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
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
