CONSULTATION SECTION
Cataract Surgical Problem Edited by Samuel Masket, MD
A 74-year-old woman was referred for evaluation of visual complaints after cataract surgery performed 5 months earlier in the left eye. She notes marked difficulty at nighttime, observing a C-shaped light arc, glare, and monocular diplopia. Examination of the left eye (Figure 1) shows a nasally decentered 3-piece acrylic intraocular lens (IOL) (Tecnis ZA9003, Abbott Medical Optics) with the loops oriented horizontally. In addition, the eyelets of a capsular tension ring (CTR) are visible in the capsular bag inferotemporally. The anterior and posterior capsule leaflets are fused to form a stellate fibrotic scar adjacent to the temporal edge of the IOL. The posterior capsule is intact, the IOL–capsular bag– CTR complex appears to be stable, and there is no evidence of vitreous in the anterior chamber (AC). Gonioscopic examination suggests that the nasal IOL loop is in the ciliary sulcus anterior to the capsular bag. The posterior segment examination was unremarkable. Other than moderate nuclear cataract, the fellow right eye is physically normal. A review of the surgeon’s operative note indicates that the anterior capsulotomy extended radially in the horizontal meridian after nuclear emulsification, although the posterior capsule remained intact. Furthermore, the surgeon’s note states, “A capsule tension ring was positioned to span the area of the anterior capsular tear.” Current findings include a corrected distance visual acuity of 20/40 with 0.50 diopter sphere in the right eye and 20/30 with +0.50 0.50 170 in the
Figure 1. Slitlamp photograph of the left eye shows a nasally decentered 3-piece IOL and a stellate star of the fused anterior and posterior capsules; the eyelets of a CTR are visible inferotemporally.
1390
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
left eye. The intraocular pressure is 17 mm Hg and 13 mm Hg, respectively. Given the patient’s symptoms and findings, how would you proceed?
- I would address the following 2 issues to reduce this patient’s dysphotopsia and diplopia: IOL centration and removal of scarred capsule from the visual pathway. Under Arshinoff soft-shell tamponade of ophthalmic viscosurgical device (OVD), I would retract the iris to inspect the nasal haptic. If adhesions are present, they will require dissection. I would then viscodissect the temporal haptic from the capsule with a dispersive OVD, initiated with a 30-gauge hypodermic needle on the OVD syringe, insinuating the bevel under the anterior capsule overlying the haptic–optic junction. Once space is established, I would pursue further viscodissection with the regular OVD cannula. The IOL would then be dialed into the sulcus. After a miotic agent is instilled and pupil–optic capture achieved, I would suture each haptic to midperipheral iris with 10-0 polypropylene using a Siepser sliding knot.1 Iris fixation will help stabilize and center the optic on the pupil. The anterior optic edge of the Tecnis ZA9003 IOL is not sharply truncated and well tolerated for iris suture fixation in my experience. Given the current refraction, an acceptable slight myopic shift will occur with iris fixation of this IOL. I would not retrieve the CTR because extensive capsule dissection may be required that would further compromise zonular integrity or the posterior capsule, and the ring will likely remain stable and not impede visual performance. This procedure can be accomplished using paracenteses, and the OVD would be removed with bimanual irrigation/aspiration (I/A). The surgeon and patient should be prepared for issues that may evolve during surgery, with possible IOL exchange, capsule and CTR removal, anterior vitrectomy, and contingency IOL options. For example, if the temporal haptic cannot be dissected, it can be cut from the optic using IOL cutting microscissors. After the optic is bisected and removed, the temporal haptic would be more easily manipulated out of the capsule with a microforceps. I would then introduce a new IOL via an injector into the sulcus. I find iris-suture fixation of the CQ2015A IOL (Staar Surgical Co.) works 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.06.003
CONSULTATION SECTION
