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Although the history mentions that the posterior capsule is intact, Figure 1 does make me wonder. There seems to be a tear or fold behind the optic from about 1 o’clock to 7 o’clock. Placement of a CTR with a radial tear is risky and can cause the radial tear to become a posterior tear, a possibility in this case. The issue is particularly important because with further manipulation of the IOL or bag, the stability of the CTR may also be in question. I think the IOL is mostly decentered because 1 haptic is in and 1 is out of the bag. However, I wonder whether the bag itself is decentered as a result of zonular damage. I do not think that simply repositioning the sulcus haptic into the bag would completely center the IOL. Similarly, I do not think that simply suturing the CTR to better center the bag complex would completely center the IOL. Usually this soon after surgery one can free a 3-piece IOL haptic with minimal effort. However, it could be tricky if the zonular fibers are really weak. Although it would be nice to completely free the existing IOL to reposition or suture it if the zonular fibers are weak and the capsule is sufficiently fused, it may be best to simply cut off the haptic and start over with a new IOL. So all considered, I would free the haptic from the bag with viscodissection using a dispersive OVD. Next, I would rotate the IOL so both haptics are clearly in the sulcus. If the IOL seemed stable, I might stop at this point. However, if the IOL were not stable, I would probably suture the haptics to the iris using a sliding-knot technique.1 Thomas A. Oetting, MS, MD Iowa City, Iowa, USA
REFERENCE 1. Chang DF. Siepser slipknot for McCannel iris-suture fixation of subluxated intraocular lenses. J Cataract Refract Surg 2004; 30:1170–1176
- The precis provides several important pieces of information. First, a CTR is in place. Second, the temporal haptic is in the bag and the nasal haptic is in the sulcus. Third, the IOL–bag complex is decentered nasally. Fourth, the spherical equivalent is slightly hyperopic and insufficient to justify an IOL exchange on the basis of power need. Because the patient is now 5 months postoperative, the IOL–bag complex is “mature.” Hence it should tolerate a suture passed through it without causing further tearing of the capsule. However, it is unlikely
to be reopened without damage, especially given the stellate scar and the degree of capsule edge–capsule contact. Inferred is that the nasal haptic may be through the zonular fibers or zonular gap. Thus, although the bag–CTR complex may be reasonably well centered, the IOL may be more nasally decentered than the capsule. The first step is to determine whether simply moving the IOL–bag complex temporally would be sufficient to properly position the IOL. To do this, one could engage the nasal optic with a Sinskey hook and attempt to gently move the entire capsular bag complex temporally. It appears as though we have only a few millimeters of slack space between the periphery of the CTR and the ciliary sulcus. Thus, lateral movement may not be enough to place the IOL optic in a position to reduce the patient’s symptoms. If successful, I would pass a 9-0 polypropylene or polytetrafluoroethylene (Gore-Tex) suture through the peripheral bag encompassing the CTR and then retrieve the suture through the sclera via the ciliary sulcus to secure the IOL in position. Because the nasal haptic is in the sulcus, moving the IOL bag complex temporally to recenter the IOL may cause the nasal haptic, especially if the patient develops a Soemmerring ring, to become displaced anteriorly into the posterior iris and result in uveitis–glaucoma–hyphema syndrome. I suspect, however, that even though there may be zonular loss temporally with nasal shift of the CTR bag complex, due to the sulcus placement of the nasal haptic the IOL is more nasally displaced than the capsule. If this is the case, the IOL must be removed from the capsular bag, repositioned in the PC, and secondarily fixated. Fixation of the IOL could be accomplished by several methods, such as scleral or iris fixation of the haptics. As a final note, it is generally unwise to place a CTR in an eye with an anterior capsule tear. Although the surgeon was able to accomplish that in this case, it is likely that the spreading forces generated by the placement and presence of a CTR will cause a fresh anterior capsule tear to extend posteriorly, thus going from a minor inconvenience to a catastrophic bag failure. M. Bowes Hamill, MD Houston, Texas, USA
- This patient has marked nasal decentration of a 3-piece acrylic IOL. It appears from Figure 1 that the majority of the optic and nasal haptic are outside the
