EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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16 EW NEWS & OPINION March 2012 Sunken bag does the "wiggle dance" Anterior segment grand rounds by Steven G. Safran, M.D. Case presentation T his is a 70-year-old gentle- man who originally presented to me about 5 years ago with severe pseudoexfoliation, cataract, and glaucoma in the right eye. He had an IOP of 38 with a dense cataract, mild phacodonesis, and advanced visual field (VF) changes in his right eye. His left eye was essentially normal with a pres- sure of 18, a normal VF, and mild to mod- erate cataract changes. At that time I did a phaco/trabeculectomy with mitomycin-C, and because his zonules were weak and the bag floppy, I decided to place the im- plant (an AR40e [Abbott Medical Optics, Santa Ana, Calif.]) with the haptics in the sulcus and capture the optic in the bag. I also sutured the superior haptic to the sclera (under the trabeculectomy flap). The IOP was low in the early post-op period due to the trabeculectomy, and the optic came out of the capsular bag, but the im- plant remained in the sulcus with excellent visual acuity and good pressure control for over 4 years of follow-up. The patient pre- sented about 6 months ago, however, complaining of sudden decreased vision. His implant was centered in the pupillary space but tilted back about 20 degrees with the superior haptic positioned more anterior where it remained fixated to the sclera, but the inferior portion of the lens was tilted posterior and dangling without support. This was inducing some myopic astigmatism (his refraction in this eye was –1.0-1.25X180). The capsular bag with Soemmering's ring was sunken and bobbing up and down behind his implant, disturbing his vision. Steven G. Safran, M.D., ASGR editor I consulted a panel of David F. Chang, M.D., Jim Lewis, M.D., Reay H. Brown, M.D., and John Hart, M.D., to get their thoughts on this case. Dr. Chang felt that a YAG proce- dure was a reasonable first option to consider here but had somewhat low expectations for its chance of suc- cess. "I think that it is reasonable to try a YAG laser capsulotomy in the first place to attempt to create a clear visual axis. However, given the lack of zonular counter-fixation, this often will not work." I did perform a YAG laser in an attempt to reduce the visual distur- bance in the central visual axis caused by the sunken capsular bag, but this did not help matters much. The patient did not feel that things had improved much, and he was expressing an interest in having something more definitive done. Dr. Chang had some suggestions for a surgical approach. "If the patient was amenable to Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Or view the video of Dr. Safran's procedure at www.youtu.be/8-tqKVvXlMw. surgical intervention, the goal is to remove the loose capsular bag that is impairing vision and to suture-fixate the second haptic. I would use iris retractors to permit visualization and then use a dispersive OVD (e.g., Viscoat, Alcon, Fort Worth, Texas) to levitate the capsular bag into the pupillary plane, while displacing the hyaloid face posteriorly. I would try to pull the dehisced capsular bag into the anterior chamber using MST [Redmond, Wash.] microfor- ceps through two paracentesis sites. If successful, I would then remove the iris hooks and levitate the IOL optic forward for pupil capture. I would try to push the capsular- Soemmering's ring complex off to one side so that I could suture the loose IOL haptic to the iris. After in- stilling acetylcholine chloride, a 10- 0 prolene McCannel suture is passed and then tied with a Siepser slip- knot. With a barrier to vitreous pro- lapse in place, I would then remove the capsular bag complex with a vit- rectomy cutter via a tight limbal in- cision, while infusion was separately delivered with a self-retaining can- nula through a paracentesis site. If vitreous were encountered earlier or if the capsular bag could not be pulled anteriorly, I would introduce the vitreous cutter through a pars plana sclerotomy with the iris retrac- The patient's right eye pre- and post-dilation The eye post-YAG laser Source (all): Steven G. Safran, M.D.