CONSULTATION SECTION: CATARACT
26-gauge needle using a second instrument to stabilize and prevent excessive movement of the IOL–capsular bag complex. (The inferior zonular fiber is already compromised judging by the inferior haptic position.) I would then reinsert the 26-gauge needle just anterior and medial to the original insertion site and pass the second polypropylene needle in front of the haptic into the lumen. Next, remove the 26-gauge needle in the same fashion as the first needle. With both ends of the 9-0 polypropylene suture externalized, place a releasable throw on the suture and tighten it until the IOL is in a good position. After securing the upper haptic and recentralizing the IOL, the same process might be repeated via the inferior scleral flap so there is 2-point scleral fixation. Knot the polypropylene sutures onto the sclera without undue tension, and close the sclera and conjunctiva with absorbable sutures or tissue glue. After the OVD has been aspirated, the anterior chamber should be carefully assessed for vitreous and the pupil constricted to ensure no fine vitreous strands extend to the paracenteses. Maximum postoperative treatment should be commenced to prevent CME and might include topical corticosteroids, topical NSAIDs, and topical or systemic carbonic anhydrase inhibitors.
Sadeer B. Hannush, MD Philadelphia, Pennsylvania, USA As is the case in situations like this, surgeons who frequently manage subluxated IOLs will offer the treatment option with which they have the most experience. The setting is of late subluxation of a 3-piece PMMA IOL in a patient with retinitis pigmentosa. In my hands, I favor 1 of 2 approaches (among many). First, there is the less-is-better approach, a minimalist albeit less definitive approach with the least morbidity, especially CME in a patient with retinitis pigmentosa. This would have to be weighed against the life expectancy of the patient. The technique involves suspension of the IOL–capsular bag complex to the sclera in the 1 o’clock direction. Because the haptics are oriented orthogonally to the vector direction of the intended repositioning of the IOL, 2 imbricating 9-0 polypropylene sutures would be required, 1 for each haptic, fixated at 10 o’clock and 4 o’clock, respectively. This approach requires small incisions and probably no vitrectomy. Alternatively, an attempt could be made to exteriorize the haptics through sclerotomies. The residual capsule will almost certainly get in the way, and care must be given to ensure symmetric placement of the sclerotomy sites 180 degrees apart to achieve maximum centration. The second option is the definitive approach, which is explantation of the entire IOL–capsular bag complex. This would require a large incision to accommodate the
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delivery of the PMMA IOL optic and almost certain vitrectomy, preferably through the pars plana. It would be followed by transscleral fixation of a 7.0 mm optic CZ70BD IOL (Alcon Laboratories, Inc.) to the sclera with 10-0 or 9-0 polypropylene suture or intrascleral fixation of a 6.0 mm optic EC-3 PAL IOL (Aaren Scientific), glued or needle guided. However, this approach will involve a risk for more morbidity and possible CME. EDITOR’S COMMENT Samuel Masket, MD Los Angeles, California, USA
As noted by the respondents, retinitis pigmentosa is among those conditions associated with progressive zonulopathy after cataract surgery; as such, the problem at hand is not surprising.1 Although management options include IOL removal and replacement, given that the existing IOL is 7.0 mm and rigid, a large incision would be required for removal. Therefore, it is most desirable to retain the current IOL, in particular because the patient was satisfied with her vision before zonulysis. Under these circumstances, the surgical choices are to suture the loops to the iris or sclera or to fixate the loops intrasclerally. Whereas most respondents suggested that scleral suture fixation was the logical choice, one respondent opted for suture fixation of the anterior capsule edge to the iris, as originally conceived by Condon,A which would reduce the risk for intraoperative vitreous hemorrhage that might be associated with scleral suturing. The condition of the capsular bag might also dictate the most opportune surgical method. In this case, there is little to no Soemmerring ring, allowing the surgeon to sew through the bag without a risk for liberating regenerative lens cortex or inducing iris chafe. Would there have been significant ring formation, I might have removed the IOL from the bag, used the vitrector to evacuate the capsular bag, and then employed intrascleral fixation (either glue or flange method) of the IOL loops. However, in this case, all findings, including the primarily fibrotic structure of the bag, suggest lasso suture of both loops through the capsular bag to the sclera as a preferred method. As Video 1 shows (available at www.jcrsjournal.org), the sclera is marked 180 degrees apart in the meridian of the IOL loops, a safetybasket suture is passed across the pars plana, and radially oriented polytetrafluoroethylene lasso sutures are passed around the loops, tied with slipknots for appropriate tensioning, and rotated into the sclera. Given the need to pierce the capsular bag, I opted to use the suture needles rather than the needleless technique. Vitrectomy was unnecessary. Certainly, several options exist to manage cases of this type and the surgeon can apply the most appropriate, varying with the nature of the IOL, the capsular bag, and other factors.
