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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
CONSULTATION SECTION
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
