Eyeworld

EW NEWS & OPINION 14 months. If the IOL is stable and this is from chaffing, I might just shunt and avoid IOL surgery as long as vision is 20/20. I realize the decision is mainly determined by surgeon experience in all these options." Next, Mark Pyfer, MD, Northern Ophthalmic Associates, Jenkintown, Pa., commented. "The pigment deposition in the angle is clearly the cause of this patient's elevated IOP, and any treat- ment must address this. Without any clearly defined pattern of focal iris TIDs, such as the outline of a misplaced haptic or a tilted optic edge abrading the posterior iris, it is more difficult to determine the cause of the pigment dispersion. In this case almost the entire iris is uni- formly depigmented. Since the IOL is in the sulcus over a collapsed and fibrosed capsular bag, this could occur when the anterior edge of the optic abrades the posterior iris, espe- cially if there is an element of inter- mittent reverse pupillary block. The Z9002 should have a square poste- rior optic edge and rounded anterior edge. The present situation could be exacerbated if the Z9002 was placed in the sulcus upside down, where the vaulted haptics push the optic and its square posterior edge in closer contact with the iris. Anterior segment UBM could help confirm both the position of the IOL and haptics, and if done carefully could determine the haptic orientation to rule out IOL inversion." (Author's note: The IOL was determined to be right side up, based on haptic orienta- tion.) "Treatment is fairly urgent to control the IOP, which is uncon- trolled on maximum medical treat- ment in the presence of significant glaucomatous optic nerve damage. I cannot determine from the photo if the iris is bowed posteriorly, but it is reasonable to perform YAG laser iri- dotomy to prevent reverse pupillary block. This conservative treatment alone may be sufficient." "However, if there is persistent irido-optic contact after LPI, then surgical repositioning or exchange of the IOL is necessary. I would avoid an ACIOL in a compromised angle, as well as iris suturing in this case with severe pigment dispersion, so options for exchange include scleral suture fixation or intrascleral 'glue' fixation. Both of these would require vitrectomy with removal of the capsular bag. Intrascleral glue fixation could be performed on the present IOL through a small inci- sion, combined with PPV/capsulec- tomy, while making sure the IOL is not inverted. A posterior capsulo- tomy with limited anterior vitrectomy and capture of the optic behind the fused anterior and posterior capsule rim is an option, but this is surgically challenging and would not succeed long term if the posterior capsulotomy was too large or not centered." "For IOP control, AC and angle washout at a minimum should be performed during any surgical repositioning or exchange. I would have a low threshold to perform a guarded filtration procedure later if the IOP did not come down quickly, but would avoid a combined trab/ IOL exchange. I would consider one or two quadrants of SLT or ALT cautiously if the LPI was successful in stopping the pigment dispersion but the IOP remained elevated, prior to resorting to a guarded filtering procedure." Finally, Baseer Khan, MD, executive physician lead, Eye Insti- tute, Southlake Regional Hospital, Newmarket, Ontario, assistant pro- fessor, University of Toronto, med- ical director, Clarity Eye Institute, Toronto, gave his thoughts: "Given 1) the unilaterality of the glaucoma, 2) associated features of pigment dispersion, and 3) the sulcus position of the IOL, the unifying problem here is a sulcus- based IOL that is causing pigment dispersion." "That being said, this assertion could be counter argued given that this is a 3-piece lens with an anterior rounded edge. Given the history of the anterior capsular tear, the only other consideration might be an aberrant flap of capsule or retained cortex that, through the formation of Elschnig's Pearls, is now rubbing against the posterior surface of the iris. Finally, a reverse pupil block should also be considered in the differential." "Further diagnostic testing should include a UBM to rule out any abnormal interactions between the iris and capsular complex either from a reverse pupil block or iris chaffing from capsular or lenticular debris." "Management: I would do a laser PI irrespective of the findings simply because the risk benefit ratio is favorable. Surgical management of this patient warrants two considera- tions: managing the etiology of the pigment dispersion and dealing with the glaucoma." "Dealing with the IOL: The intended effect is to remove any interaction between the iris and the IOL. The options are to reposition the existing IOL or do an IOL ex- change. An IOL exchange would then beg the question of placement of the new IOL. A great option is the Artisan IOL [Ophtec, Groningen, the Netherlands], however this IOL is not approved for use in the U.S. The principle drawback is that it requires a 5.3 mm incision, but this would maintain the posterior capsule. The second option is to suture in a scle- ral-fixated IOL. However, this would almost certainly involve removing the capsular complex, also obligat- ing a vitrectomy. In my mind, plac- ing another IOL in the sulcus will not work—the capsule complex has fibrosed and moved forward and would vault any lens forward against the iris again resulting in chafe. If this was an issue of pseudophakodonesis, an IOL of 13.0 mm diameter will have the same issue." "The other option is to reposi- tion the existing IOL. Two choices exist here. The first is to attempt to open the capsular bag and place the IOL in the bag. However, opening a bag that has an anterior capsular tear would likely be very difficult. May 2014 Rubbin' continued from page 13 Radial tear seen in anterior capsule behind IOL (blue arrow). This tear out begins at about 1-2 o'clock and extends to about 5 o'clock. The "sharp" exposed edge of the IOL (blue arrows). The IOL is now within the reopened capsular bag with pre-existing radial tear from 1 to 5 o'clock visible. Source (all): Steven G. Safran, MD IOL in the sulcus with the capsular bag collapsed behind it. continued on page 16

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