EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/357599
15 EW NEWS & OPINION August 2014 lenging, requiring good visualization with iris hooks to expose the bag equator. Under direct visualization, the eyelet of the CTR can be exposed from the bag and drawn up into a Grieshaber CTR insertion device and extracted before the bag lens is bisected with intraocular scissors and removed through a self-sealing 2.5 mm CCI. Though this may leave some debris behind and violate the vitreous face, if a glued IOL is planned, this will require a thorough anterior vitrectomy anyway." "The flaps should be made prior to entering the eye. Alternatively a larger incision will be required for explantation and, in the event there is no vitreous presentation, the larger incision can be used for an anterior chamber implant." "Of the three evils, leaving a marred optic in place, making a large incision for explantation and anterior chamber IOL, or planning the anterior vitrectomy (rather than managing it if needed), I would opt for the latter and place a glued IOL." Dr. Beiko agreed that the pa- tient's complaints since the surgery was initially performed implicates the damaged IOL and suggests that it needs to be explanted. "The problem is the patient's complaint of poor vision since the surgery. If the cornea and retina are good, then I would 'blame' optically poor material as the cause. I would explant the lens with capsule and implant a 3-piece, good quality acrylic and scleral fixate with haptic in scleral tunnels." Dr. Hart would consider a different approach: "Any time that there is damage to the center of the optic and the patient is com- plaining, then the IOL should be exchanged. I would viscodissect the bag open. It may be necessary to use a 30-gauge needle to get between the optic and the edge of the capsulor- hexis. I would reposition and sclerally fixate the bag with two Ahmed capsular segment rings [Morcher, Stuttgart, Germany/FCI Ophthalmics, Pembroke, Mass.] placed 180 degrees apart. Using Ahmed capsular tension segments would maintain the integrity of the capsular bag. Since a standard ECTR is already in the bag, the bag should not collapse when the damaged IOL is removed by viscodissection. I would then place an IOL of the appropriate power in the capsular bag." What was done In this case I decided that the IOL needed to be exchanged. I felt that the patient's complaint of poor vision after the cataract surgery was first performed was compelling. Ini- tially I had planned to remove the IOL bag complex, do a pars plana vitrectomy and intrascleral haptic fixation of a new 3-piece lens, but when I read the operative report and saw that there was a CTR in the bag, I decided to rethink the approach. Rather than trying to wrestle with and remove the whole CTR/ bag complex through a small pupil, I decided to use iris retractors to di- late the pupil and then advance the iris retractors to hook the anterior capsule and support it while I did an IOL exchange. I was able to reopen the bag using a spatula tip 26-gauge LASIK cannula (Katena, Denville, N.J.) with viscoelastic injection and then placed the iris retractors under the anterior capsule rim to support it. I was then able to extract the damaged IOL from the capsular bag and bring it up into the anterior chamber where it was cut in half using MST scissors (MicroSurgical Technology, Redmond, Wash.) and removed through a 2.75-mm inci- sion. I injected a 3-piece Softport AO (Bausch + Lomb, Bridgewater, N.J.) into the capsular bag and fixated the bag with an Ahmed capsular tension segment sutured at 12:00. I also lassoed the CTR at 6:00 to give two-point fixation. Although there was some bleeding into Berger's space (between the anterior hyaloid face and the posterior capsule) this cleared within a few days, and at 1 week, the patient had a perfectly centered capsular bag with 20/25 vision uncorrected (Figure 3). I performed YAG capsulotomy at 1 month, and she is now 20/20 un- corrected and quite pleased with the outcome. EW Editors' note: Drs. Agarwal, Hart, and Safran have no financial interests related to this article. Dr. Arbisser has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.) and Alcon. Dr. Beiko has financial interests with AMO, Bausch + Lomb, and CROMA (Leobendorf, Austria). NIDEK Inc. 47651 Westinghouse Drive Fremont, California 94539-7474 USA Telephone: 1-800-223-9044 usa.nidek.com NAVEX Quest with Final Fit ™ , topography-assisted excimer laser system featuring CATz software. #14-0023 CATz, our latest innovation in Laser Vision Correction, enables surgeons to treat myopic astigmatism with corneal irregularities. According to George O. Waring III, MD, principle investigator of the US FDA Study, "the outcomes of the CATz study are astoundingly good. 51% of patients see 20/16 or better without correction*." Dr. CATz CoNTACT NIDEK To ElImINATE yoUr USEr FEES ToDAy! P r o d u c t s • s e r v i c e s • t e c h n o l o g i e s • 200Hz Active Eye Tracker. • TED: Torsion Error Detection, captured by the OPD. • Proprietary Final Fit TM software for accurate outcome simulation and customized corneal treatment. • Full Nidek support including customer tailored service options. • No User or Click Fees associated with Nidek Laser use or service. * Pg 29, 7.4.2 FDA Professional Use of Nidek Topography assisted Lasik. Dr. Hovanesian has financial interests with AMO and Bausch + Lomb. Contact information Agarwal: dragarwal@vsnl.com Arbisser: drlisa@arbisser.com Beiko: george.beiko@sympatico.ca Hart: j.c.hartjr@sbcglobal.net Hovanesian: drhovanesian@harvardeye.com Safran: safran12@comcast.net Watch this video on your smartphone or tablet using you QR code reader. (Scanner available for free at your app store.)