Eyeworld

EW CATARACT 16 January 2015 This series of articles highlights the hot topics presented at the "Cataract Dilemmas" symposium at the 2014 ASCRS•ASOA Symposium & Congress. In this article, we review options of what the cataract surgeon can do fail- ing capsular support for IOL fixation. When the audience was posed this question, 58% stated they would use an ACIOL, while 33% use a sutured or glued PCIOL, and 9% would refer the patient to a colleague. In his presentation, Richard Hoffman, MD, reviewed options and their inherent benefits and downfalls. In this review, we are taught to try to adapt to the case at hand, educated on different options, and advised to work within our comfort level. –Rosa Braga-Mele, MD, ASCRS Cataract Clinical Committee chair While the procedure is fairly new, 5-year follow-up of patients with glued IOLs has shown that the haptics are not extruding out of or into the eye as Dr. Hoffman had feared, but longer follow-up is still needed. "I'm fairly confident that the intrascleral haptic technique will probably be found to be safe in the long run," he said. Dr. Hoffman also cited several recent studies that have investigated the outcomes associated with ante- rior chamber lenses versus posterior chamber lenses. All concluded that there were no significant differences in outcomes between the 2 types of lenses, he said. Because each case is different and a myriad of complications can arise, the most important concept to understand is that "all of the tech- niques are valid, and none has been shown to be superior to another one," Dr. Hoffman said. "There are situations where you might have to perform iris fixation or scleral fixation, and you should be familiar with all of the techniques." EW Editors' note: Dr. Hoffman has no financial interests related to this article. Contact information Hoffman: rshoffman@finemd.com place ACIOLs in eyes that have corneal endothelial dystrophy, it is still possible to perform endothelial keratoplasties in the presence of an anterior chamber lens, he said. Dr. Hoffman also discussed complications associated with anterior chamber lenses, which have usually been related to older closed- loop lenses or newer lenses that have not been appropriately sized. "With the modern, Kelman-style open-loop IOLs that are appropriate- ly sized, the complications are fairly few," he said. He also offered pearls to the audience for suturing PCIOLs to the sclera, such as using 9-0 prolene or CV-8 Gore-Tex instead of 10-0 prolene because it can break. When choosing fixation points, surgeons should avoid the 9 o'clock and 3 o'clock positions, he said. Most surgeons are now performing 4-point fixation rather than 2-point fixation, he said, but both are valid techniques for scleral fixation. The glued IOL technique was originally developed by Gabor Scharioth, MD, and more recently popularized by Amar Agarwal, MD. Also known as the intrascleral haptic technique, in this method the haptics are buried within the sclera and fibrin glue is used to hold down the conjunctiva and scleral flaps, Dr. Hoffman explained. Implanting the IOL in the anterior chamber is the simplest approach, Dr. Hoffman said, so it makes sense that the majority of respondents use anterior cham- ber lenses. Because the glued IOL technique is a newer procedure and many surgeons feel confident with an ACIOL or sutured PCIOL, it is not surprising that only 8% of respon- dents who prefer PCIOLs use it. "Surgeons who have become very good at it feel that it's easier than suturing in a posterior cham- ber lens, so that would be the main advantage," he said. "Once you get over the learning curve, it's probably faster and easier than using a scleral sutured posterior chamber lens." The presentation In his presentation at the sympo- sium, Dr. Hoffman discussed several scenarios that a cataract surgeon might run into that would require extracapsular IOL fixation, reviewed the various approaches that a surgeon can take, and offered pearls for each option. While anterior chamber lenses are the most popular, they do have several contraindications, such as peripheral synechiae, uncon- trolled glaucoma, a shallow anterior chamber, and large iris defects, Dr. Hoffman said in his presentation. Although some surgeons do not W hen conditions arise that require extracap- sular IOL fixation, cataract surgeons have several options, but it can be difficult to determine which course of action will yield the best visual results for the individual patient. Richard S. Hoffman, MD, clinical associate professor, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., discussed the merits and challenges of selecting anterior chamber lenses (ACIOLs) and fixated posterior chamber lenses (PCIOLs) for extracapsular IOL fixation at the "Cataract Dilemmas" symposium at the 2014 ASCRS•ASOA Symposium & Congress. Audience response questions, answers An audience response question during the symposium revealed that the majority of surgeons—about 58%—place the IOL in the anterior chamber when there is a lack of capsular support. About 33% of the respondents use a sutured or glued PCIOL, and about 9% close and refer the patient to a colleague. Of the surgeons who use PCIOLs, about 43% suture the IOL to the iris, about 49% suture the IOL to the sclera, and about 8% glue the IOL to the sclera. Extracapsular IOL fixation: ACIOLs versus PCIOLs by Lauren Lipuma EyeWorld Staff Writer Audience members at the symposium were asked what technique they use if there is a lack of capsular support. Source: ASCRS

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