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20 EW NEWS & OPINION Taking continued from page 19 dure was done on the other eye 2 months later with a similar out- come. Case 3 discussion Figure 10. Note how the string-like band of white fibrosis extending from 6:30-4:00 has been separated from the anterior capsule rim. The nasal hinge has fallen back to proper position relieving the Z syndrome This case differs from the other two cases in that extensive YAG capsulo- tomy had already been performed and yet a significant Z syndrome persisted. The surgeons were split on this case with some recommending IOL repositioning and others sug- gesting that glasses or refractive sur- gery might be the best option here. I felt that it was possible that an IOL exchange with pars plana vitrec- tomy would be needed in this case, but I didn't see the harm in trying to resolve the problem with more YAG treatment as there was really noth- ing to lose as long as I didn't dam- age the anterior capsule. I wanted the anterior capsule intact so I could put a new lens in the bag or at least optic capture if lens exchange be- came necessary. The first thing I did was cut the Figure 11. The 30 mm eye 8 months after Crystalens surgery (6 D AO) with extensive anterior capsule polishing. Uncorrected 20/20 for distance and J2+ for near vision bridge of the capsule that was pres- ent under the nasal hinge to con- nect the two previous YAG capsulotomies that were done by the referring surgeon (Figure 9). I was hoping that this would allow the hinge to fall back. Unfortunately this had no effect Figure 12. Retroillumination image Source (all): Steven G. Safran, M.D. would first perform a YAG PC OU followed by laser vision correction OU on this gentleman." Dr. Goldman would also perform a primary YAG on this patient. "In this case I would YAG to open the posterior capsule but also relieve the fibrosis whereas Dr. Whitman would choose the surgical option of 'break- ing adhesions and rotating the lens with placement of a CTR if possible.'" As this patient was a relatively young engineer, extremely percep- tive, and astute, my goal was to completely resolve the lens tilt while avoiding the risk of retina complica- tions. I felt that the best way to do this was to simply remove and re- place this implant with a three-piece acrylic lens in the capsular bag. This was done after extensive discussion of all the possible options. I did not believe that a YAG would completely resolve the problem here, and I did not want to face a significant resid- ual Z with vitreous now present in the anterior chamber. I used an AR40 implant (Abbott Medical Optics, AMO, Santa Ana, Calif.) in this case, and the patient was 20/20 day 1 uncorrected without the need for a YAG. Here is a link to the surgical video: http://youtu.be/G2CNmMYAGfo. Figure 8 is a post-op day 1 slit lamp photograph. Note how rela- tively clear the PC is now after the IOL exchange. The patient was thrilled with this outcome, and the same proce- on the patient's refraction. On close inspection I saw that there was a white string-like band of fibrosis that was putting tension on an area where it was fusing the anterior and posterior capsule (at 4:00), and this was pulling the inferior nasal hinge forward. In the February 2012 ASGR column ("Golfer gets a new bag"), I illustrated a case where there was a band of fibrosis bridging the anterior capsule, and I showed a surgical video demonstrating how this could be dissected off. In this case I was hoping I could use the YAG laser to separate the anterior and posterior capsule from each other by using the defocused laser to create shock waves that would unzip the band of fibrosis holding them together. This was successfully achieved with a sec- ond laser treatment, and upon get- ting the band of fibrosis to separate from where it was fused to the ante- rior capsule, the nasal haptic fell back and was no longer in a Z con- figuration. The patient's vision re- turned to 20/20 uncorrected with residual astigmatism matching cornea topography (no lenticular component). Figure 10 shows the patient's eye 1 week after this second laser treatment was performed. The patient was very happy with this outcome. We decided to offer her cataract surgery in the sec- ond eye with a Crystalens, but in this case a CTR was used in combi- nation with meticulous anterior capsule polishing to prevent future fibrosis. The lens epithelial cells (LECs) that are left behind undergo metaplastic transformation into my- ofibroblasts, which leads to the fi- brosis and capsule shrinkage that causes the problems in these cases. The combination of fibrosis and slightly asymmetric positioning of the haptics in the bag is a particu- larly potent cause of Z syndrome that can be avoided. Dr. Pepose commented: "The key, of course, is prevention. That means 1) marking the cornea to fa- cilitate creating a central, round cap- sulorhexis of around 5.5 mm; 2) polishing the underside of the ante- rior capsular leaflets with I/A and capsular polisher; 3) in-the-bag IOL placement with easy rotation, ensur- ing both haptics are in the bag and that the polyimide loops are seated at the fornix of the capsular bag, not pinched; 4) hydrating the wound right after IOL placement and rock- ing the IOL back and forth so the optic is posteriorly vaulted; 5) the ciliary ring is not round, so some- times finding the orientation of the IOL that allows the optic to remain most stable posteriorly is useful, par- ticularly in long eyes with a large bag or in post-myopic LASIK eyes; 6) testing to ensure the wound is wa- tertight and low threshold to suture if needed; 7) appropriate wound construction to allow watertight wounds; 8) lengthy post-op corticos- teroid to minimize capsular fibrosis; and 9) no eye rubbing and stressing compliance with shield at night." I agree with all these comments, but I typically make the rhexis the same size or slightly smaller than the optic 360 degrees. With com- plete removal of all LECs, the rhexis size becomes less consequential as there is no fibrosis. Figures 11 and 12 show the patient with a 30 mm eye 8 months out from Crystalens surgery with a 6 D lens. Meticulous anterior capsule polishing was done, and we can see that there is virtually no fibrosis as a result. These eyes have excellent, extremely stable, and predictable outcomes. EW Editors' note: Drs. Goldman, Gorovoy, Khodabakhsh, Weinstock, and Whitman have no financial interests related to this article. Dr. Pepose has financial interests with AMO and B+L. Contact information Safran: safran12@comcast.net June 2012