Eyeworld

EW FEATURE 74 Complex cataract cases October 2015 by Maxine Lipner EyeWorld Senior Contributing Writer AT A GLANCE • Use of anterior chamber lenses can be a simple approach for handling non-capsular IOL fixation but can have complications in the long run. • Suturing the lens to the iris or sclera are effective options for cases where capsular fixation is not possible. • Gluing an IOL in place is gaining traction as an approach that minimizes movement. Using a glued approach Another way to fixate an IOL with- out capsular support is with the use of glue. Amar Agarwal, MD, chairman and medical director, Dr. Agarwal's Group of Eye Hospitals, Chennai, India, uses this approach. He credits Gabor B. Scharioth, MD, with performing the first glued intrascleral haptic fixation. The technique involves making scleral flaps and using fibrin glue to seal the IOL inside, Dr. Agarwal explained, adding that Tisseel glue (Baxter Healthcare, Deerfield, Ill.) is made from normal blood and is safe. With this approach, the lens remains solidly in place and does not move as a sutured or anterior chamber lens would, he said. With the suture technique, the lens can swing between the 2 suture points and there can be tilt of the IOL, which can be tighter on one side than the other. With the glued IOL technique, such tilt is negligible and the IOL remains steady, he said. Because there is no movement with glued IOLs, there is no inflam- mation postoperatively. This can have particular appeal for young haptic 180 degrees away through the capsular bag," he said. The other suture is placed in front of the cap- sular bag so that when the surgeon pulls that one out of the sclera, it is lassoed around the haptic because it is double-armed. "I do that through a Hoffman pocket so that I don't have to dissect the conjunctiva," he said. These Hoffman pockets are made 180 degrees away from each other, overlying where the haptics are. The surgeon makes two 350- micron grooves 180 microns apart. These are dissected posteriorly un- derneath the conjunctiva to create a space that's intrascleral. So there is a roof of sclera on top of the pocket and the surgeon can keep a suture knot underneath, Dr. Hoffman ex- plained, adding that this way it can't erode through the conjunctiva and allow bacteria to get in. If there is a capsular tension ring left in place, as Dr. Hoffman tends to do in pseudoexfoliation cases, over the years if the lens becomes loose, the surgeon can fixate the ring to the sclera anywhere for 360 degrees around the capsular bag, he said. Fixation fixes For cases involving posterior cham- ber lenses with no capsule support, Dr. Hoffman uses a different ap- proach. If the lens is already in the eye and is decentered, his preference is to iris fixate the lens. "In my opin- ion it's less invasive and you don't have to suture to the sclera or create scleral pockets or tunnels or mess with the conjunctiva," he said. How- ever, if the entire capsular bag with a lens inside is loose but approachable from the anterior, Dr. Hoffman will usually scleral fixate both the bag and the IOL using pockets. "It's very simple to do, and you're fixating the IOL haptic through the capsular bag to the sclera," he said. The iris fixation technique itself is very simple, Dr. Hoffman said. He uses the double-needle iris-IOL fixation modification demonstrated by John C. Hart Jr., MD, at the 2015 ASCRS Film Festival. This entails first cleaning up any vitreous that is present and prolapsing the optic in front of the iris. The practitioner constricts the pupil so that the lens will stay centered in front of the iris. With the haptics placed behind the iris, the practitioner takes a double- armed needle and cuts off one of the needles so that just a very long suture remains on the other needle, Dr. Hoffman explained. Next, the practitioner takes a needle without a suture attached to it and passes that through a paracentesis. This goes through the iris underneath the haptic. "That lifts up the haptic and makes it much more obvious where this is behind the iris," Dr. Hoffman said. The idea is to take the second needle that has the suture on it and pass it through the same paracente- sis, this time taking as small a bite of the iris in the periphery and passing that through the cornea and remov- ing it. The first needle that initially held up the haptic is also removed. The beauty of this technique is that you don't get ovalization of the pupil, he said. In cases involving fixating the bag to the sclera, Dr. Hoffman uses a different technique. "With this technique you pass a double-armed suture through a paracentesis and pass one suture behind the IOL Non-capsular IOL fixation Moving beyond the usual bag of tricks W hile typical cataract cases are usually a no-brainer for practi- tioners, in instances where there is a tear in the posterior capsule, pseudoex- foliation, or no capsule remaining inside the eye at all, innovative strategies are needed. Here are some of the leading techniques experts recommended for handling cases of non-capsular IOL fixation. Anterior chamber lens Richard Hoffman, MD, clinical as- sociate professor of ophthalmology, Oregon Health & Science University, Portland, finds there are a variety of approaches from which to choose in such cases. Putting in an anterior chamber lens can be the simplest approach but is not for every patient. "I still do this on occasion when I have an older patient," he said, adding that potential complications associat- ed with anterior chamber lenses include endothelial compromise, iritis, and glaucoma. Still, there are patients who have had these lenses in for 40 or 50 years who haven't had any trouble, Dr. Hoffman said. "If a 50-year-old patient came in and needed a secondary IOL, I don't think I would use an anterior cham- ber lens. But if an 80- or 85-year- old came in and I thought the case might be complicated, I might go ahead and put an anterior chamber lens in that patient." This case involving a dislocated IOL/capsular bag complex is ideal for sclera fixation using sclera pockets. Source: Richard Hoffman, MD

• Cover