EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/82503
September 2012 Dell* Toric Axis Markers Case 1 discussion Most of the surgeons consulted here recommended extending the YAG and giving the patient glasses or doing PRK if unsuccessful. For some the relatively low endothelial cell count is a turnoff in the considera- tion of intraocular surgery. Dr. Goldman commented, "Because of the patient's low cell count I would try to avoid significant intraocular surgery and extend the PC opening under the haptics, which I think would be successful in this case. If unsuccessful, I would try placing one (possibly two) CTRs to redistrib- ute the bag forces, but nothing more aggressive than that." This case was complicated by the fact that the lens was tilted about the different axis—the vertical and horizontal. The cornea endothe- lium was somewhat compromised as well. I took this patient to the OR with the thought that I could reposi- tion the lens, strip fibrosis, and place a CTR to treat the Z. In the OR I found that the haptics were absolutely socked in to the capsular bag and could not be freed up. I de- cided to place a CTR over the plates (using the "fishtail technique"), strip fibrosis, do a pars plana vitrectomy, and push the implant behind the posterior capsule to resolve the Z. I felt that if the haptics were so socked in that they were impossible to free up surgically, they could be relied on to securely hold the lens in place in the future, and with no other forces acting on the lens it would end up like a hammock sus- pended from two points by the hap- tic insertion; this would alleviate all the astigmatism. This worked out very well, and the patient ended up 20/20 uncorrected with a refraction of +0.25. Her cornea remained clear (Figures 7 and 8). One of the teaching points of this case is that it demonstrates that with only two points of attachment and with no other forces acting on the implant, the lens will naturally assume a normal symmetric configu- ration like a hammock. Pushing the optic behind the posterior capsule after significant fibrosis has occurred to secure the plates is a reasonable option to consider with the understanding that it may lead to a slightly hyperopic outcome. In some cases this outcome can be achieved 0RECISE!LIGNMENT&OR#ORRECT4ORIC!XIS0LACEMENT &ROM5PRIGHT4HROUGH4HE3UPINE0OSITION with YAG laser rather than surgery, but in this case I felt that surgery was required. In a situation like this there is minimal or no accommoda- tion that can be expected from the implant, but the patient's visual problems are completely resolved. Case 2 discussion In this case although some would attempt further YAG first, most of the panel felt surgery would be required to address this patient's problems. Dr. Whitman succinctly commented to "exchange the lens," while Dr. Khodabakhsh elaborated: "This patient has a severely tilted Crystalens. This will have to be surgically treated. I would place viscoelastic above and behind the lens and try to gently dissect it free. If possible, I would rotate the lens 90 degrees and place a CTR. I would also attempt to clean up all of the residual cortex that remains. Unfor- tunately, sometimes this cannot be performed as the haptics may be stuck so strongly in the area that the lens cannot be freed and rotated without damaging the capsular bag. In that instance, I would cut the optic from the hinge and remove it from the eye. I would then attempt to remove the haptics. If this was done, I would then place a three- piece lens of choice in the sulcus with optic capture." Dr. Goldman also commented that he would consider further YAG but prepare the patient for the likeli- hood of needing an IOL exchange. His choice would be a three-piece IOL in the sulcus with optic capture. My choice for this patient was to avoid further YAG to preserve as much capsule as possible for an in- the-bag replacement. I chose to do a pars plana vitrectomy prior to lens manipulation as vitreous was pro- lapsed and adherent to this implant and then to remove and replace this lens with a three-piece IOL in the capsular bag. A video of that proce- dure can be viewed at www.youtube.com/ watch?v=YxMAZmetpfc. Figure 9 shows a day 1 post-op slit lamp image. She was 20/20 with a –0.5 correction. The three-piece implant can be seen within the cap- sular bag. The patient was extremely pleased with this outcome. continued on page 18 Rotat ing Automatically Orients The Placement Of A The Correct Me r id i a n. Inner Bezel Mark s F o r Toric IOL In Wh ile The Patient Is Upr ight, An Orientation Mark Is P l a c e d Ve r t i c a l l y On The Conjunctiva. Rotating Inner Bezel Is Set To The Desired In Surgery The Meridian. While The Instrument Is Positioned So That The Vertical Conjunctival Mark Is Aligned With The 90 Degree Position On The Outer Bezel Of The Marker. The Marking Blades On The Undersurface Of The Instrument Will Automatically Place A Mark In The Correct Meridian When The Cornea Is Indented. Is Assured. Rotating Weighted So That Correct Horizontal Orientation Inner Bezel Automatically Orients Blades For Corneal Marks For The Placement Of A Toric IOL In The Correct Meridian. Designed For Use With The Patient Upright Immediately Prior To Surgery, The Inner Bezel Is Rotated To The Desired Meridian, And The Cornea Is Indented. The Marking Blades On The Undersurface Of The Instrument Will Automatically Place Marks In The Correct Meridian. 3360 Scherer Drive, Suite B. St.Petersburg, Florida s4EL #OME3EE5S!T!!/"OOTH s&AX 1269 Rev.C -OSES -ICHELANGELO %MAIL )NFO 2HEIN-EDICAL COMs7EBSITE WWW 2HEIN-EDICAL COM $EVELOPED)N#OORDINATION7ITH3TEVEN* $ELL - $ AGAJ 8-12119: Dell Fixed Toric Lens Marker With Rotating Bezel Used When Patient Is In Supine Position 8-12120: Dell Swivel Toric Lens Marker With Rotating Bezel Used When Patient Is In Upright Position