Eyeworld

EW CATARACT 38 byline plus face June 2016 Device focus One surgeon's technique Dr. Safran's surgical approach in scleral-fixated cases includes a pars plana vitrectomy with pars plana trochar infusion. He prefers suture- less approaches for secondary IOLs if capsular support is lacking, especial- ly if a smaller incision is desirable, and he uses flaps to cover the ostium created with tunnels placed adjacent to the flaps. "I adjust the haptic position carefully to control the position of the optic, and I will often use a suture to fixate the haptic to the bed of the scleral flap dissection, which stabilizes everything until the haptic can get some more permanent fix- ation in the tunnels with healing," Dr. Safran said. "This prevents early slippage that may occur, especially in myopic eyes where it may not be possible to externalize much haptic length. Axial myopes may have thinner sclera and be prone to post- operative hypotony, and these fac- tors can lead to a greater incidence of early haptic slippage out from the tunnels, which can be prevented by adding a suture around the haptic to the scleral bed." Dr. Safran thinks that flaps that are too thin or haptic tunnels that are too shallow can lead to exposure of the haptic through sclera and conjunctiva over time, which may require patch grafting. If there is not enough scleral thickness to make a strong flap or a deep tun- nel for the haptic, he recommends performing a sutured lens instead. When scleral suturing, Dr. Safran prefers CV-8 Gore-Tex, but sometimes uses 9-0 prolene in older patients or if there is some capsular rim present and he needs to keep the lens in position relative to that. Dr. Safran ties the prolene directly to the eyelet rather than passing it through the eyelet to prevent a sawing action that cuts the suture over time. "With either technique it's important to use excellent vitrecto- my techniques and to avoid postop wound leaks and hypotony," Dr. Safran said. "It's also critical to make sure that your haptics are placed exactly 180 degrees apart from each other and in the sulcus if possible to avoid tilt and decentration." EW Reference 1. Sindal MD, et al. Comparison of sutured versus sutureless scleral-fixated intraocular lenses. J Cataract Refract Surg. 2016;42:27– 24. Editors' note: Drs. Henderson and Safran have no financial interests related to their comments. Contact information Henderson: BAHenderson@eyeboston.com Safran: safran12@comcast.net Comparable continued from page 37 Dislocated Crystalens (Bausch + Lomb)/capsular bag complex in highly myopic eye. The implant and capsule were removed and replaced with an intrascleral haptic fixated IOL. Source: Steven Safran, MD

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