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capsular bag. There does not appear to be a usable capsular bag due to the degree of fusion of the anterior capsule and posterior capsule elements, particularly temporal to the IOL. The overall position of the capsular bag, however, appears to be fairly central. This is evidenced by the position of the CTR, which is outside the confines of the pupillary margin, except in the area where the islets are barely visible. The capsular bag diameter would appear to be large because there is no overlap of the islets of the CTR. There also appears to be a fairly large anterior segment diameter overall based on the ratio of the optic diameter to the limbal diameter. The operating surgeon was apparently fortunate to avoid complications after placing a CTR in a capsular bag with a noncontinuous anterior capsulorhexis. In my opinion, it is not possible to place the existing IOL in the capsular bag; therefore, any surgical plan would involve extricating the portion of the IOL that remains in the capsular bag. The options would then include exchanging the existing IOL for a largediameter 3-piece sulcus IOL if there is good support and centration or creating a posterior capsulorhexis and capturing the optic of the existing IOL while leaving both haptics in the sulcus. If neither of these options provides adequate IOL stability, additional support with peripheral iris suture fixation would be a consideration and could be performed using the existing IOL. I would begin the surgical procedure with a combination of a dispersive and cohesive OVD in the AC in a soft-shell configuration. I would inspect the areas behind the peripheral iris, looking for intact zonular support. I suspect in this case there is good support
because of apparent centration of the capsular bag and the absence of prolapsed vitreous. Because the patient is only 5 months postoperative, it would probably be fairly easy to rotate the temporal haptic out of the capsular bag and thus free the IOL with a minimal amount of manipulation. If this were difficult, amputation of the haptic could be an option, although I doubt that is necessary here. I would move the IOL a little more anteriorly and then into the AC, at least on a temporary basis while the options are being considered. I believe that to place an IOL in this eye purely in the sulcus would require the largest overall diameter 3-piece IOL, which for me would be the AQ2010V (Staar Surgical Co.). I would have 1 of those on hand with a power appropriate for sulcus positioning. Another consideration would be creating a posterior capsulorhexis opening underneath the existing IOL. The concern I have with that approach in this case is that the prominent stellate fibrosis might preclude simply tearing a posterior capsule opening and instead require sharp cutting with microscissors. If posterior capture did not appear to be a feasible maneuver, I would abort and use IOL-cutting instruments to remove the existing IOL, place the 13.5 mm diameter 3-piece IOL in the sulcus, and consider peripheral iris suturing. Using 1 or a combination of these approaches, I believe the patient has an excellent chance of obtaining improved visual symptoms with a reasonably wellcentered PC IOL.
Figure 2. Endoscopic view of the nasal ciliary sulcus. The tip of the IOL loop haptic can be seen above the peripheral anterior capsule remnant and in contact with the ciliary processes.
Figure 3. Postoperative photograph shows a well-centered IOL in the ciliary sulcus with iris suture fixation and an unchanged capsular bag.
Garry P. Condon, MD Pittsburgh, Pennsylvania, USA
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
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EDITOR’S COMMENTS As mentioned by some of the respondents, this case offers 2 important teaching points. First, placing a CTR with an incomplete continuous anterior capsulotomy is not helpful and is indeed contraindicated because it may cause the tear to extend with several possible negative consequences. Second, in the situation of a single radial tear, the IOL may be placed in the capsular bag and be expected to remain stable if the loops are oriented perpendicular to, rather than parallel to, the meridian of the capsule tear. Neither of these tenets was respected in the original surgery. Although the oblique line in the posterior capsule may appear as a defect, the posterior capsule was indeed intact. The surgical plan was devised to avoid further damage to the capsular bag in view of the CTR, which would be best left undisturbed given that it was stable. Moreover, considering the modest hyperopic error, it would be advantageous to bring the optic anteriorly. And, finally, given that the particular IOL has built-in negative asphericity, permanent centration would be important. In light of these concerns it seemed most logical to rotate the temporal loop out of the capsule bag and into the ciliary sulcus, orient the loops superior to inferior, and sew the loops to the iris for stability. That plan was followed at surgery and the capsular bag–CTR complex remained undisturbed. Endoscopy with the endoscopic cyclophotocoagulation unit confirmed that the nasal loop of the IOL was in the ciliary sulcus (Figure 2) and that the CTR was in the peripheral capsule. The IOL centered well (Figure 3), and subsequently the posterior capsule was opened with an Nd:YAG laser.
