Eyeworld

FEB 2012

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

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64 EW FEATURE February 2011IOLs February 2012 Mastering IOL dislocation by Jena Passut EyeWorld Staff Writer AT A GLANCE • Surgeons may manage a dislocated lens either anteriorly or posteriorly, with benefits for each • A lens can either be fixated to the sclera or iris, depending on the situation • ACIOLs may be an easy surgical intervention, but drawbacks may include endothelial damage Experts offer advice on how to handle complicated surgical situation F ew cataract surgery compli- cations are as frustrating as an IOL dislocation, but mastering some simple tools and tricks can turn a slippery situation around, according to several experts who spoke to EyeWorld. George D. Kymionis, M.D., lec- turer, Institute of Vision and Optics, Faculty of Medicine, University of Crete, Heraklion, Greece, said there are several factors that an eye sur- geon should consider when facing a dislocated IOL. "The first consideration is if the IOL is a one-piece or a three-piece lens, and second, if there is suffi- cient remaining anterior capsule in order to support a sulcus implanta- tion," he said. "In case sulcus im- plantation is possible, then this is the easiest approach to correct cases with dislocated IOLs, but in such cases, the surgeon has to always re- member the refractive outcome of such an intervention." Some causes of dislocated IOLs include trauma, pseudoexfoliation syndrome (PXE), aniridia, and other congenital causes of zonular damage, according to Iqbal (Ike) K. Ahmed, M.D., assistant professor, University of Toronto, and clinical assistant professor, University of Utah, Salt Lake City. Best approach? Surgeons may manage a dislocated lens either anteriorly or posteriorly. If the IOL is subluxated but still lo- cated in the anterior segment, an an- terior approach is best, surgeons agreed. If the lens is unstable or lo- cated in the posterior of the eye or if there are other vitreoretinal issues, management through the pars plana is recommended. The cause often will dictate the surgical plan, as well as lens choices, Dr. Ahmed said. "With progressive problems, such as pseudoexfoliation, even though there may be a localized area of zonular problems, we want to support the entire lens complex," he said. "In a traumatic case—one in which there is an area where the zonules are gone—we would manage it by fixing the area of the problem." Richard S. Hoffman, M.D., clinical associate professor of oph- thalmology, Oregon Health & Sci- ence University, Portland, said he's seeing more and more PXE patients who had uncomplicated cataract surgeries only to have everything come loose 7-10 years later. "I think we're going to see an epidemic of them in the future," he said. "Sometimes the whole bag and lens are sitting on the retina, but usually before it does that it starts to have pseudophakodonesis where the lens implant shakes in the eye when the patient moves his eye back and forth." If the lens is still in the bag and not resting on the retina, surgeons may use scleral suturing techniques to attach the entire capsular bag and lens to the sclera. "It's minimally invasive and quite effective," Dr. Ahmed said. Dr. Hoffman, too, would take an anterior approach to a case where the lens is not sitting on the retina and fixate the haptics to the sclera. "If you're lucky, they have cap- sular tension rings," he said. Depending on the lens design, an out-of-the-bag IOL can be sutured to the iris, Dr. Ahmed continued. "A single-piece lens that is not in the capsular bag should not be su- tured to the iris, and I would avoid suturing to the sclera. Although it can be done, it's a little difficult," Dr. Ahmed said. "A three-piece lens out of the bag can be sutured fairly well to the iris and is a nice choice for that. In my opinion, most lenses in the bag can be sutured to the sclera." Salvaging the lens is less inva- sive and includes smaller incisions and less trauma to the eye. Having the right suture material is important when fixating the lens, he added. Dr. Ahmed uses a 9-0 or 10-0 prolene when suturing to the iris and uses Gore-Tex to suture to the sclera. "I've also used the intrascleral haptic fixation where we don't use a suture; we use the haptics and put them into the sclera. It's a nice tech- nique for when you have to fixate the lens without capsular support because the zonules are missing." Sutureless fixation of a three- piece posterior chamber IOL in the sulcus was first described in a 2007 edition of the Journal of Cataract and Refractive Surgery by Gábor Scharioth, M.D., while Amar Agarwal, M.D., updated the tech- nique by using fibrin glue on the scleral flaps. If there is no sulcus support then suturing the IOL on the iris using McCannel sutures could be an- other approach, Dr. Kymionis said. Susan M. MacDonald, M.D., Burlington, Mass., said she prefers saving the lens, unless there is sig- Monthly Pulse Keeping a Pulse on Ophthalmology A lthough none of the currently available presbyopia- correcting IOLs can be considered perfect, the majority of respondents (65%) are satisfied with them, and a large percentage (48%) plans on increasing the usage of these IOLs in the next year. It is also interesting to note that the top two factors in choosing the primary monofocal IOL were material (acrylic or silicone) and design (one-piece or three-piece) rather than cost. Bonnie An Henderson, M.D., cataract editor

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