Eyeworld

EW RESIDENTS 118 March 2017 by Daniel C. Terveen, MD, Stephanie K. Lynch, MD, Lorraine M. Provencher, MD, Aaron M. Ricca, MD, Spenser J. Morton, MD, Lindsay K. McConnell, MD, Austin Fox, MD, Brittni Scruggs, MD, PhD, Lucas T. Lenci, MD, Steven M. Christiansen, MD, Matthew A. Miller, MD, Tyler B. Risma, MD, Thomas JE Clark, MD, William Flanary, MD, Prashant Parekh, MD, MBA, Anthony T. Chung, MD, and Jaclyn M. Haugsdal, MD prior retinal detachment (9%), and corneal pathology (9%). There was no mention of prior ocular trauma or previous surgeries. Lens subluxation and aphakia were the two most common indications for secondary IOL placement. Howev- er, no patients in the sulcus groups were aphakic prior to surgery. Addi- tionally, in the sulcus group, there was a higher proportion of patients whose indication for secondary IOL placement was dissatisfaction with a multifocal IOL. Although the paper divided complications into "early" and "late," it was not clear if any one patient experienced a complication during both time periods. Data on concurrent intraoperative proce- dures (other than anterior vitrec- tomy) were not collected, nor were data on subsequent complication-re- lated procedures. Cystoid macular edema (CME) was the most common early postoperative complication. Two patients in the S-OC group had early IOL subluxation. With regard to the primary out- come of CDVA, the S+OC group had the best visual outcomes; significant- ly more patients had postop vision better than 20/40 and fewer patients had vision worse than 20/200. There was no statistically significant differ- ence between the ACIOL, IFIOL, and TSSIOL groups. The authors per- Several preoperative and post- operative variables were collected, including demographic data, indica- tion for surgery, corrected distance visual acuity (CDVA), comorbid conditions, length of follow-up, CDVA at one month postoperative, early postoperative complications (within one month of surgery), late postoperative complications (greater than one month after surgery), and manifest refraction at the time of last visit. The primary outcome mea- sure was CDVA. For patients with final CDVA of 20/40 or better, an additional secondary outcome was refractive prediction error (RPE), de- termined by subtracting a patient's post-operative spherical equivalent refraction from his or her predicted target refraction (based on biometry data from the Holladay 1 formula). Demographics varied signifi- cantly between study groups. The mean age of the ACIOL group was approximately 10 years older than the other groups. The TSSIOL and IF- IOL group had a larger proportion of males. The TSSIOL and ACIOL group had the worst pre-operative CDVA. The mean length of follow-up was roughly 12 months across all groups, but the standard deviation (SD) ranged greatly, from 15.1 to 23.8 months. Preoperative comorbid con- ditions included glaucoma (15%), large-incision extracapsular cataract extraction (ECCE). Several were confounded by concomitant pene- trating keratoplasty. Ultimately, the review suggested that surgeons select the procedure with which they are most comfortable in these difficult cases. In the 15 years since Wagoner et al.'s review article, the state of the art has evolved, and several novel techniques utilizing small incisions and foldable IOLs have recently been developed. Here, we review a study pub- lished recently in the Journal of Cata- ract and Refractive Surgery (JCRS). This retrospective review aims to address the challenge of selecting a particu- lar method for placing a secondary IOL in cases of inadequate capsular support. Study summary This study was a retrospective case series that evaluated all cases of secondary IOL placement by five anterior segment surgeons at a sin- gle site between January 2004 and December 2015. Based on final IOL position, 167 patients were divided into five groups: sulcus with optic capture (S+OC) (N=40), sulcus with- out optic capture (S-OC) (N=18), an- terior chamber IOL (ACIOL) (N=37), iris-fixated IOL (IFIOL) (N=48), and transscleral-sutured IOL (TSSIOL) (N=24). S econdary intraocular lens (IOL) placement can be challenging. Ophthalmol- ogists lack clear guidance regarding the best tech- nique for secondary IOL placement, especially in difficult cases with no capsular support. Surgical approach- es for these cases vary and continue to be a matter of controversy. The best guidance in the oph- thalmic literature is Wagoner et al.'s 2003 ophthalmic technology assess- ment paper, which addressed wheth- er there was a preferred IOL subtype or preferred fixation site in eyes with inadequate capsular support. 1 In that paper the authors conducted an exhaustive review of the literature, scrutinizing 90 papers related to this topic, and concluded that there was insufficient evidence to demon- strate the superiority of one lens type or fixation site. The literature supported the safe and effective use of open-loop anterior chamber IOLs (ACIOLs), scleral-fixated posterior chamber IOLs (SFIOLs) and iris-fixat- ed posterior chamber IOLs (IFIOLs) for secondary lens placement in eyes with little or no capsular support. Of note, many of the studies in the review were case series of intracap- sular cataract extraction (ICCE) or of Review of "Secondary intraocular lenses: Complication rates, visual acuity, and refractive outcomes" EyeWorld journal club Front row, left to right: Daniel Terveen, MD, Jaci Haugsdal, MD, Will Flanary, MD, Steve Christiansen, MD, Luke Lenci, MD, Spenser Morton, MD. Middle row: Lindsay McConnell, MD, Stephanie Lynch, MD, Brittni Scruggs, MD, Aaron Ricca, MD, Prashant Parekh, MD. Back Row: Tyler Risma, MD, Lori Provencher, MD, TJ Clark, MD, Matt Miller, MD. Source: Jaci Haugsdal, MD Thomas Oetting, MD, director, ophthalmology residency program University of Iowa, Iowa City, Iowa We have many different anatomic options for secondary IOL fixation, but a paucity of evidence based publications. The Iowa residents reviewed this impressive compari- son study published in the current issue of JCRS. —David F. Chang, MD, EyeWorld journal club editor

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