Eyeworld

FEB 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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14 EW NEWS & OPINION February 2012 Anterior segment grand rounds Golfer gets a new bag by Steven G. Safran, M.D. Roundtable discussion Case presentation T his is a very young and active 85-year-old gentleman who is an avid golfer. He was referred to me 5 years after his cataract surgery with an SI40 implant decentered within the capsular bag. He was complain- ing of glare and decreased vision in his left eye. He has no problem with the other eye, which is also pseudophakic and 20/20 un- corrected. On examination, his vision in this eye is 20/50 but corrects to 20/25-2 with a plus 1.0 refraction. His implant is completely within the capsular bag, but is decentered 2 mm to 3 mm superiorly within the confines of the bag. There is significant posterior capsule haze, and the anterior and posterior capsules are fused inferiorly from 4:00 to 8:00. His cornea topography is unremark- able, his macula optical coherence tomography is completely normal, and he has an endothelial cell count of 2,400. He does not wear distance glasses nor does he wish to start. Steven G. Safran, M.D., ASGR editor To discuss this case, I am fortunate to have an experienced and erudite panel of superb anterior segment surgeons: Uday Devgan, M.D., Robert Nasser, M.D., Garry Con- don, M.D., Baseer Khan, M.D., and Dan Goldberg, M.D. Dr. Devgan commented: "From the photo, it appears that one haptic of this three-piece IOL is above the capsulorhexis edge and in the sul- cus. This asymmetric placement of the IOL, with one haptic in the bag and the other in the sulcus, very often leads to IOL decentration and excessive capsular bag contraction and fibrosis. "Since the patient desires surgi- cal correction of the vision in this eye, the treatment must address IOL centration as well as residual refrac- tive error. In this situation, the IOL can be brought out of the capsular bag and placed entirely within the sulcus to help center the IOL as well as provide a more anterior position- ing of the optic, which would likely result in a near plano post-op refrac- tion. The alternative would be to ex- plant this IOL and place a new, appropriate-power sulcus IOL." Dr. Nasser also felt that the im- plant appeared to have an "in and out of the bag" configuration based on Figure 1. "I suspect the IOL has one haptic in and one out of the bag. I'd exchange the IOL rather than reposition as the lens power needs to be addressed (+1 versus plano other eye). A properly sized sulcus lens is likely the best choice. I suspect the capsule has fused and will be difficult to open fully, but if one can tease open the capsular leaves and be sure of in-the-bag placement, I would place a lens in the bag. I'd use both topical NSAIDs and steroids pre- and post-op. "If the posterior chamber had not been able to be cleaned at sur- gery, 6 to 8 weeks post-op I'd YAG the capsule." Although an "in and out" syn- Figure 1. Slit lamp image of his left eye at presentation drome, one haptic in the bag and one haptic out, can certainly look much like this implant does, in this case I was able to ascertain at slit lamp exam and with gonioscopy that both haptics (as well as the optic) were completely within the confines of the capsular bag. Dr. Condon commented: "The Watch video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) IOL appears to be completely in the bag. It looks as though its edge might well be covered by the pupil if it wasn't dilated pharmacologically. It's not likely a new or recent IOL placement. So the key question is whether his symptoms arose as the PCO [posterior capsule opacifica- tion] developed. If there are prior records suggesting longstanding de- centration, then that's more support in favor of trying simple YAG as the initial step. That still leaves the op- tion of recentering with a suture or a more involved repos or exchange. Since the IOL is in the bag, I'm not convinced trying the YAG first burns any bridges. "Also if YAG does not help, Figure 2. The patient looked like this post-op day 1 Source: Steven G. Safran, M.D. moving the IOL from the bag to sul- cus and suturing haptics to the iris to stabilize would be something I'd think about. That might also help get him closer to emmetropia." Dr. Khan was willing to consider the possibility of doing a YAG capsu-

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