REFERENCE
1. Masket S, Ceran BB, Fram NR. Spontaneous dislocation of posterior chamber intraocular lenses (PC IOLs) in patients with retinitis pigmentosa – case series. Saudi J Ophthalmol 2012; 26:61–65. Available at: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3729523/pdf/main.pdf. Accessed June 26, 2017 OTHER CITED MATERIAL A. Condon GP, “Fixation Frustration,” presented at the EyeWorld Surgical Summit. Innovative Techniques and Controversies in Ophthalmology, Park City, Utah, USA, February 2017
Volume 43 Issue 8 August 2017
26-gauge needle using a second instrument to stabilize and prevent excessive movement of the IOL–capsular bag complex. (The inferior zonular fiber is already compromised judging by the inferior haptic position.) I would then reinsert the 26-gauge needle just anterior and medial to the original insertion site and pass the second polypropylene needle in front of the haptic into the lumen. Next, remove the 26-gauge needle in the same fashion as the first needle. With both ends of the 9-0 polypropylene suture externalized, place a releasable throw on the suture and tighten it until the IOL is in a good position. After securing the upper haptic and recentralizing the IOL, the same process might be repeated via the inferior scleral flap so there is 2-point scleral fixation. Knot the polypropylene sutures onto the sclera without undue tension, and close the sclera and conjunctiva with absorbable sutures or tissue glue. After the OVD has been aspirated, the anterior chamber should be carefully assessed for vitreous and the pupil constricted to ensure no fine vitreous strands extend to the paracenteses. Maximum postoperative treatment should be commenced to prevent CME and might include topical corticosteroids, topical NSAIDs, and topical or systemic carbonic anhydrase inhibitors.
Sadeer B. Hannush, MD Philadelphia, Pennsylvania, USA As is the case in situations like this, surgeons who frequently manage subluxated IOLs will offer the treatment option with which they have the most experience. The setting is of late subluxation of a 3-piece PMMA IOL in a patient with retinitis pigmentosa. In my hands, I favor 1 of 2 approaches (among many). First, there is the less-is-better approach, a minimalist albeit less definitive approach with the least morbidity, especially CME in a patient with retinitis pigmentosa. This would have to be weighed against the life expectancy of the patient. The technique involves suspension of the IOL–capsular bag complex to the sclera in the 1 o’clock direction. Because the haptics are oriented orthogonally to the vector direction of the intended repositioning of the IOL, 2 imbricating 9-0 polypropylene sutures would be required, 1 for each haptic, fixated at 10 o’clock and 4 o’clock, respectively. This approach requires small incisions and probably no vitrectomy. Alternatively, an attempt could be made to exteriorize the haptics through sclerotomies. The residual capsule will almost certainly get in the way, and care must be given to ensure symmetric placement of the sclerotomy sites 180 degrees apart to achieve maximum centration. The second option is the definitive approach, which is explantation of the entire IOL–capsular bag complex. This would require a large incision to accommodate the
1123
delivery of the PMMA IOL optic and almost certain vitrectomy, preferably through the pars plana. It would be followed by transscleral fixation of a 7.0 mm optic CZ70BD IOL (Alcon Laboratories, Inc.) to the sclera with 10-0 or 9-0 polypropylene suture or intrascleral fixation of a 6.0 mm optic EC-3 PAL IOL (Aaren Scientific), glued or needle guided. However, this approach will involve a risk for more morbidity and possible CME. EDITOR’S COMMENT Samuel Masket, MD Los Angeles, California, USA
As noted by the respondents, retinitis pigmentosa is among those conditions associated with progressive zonulopathy after cataract surgery; as such, the problem at hand is not surprising.1 Although management options include IOL removal and replacement, given that the existing IOL is 7.0 mm and rigid, a large incision would be required for removal. Therefore, it is most desirable to retain the current IOL, in particular because the patient was satisfied with her vision before zonulysis. Under these circumstances, the surgical choices are to suture the loops to the iris or sclera or to fixate the loops intrasclerally. Whereas most respondents suggested that scleral suture fixation was the logical choice, one respondent opted for suture fixation of the anterior capsule edge to the iris, as originally conceived by Condon,A which would reduce the risk for intraoperative vitreous hemorrhage that might be associated with scleral suturing. The condition of the capsular bag might also dictate the most opportune surgical method. In this case, there is little to no Soemmerring ring, allowing the surgeon to sew through the bag without a risk for liberating regenerative lens cortex or inducing iris chafe. Would there have been significant ring formation, I might have removed the IOL from the bag, used the vitrector to evacuate the capsular bag, and then employed intrascleral fixation (either glue or flange method) of the IOL loops. However, in this case, all findings, including the primarily fibrotic structure of the bag, suggest lasso suture of both loops through the capsular bag to the sclera as a preferred method. As Video 1 shows (available at www.jcrsjournal.org), the sclera is marked 180 degrees apart in the meridian of the IOL loops, a safetybasket suture is passed across the pars plana, and radially oriented polytetrafluoroethylene lasso sutures are passed around the loops, tied with slipknots for appropriate tensioning, and rotated into the sclera. Given the need to pierce the capsular bag, I opted to use the suture needles rather than the needleless technique. Vitrectomy was unnecessary. Certainly, several options exist to manage cases of this type and the surgeon can apply the most appropriate, varying with the nature of the IOL, the capsular bag, and other factors.
REFERENCE
1. Masket S, Ceran BB, Fram NR. Spontaneous dislocation of posterior chamber intraocular lenses (PC IOLs) in patients with retinitis pigmentosa – case series. Saudi J Ophthalmol 2012; 26:61–65. Available at: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3729523/pdf/main.pdf. Accessed June 26, 2017 OTHER CITED MATERIAL A. Condon GP, “Fixation Frustration,” presented at the EyeWorld Surgical Summit. Innovative Techniques and Controversies in Ophthalmology, Park City, Utah, USA, February 2017
Volume 43 Issue 8 August 2017
