846
CONSULTATION SECTION
windshield wiper, inducing hemorrhage and presumably some pigment dispersion from abraded uveal tissue. This recurrent bleeding is the cause of the repeated transient IOP spikes and consequent blurry vision. I envision 2 surgical strategies to resolve this situation. The first is to explant the sulcus-fixated IOL and replace it with an iris-supported anterior chamber IOL (AC IOL). The second is to fixate the unstable PC IOL by suturing the haptics to the iris. I would prefer the second option because the patient is 79 years old. To remove the 3-piece PMMA optic PC IOL, one would have to create a 7.0 mm sclerocorneal wound, which would have to be sutured to reduce the risk for induced astigmatism. Also, there is a risk for expulsive intraoperative hemorrhage and postoperative endophthalmitis. This surgery would have to be performed using peribulbar or general anesthesia. Because the CDVA is 0.9 in this eye and the patient has little astigmatism, I would avoid such an incision and intraocular manipulation and instead simply fixate the PC IOL with iris sutures rather than remove it. After constricting the pupil with topical pilocarpine drops, I would introduce an iris spatula through a 1.0 mm clear corneal wound at 12 o'clock, through the iridectomy, and under the IOL optic. By lifting the optic from behind through the pupil into the anterior chamber with the spatula and thus capturing it within the pupil, the IOL could be well centered and the contour of the haptics seen through the iris. In this position, the 2 haptics could be fixated to the iris with 10-0 polypropylene McCannel sutures. The needle and suture would pass through the clear cornea and iris, under the haptic, and then out through the iris and clear cornea again. After the needle is cut off, the suture ends would be pulled out through the incision at 12 o'clock with a hook and then tied. Peripheral placement of the haptic sutures is preferred to avoid postoperative pupil ovalization. Once suturing is completed, the optic is gently pushed backward behind the iris. With this suture technique described by McCannel in 1976, one can center and stabilize the subluxated IOL through a small incision, avoiding the risk for induced astigmatism and other complications associated with more invasive surgery. The patient's problem will be solved by this surgery, which can be performed under topical or intracameral anesthesia. Biro Zsolt, MD, DSc Pecs, Hungary
the recurrent attacks with intraocular bleeding and secondary IOP rise have not yet damaged the optic nerve. Even so, intervention is indicated because the UGH syndrome has occurred with increasing frequency. The bleeding is likely caused by the IOL haptic in the ciliary sulcus or ciliary body. It is unlikely that the optic is causing the bleeding because PMMA IOLs at that time had a rounded, polished edge. Figure 1 shows peripheral iris atrophy at 3 o'clock and some Soemmerring-type posterior capsule opacification (PCO) in the peripheral coloboma. A tilted and inferiorly decentered IOL optic might be caused by haptic dislocation through an area of zonular defect. In my experience, an asymmetric, excessive Soemmerring ring could cause similar problems. I would perform UBM of this area using an ultra-high-resolution 80 MHz system with a self-contained probe. This will allow much better access to the area of the ciliary sulcus and ciliary body. Even if IOL decentration could not be provoked by massage with a cotton swab, I believe the IOL is mobile and a change in head position might cause decentration and rubbing against intraocular tissue. In addition, bowing the head might increase the intravascular pressure and blood vessel diameter. Recentration and permanent fixation of the IOL should be achieved. I would perform the intervention using local or, even better, general anesthesia. After preparation of 3 side-port incisions, I would place an anterior chamber maintainer. An ophthalmic viscosurgical device (OVD) would change the environment and make it difficult to estimate the postoperative IOL position and stability. Using a Kuglen push–pull lens hook, I would now check the iris for synechiae and the retroiridal space. If I found excessive Soemmerring-type PCO, I would prefer to extract it. Next, I would rotate the IOL for recentration. If the haptic is intact, this maneuver is usually easy and successful. To prevent recurrent decentration, I would fixate the superior haptic to the iris with a 10-0 polypropylene suture. Only if there were a damaged haptic or postoperative recurrence of the symptoms would I exchange the IOL. In this case, intrascleral haptic fixation could be performed. This is possible even in the presence of an intact capsular bag and is especially useful in an eye with a large zonular defect in which an IOL cannot be stably fixated. If the patient is not bothered by the mild myopia, I would not target emmetropia if I performed an IOL exchange.
