CONSULTATION SECTION
- Considering the clinical picture, this is a case with an unstable sulcus-fixated IOL with friction to the back of the iris (pigment epithelium and blood vessels). This is causing recurrent attacks of secondary glaucoma. I would like to ask the patient whether she has a history of trauma to the eye. Considering the older age of the patient and the displacement of the IOL inferiorly, as seen in Figure 1, a cause could be an inferior zonulysis. Another possible cause is a bend in the superior IOL haptic near the haptic–optic junction. Also, there is a small iridodialysis at 3'clock, which could indicate a somewhat compromised angle. I would add gonioscopy to the clinical examination to study the angle and, after dilation, to examine the haptics. My surgical approach would aim at stabilizing the IOL or exchanging it. Using topical anesthesia and with a fully dilated pupil, I would start with a temporal 20-gauge paracentesis. This would allow easier manipulation and better visualization. I would then inject a cohesive OVD to fill the anterior chamber and open the sulcus for 360 degrees. Using a push– pull hook, I would examine the ciliary sulcus and posterior capsule all around and deliver the superior haptic into the anterior chamber to examine it for a bend or fracture. If the problem is inferior zonulysis, I would go ahead with scleral fixation of the superior haptic at 12 o'clock using the Hoffman reversed scleral pocket technique,1,2 starting in the corneal periphery at the base of the iridectomy. The superior iridectomy would allow perfect visualization of the needle during its passage to exit the sclera. Next, 10-0 or 9-0 polypropylene sutures mounted on double-armed long curved needles would be used. The IOL would be rotated so the superior haptic is at the 12 o'clock position. The temporal paracentesis would be enlarged to a 2.0 to 2.4 mm incision to allow introduction of the first needle with a microforceps. I would pass the needle behind the haptic and exit it 2.0 mm behind the limbus through the conjunctiva. A high-viscosity OVD would help open the space between iris and capsule and protect the latter from being punctured. Then, the second needle would be passed in front of the haptic and exited at the same location. Using a Sinskey hook, I would retrieve the suture ends through a scleral pocket after cutting the needles, tighten a triple knot to fixate the haptic in the proper position, and bury the knot in the pocket. I would wash out the OVD, hydrate the wound, and inject an intracameral antibiotic. This technique would provide the least amount of manipulation and induction of wound-related astigmatism, if any, keeping in mind the patient had only 0.5 D of astigmatism and excellent visual potential.
847
If the haptic is markedly damaged, the IOL would have to be exchanged after the wound is enlarged (PMMA, 6.0 mm optic). A new IOL with an overall diameter of 13.0 mm would be implanted in the sulcus and suture fixated to the sclera. Finally, the wound would be closed with 2 interrupted 10-0 nylon sutures. Yehia Salah Mostafa, MD Cairo, Egypt REFERENCES 1. Hoffman RS, Fine IH, Packer M, Rozenberg I. Scleral fixation using suture retrieval through a scleral tunnel. J Cataract Refract Surg 2006; 32:1259–1263. Available at: http://www.finemd.com/ reprints/Scleral%20Fixation%20Using%20suture%20Retrieval% 20Through%20a%20Scleral%20Tu.pdf. Accessed March 3, 2014 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 March 3, 2014
- There are 3 points to consider regarding this case; that is, the implantation of the IOL in the ciliary sulcus; the obvious rotation, shown by the haptic's intermittent presentation in the iridectomy; and the material and design of the haptics. Immediately after implantation of an IOL in the ciliary sulcus, the IOL can rotate if its diameter does not fit the sulcus dimensions. Twenty-three years after implantation, IOL rotation or decentration can occur only if the structure of the sulcus and/or the capsule changes. I believe 2 situations are the most likely causes of the problem. First is erosion of the peripheral zonular fibers or a zonulysis by the haptic, especially if the material is polypropylene. If the end of a haptic finds its way through such a defect, it may cause slight IOL decentration and bleeding or pigment dispersion from the iris or ciliary body. With 1 loose haptic within a zonular defect, backward and forward IOL rotation can occur after abrupt movements of the head or eye. Concomitant bleeding might cause an increase in IOP. The second situation is that after years, a polypropylene haptic can break, causing IOL decentration and bleeding if the end of the haptic penetrates the iris or ciliary tissue. Bleeding may also result from posterior synechiae between the iris and capsule passing through the positioning hole. After abrupt head movements, the synechiae may rupture and cause bleeding. With UBM, it may be difficult to detect the real position of the haptic end. Another option, although invasive, is to use an endoscope designed for endocyclophotocoagulation for diagnostic purposes if the patient agrees to a surgical solution of the problem
