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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
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7 o’clock positions. This would allow the haptics to span the sulcus in the region with no apparent zonular problems and no history of anterior capsule tears. With an intact capsular bag and good zonular support, I would expect good long-term stability with simple sulcus fixation. If the IOL were indeed clinically stable postoperatively, I would then consider an Nd:YAG laser capsulotomy of the fibrotic capsule scar. If the IOL cannot be released from the capsular bag, if there is significant loss of zonular stability, or if vitreous prolapses, appropriate anterior vitrectomy, secondary haptic fixation, or an IOL exchange may be indicated. Daniel H. Chang, MD Bakersfield, California, USA Dr. Chang is a paid consultant to Abbott Medical Optics. - Decentration of this woman’s IOL may have been avoided by orienting the IOL haptics vertically, away from the region of the nasal radial tear, at the time of the primary cataract operation. Recentering the IOL should alleviate her symptoms. When approaching these cases, it is important to have a primary plan and 1 or 2 backup plans should things not progress as intended. Viscodissection of the capsular bag could be accomplished by initially creating a superior paracentesis and injecting a dispersive OVD between the IOL optic and the small area of overlapping anterior capsule inferiorly. A 30-gauge needle on the OVD syringe would help with this initial step if the viscoelastic cannula were not successful. Once the viscodissection is started, the bag could be opened sequentially from this region, working counterclockwise and using as many paracenteses as is needed to open the bag.1 The nasal region of the bag where the radial tear is located should probably be avoided to prevent extension of the tear to the posterior capsule. Once the majority of the bag is opened, the inferotemporal haptic can be rotated clockwise out of the bag and the IOL can be reinserted into the capsular bag with the haptics oriented at 12 o’clock and 6 o’clock. Although the IOL–capsular bag–CTR complex is described as appearing stable, examination of Figure 1, showing the decentered capsulorhexis and visible CTR eyelets, suggests the possibility of temporal zonular fiber damage with possible nasal decentration of the capsular bag. Thus, if the IOL is still decentered after it is repositioned in the capsular bag, the surgeon should be prepared for additional maneuvers. Scleral fixation of the CTR to a temporal scleral pocket using double-
armed 9-0 polypropylene and needle passage through 1 of the nasal viscodissection paracenteses would easily recenter the bag and IOL if needed.2 Enlargement of the temporal fibrosed anterior capsule might also have to be performed with microincision scissors and a forceps if the capsule were close to the visual axis after all these maneuvers. Because the case is only 5 months old, the stellate area of fibrosis should open with a combination of viscodissection and blunt dissection with the OVD cannula using sweeping movements and a broad angle of contact. If it were not possible to viscodissect the bag open sufficiently or if a significant posterior capsule tear were created, the IOL haptic could still be dissected free and rotated clockwise out of the bag. Because the nasal haptic is already out of the bag, the IOL would essentially be free in the sulcus. The IOL could then be fixated to the iris. This would be accomplished by prolapsing the optic through an acetylcholine chloride–constricted pupil to ensure centration. This would be followed by fixation of each haptic to the peripheral iris with 9-0 or 10-0 polypropylene using the Siepser slip-knot technique.3,4 The centered optic would then be prolapsed back behind the iris and OVD removed using bimanual I/A handpieces through any 2 of the paracenteses. Richard S. Hoffman, MD Eugene, Oregon, USA
REFERENCES 1. Fine IH, Hoffman RS. Late reopening of fibrosed capsular bags to reposition decentered intraocular lenses. J Cataract Refract Surg 1997; 23:990–994 2. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www.finemd.com/reprints/Scleral%20Fixation %20Without%20Conjunctival%20Dissection.pdf. Accessed May 23, 2014 3. Siepser SB. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol 1994; 26:71–72 4. Chang DF. Siepser slipknot for McCannel iris-suture fixation of subluxated intraocular lenses. J Cataract Refract Surg 2004; 30:1170–1176
- This patient has troublesome monocular diplopia and dysphotopsia from a significantly decentered IOL, which has to be repositioned or replaced. Understanding how this situation arose in the first place is a constructive lesson in itself. The surgeon’s operative note describes a radial tear that developed in the edge of the capsulorhexis and extended along the horizontal meridian during surgery. Two cognitive errors were then made. First, a CTR was implanted. This is absolutely contraindicated in the
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
