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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
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presence of a torn capsular bag, whether anterior or posterior capsule, because the expansion of the ring will inevitably lead to its own decentration and further extension of any preexisting tear. It also highlights a lack of understanding by the original surgeon of the function of a CTR, which has nothing to do with bridging or reinforcing a capsule tear. Second, the IOL was placed in the bag in the same (horizontal) meridian as the tear, which is highly likely to lead to extrusion of the nasal haptic as capsule contraction progresses. It would not have been unreasonable to implant the IOL in the bag with an anterior capsule tear as long as the haptics were aligned at right angles to the tear (ie, vertically). Close examination of Figure 1 suggests that the posterior capsule is not intact, contrary to the surgeon’s report. The oblique line diametrically across the optic has the characteristically straight, rolled edge of a torn posterior capsule lying on an intact anterior hyaloid face. If there is rupture of the anterior hyaloid face, the capsule edge would be pushed peripherally by the forward herniation of the gel and adopt a semicircular profile. Over the five months since surgery, numerous small and discrete opacities have developed and are visible on the posterior capsule temporal to this line; however, the area lying nasal to the line is suspiciously clear. Such clarity strongly suggests the absence of capsule in this nasal area. Last, the degree of IOL decentration would be less likely to occur were the bag and zonular fibers intact on the nasal side. Therefore, my surgical strategy would be based on the suspicion that there is a nasal wrap-around tear of the capsular bag. I would counsel the patient in detail about the potential risks of surgery, particularly if vitreous loss were encountered, and would express my intention to reposition the IOL, although IOL exchange may be required. Further surgery may be necessary. I would operate temporally and make 4 paracenteses (temporal, nasal, superotemporal, superonasal) with a microvitreoretinal blade. First, I would check for the presence of vitreous in the anterior chamber using triamcinolone. “No vitreous seen at the slitlamp” is not adequate proof of its absence. Assuming no vitreous is present, I would inject cohesive OVD behind the optic to push back the anterior hyaloid face and lift the optic forward. Using 2 Sinskey or Lester hooks engaged in the haptic–optic junctions (via the upper and lower paracenteses), I would bimanually rotate the IOL 90 degrees clockwise, rotating the haptics out of the bag so they can be released into the sulcus, oriented from 12 to 6 o’clock where there appears to be adequate capsule support. The CTR can be left in situ with impunity. Removal of OVD must be gentle to ensure no sudden
chamber collapse and confirm that the IOL sits centrally without OVD in the eye. Brian Little, MA, FHEA, FRCS, FRCOphth London, United Kingdom
- This is a case of positive dysphotopsia and monocular diplopia resulting from a dislocated, nasally decentered IOL. The surgeon’s records indicate that a CTR was used incorrectly to help stabilize a bag with an anterior capsule extension. Capsular tension rings are helpful in cases of zonular dehiscence or zonular dialysis, but not in cases of anterior capsule compromise. In addition, it appears as though the 3-piece IOL the surgeon placed in the sulcus has a 13.0 mm overall length, which is best suited for in-the-bag placement. I would begin by making 2 bimanual incisions temporally and inferotemporally with a diamond blade. I would use a viscoadaptive OVD and Kuglen hooks to viscodissect the IOL from the capsule. I would then use a microforceps and microscissors to cut the IOL. After enlarging the temporal incision with a keratome, I would remove the cut IOL segments. I would be prepared for a vitrectomy in case vitreous presented during IOL dissection and removal. Because the nasal haptic is most likely not fused to the capsule, careful IOL dissection and removal should leave an intact capsule. I would then refill with OVD and place an AQ2010 IOL (Staar Surgical Co.) in the ciliary sulcus because this is a 13.5 mm IOL that is best suited for sulcus placement. If the IOL centers well, I would remove the OVD with gentle bimanual I/A, inject acetylcholine chloride, and close the incision sites. If the IOL does not center well, I would plan to suture 1 or both haptics to the iris using 10-0 polypropylene with a CIF 4 needle (Ethicon), using paracenteses and a 25-gauge needle as a guide for the suture needle, and secure the haptics with Siepser sliding knots. Because of the fibrosis of the fused anterior capsule and posterior capsule, I would make the patient aware that she would require an Nd:YAG laser capsulotomy at a later date. Audrey Talley Rostov, MD Seattle, Washington, USA
- This is a very interesting case. Three things I am wondering about are the integrity of the posterior capsule, zonular stability, and how fused the capsule holding the 1 haptic is.
