Eyeworld

63 EW GLAUCOMA December 2017 rotated 75 degrees in the clockwise direction to minimize the postoper- ative astigmatism. I took the patient to surgery with the plan to reposi- tion and secure this implant rather than to exchange. I was hoping to avoid a vitrectomy in this highly myopic patient to minimize the risk of retinal detachment. A peribulbar block was used. After reopening the capsular bag with viscoelastic I placed iris retractors on the anterior capsule rim to support the capsu- lar bag while I rotated the lens. I chose to use these instead of capsule retractors as I thought they would afford more control in this situation and be less cumbersome to work with. A capsule tension ring was then injected to stabilize the capsu- lar bag equator, and two Gore-Tex sutured capsule tension segments were placed 180 degrees apart to completely secure the capsular bag complex. An iStent was placed in Schlemm's canal and the viscoelastic completely removed to reduce the risk of a pressure spike in the post- operative period. A vitrectomy was not needed in this case. The patient has done well since surgery and had an uneventful postoperative course. The vision recovered to 20/20- with low myopic correction, and the pressure has re- mained controlled in the low teens on dorzolamide/timolol BID. This case demonstrates that cap- sule tension segments can be used not just at the time of cataract sur- gery but at any point in the postop- erative period when stabilization of the capsular bag is needed, provided the capsular bag can be opened for their successful placement. While there were many surgical options available in this case, I think that preserving the capsular bag and making the effort to avoid a vitrec- tomy in this myopic eye justified the cost of the hardware placed in the patient's eye and the time and manipulation it took to place it. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Hart: j.c.hartjr@sbcglobal.net Khan: baseer.khan@mac.com Riaz: kamranmriaz@gmail.com Safran: safran12@comcast.net Sulewski: Michael.Sulewski@uphs.upenn.edu from the IOL using a Sinskey hook followed by inflation of the capsular bag with 1% sodium hyaluronate. Insert three capsular hooks nasally to stabilize the dehisced portion of the capsular bag. The IOL could then be freed up and rotated out of the capsular bag and into the ante- rior chamber. The IOL could be bi- sected using IOL cutting scissors and microforceps, or just make a subtotal cut in the optic and remove the IOL through the temporal incision using the Pac-Man rotational technique. Then perform intra-bag placement of either a Cionni ring or stabilizing segment such that the hook com- ponent of the ring is positioned at the 8–9 o'clock region, which can be sutured to the sclera under a flap or within a groove using 9-0 poly- propylene or a Gore-Tex suture. The other option, depending on what your OR has available, would be to use the Ahmed CTS to place along that dehisced 6–11 o'clock region, suturing the ring to the sclera to stabilize the capsular bag using the suturing technique previously men- tioned. I would then perform ORA [Alcon, Fort Worth, Texas] on the patient and check to see what IOL is recommended (should be about a +14.5 or 15.0 ZCT150 based on the previous +16.0 ZCT150 leaving a spherical equivalent of –1.50) for the –0.50 refractive result, and rotate the IOL to the correct 75-de- gree meridian or whatever the ORA recommends. If you are going for the home run, consider an iStent [Glaukos, San Clemente, California] nasally or maybe even a Xen Gel Stent [Allergan, Dublin, Ireland], which is a more effective pressure lowering intervention. Don't forget to remove the viscoelastic agent and capsule stabilizing hooks, and there may be a need to do a bimanual anterior or par plana vitrectomy approach at some point during the case if vitreous prolapsed around the dehisced capsular bag. "If it all works out, he should end up –0.50 to –0.75 range with an IOP of 12 on no drops." What was done All of the physicians had similar ideas about fixating the capsular bag, and this is mirrored by what was actually done to correct the patient's problem. First, I consulted astigmatismfix.com, which advised that the current toric IOL should be 22 nd ESCRS Winter Meeting 9 – 11 February 2018 Sava Centar, Belgrade, Serbia www.escrs.org In conjunction with the Serbian Society of Cataract and Refractive Surgeons

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