Eyeworld

EW INTERNATIONAL 166 April 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer bly placing an IOL into the ciliary sulcus. What we realized during the surgery is that we could reopen the capsular bag by combining mechani- cal dissection and viscodissection." Knowing how to approach the scenario of a closed capsular bag with a partially or completely extruded IOL is key to getting good results. Dr. Morkos sets about the dissection of the lens bag by cutting through the tight adhesions near the anterior capsule. At this point, he looks for an important landmark: the thick white line denoting the edge of the anterior capsulotomy. Once identified, he begins to me- chanically dissect the capsular bag adding a bolus of viscoelastic mate- rial to enable him to open the bag further. He uses a fine cannula and a viscoelastic-filled syringe. By using both mechanical and viscodissec- tion, Dr. Morkos is able to pry open the entire capsular bag. "Partial or total escape of IOLs from the capsular bag to the sulcus occurs with subsequent closure of the bag by adhesions between anterior and posterior capsules. We have identified the suitable place to start and the best techniques for dis- secting and reopening the capsular bag, no matter how long it has been closed. These peculiar white lines are of great significance, as they give a clear landmark to the edge of the anterior capsulotomy. Once the bag starts to open, the rest of the dissection becomes a little easier, and when the bag is reopened, an implantation in the bag becomes possible. We have been able to im- plant either the same or a new IOL inside the newly opened capsular bag, where it remained stable and perfectly centralized," he said. Cases Dr. Morkos described the case of a male patient who had undergone surgery 6 years earlier. The patient had continuous complaints of un- clear vision and monocular diplopia, and a reoperation was scheduled. Dissection of the lens bag began in the same way, starting at the specific thick white line along the edge of the anterior capsulotomy. The IOL was found to be mobile in the sul- cus, with an intact posterior capsule and closed bag. Mechanical dissec- tion of the bag was initiated until a slight opening was achieved. A bolus How a simple technique can open up the closed capsular bag and free a long-standing displaced sulcus IOL I ntraocular lenses (IOL) need to be well-centered to be any good. Dislocations can cause complaints of ghosting, glare, visual distortions, and diplo- pia and need to be repositioned, removed, or exchanged. Different surgical options are available for this scenario but they can be tricky and cause additional complications. At the 2016 American Academy of Ophthalmology annual meeting in Chicago, Fathy Morkos, MD, Alwatany Eye Hospital, Cairo, Egypt, described his technique for freeing a sulcus-lodged, dislocated IOL and opening the closed capsular bag. "Patients who suffer early or late postoperative displaced IOL often complain of inadequate vision or monocular diplopia. Occasionally, IOL displacement occurs as a result of failure to implant inside the bag. A small pupil during surgery or a lack of enough surgical experience are among the common causes of this problem. Trials at repositioning those lenses into the capsular sulcus usually result in recurrent displace- ment. We introduce here a tech- nique to reopen the capsular bag, even if it was closed for many years. It facilitates in-the-bag implanta- tion and the correction of displaced sulcus IOLs," said Dr. Morkos, the author of the study. How to reopen the capsular bag Dr. Morkos' technique originated as a way to remove opacities caused by posterior capsule opacification (PCO), without the added risk of Nd:YAG laser, which he then translated into a safe way to manage sulcus-displaced IOLs. He explained, "The idea started by a high myopic patient that had cataract surgery before the introduction of low-pow- er intraocular lenses. You were faced with those patients who later developed PCO in an aphakic status. Nd:YAG laser on these eyes carried a great deal of risks. The decision was then taken to clear the capsular opacity surgically while trying to keep the capsule intact and possi- When your dislodged sulcus IOL needs fixing Dissecting the capsular bag open Tips and tricks Specific white line marking the edge of the anterior capsulotomy Postop new IOL sitting nicely inside the reopened bag Source (all): Fathy Morkos, MD

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