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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
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CONSULTATION SECTION
presence of a torn capsular bag, whether anterior or posterior capsule, because the expansion of the ring will inevitably lead to its own decentration and further extension of any preexisting tear. It also highlights a lack of understanding by the original surgeon of the function of a CTR, which has nothing to do with bridging or reinforcing a capsule tear. Second, the IOL was placed in the bag in the same (horizontal) meridian as the tear, which is highly likely to lead to extrusion of the nasal haptic as capsule contraction progresses. It would not have been unreasonable to implant the IOL in the bag with an anterior capsule tear as long as the haptics were aligned at right angles to the tear (ie, vertically). Close examination of Figure 1 suggests that the posterior capsule is not intact, contrary to the surgeon’s report. The oblique line diametrically across the optic has the characteristically straight, rolled edge of a torn posterior capsule lying on an intact anterior hyaloid face. If there is rupture of the anterior hyaloid face, the capsule edge would be pushed peripherally by the forward herniation of the gel and adopt a semicircular profile. Over the five months since surgery, numerous small and discrete opacities have developed and are visible on the posterior capsule temporal to this line; however, the area lying nasal to the line is suspiciously clear. Such clarity strongly suggests the absence of capsule in this nasal area. Last, the degree of IOL decentration would be less likely to occur were the bag and zonular fibers intact on the nasal side. Therefore, my surgical strategy would be based on the suspicion that there is a nasal wrap-around tear of the capsular bag. I would counsel the patient in detail about the potential risks of surgery, particularly if vitreous loss were encountered, and would express my intention to reposition the IOL, although IOL exchange may be required. Further surgery may be necessary. I would operate temporally and make 4 paracenteses (temporal, nasal, superotemporal, superonasal) with a microvitreoretinal blade. First, I would check for the presence of vitreous in the anterior chamber using triamcinolone. “No vitreous seen at the slitlamp” is not adequate proof of its absence. Assuming no vitreous is present, I would inject cohesive OVD behind the optic to push back the anterior hyaloid face and lift the optic forward. Using 2 Sinskey or Lester hooks engaged in the haptic–optic junctions (via the upper and lower paracenteses), I would bimanually rotate the IOL 90 degrees clockwise, rotating the haptics out of the bag so they can be released into the sulcus, oriented from 12 to 6 o’clock where there appears to be adequate capsule support. The CTR can be left in situ with impunity. Removal of OVD must be gentle to ensure no sudden
chamber collapse and confirm that the IOL sits centrally without OVD in the eye. Brian Little, MA, FHEA, FRCS, FRCOphth London, United Kingdom
- This is a case of positive dysphotopsia and monocular diplopia resulting from a dislocated, nasally decentered IOL. The surgeon’s records indicate that a CTR was used incorrectly to help stabilize a bag with an anterior capsule extension. Capsular tension rings are helpful in cases of zonular dehiscence or zonular dialysis, but not in cases of anterior capsule compromise. In addition, it appears as though the 3-piece IOL the surgeon placed in the sulcus has a 13.0 mm overall length, which is best suited for in-the-bag placement. I would begin by making 2 bimanual incisions temporally and inferotemporally with a diamond blade. I would use a viscoadaptive OVD and Kuglen hooks to viscodissect the IOL from the capsule. I would then use a microforceps and microscissors to cut the IOL. After enlarging the temporal incision with a keratome, I would remove the cut IOL segments. I would be prepared for a vitrectomy in case vitreous presented during IOL dissection and removal. Because the nasal haptic is most likely not fused to the capsule, careful IOL dissection and removal should leave an intact capsule. I would then refill with OVD and place an AQ2010 IOL (Staar Surgical Co.) in the ciliary sulcus because this is a 13.5 mm IOL that is best suited for sulcus placement. If the IOL centers well, I would remove the OVD with gentle bimanual I/A, inject acetylcholine chloride, and close the incision sites. If the IOL does not center well, I would plan to suture 1 or both haptics to the iris using 10-0 polypropylene with a CIF 4 needle (Ethicon), using paracenteses and a 25-gauge needle as a guide for the suture needle, and secure the haptics with Siepser sliding knots. Because of the fibrosis of the fused anterior capsule and posterior capsule, I would make the patient aware that she would require an Nd:YAG laser capsulotomy at a later date. Audrey Talley Rostov, MD Seattle, Washington, USA
- This is a very interesting case. Three things I am wondering about are the integrity of the posterior capsule, zonular stability, and how fused the capsule holding the 1 haptic is.
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
