Eyeworld

EW NEWS & OPINION 17 Soon-Phaik Chee, F.R.C.Ophth., senior consultant and head, cataract service, Singapore National Eye Centre, describes a limbal approach to posteriorly dislocated IOLs T he location of a posteriorly dislocated IOL can vary widely, from just behind the pupillary plane to the posterior vitreous cavity. It may be found within the capsular bag or "naked," and either hinged, free floating, or lying on the retina. IOLs on the retina and those found in the posterior vitreous cavity are best managed in conjunction with a vitreo-retina specialist. IOLs accessi- ble to posterior (PAL) or anterior as- sisted levitation (AAL) may be safely retrieved and fixated to the iris or sclera for support, or exchanged. PAL may be performed by in- serting a 25-gauge needle at the pars plana, choosing a position at which the IOL is hinged or positioned most anteriorly, and bringing the needle tip with the IOL forward. In the AAL technique, prolapsed vitreous is avoided as a 27-gauge needle is in- serted through a paracentesis oppo- site the site of greatest descent of the IOL. The capsular rim or haptic is engaged by the needle tip and deliv- ered into an OVD-filled anterior seg- ment. The capsular bag may be preserved or stripped off when pres- ent. Retrieving the IOL anteriorly I generally prefer an anterior ap- proach for IOL retrieval. The sublux- ated IOL can be brought into direct visualization or supported to a more central and anterior position with the help of sclera indentation using a cotton tip. IOL rescue has been fa- cilitated by the use of a 21-gauge grasping forceps I recently designed to help retrieve and support sublux- ated implants (Chee Subluxated IOL Grasping Forceps, ASICO, West- mont, Ill.). The sand-blasted grip- ping surfaces allow the surgeon to reach and hold on to the IOL optic (including PMMA ones) or haptic as needed. The ability to grip and ma- neuver the IOL facilitates its fixa- tion. I prefer suturing the implant to the iris rather than the sclera as this is technically less tedious and in the long term may be safer without in- curring the risk of suture-related late-onset endophthalmitis. How- ever, when the IOL is not a three- piece design, its fixation to the iris or sclera is best avoided, and I either exchange the IOL or suture the fi- brotic capsulorhexis rim to the sclera as described by Gimbel. Once the position of the sublux- ated IOL has been identified, two paracentesis incisions are made tem- porally 3-4 clock hours apart and an- other nasally (positioned for passing of the suture), sized to admit 21- gauge instruments. Choosing an ap- propriate paracentesis site, OVD is injected to displace and tamponade presenting vitreous. The IOL optic is grasped directly using the lens mi- crograsper. Alternatively, the capsu- lar bag or haptic is grasped with microforceps, lifting the bag-IOL by Soon-Phaik Chee, F.R.C.Ophth. Managing the posteriorly dislocated IOL November 2011 pleased with the cosmetic and visual outcome of the procedure. Dr. Snyder commented on what was done and the outcome: "This patient achieved an awesome result. Fortunately, the iris was elastic enough to cover the IOL edges, pre- venting glare. This patient's brown iris is much more forgiving cosmeti- cally than the similarly affected light blue iris." Dr. Arbisser commented: "It is very clever how you sutured the iris. I still think a Morcher ring in the bag would have been the safest and most effective option, however, were it available. I prefer to use a double- armed prolene and suture ab interno for both bites of the horizontal mat- tress suture rather than come in and then out, but this is style alone. Also I don't make a flap or groove but rather rotate the knot intrascleral. I might have stabilized the capsule as well as the iris with the hook during lens removal and replacement. Con- gratulations on a wonderful case." EW Editors' note: Drs. Arbisser, Masket, and Snyder have no financial interests related to this article. Contact information Safran: safran12@comcast.net A puzzle continued from page 16 Figure 1. The Chee Subluxated IOL Grasping Forceps grips the optic of the IOL and maneuvers the implant as the anterior vitrector removes the capsular bag remnants and vitreous Source: Soon-Phaik Chee, F.R.C.Ophth. continued on page 18 M anagement of the dislo- cated IOL is a complex topic with many avail- able options depending on the particular clinical presentation. A subluxed sulcus lens is usually ad- dressed easiest by means of iris fixa- tion. When the IOL is still within the capsular bag and the complex is ap- proachable from an anterior direction, I personally have found scleral fixation of the haptics and bag to the ciliary sulcus as the best approach. When the lens is far posterior from the iris, I usually tag team the eye with a retina colleague. In this month's column, the tal- ented Soon-Phaik Chee presents a step-by-step approach for managing the various presentations of subluxed IOLs. I believe that there is a wave of subluxed IOL/capsular bag complexes that will be washing up into our prac- tices in the near future as our aging population of pseudophakic pseudoex- foliation patients start to relax the zonu- lar grip on their capsular bags. This article will provide some valuable in- sights and options for treating these pa- tients, and I am certain it will be a useful reference for surgeons wishing to take on these challenging cases. Enjoy. Richard Hoffman, M.D., tools and techniques editor Tools and techniques

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