OCT 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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16 EW NEWS & OPINION October 2012 Tools & techniques Suturing the peripheral fibrotic capsule with bag dislocation by Howard Gimbel, M.D. I OL-in-bag subluxations are becoming a more frequent occurrence in my practice. I continue to be impressed with how many of these patients had initial routine cataract surgery in the presence of pseudoexfoliation (PXF) with no evidence of zonular weakness or intraoperative com- promise, only to later develop significant pseudophacodonesis and subluxation 7-10 years later. Although the vast majority of PXF patients will never develop this compli- cation, I now implant a capsular tension ring (CTR) in all my PXF patients in order to assist in scleral fixation when the rare case of subluxation does develop. When the haptics of an IOL-in-bag subluxation are aligned at 12 and 6 o'clock with an inferi- orly subluxed complex, fixation is fairly straightforward. When the haptics are oriented at 9 and 3 o'clock with an inferi- orly subluxed lens, the surgical strategy becomes slightly more challenging. Although a CTR may not prevent IOL-in-bag subluxations, it does offer 360 degrees of choices for fixating the bag to the sclera. Unfortunately, I still encounter subluxed bags with either plate haptic IOLs or IOLs with unfavorably oriented haptics where a simple previously placed CTR would have made the case less complicated. In this month's column, Howard Gimbel, M.D., describes his approach for suturing subluxed lenses to the sclera utilizing the fibrosed capsule as his fixation point. This technique should be especially useful in those cases where fixation of the actual IOL is not possible. Richard Hoffman, M.D., Tools & techniques editor Figure 1: Paracentesis and superior Hoffman scleral incisions are made and a double-armed 10-0 prolene suture is passed through the fibrotic CCC and out through the main superior incision Figure 2. The second needle of the double-armed suture is passed over the fibrotic CCC where the needles are cut and sutures are left untied or temporarily tied with a slip knot Two point fixation and IOL centration is achieved Source (all): Howard Gimbel, M.D. D ecentration and subluxa- tion of in-bag posterior chamber IOLs is usually a late complication that occurs many years follow- ing cataract surgery. Causes include a poorly constructed anterior con- tinuous curvilinear capsulorhexis (CCC), asymmetric intraoperative haptic placement, trauma, previous vitrectomy, pseudoexfoliation syndrome, connective tissue dis- eases, high myopia, and progressive zonular dehiscence, among others.1 Several options have been proposed in the literature to secure IOLs in this context, including iris-sutured posterior chamber IOLs (PC IOLs),2,3 scleral-sutured PC IOLs,2-9 and IOLs with haptics tunneled within the sclera.10 More recently, an anchoring device that grasps the edges of the capsulorhexis and is secured to the scleral wall has been successful in experimental models.11 ing loose or eccentric three-piece IOL haptics to fibrotic elements of capsular membranes to achieve proper centration and fixation.12 I propose su- turing the peripheral fibrotic capsule with bag dislocation as a technique for the surgical management of in- bag IOL subluxation. This technique involves centering and fixating the bag-IOL complex by suturing only the fibrotic CCC directly to the sclera using a modified Hoffman technique. The concept of using the fibrotic anterior CCC rim for suture fixation is an extension of our previ- ously published technique of sutur- Surgical technique I recently had a surgical case that involved a 95-year-old woman who had uneventful and uncomplicated left eye phacoemulsification with in- bag IOL implantation in 2003. She presented with increasingly blurred vision in the left eye and bilateral floaters. On examination, the best corrected distance visual acuity (BCVA) in the left eye was 20/40 with a manifest refraction of +0.75 –1.25 x 090, and IOP was 22 mm Hg by Goldmann applanation. Slit lamp examination of the left eye demon- strated prolapsed vitreous though the pupil superiorly, patent periph- eral iridotomies at 1 and 11 o'clock, and 3.5 mm central posterior capsu- lotomy. The entire bag-IOL complex was subluxated inferiorly, and the capsule membrane had a ring of fibrosis around the CCC, which was smaller than the optic. Examination of the posterior segment was only significant for bilateral posterior vit- reous detachments. After discussion of all relevant risks, benefits, and alternatives, the patient agreed to undergo scleral fixation of the subluxated IOL-bag complex with sutures through the fibrotic CCC. Suturing of the peripheral fi- brotic capsule with bag dislocation was used for the surgical manage- ment of this in-bag IOL subluxation. It involved routine surgical prepara- tion and draping, tetracaine 0.5% drops instilled on the eye, and the white-to-white corneal diameter, measured with calipers. It was 11 mm. Two limbal paracenteses were fashioned at 2:30 and 9:30 using a 2 mm diamond blade. Approximately 0.5 ml of preservative-free lidocaine 1% was then instilled into the ante- rior chamber for intracameral anes- thesia. A small amount of OcuCoat (Bausch + Lomb, Rochester, N.Y.) was injected to maintain the ante- rior chamber. In order to stabilize the IOL prior to anterior vitrectomy, a single-armed 10-0 prolene suture on a curved needle was passed from the 9:30 paracentesis, through the pupil and capsular membrane, and out through the 2:30 paracentesis using a 26-gauge needle to guide it. A thorough bimanual anterior vitrectomy was performed using a small bolus of triamacinolone 40 mg to better visualize the vitreous. After a limited superior conjunctival perit- omy, a 3 mm half-thickness scleral tunnel pocket incision was made 2 mm posterior to the limbus for a modified Hoffmann technique.8 To fixate the bag/IOL, the first needle of a double-armed 10-0 pro-

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