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February 2012 IOLs February 2011 EW FEATURE 65 Folding and removing an acrylic lens is simple and safe, but a silicone lens should be cut, Dr. MacDonald said. She offered the following steps for removing an acrylic lens: • Slightly enlarge the main wound to 3.4-3.6 mm. • Create a paracentesis 180 degrees away from the main incision. • Bring the lens into the anterior chamber using viscoelastic to cre- ate a workspace and to protect the endothelium. Figure 1 nificant iris trauma, in which case she would take out the IOL and re- place it, possibly with an anterior chamber IOL (ACIOL). "Part of that is understanding what the patient's limitations are," she explained. "If the patient has a cornea that is borderline, I don't want to do a lot of manipulation be- cause I'd like to be able to spare the cornea, and if we're doing a lot of sophisticated manipulation in the anterior chamber that would proba- bly increase the risk of corneal de- compensation." Exchange time If a lens exchange is necessary, Dr. Ahmed offered some tips on how to accomplish it. Poll Size: 554 Figure 2 Source: Susan M. MacDonald, M.D. "The first thing you have to think about is if there is any vitreous that you need to be worried about. Often these lenses are subluxed in the vitreous. If there is vitreous around the lens, you have to man- age that before pulling the lens out," he said. "You may want to support the lens first. Don't extract it until you've actually done a vitrectomy to free up any vitreous attachment to the lens to reduce the risk of retinal detachment." Anterior surgeons should be well versed in doing a vitrectomy, Dr. Ahmed said. "Unfortunately, we do en- counter unplanned vitreous pro- lapse," he said. "We need to be able to manage that." Dr. Kymionis said anterior chamber IOLs often are an easy sur- gical intervention to correct these complicated cases. "The drawback of ACIOLs is the short- and long-term impact they demonstrate on the corneal en- dothelium," he said. "It has been proven by several studies that en- dothelial cell density decreases with time after ACIOL implantation, leading many times to endothelial decompensation and corneal trans- plantation. On the other hand, the posterior approach, even though surgically and technically demand- ing, is a safer overall surgical inter- vention to manage dislocated IOLs." For removal of the old lens, knowing the material is key. • Bring the leading haptic out of the wound. With the non-dominant hand, place the iris spatula through the paracentesis and under the optic (Figure 1). • With the dominant hand, put the lens forceps through the main in- cision and over the lens. • Gently push the lens forceps on the surface of the lens and use the iris spatula to keep the lens in place and create resistance so the lens will fold over the spatula (Figure 2). • Once the lens is folded, allow a slight opening of the forceps and remove the spatula. • Twist your wrist left or right to rotate the forceps 90 degrees, then gently remove the lens. "This can be practiced ahead of time in a wet lab setting to get the maneuver correct," Dr. MacDonald said. continued on page 66 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email ksalerni@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2012