg. 2000 26(9): 1346-55. 2. Masket S, Fram N. Pseudophakic negative dysphotopsia: Surgical management and new theory of etiology. J Cataract Refract Surg. In press. 3. Vámosi P, Csákány B, Németh J. Intraocular lens exchange in patients with negative dys- photopsia symptoms. J Cataract Refract Surg. 2010; 36(3): 418-24. 4. Ernest PH. Severe photic phenomenon. J Cataract Refract Surg. 2006; 32:685–686. Editors' note: Drs. Ceran, Fram, and Masket have no financial interests related to this article. Contact information Ceran: basakbostanci@aol.com Fram: 310-229-1220 Masket: 310-229-1220, sammasket@aol.com Henry* Anterior/Posterior Capsule Polisher 3360 Scherer Drive, Suite B, St. Petersburg, FL 33716 s 4EL s &AX %MAIL )NFO 2HEIN-EDICALCOM s 7EBSITE WWW2HEIN-EDICALCOM $EVELOPED )N #OORDINATION 7ITH -ICHAEL - (ENRY -$ -ARY -AGDALENE IN 0ENITENCE 4ITIAN AEBB 1318 Rev.A Product #8-13229 s $ESIGNED 4O 0OLISH "OTH 4HE 5NDERSIDE /F 4HE !NTERIOR 4OPSIDE /F 4HE 0OSTERIOR #APSULES s #AN &IT 4HROUGH ! 3TANDARD MM 0ARACENTESIS s 3PECIAL MM .OTCHES /N 4HE !NTERIOR 3URFACE &OR 3IZING 4HE #APSULORRHEXIS s 5NIQUE MM .OTCH /N 4HE !NTERIOR 3URFACE &OR 1UICK 2EFERENCE s !UTOCLAVEABLE -ADE /F 3TAINLESS 3TEEL )N 4HE 53! 'UARANTEED &OR ,IFE !ND !VAILABLE &OR ! $AY 3URGICAL %VALUATION 7ITHOUT /BLIGATION #ALL &OR -ORE )NFORMATION #OME 3EE 5S !T %3#23 "OOTH " HenryPolish1318EWescrs.indd 1 7/14/11 1:08 PM September 2011

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