Samuel Masket, MD Los Angeles, California, USA
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
CONSULTATION SECTION
Although the history mentions that the posterior capsule is intact, Figure 1 does make me wonder. There seems to be a tear or fold behind the optic from about 1 o’clock to 7 o’clock. Placement of a CTR with a radial tear is risky and can cause the radial tear to become a posterior tear, a possibility in this case. The issue is particularly important because with further manipulation of the IOL or bag, the stability of the CTR may also be in question. I think the IOL is mostly decentered because 1 haptic is in and 1 is out of the bag. However, I wonder whether the bag itself is decentered as a result of zonular damage. I do not think that simply repositioning the sulcus haptic into the bag would completely center the IOL. Similarly, I do not think that simply suturing the CTR to better center the bag complex would completely center the IOL. Usually this soon after surgery one can free a 3-piece IOL haptic with minimal effort. However, it could be tricky if the zonular fibers are really weak. Although it would be nice to completely free the existing IOL to reposition or suture it if the zonular fibers are weak and the capsule is sufficiently fused, it may be best to simply cut off the haptic and start over with a new IOL. So all considered, I would free the haptic from the bag with viscodissection using a dispersive OVD. Next, I would rotate the IOL so both haptics are clearly in the sulcus. If the IOL seemed stable, I might stop at this point. However, if the IOL were not stable, I would probably suture the haptics to the iris using a sliding-knot technique.1 Thomas A. Oetting, MS, MD Iowa City, Iowa, USA
REFERENCE 1. Chang DF. Siepser slipknot for McCannel iris-suture fixation of subluxated intraocular lenses. J Cataract Refract Surg 2004; 30:1170–1176
- The precis provides several important pieces of information. First, a CTR is in place. Second, the temporal haptic is in the bag and the nasal haptic is in the sulcus. Third, the IOL–bag complex is decentered nasally. Fourth, the spherical equivalent is slightly hyperopic and insufficient to justify an IOL exchange on the basis of power need. Because the patient is now 5 months postoperative, the IOL–bag complex is “mature.” Hence it should tolerate a suture passed through it without causing further tearing of the capsule. However, it is unlikely
to be reopened without damage, especially given the stellate scar and the degree of capsule edge–capsule contact. Inferred is that the nasal haptic may be through the zonular fibers or zonular gap. Thus, although the bag–CTR complex may be reasonably well centered, the IOL may be more nasally decentered than the capsule. The first step is to determine whether simply moving the IOL–bag complex temporally would be sufficient to properly position the IOL. To do this, one could engage the nasal optic with a Sinskey hook and attempt to gently move the entire capsular bag complex temporally. It appears as though we have only a few millimeters of slack space between the periphery of the CTR and the ciliary sulcus. Thus, lateral movement may not be enough to place the IOL optic in a position to reduce the patient’s symptoms. If successful, I would pass a 9-0 polypropylene or polytetrafluoroethylene (Gore-Tex) suture through the peripheral bag encompassing the CTR and then retrieve the suture through the sclera via the ciliary sulcus to secure the IOL in position. Because the nasal haptic is in the sulcus, moving the IOL bag complex temporally to recenter the IOL may cause the nasal haptic, especially if the patient develops a Soemmerring ring, to become displaced anteriorly into the posterior iris and result in uveitis–glaucoma–hyphema syndrome. I suspect, however, that even though there may be zonular loss temporally with nasal shift of the CTR bag complex, due to the sulcus placement of the nasal haptic the IOL is more nasally displaced than the capsule. If this is the case, the IOL must be removed from the capsular bag, repositioned in the PC, and secondarily fixated. Fixation of the IOL could be accomplished by several methods, such as scleral or iris fixation of the haptics. As a final note, it is generally unwise to place a CTR in an eye with an anterior capsule tear. Although the surgeon was able to accomplish that in this case, it is likely that the spreading forces generated by the placement and presence of a CTR will cause a fresh anterior capsule tear to extend posteriorly, thus going from a minor inconvenience to a catastrophic bag failure. M. Bowes Hamill, MD Houston, Texas, USA
- This patient has marked nasal decentration of a 3-piece acrylic IOL. It appears from Figure 1 that the majority of the optic and nasal haptic are outside the