well. The collagen copolymer material is well tolerated, the anterior optic edge is not truncated, and the haptics are robust. The power for this IOL would be calculated for sulcus placement as per the adjustment table of Hill.A Preparation of other IOL placement options, including AC IOL or posterior chamber (PC) IOL scleral fixation, should be considered. If the posterior capsule is not removed, disrupted, or opened during the procedure, subsequent neodymium:YAG (Nd:YAG) capsulotomy will be required. In the presence of a radial tear, a CTR is contraindicated. The CTR loop is likely in the nasal sulcus and should be stable. Placing the CTR probably extended the radial tear to the capsule fornix and displaced the capsule flaps peripherally, leading to IOL decentration. In such a case, I would avoid the CTR and place a 1-piece acrylic PC IOL with haptics positioned superiorly and inferiorly; that is, away from the radial tear but in the capsule. Jason Jones, MD Sioux City, Iowa, USA Dr. Jones is a consultant to Abbott Medical Optics. REFERENCE 1. Osher RH, Snyder ME, Cionni RJ. Modification of the Siepser slipknot technique. J Cataract Refract Surg 2005; 31:1098–1100
OTHER CITED MATERIAL A. Hill W. IOL power calculations; bag vs. sulcus IOL power. Available at: http://www.doctor-hill.com/iol-main/bag-sulcus.htm. Accessed May 23, 2014
- I am convinced that this patient’s symptoms are from the subluxated IOL and, to a lesser degree, the capsule fibrosis. The centration of the bag itself and the placement of the CTR in the fornix of the capsular bag are quite acceptable. I would approach this case by pressurizing the AC with an OVD that has both dispersive and cohesive properties, watching for a slight posterior concavity to the fused anterior and posterior capsules. I would dial the capsule-fixated haptic into the ciliary sulcus and then create a small opening in the fused capsule complex as close to center as reasonably possible, given the fibrotic changes. I would use a 23- or 25gauge microscissors to create a central opening in the capsule, spiraling slowly outward and aiming for an approximately 4.0 to 4.5 mm final opening, recognizing that as the central tractional forces are released, the opening will become bigger. If I encountered normal, nonfibrotic capsule during this process, I would convert my increasing spiral to a continuous tear. A Seibel-style forceps and a 23-gauge Snyder
1391
ruler (both Microsurgical Technology) have a ruler incorporated into them, and either can be used to measure the size of the opening during this process. Alternatively, one can estimate the size based on the 6.0 mm size of the IOL optic. As long as the AC pressure is maintained, vitreous will not come forward. If vitreous is encountered, a 23-gauge cutter could be placed through a pars plana trocar and, using anterior irrigation from a paracentesis, the vitrector could be used to truncate the offending gel and to carve the remainder of the capsule opening to the desired size. Once the aperture is achieved, I would capture the optic into Berger space, leaving the haptics in the sulcus. I would remove the OVD via the paracenteses and place intraocular carbachol. Michael E. Snyder, MD Cincinnati, Ohio, USA
- In this case of a 3-piece acrylic IOL in a bag–sulcus position, capsule contraction and scarring have caused a nasal dislocation that has become visually disabling. When planning the surgical approach to repair, one must consider the style of the IOL, state of the capsule, and condition of the zonular fibers. A 3-piece acrylic IOL offers maximum flexibility with haptics that can be safely placed in the ciliary sulcus, sutured to the iris, or externalized and fixated in the sclera. With an intact posterior capsule, the ability to manipulate the IOL without entanglement from vitreous is good, with little risk for posterior dislocation. With a stable-appearing IOL–capsular bag–CTR complex and no vitreous prolapse, the zonular fibers are likely to be intact. However, visualization of the CTR eyelets and the noncompressed temporal IOL haptic suggests some nasal decentration of the entire capsular bag. Careful attention must be paid to temporal zonular support, which may be compromised or missing. My initial surgical approach would be to free the IOL from the capsular bag. Injection of OVD behind the optic should separate it from the bag. I would then rotate clockwise to release the haptics from the ciliary sulcus and the capsular bag. Unlike the haptics of a 1-piece IOL, the thin haptics of a 3-piece IOL exert minimal countertraction due to their smooth contour. Being particularly mindful of the temporal zonular fibers during this critical step, I may apply some countertraction on the capsular bag near the site of the haptic–optic junction. The presence of the CTR is advantageous and should help stabilize the entire capsule complex during IOL mobilization. After freeing the IOL, I would rotate the haptics and place them in the sulcus at the 2 o’clock and
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
