Eyeworld

EW NEWS & OPINION March 2015 20 posterior surface of the iris, but I was concerned that the zonules may be weak and lead to dislocation of the sulcus piggyback IOL. At the time of surgery I needed iris retractors to manually dilate the pupil, and it did not dilate well enough pharmacologically. I then advanced the iris retractors to the anterior capsule rim to support the capsular bag during lens exchange as it became very clear while I was trying to reopen the bag that the zonules were extremely weak and the IOL/bag complex quite unstable. I was able to remove the IOL easily while the capsular bag was supported with the iris retractors, but the capsular bag collapsed im- mediately after removing the IOL. I tried to place a capsular tension ring (CTR) to expand the capsular bag, but the CTR appeared to pass through deficiencies in the capsular bag equator in the region where the haptics previously resided. At this point I felt the capsular bag was useless, and I decided to do a pars plana vitrectomy, sacrifice the capsu- lar bag, and perform an intrascleral haptic fixated ("glued in") IOL. While the surgery looked very nice at the conclusion of the case, on day 1 the patient showed up with iris capture of the optic on the nasal side. I digitally massaged the IOL behind the iris at the slit lamp and gave her pilocarpine to hold it in place (Figure 5). On day 2 postop I decided to reposition her superior haptic at the slit lamp. I felt that if I could pull it out of its groove and put it in a more anterior groove, it would bend the optic more poste- riorly and away from the iris. I was able to do this successfully at the slit lamp by lifting the superior scleral flap (Figure 6) and pulling the haptic out of its scleral groove, making a new groove slightly more anterior to the old one with a 25-gauge needle and then reinserting the haptic with McPherson forceps (Figure 7). The optic shifted posterior to the iris plane and remained there. This pa- tient is now 5 months postop with no iris capture issues, no recurrence of bleeding, and normal IOP with 20/20 best corrected vision. In the post image, one can see that there is a nice gap between the iris and the IOL optic, which is more centered, as the haptic is no longer pulling the optic forward and tilting the optic forward into the iris (Figure 8). This slit lamp maneuver pre- vented me from having to go back to the OR and reposition the IOL. belief holds that IOLs that are confined to the capsule bag will not induce iris chafe or the eventual manifestations of the UGH syn- drome. However, progressive zonuly- sis can cause intermittent touch and trauma to the posterior iris surface. With repeated episodes, the posteri- or iris may be vulnerable to damage even to endocapsular IOLs, and perhaps more so with pseudoexfoli- ation (PFX) as PFX tends to induce large Soemmering's ring formation. We have recently submitted a 4-case series in which progressive zonu- lopathy associated with PFX led to recurrent vitreous hemorrhage (UGH plus syndrome) from endocapsular IOLs of mixed varieties. At surgery it was confirmed that all IOLs were within the confines of the capsule bag. Our strategy was to remove the inciting posterior chamber IOL and replace it with an anterior chamber IOL based on the assumption that previous posterior iris chafe may have induced permanent changes to the iris vasculature and stroma, potentially allowing recurrence of bleeding with any posterior chamber IOL. All 4 cases had immediate relief of bleeding with no incidence of recurrence. While anterior cham- ber IOLs are frequently impugned, I believe that they have certain indications, the present scenario among them. That said, in cases with modest pseudophakodonesis, endocapsular IOL fixation and UGH syndrome, success may be achieved by fixating the IOL/capsule bag com- plex to either the iris or preferably the sclera, as long as the IOL/capsule bag complex is immobilized." What was done I felt it was clear that while this patient had a single-piece lens in the confines of the capsular bag, it was somehow still managing to irritate the posterior surface of the iris through the thin, diaphanous anterior capsule and that this was exacerbated by the zonular laxity and iridodonesis. First I decided to do a laser peripheral iridotomy to eliminate any chance that intermit- tent reverse pupillary block could be contributing to the problem here. That did not eliminate the micro- hyphema, so at that point my plan was to exchange the IOL for a new 3-piece silicone lens in the capsular bag. I considered leaving the current IOL and placing a plano piggyback silicone lens in the sulcus to act as a barrier, preventing the 1-piece acryl- ic lens from causing irritation to the Groundhog Day continued from page 18 Figure 5: Day 1 slit lamp photo showing nasal optic in contact with iris. This is after "massaging" the optic behind the iris. The patient presented day 1 with iris capture nasally but by indenting the sclera superiorly with his finger at the limbus, Dr. Safran was able to massage it behind the iris and give pilocarpine to bring the pupil down over it. This photo was taken before the pilocarpine took effect. Figure 4: Iris transillumination defects seen at 2:30 and 8:30 Figure 3: Slit lamp gonioscopic image showing IOL completely within capsular bag and covered by anterior capsule While there may be some challenge in fully mobilizing the haptics with viscodissection, I suspect that the offending haptic is not within the bag, thus not fibrosed. If the other (non-offending) haptic is not easily mobilized, it can be pedunculated and left within the bag." Finally, Samuel Masket, MD, added his thoughts: "Common

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