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capsular bag. There does not appear to be a usable capsular bag due to the degree of fusion of the anterior capsule and posterior capsule elements, particularly temporal to the IOL. The overall position of the capsular bag, however, appears to be fairly central. This is evidenced by the position of the CTR, which is outside the confines of the pupillary margin, except in the area where the islets are barely visible. The capsular bag diameter would appear to be large because there is no overlap of the islets of the CTR. There also appears to be a fairly large anterior segment diameter overall based on the ratio of the optic diameter to the limbal diameter. The operating surgeon was apparently fortunate to avoid complications after placing a CTR in a capsular bag with a noncontinuous anterior capsulorhexis. In my opinion, it is not possible to place the existing IOL in the capsular bag; therefore, any surgical plan would involve extricating the portion of the IOL that remains in the capsular bag. The options would then include exchanging the existing IOL for a largediameter 3-piece sulcus IOL if there is good support and centration or creating a posterior capsulorhexis and capturing the optic of the existing IOL while leaving both haptics in the sulcus. If neither of these options provides adequate IOL stability, additional support with peripheral iris suture fixation would be a consideration and could be performed using the existing IOL. I would begin the surgical procedure with a combination of a dispersive and cohesive OVD in the AC in a soft-shell configuration. I would inspect the areas behind the peripheral iris, looking for intact zonular support. I suspect in this case there is good support
because of apparent centration of the capsular bag and the absence of prolapsed vitreous. Because the patient is only 5 months postoperative, it would probably be fairly easy to rotate the temporal haptic out of the capsular bag and thus free the IOL with a minimal amount of manipulation. If this were difficult, amputation of the haptic could be an option, although I doubt that is necessary here. I would move the IOL a little more anteriorly and then into the AC, at least on a temporary basis while the options are being considered. I believe that to place an IOL in this eye purely in the sulcus would require the largest overall diameter 3-piece IOL, which for me would be the AQ2010V (Staar Surgical Co.). I would have 1 of those on hand with a power appropriate for sulcus positioning. Another consideration would be creating a posterior capsulorhexis opening underneath the existing IOL. The concern I have with that approach in this case is that the prominent stellate fibrosis might preclude simply tearing a posterior capsule opening and instead require sharp cutting with microscissors. If posterior capture did not appear to be a feasible maneuver, I would abort and use IOL-cutting instruments to remove the existing IOL, place the 13.5 mm diameter 3-piece IOL in the sulcus, and consider peripheral iris suturing. Using 1 or a combination of these approaches, I believe the patient has an excellent chance of obtaining improved visual symptoms with a reasonably wellcentered PC IOL.
Figure 2. Endoscopic view of the nasal ciliary sulcus. The tip of the IOL loop haptic can be seen above the peripheral anterior capsule remnant and in contact with the ciliary processes.
Figure 3. Postoperative photograph shows a well-centered IOL in the ciliary sulcus with iris suture fixation and an unchanged capsular bag.
Garry P. Condon, MD Pittsburgh, Pennsylvania, USA
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
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CONSULTATION SECTION
EDITOR’S COMMENTS As mentioned by some of the respondents, this case offers 2 important teaching points. First, placing a CTR with an incomplete continuous anterior capsulotomy is not helpful and is indeed contraindicated because it may cause the tear to extend with several possible negative consequences. Second, in the situation of a single radial tear, the IOL may be placed in the capsular bag and be expected to remain stable if the loops are oriented perpendicular to, rather than parallel to, the meridian of the capsule tear. Neither of these tenets was respected in the original surgery. Although the oblique line in the posterior capsule may appear as a defect, the posterior capsule was indeed intact. The surgical plan was devised to avoid further damage to the capsular bag in view of the CTR, which would be best left undisturbed given that it was stable. Moreover, considering the modest hyperopic error, it would be advantageous to bring the optic anteriorly. And, finally, given that the particular IOL has built-in negative asphericity, permanent centration would be important. In light of these concerns it seemed most logical to rotate the temporal loop out of the capsule bag and into the ciliary sulcus, orient the loops superior to inferior, and sew the loops to the iris for stability. That plan was followed at surgery and the capsular bag–CTR complex remained undisturbed. Endoscopy with the endoscopic cyclophotocoagulation unit confirmed that the nasal loop of the IOL was in the ciliary sulcus (Figure 2) and that the CTR was in the peripheral capsule. The IOL centered well (Figure 3), and subsequently the posterior capsule was opened with an Nd:YAG laser.
Samuel Masket, MD Los Angeles, California, USA
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