Cataract Surgical Problem Edited by Samuel Masket, MD
A 74-year-old woman was referred for evaluation of visual complaints after cataract surgery performed 5 months earlier in the left eye. She notes marked difficulty at nighttime, observing a C-shaped light arc, glare, and monocular diplopia. Examination of the left eye (Figure 1) shows a nasally decentered 3-piece acrylic intraocular lens (IOL) (Tecnis ZA9003, Abbott Medical Optics) with the loops oriented horizontally. In addition, the eyelets of a capsular tension ring (CTR) are visible in the capsular bag inferotemporally. The anterior and posterior capsule leaflets are fused to form a stellate fibrotic scar adjacent to the temporal edge of the IOL. The posterior capsule is intact, the IOL–capsular bag– CTR complex appears to be stable, and there is no evidence of vitreous in the anterior chamber (AC). Gonioscopic examination suggests that the nasal IOL loop is in the ciliary sulcus anterior to the capsular bag. The posterior segment examination was unremarkable. Other than moderate nuclear cataract, the fellow right eye is physically normal. A review of the surgeon’s operative note indicates that the anterior capsulotomy extended radially in the horizontal meridian after nuclear emulsification, although the posterior capsule remained intact. Furthermore, the surgeon’s note states, “A capsule tension ring was positioned to span the area of the anterior capsular tear.” Current findings include a corrected distance visual acuity of 20/40 with 0.50 diopter sphere in the right eye and 20/30 with +0.50 0.50 170 in the
Figure 1. Slitlamp photograph of the left eye shows a nasally decentered 3-piece IOL and a stellate star of the fused anterior and posterior capsules; the eyelets of a CTR are visible inferotemporally.
1390
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
left eye. The intraocular pressure is 17 mm Hg and 13 mm Hg, respectively. Given the patient’s symptoms and findings, how would you proceed?
- I would address the following 2 issues to reduce this patient’s dysphotopsia and diplopia: IOL centration and removal of scarred capsule from the visual pathway. Under Arshinoff soft-shell tamponade of ophthalmic viscosurgical device (OVD), I would retract the iris to inspect the nasal haptic. If adhesions are present, they will require dissection. I would then viscodissect the temporal haptic from the capsule with a dispersive OVD, initiated with a 30-gauge hypodermic needle on the OVD syringe, insinuating the bevel under the anterior capsule overlying the haptic–optic junction. Once space is established, I would pursue further viscodissection with the regular OVD cannula. The IOL would then be dialed into the sulcus. After a miotic agent is instilled and pupil–optic capture achieved, I would suture each haptic to midperipheral iris with 10-0 polypropylene using a Siepser sliding knot.1 Iris fixation will help stabilize and center the optic on the pupil. The anterior optic edge of the Tecnis ZA9003 IOL is not sharply truncated and well tolerated for iris suture fixation in my experience. Given the current refraction, an acceptable slight myopic shift will occur with iris fixation of this IOL. I would not retrieve the CTR because extensive capsule dissection may be required that would further compromise zonular integrity or the posterior capsule, and the ring will likely remain stable and not impede visual performance. This procedure can be accomplished using paracenteses, and the OVD would be removed with bimanual irrigation/aspiration (I/A). The surgeon and patient should be prepared for issues that may evolve during surgery, with possible IOL exchange, capsule and CTR removal, anterior vitrectomy, and contingency IOL options. For example, if the temporal haptic cannot be dissected, it can be cut from the optic using IOL cutting microscissors. After the optic is bisected and removed, the temporal haptic would be more easily manipulated out of the capsule with a microforceps. I would then introduce a new IOL via an injector into the sulcus. I find iris-suture fixation of the CQ2015A IOL (Staar Surgical Co.) works 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.06.003
CONSULTATION SECTION
