Eyeworld

EW CATARACT 63 March 2017 Unfortunately, in many such cases an unnecessary and ineffective posterior capsulotomy has been performed in an attempt to alleviate symptoms. "Given that we have performed corrective surgery for nearly 60 patients with ND, I explain that we have great success with reverse optic capture (ROC), a method that we originally described for this prob- lem in our 2011 publication. We have noted improvement in 21 of 21 cases with ROC for symptomatic ND and have prevented ND in 19 of 19 second eyes for highly symp- tomatic patients. I also mention IOL exchange with sulcus placement, also successful in our experience. We have not had favorable results with IOL exchange where a lens of a different material or design is placed into the existing capsule bag, unless the optic is reverse captured. I also mention a piggyback add on lens. However, the recent removal of the STAAR 3-piece silicone IOLs (STAAR Surgical) from the market- place limits our options. Finally, I mention neodymium (Nd):YAG laser relaxation of the nasal portion of the anterior capsule, which has been reported as successful; we have no experience with that method. I am careful to mention that no guaran- tees for success can be offered but that a stepwise approach is likely to help. "The patient at hand presents case specific challenges. The de- sign of the current IOL precludes ROC, and the presence of pseudo- exfoliation risks zonular damage. Given this setting I would prefer to leave the IOL in place and attempt Nd:YAG laser relaxation of the nasal anterior capsule remnant. As a second tier, I would also petition the U.S. Food and Drug Administra- tion for CUDE (Compassionate Use Device Exemption) to allow use of a Sulcoflex (Rayner, United Kingdom) add on a sulcus-placed IOL. This de- vice is specifically designed for this purpose, and European experience has been somewhat favorable. Sim- ilar to our experience, 70% of cases will benefit. Hopefully, one of these "simple" methods will alleviate the patient's condition. However, as a last-ditch approach, consideration may be given to removal of the ex- isting IOL with sulcus placement of a 3-piece-lens, employing iris suture fixation for long-term stability and centration." Dale Pilkinton, MD, Nashville, Tennessee, commented, "With the intact bag and space visible between the anterior capsule and IOL, an exchange should not be too terribly difficult. Even if you had to ampu- tate part of the IOL and leave it, the remaining part just bolsters the shelf. I would put the new IOL in the sulcus and not do optic capture, as you want to leave this IOL as for- ward as possible. If you end up with a perfect bag, the HDO (Lenstec, St. Petersburg, Florida) is the only in- the-bag IOL that I am confident to go with here." What was done The first thing I did in evaluating this patient was to confirm that this was true classic ND related to the IOL by dilating her. Her symp- toms resolved almost completely in the dilated state, which I felt was confirmatory. I then offered this patient cataract surgery in the OD first to improve her vision there and to see if a 3-piece silicone IOL in the bag would be better tolerated, but she refused to touch the right eye until the problem in the left eye was addressed. After a long discussion on the relative risks and possible complications of a lens exchange, a decision was made to remove the Akreos A060 and replace it with a three-piece silicone lens in a ROC configuration. It is my experience that silicone IOLs are rarely if ever associated with ND, and if the optic is moved up anterior to the capsular bag by either placing the lens in the sulcus or by ROC of the optic, ND is virtually nonexistent. The advantage of ROC over sulcus placement is that it provides a more stable IOL fixa- tion with less risk of lens decentra- tion and also prevents capsular bag phimosis and collapse behind the IOL. ROC of a single-piece Akreos Day 1 post-op after IOL exchange for 3-piece Silicone IOL in reverse optic capture configuration Source (all): Steven G. Safran, MD IOL of course is not possible, so a lens exchange would be required to achieve this configuration. In cases where the rhexis opening is too large, ROC may not be possible, and this is one reason why I chose not to experiment with YAG laser to the nasal anterior capsule prior to offer- ing lens exchange. I have found YAG treatment of the anterior capsule to be helpful in reducing symptoms in about half of the cases where I've tried it, and I do not consider it a reliable cure for the problem. I have also found that it is possible to inadvertently damage the poste- rior capsule when performing laser expansion of the anterior capsule, which would make an IOL exchange more challenging. I did not offer a piggyback implant in this case because I felt an IOL exchange with ROC would be a more reliable and stable intervention. After placing iris retractors, the capsular bag was dilated with viscoelastic material, the lens freed up from the capsular bag and then carefully brought up into the an- terior chamber where it was cut in half and removed. The new lens, a Bausch + Lomb SofPort AO 3-piece silicone IOL, was injected into the capsular bag and the optic then brought anterior to the anterior capsule in an ROC configuration. A CTR was considered but not placed because I did not feel it was required in this case. On day 1, the patient was relieved of all ND symptoms and was 20/25 uncorrected (see Im- age 3). Over the next month her vision dropped to 20/60 due to posterior capsule opacification, but after a YAG laser capsulotomy was performed at 6 weeks, her vision re- turned to 20/20. She was extremely happy with this outcome. EW Editors' note: Dr. Masket has financial interests with Morcher GMBH (Stutt- gart, Germany). The other physicians have no financial interests related to their comments. Contact information Novis: clivenovis@mweb.co.za Riaz: kriaz@bsd.uchicago.edu McKee: mckeeonline@mac.com Masket: sammasket@aol.com Fram: nicfram@yahoo.com Pilkinton: fp_pilkinton@comcast.net Safran: safran12@comcast.net Watch a video from this case now at clinical.ewreplay.org.

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