EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW NEWS & OPINION 14 August 2014 by Steven G. Safran, MD I consulted 5 experts to gather opinions on how they would manage this case: John Hovanesian, MD, UCLA Jules Stein Eye Institute, Los An- geles, and in private practice at Har- vard Eye Associates, Laguna Hills, Calif.; Amar Agarwal, FRCS, Dr. Agarwal's Eye Hospital and Eye Re- search Centre, Chennai, India; Lisa Arbisser, MD, Moran Eye Center, University of Utah, Salt Lake City; George Beiko, BM BCh, FRCSC, assistant professor at McMaster University, St. Catharines, Canada; and John C. Hart Jr., MD, professor of ophthalmology at the Oakland University William Beaumont School of Medicine, Rochester, Mich., and co-chief of anterior segment surgery at Wil- liam Beaumont Hospital, Royal Oak, Mich. The patient's IOL is reasonably well centered and of the appropriate power, but it is damaged centrally and this is affecting her vi- sion. She is 20/25 but very unhappy. Her bag is loose and jiggling but has a CTR in it. The other eye also has PXS and a moderate 20/30 cataract that will need to be addressed with- in the next few years. She does not dilate well in either eye. Dr. Hovanesian commented: "First, we need to decide whether this implant can be salvaged. This depends mostly on whether the 'damage' to the IOL optic is thought to be problematic by itself, which would necessitate explantation. I doubt explantation will be neces- sary. The image suggests that, aside from imperfections in the optic of the lens implant, there is significant posterior capsular opacity, as well Kaleidoscope eye as anterior capsule phimosis in the visual axis. The latter two capsule problems are likely responsible for at least some complaints related to quality of vision. This would be easily addressed with a YAG capsu- lotomy, but that should probably be the last step taken, so that it can be centered on the pupil once the lens/ bag complex is secured." "The lens/bag complex needs to be secured because, evidently, capsu- lar phimosis has caused centripetal contraction of the anterior capsule rim, which has probably caused the zonular loss that is responsible for the pseudophakodonesis." "Deciding how to secure the lens/bag complex depends on what type of haptics the IOL has, which isn't visible from the images. If this is a 3-piece lens, the simplest approach would be to suture the haptics to the iris using 10-0 prolene suture delivered through paired paracentesis incisions 180 degrees apart and tying the ends with the slip knot technique described by Steven Siepser, MD. If this is a 1-piece lens, one might consider suturing the capsular tension ring to the sclera under a Hoffman pocket, again using 10-0 prolene suture. Either of these techniques should provide good long-term stability of the lens. The last step would be using a YAG laser to clear the visual axis of both anterior and posterior capsular opacity." Other surgeons felt that this IOL would likely need to be explanted and preferred to exchange for a scleral fixated IOL. Dr. Agarwal commented: "This patient has a single-piece AcrySof [Alcon, Fort Worth, Texas] in the bag, which is subluxated. There is pseudophakodonesis in the patient and the central optic of the IOL is also damaged. Whenever there is pseudoexfoliation leading to pseudophakodonesis, the problem of pseudophakodonesis persists, though reduced on suturing the lens as the suture works like a hammock. This is like a camera with the lens broken, and we suture the lens to the camera. The picture quality will never be good as the lens moves. The situation is the same with pa- tients having pseudophakodonesis. Imagine the same camera analogy and if we glue the lens to the cam- era, the picture quality will be very good. So the answer to this patient's problem is to do a glued IOL." "The problem now is that the patient has a single-piece foldable IOL, which cannot be glued. Anoth- er problem is that the optic is dam- aged. If the patient had a 3-piece IOL without optic damage, we could have refixated the same IOL and glued it into the Scharioth tunnels. In this case we have to explant the IOL and glue in a fresh 3-piece IOL to solve the patient's problem." Dr. Arbisser would take a similar approach and has a novel method to remove the CTR in the bag. "This PXF patient with a subluxated IOL, who never had good vision after surgery presumably due to a marred optic, should not have the same lens secured in place by lasso technique. Rather, the bag/ lens/CTR complex can be removed and a new 3-piece IOL glued into scleral tunnels. The presence of the CTR makes this slightly more chal- Anterior segment grand rounds Figure 1: Patient at presentation prior to dilation Figure 2: Patient after dilation. Note the central damage to the IOL. Figure 3: One week postop. VA is 20/25 uncorrected. The patient subsequently underwent YAG laser capsulotomy. Source (all): Steven G. Safran, MD A 72-year-old with pseudoexfoliation syndrome is referred to me for "lasso repair" of a "dislocated bag IOL complex." Her cataract surgery was performed just over a year previously, and the referring surgeon feels the bag/lens complex is displaced inferiorly. Figure 1 shows what the patient looked like when I examined her. Figure 2 shows what the patient looked like when I dilated and retroilluminated her. The IOL is within the bag and the whole bag complex is "jiggling" and loose due to diffuse zonular deficiency. The bag/ IOL complex is only slightly dislocated inferiorly about 1 mm, but the center of her implant is markedly damaged by three prominent "dings" in the matrix of the lens optic. The damage was clearly not caused by a laser, as she has not had YAG capsulotomy performed yet. The patient tells me that she has nev- er seen well in this eye since her surgery and that from day 1, it seemed to her as if she was looking through a "kaleidoscope" with distorted vision and glare. I suspect the damage to the lens optic occurred at the time of her original cataract surgery, perhaps by a serrated forceps. When I reviewed the cataract surgeon's operative note, it turns out that the patient had a CTR placed at the time of her cataract surgery within the bag. Steven G. Safran, MD, ASGR editor