well. The collagen copolymer material is well tolerated, the anterior optic edge is not truncated, and the haptics are robust. The power for this IOL would be calculated for sulcus placement as per the adjustment table of Hill.A Preparation of other IOL placement options, including AC IOL or posterior chamber (PC) IOL scleral fixation, should be considered. If the posterior capsule is not removed, disrupted, or opened during the procedure, subsequent neodymium:YAG (Nd:YAG) capsulotomy will be required. In the presence of a radial tear, a CTR is contraindicated. The CTR loop is likely in the nasal sulcus and should be stable. Placing the CTR probably extended the radial tear to the capsule fornix and displaced the capsule flaps peripherally, leading to IOL decentration. In such a case, I would avoid the CTR and place a 1-piece acrylic PC IOL with haptics positioned superiorly and inferiorly; that is, away from the radial tear but in the capsule. Jason Jones, MD Sioux City, Iowa, USA Dr. Jones is a consultant to Abbott Medical Optics. REFERENCE 1. Osher RH, Snyder ME, Cionni RJ. Modification of the Siepser slipknot technique. J Cataract Refract Surg 2005; 31:1098–1100
OTHER CITED MATERIAL A. Hill W. IOL power calculations; bag vs. sulcus IOL power. Available at: http://www.doctor-hill.com/iol-main/bag-sulcus.htm. Accessed May 23, 2014
- I am convinced that this patient’s symptoms are from the subluxated IOL and, to a lesser degree, the capsule fibrosis. The centration of the bag itself and the placement of the CTR in the fornix of the capsular bag are quite acceptable. I would approach this case by pressurizing the AC with an OVD that has both dispersive and cohesive properties, watching for a slight posterior concavity to the fused anterior and posterior capsules. I would dial the capsule-fixated haptic into the ciliary sulcus and then create a small opening in the fused capsule complex as close to center as reasonably possible, given the fibrotic changes. I would use a 23- or 25gauge microscissors to create a central opening in the capsule, spiraling slowly outward and aiming for an approximately 4.0 to 4.5 mm final opening, recognizing that as the central tractional forces are released, the opening will become bigger. If I encountered normal, nonfibrotic capsule during this process, I would convert my increasing spiral to a continuous tear. A Seibel-style forceps and a 23-gauge Snyder
1391
ruler (both Microsurgical Technology) have a ruler incorporated into them, and either can be used to measure the size of the opening during this process. Alternatively, one can estimate the size based on the 6.0 mm size of the IOL optic. As long as the AC pressure is maintained, vitreous will not come forward. If vitreous is encountered, a 23-gauge cutter could be placed through a pars plana trocar and, using anterior irrigation from a paracentesis, the vitrector could be used to truncate the offending gel and to carve the remainder of the capsule opening to the desired size. Once the aperture is achieved, I would capture the optic into Berger space, leaving the haptics in the sulcus. I would remove the OVD via the paracenteses and place intraocular carbachol. Michael E. Snyder, MD Cincinnati, Ohio, USA
- In this case of a 3-piece acrylic IOL in a bag–sulcus position, capsule contraction and scarring have caused a nasal dislocation that has become visually disabling. When planning the surgical approach to repair, one must consider the style of the IOL, state of the capsule, and condition of the zonular fibers. A 3-piece acrylic IOL offers maximum flexibility with haptics that can be safely placed in the ciliary sulcus, sutured to the iris, or externalized and fixated in the sclera. With an intact posterior capsule, the ability to manipulate the IOL without entanglement from vitreous is good, with little risk for posterior dislocation. With a stable-appearing IOL–capsular bag–CTR complex and no vitreous prolapse, the zonular fibers are likely to be intact. However, visualization of the CTR eyelets and the noncompressed temporal IOL haptic suggests some nasal decentration of the entire capsular bag. Careful attention must be paid to temporal zonular support, which may be compromised or missing. My initial surgical approach would be to free the IOL from the capsular bag. Injection of OVD behind the optic should separate it from the bag. I would then rotate clockwise to release the haptics from the ciliary sulcus and the capsular bag. Unlike the haptics of a 1-piece IOL, the thin haptics of a 3-piece IOL exert minimal countertraction due to their smooth contour. Being particularly mindful of the temporal zonular fibers during this critical step, I may apply some countertraction on the capsular bag near the site of the haptic–optic junction. The presence of the CTR is advantageous and should help stabilize the entire capsule complex during IOL mobilization. After freeing the IOL, I would rotate the haptics and place them in the sulcus at the 2 o’clock and
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