- I believe this patient with a sulcus-fixated PC IOL has Valsalva-associated UGH syndrome. Fortunately, J CATARACT REFRACT SURG - VOL 40, MAY 2014
Gabor B. Scharioth, MD, PhD Recklinghausen, Germany Szeged, Hungary
CONSULTATION SECTION
windshield wiper, inducing hemorrhage and presumably some pigment dispersion from abraded uveal tissue. This recurrent bleeding is the cause of the repeated transient IOP spikes and consequent blurry vision. I envision 2 surgical strategies to resolve this situation. The first is to explant the sulcus-fixated IOL and replace it with an iris-supported anterior chamber IOL (AC IOL). The second is to fixate the unstable PC IOL by suturing the haptics to the iris. I would prefer the second option because the patient is 79 years old. To remove the 3-piece PMMA optic PC IOL, one would have to create a 7.0 mm sclerocorneal wound, which would have to be sutured to reduce the risk for induced astigmatism. Also, there is a risk for expulsive intraoperative hemorrhage and postoperative endophthalmitis. This surgery would have to be performed using peribulbar or general anesthesia. Because the CDVA is 0.9 in this eye and the patient has little astigmatism, I would avoid such an incision and intraocular manipulation and instead simply fixate the PC IOL with iris sutures rather than remove it. After constricting the pupil with topical pilocarpine drops, I would introduce an iris spatula through a 1.0 mm clear corneal wound at 12 o'clock, through the iridectomy, and under the IOL optic. By lifting the optic from behind through the pupil into the anterior chamber with the spatula and thus capturing it within the pupil, the IOL could be well centered and the contour of the haptics seen through the iris. In this position, the 2 haptics could be fixated to the iris with 10-0 polypropylene McCannel sutures. The needle and suture would pass through the clear cornea and iris, under the haptic, and then out through the iris and clear cornea again. After the needle is cut off, the suture ends would be pulled out through the incision at 12 o'clock with a hook and then tied. Peripheral placement of the haptic sutures is preferred to avoid postoperative pupil ovalization. Once suturing is completed, the optic is gently pushed backward behind the iris. With this suture technique described by McCannel in 1976, one can center and stabilize the subluxated IOL through a small incision, avoiding the risk for induced astigmatism and other complications associated with more invasive surgery. The patient's problem will be solved by this surgery, which can be performed under topical or intracameral anesthesia. Biro Zsolt, MD, DSc Pecs, Hungary
the recurrent attacks with intraocular bleeding and secondary IOP rise have not yet damaged the optic nerve. Even so, intervention is indicated because the UGH syndrome has occurred with increasing frequency. The bleeding is likely caused by the IOL haptic in the ciliary sulcus or ciliary body. It is unlikely that the optic is causing the bleeding because PMMA IOLs at that time had a rounded, polished edge. Figure 1 shows peripheral iris atrophy at 3 o'clock and some Soemmerring-type posterior capsule opacification (PCO) in the peripheral coloboma. A tilted and inferiorly decentered IOL optic might be caused by haptic dislocation through an area of zonular defect. In my experience, an asymmetric, excessive Soemmerring ring could cause similar problems. I would perform UBM of this area using an ultra-high-resolution 80 MHz system with a self-contained probe. This will allow much better access to the area of the ciliary sulcus and ciliary body. Even if IOL decentration could not be provoked by massage with a cotton swab, I believe the IOL is mobile and a change in head position might cause decentration and rubbing against intraocular tissue. In addition, bowing the head might increase the intravascular pressure and blood vessel diameter. Recentration and permanent fixation of the IOL should be achieved. I would perform the intervention using local or, even better, general anesthesia. After preparation of 3 side-port incisions, I would place an anterior chamber maintainer. An ophthalmic viscosurgical device (OVD) would change the environment and make it difficult to estimate the postoperative IOL position and stability. Using a Kuglen push–pull lens hook, I would now check the iris for synechiae and the retroiridal space. If I found excessive Soemmerring-type PCO, I would prefer to extract it. Next, I would rotate the IOL for recentration. If the haptic is intact, this maneuver is usually easy and successful. To prevent recurrent decentration, I would fixate the superior haptic to the iris with a 10-0 polypropylene suture. Only if there were a damaged haptic or postoperative recurrence of the symptoms would I exchange the IOL. In this case, intrascleral haptic fixation could be performed. This is possible even in the presence of an intact capsular bag and is especially useful in an eye with a large zonular defect in which an IOL cannot be stably fixated. If the patient is not bothered by the mild myopia, I would not target emmetropia if I performed an IOL exchange.
- I believe this patient with a sulcus-fixated PC IOL has Valsalva-associated UGH syndrome. Fortunately, J CATARACT REFRACT SURG - VOL 40, MAY 2014
Gabor B. Scharioth, MD, PhD Recklinghausen, Germany Szeged, Hungary