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
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7 o’clock positions. This would allow the haptics to span the sulcus in the region with no apparent zonular problems and no history of anterior capsule tears. With an intact capsular bag and good zonular support, I would expect good long-term stability with simple sulcus fixation. If the IOL were indeed clinically stable postoperatively, I would then consider an Nd:YAG laser capsulotomy of the fibrotic capsule scar. If the IOL cannot be released from the capsular bag, if there is significant loss of zonular stability, or if vitreous prolapses, appropriate anterior vitrectomy, secondary haptic fixation, or an IOL exchange may be indicated. Daniel H. Chang, MD Bakersfield, California, USA Dr. Chang is a paid consultant to Abbott Medical Optics. - Decentration of this woman’s IOL may have been avoided by orienting the IOL haptics vertically, away from the region of the nasal radial tear, at the time of the primary cataract operation. Recentering the IOL should alleviate her symptoms. When approaching these cases, it is important to have a primary plan and 1 or 2 backup plans should things not progress as intended. Viscodissection of the capsular bag could be accomplished by initially creating a superior paracentesis and injecting a dispersive OVD between the IOL optic and the small area of overlapping anterior capsule inferiorly. A 30-gauge needle on the OVD syringe would help with this initial step if the viscoelastic cannula were not successful. Once the viscodissection is started, the bag could be opened sequentially from this region, working counterclockwise and using as many paracenteses as is needed to open the bag.1 The nasal region of the bag where the radial tear is located should probably be avoided to prevent extension of the tear to the posterior capsule. Once the majority of the bag is opened, the inferotemporal haptic can be rotated clockwise out of the bag and the IOL can be reinserted into the capsular bag with the haptics oriented at 12 o’clock and 6 o’clock. Although the IOL–capsular bag–CTR complex is described as appearing stable, examination of Figure 1, showing the decentered capsulorhexis and visible CTR eyelets, suggests the possibility of temporal zonular fiber damage with possible nasal decentration of the capsular bag. Thus, if the IOL is still decentered after it is repositioned in the capsular bag, the surgeon should be prepared for additional maneuvers. Scleral fixation of the CTR to a temporal scleral pocket using double-
armed 9-0 polypropylene and needle passage through 1 of the nasal viscodissection paracenteses would easily recenter the bag and IOL if needed.2 Enlargement of the temporal fibrosed anterior capsule might also have to be performed with microincision scissors and a forceps if the capsule were close to the visual axis after all these maneuvers. Because the case is only 5 months old, the stellate area of fibrosis should open with a combination of viscodissection and blunt dissection with the OVD cannula using sweeping movements and a broad angle of contact. If it were not possible to viscodissect the bag open sufficiently or if a significant posterior capsule tear were created, the IOL haptic could still be dissected free and rotated clockwise out of the bag. Because the nasal haptic is already out of the bag, the IOL would essentially be free in the sulcus. The IOL could then be fixated to the iris. This would be accomplished by prolapsing the optic through an acetylcholine chloride–constricted pupil to ensure centration. This would be followed by fixation of each haptic to the peripheral iris with 9-0 or 10-0 polypropylene using the Siepser slip-knot technique.3,4 The centered optic would then be prolapsed back behind the iris and OVD removed using bimanual I/A handpieces through any 2 of the paracenteses. Richard S. Hoffman, MD Eugene, Oregon, USA
REFERENCES 1. Fine IH, Hoffman RS. Late reopening of fibrosed capsular bags to reposition decentered intraocular lenses. J Cataract Refract Surg 1997; 23:990–994 2. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www.finemd.com/reprints/Scleral%20Fixation %20Without%20Conjunctival%20Dissection.pdf. Accessed May 23, 2014 3. Siepser SB. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol 1994; 26:71–72 4. Chang DF. Siepser slipknot for McCannel iris-suture fixation of subluxated intraocular lenses. J Cataract Refract Surg 2004; 30:1170–1176
- This patient has troublesome monocular diplopia and dysphotopsia from a significantly decentered IOL, which has to be repositioned or replaced. Understanding how this situation arose in the first place is a constructive lesson in itself. The surgeon’s operative note describes a radial tear that developed in the edge of the capsulorhexis and extended along the horizontal meridian during surgery. Two cognitive errors were then made. First, a CTR was implanted. This is absolutely contraindicated in the
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
