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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
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
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
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
1394
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
J CATARACT REFRACT SURG - VOL 40, AUGUST 2014
