Eyeworld

EW CATARACT 40 September 2016 by Steven Safran, MD "My inclination is to pull out the whole IOL/capsular bag complex, and then scleral suture a CZ70BD with GORE-TEX. The bag is probably too thin and fragile to lasso, and his sulcus to sulcus diameter is probably pretty long. I have done a few 7.5 mm scleral incisions at 90 degrees, but I still like to put the scleral su- tures in the vertical meridian. Seems more stable and avoids the posterior ciliary arteries/nerve. I do a regular scleral flap for these." approach. "I would make a para- centesis, fill the AC with OVD, scleral depress to bring the lens into view, grab with a MAXGRIP forceps [Alcon, Fort Worth, Texas], pull into the AC and exchange for a sutured CZ70BD [Alcon] from a tempo- ral scleral tunnel incision, make a 90-degree superior 550 µm LRI, tie the scleral wound snugly, and release sutures sequentially based on refraction starting at 1 month." Dean Ouano, MD, New Bern, North Carolina, also would opt for an IOL exchange. He commented, How to fix lens dangling backward by a few zonules in young male golfer with toric IOL that has dislocated into vitreous cavity after retina surgery I discussed this case with col- leagues and posted it on the ASCRS cataract/refractive dis- cussion list for advice on how to best manage this case given the severe IOL dislocation, cornea astigmatism with the thin, diapha- nous capsular bag present. Mark Gorovoy, MD, Fort My- ers, Florida, commented, "This is a no-brainer for me. Suture the whole IOL/capsule complex to the sclera, aligning the sutures so the toric axis is close to the target axis. I would pass either 9-0 or 10-0 prolene sutures around the haptic through the capsule and tie on the scleral surface. The capsule almost always stays wrapped around haptics. Even if they weren't, I would still sew to sclera, but just a further millimeter back so as not to chafe the iris." Ike Ahmed, MD, Toronto, agreed that scleral lassoing would be the best approach here. He said, "Lasso, but with a very gentle technique and careful with tension. A pull too hard could cheese-wire along the haptic. I usually use CV-8 GORE-TEX [Gore, Newark, Dela- ware] but would use 9-0 prolene here for its smaller needle. If we can, we prefer to reposition to the sclera with the haptic lasso technique. In this case, iris hooks should be placed on the CCC edge to hold up the IOL/bag complex temporarily, while sutures placed around each haptic would be helpful as this bag is very loose. With thin, minimally fibrotic capsules, the risk of tear extension during suture passes and tightening is a concern, so one must be very gentle here. Of course, IOL exchange is quite reasonable if the bag cannot be used. An alternative to suture scleral fixation is intrascleral haptic fixation, which has been my prefer- ence. This also takes advantage of a smaller incision (although one can also suture fixate foldable IOLs to sclera)." Mike Snyder, MD, Cincinna- ti, said he would take a different Delicate and dangling T his is a very active 55-year-old male golfer who had cataract surgery 5 years earlier, with a plano outcome in this 27.4 mm eye with a T4 toric 11.5 D lens at axis 95 degrees to correct 1.75 D of with-the-rule (WTR) corneal astigmatism. Within a week after cataract surgery, he developed rotation of the toric lens, which was fixed 5 weeks later by repositioning the lens. He did well for 5 years and then developed a retina detachment, which was repaired by pars plana vitrectomy with an excellent anatomic outcome. He was referred back from the retina specialist with fluctuating vision and a dislocated IOL capsular bag complex as seen in Figure 1. With the patient lying flat on his back, the IOL bag complex completely swings out of the way and is no longer visible when viewed directly through a surgical micro- scope. The vision is variable, but 20/30 uncorrected with the implant in the position seen in Figure 1. The capsular bag appears to be extremely thin and friable with almost no fibrosis whatsoever. The other eye is pseudophakic with minimal refractive error. The topography can be seen in Figure 2 to have 1.75 D of WTR astigmatism with some inferior steepening. Steven Safran, MD, ASGR editor continued on page 42 Anterior segment grand rounds (ASGR) Figure 1. The patient returned with a dislocated IOL capsular bag complex. Figure 2. The topography here shows the patient's eye to have 1.75 D of WTR astigmatism with some inferior steepening.

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