Eyeworld

EW CATARACT 42 September 2016 What was done I chose to remove this lens capsular bag complex completely and replace it. While I frequently will lasso dislocated IOL/capsular bag com- plexes to sclera, I have found that if the capsular bag is too thin the bag can split and the suture may slide off the haptic, leading to problems. I felt that simply replacing with a GORE-TEX sutured one-piece PMMA lens with a large optic (CZ70BD) would be the safest long-term play for a stable outcome with the least risk for unforeseen and unfortunate incidents. The main negative to using a large one-piece PMMA lens is that it requires a large incision. By placing this on the steep axis and using a self-sealing scleral tunnel incision, I felt this could be used as a relaxing incision to resolve most of the patient's astigmatism. While I was reluctant to place corneal relax- ing incisions in this patient's cornea because of the asymmetric topogra- phy with inferior steepening, I felt that a scleral incision at 12:00 would be a safe way to reduce some of the with-the-rule astigmatism here. When the patient was brought to the OR, the lens was swung com- pletely out of view with the surgical microscope, and a BIOM viewing system (Oculus, Wetzlar, Germany) was on standby. A self-sealing scleral tunnel incision was made at 12:00, 7 mm in diameter, and a pars plana infusion line was placed. When the scleral tunnel was entered the currents created by flow from the posterior infusion to the anterior incision caused the IOL/capsular bag complex to swing back into position temporarily. A decision was made to use these currents to once again swing the lens/bag complex in place by burping the wound with a spatula while the infusion was on, and a microforceps was positioned in place, ready to grab the complex through a paracentesis, and hold it. The whole complex was then easily removed through the large incision using a second forceps in the other hand. The new lens was sutured in place using CV-8 GORE-TEX around the haptics in a girth hitch suture that can be rotated into sclera as described by Dr. Snyder. 1 A slight modification is that I like to make a scleral groove between the suture sclerotomies in order to bury and hide the suture rather than having it laying on the scleral surface. The knots are tied using a slip knot to ad- just tension and rotated on each side into a corresponding sclerotomy. have been able to use strategic air in- jections to elevate the IOL by getting the air behind the lens. This only works with a dislocated IOL/bag complex with at least 30–40% of the zonules still somewhat intact. In any case, an eye that is post-vitrectomy that does not have a stable iris-lens diaphragm will become soft very quickly. No matter which approach is used, an infusion cannula (AC or pars plana) will make this case much more manageable." Jason Jones, MD, Sioux City, Iowa, would also consider suturing right through the optic rather than the haptic. He commented, "Inter- esting that you had to go back into this eye and rotate the IOL. It's un- fortunate that a CTR wasn't placed. I recall Ehud Assia, MD, reported many years ago using a suture through the optic of a hydrophil- ic lens that had decentered. After seeing the topography, I feel that a corneal approach to correcting astig- matism is not prudent. Fortunately, you've proven that a toric lens can work well here. "I would identify the desired axis for the toric lens and mark the limbus. Peritomies would be opened and light cautery applied. Radial grooves in the sclera at this axis would be placed with sclerotomies at 1.5 and 2.5 mm posterior to the limbus. The lens would then be retrieved from the anterior vitreous with vitrectomy applied to ensure not to entangle the lens with a plan to pass sutures through the optic; I would assess whether to do this in the anterior chamber or just behind the iris. The toric marks on the optic would be the guide for placing the sutures. I think 9-0 prolene would be the preferred suture material because of its narrow gauge. And depend- ing on capsular integrity at this point the capsule could be stripped from the IOL or preferably left in place to provide some protection to uveal tissue. The sutures would be retrieved through the sclerotomies using a suture snare or microforceps. I would tie a slip knot on each to assess stability and tilt of the lens. If tilted or not well centered (but ori- ented correctly on the desired axis of astigmatism), then a third or even fourth suture passage could be done and oriented on the axis of great- est decentration. I have used three scleral sutures to center and stabilize a bag/CTR/IOL complex in a similar fashion; the only difference here is you have sutures passed through the optic. The use of slip knots would allow titration of suture tension to achieve the best position." due to the lack of fibrosis. Finally, you could remove and replace the one-piece acrylic IOL with a glued three-piece IOL. This would not fix the astigmatism, and the corneal topography suggests that this may not be the best case for LVC of the residual astigmatism. "What I have heard about, but never done or seen, is using the femtosecond laser to create suture holes in the IOL. With this degree of dislocation, it probably would not work because of the IOL falling back when the patient is supine, but the idea is somewhat intriguing. "When these lenses fall back like this, I usually use a posterior viewing system and go pars plana to retrieve it. But on a select few cases I Yuri McKee, MD, Mesa, Arizo- na, shared some other ideas. "There are a lot of options here. First, you might consider sliding a CTR into the bag and then using a suture lasso technique to secure the IOL to the sclera. Alternately you could use an Ahmed segment to sew to instead of a CTR. Another option is to snare the IOL with a needle right through the acrylic haptic. If you can snare right in line with the toric marks, then alignment would be quite easy. When I suture an IOL, I tend to use Hoffman pockets in the sclera. For suture material, I would recom- mend GORE-TEX as a first choice and 9-0 polypropylene as a second option. I probably would not trust just suturing through the bag alone Delicate continued from page 40 Figure 3. Postoperative topography at 1 week Figure 4. Postoperative slit lamp appearance of sutured PCIOL Source: Steven Safran, MD

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