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CONSULTATION SECTION
during the same procedure. It is possible to visualize the location of IOL haptic with the endoscope and then rotate the IOL into position with safe capsule and zonular support. If this is not possible or safe during surgery or a broken haptic is the problem, the IOL should be explanted and replaced by a 3-piece IOL with a 7.0 mm optic diameter, PMMA haptics, and a total diameter of at least 14.0 mm. If fixation is still not stable, I would fixate both haptics with transscleral sutures. Theoretically, retropupillary iris fixation of a reversed Artisan-style PMMA IOL in the space between the iris and posterior capsule is another option; however, because of poor control of posterior iris fixation, pseudophacodonesis, and the risk for pigment dispersion, I would not chose this as a primary solution. Gandolf Sauder, MD, PhD Stuttgart, Germany
- The reported pain, blurred vision, episodes of anterior segment Tyndall phenomenon, pressure spikes, and erythrocytes in the anterior aqueous in the left eye of this patient strongly suggest the presence of the full triad of the UGH syndrome. This syndrome was first presented in 1977 by Ellingson in a patient with an aphakic AC IOL.1 However, it has also been described years after the implantation of PC IOLs.2 The biomicroscopic photograph of the left eye shows a slightly inferiorly displaced 3-piece PMMA lens and a centrally clear posterior capsule. Also, a smooth-edged round peripheral iridectomy can be seen. The edge of the anterior capsule can be seen on the inferior side of the IOL only. It is likely a Dshaped anterior envelope capsulotomy was performed and most likely followed by extracapsular cataract extraction. The incision scar seems too large
for a first-generation phacoemulsification procedure. During expression of the nucleus, a limited superior zonulysis or posterior capsule rupture occurred. The peripheral superior iridectomy was probably made to prevent pupillary block glaucoma due to vitreous prolapse. The 3-piece acrylic IOL was probably implanted with both haptics in the sulcus. The superior haptic presumably moved slightly anteriorly as a result of irregular anterior capsule remnants or vitreous prolapse, causing unstable sulcus fixation. Anterior segment optical coherence tomography would give more accurate information on the position of the IOL in relation to the back of the iris and possible tilting of the IOL. I would presume that the prolonged chafing of 1 or both haptics against the posterior iris and possibly the ciliary body could cause recurrent microscopic bleeding in any patient. The slight peripheral iris atrophy that can be seen temporally could also be an indication of prolonged iris erosion. However, it is very likely that the bleeding was exacerbated by the use of an anticoagulant or aspirin-type medication, which is often used by elderly patients. The patient could also have a bleeding disorder. If there is no way to reduce the tendency toward bleeding and the patient is motivated to have surgery, the IOL could be removed. I would create a 6.0 mm superior incision just peripheral to the limbus with 2 additional 1.5 mm stab incisions on either side. The explantation of the IOL should be straightforward with an untoothed capsule forceps and a mydriatic pupil. I do not expect adhesions of the IOL to the capsule; however, any vitreous loss could be managed by anterior vitrectomy through the pupil opening as well as via the peripheral iridotomy. Then, 0.5 cc of 3- to 4times diluted pilocarpine 2.0% can be instilled in the anterior chamber followed by horizontal implantation of a rigid aphakic Artisan-style iris-fixated AC IOL with needle enclavation. Fortunately, this eye already has a peripheral iridectomy, so no extra precautions
Figure 2. Left: Undilated eye. Right: Dilated eye. After 1 IOL loop is sutured to the nasal ankle of the preexisting coloboma at 12 o'clock, the IOL is recentered and stably fixated. Note that the position of the suture knot does not change with the pupil fully dilated. No incidences of bleeding with blurred vision or IOP rise have occurred since.
J CATARACT REFRACT SURG - VOL 40, MAY 2014
- Considering the clinical picture, this is a case with an unstable sulcus-fixated IOL with friction to the back of the iris (pigment epithelium and blood vessels). This is causing recurrent attacks of secondary glaucoma. I would like to ask the patient whether she has a history of trauma to the eye. Considering the older age of the patient and the displacement of the IOL inferiorly, as seen in Figure 1, a cause could be an inferior zonulysis. Another possible cause is a bend in the superior IOL haptic near the haptic–optic junction. Also, there is a small iridodialysis at 3'clock, which could indicate a somewhat compromised angle. I would add gonioscopy to the clinical examination to study the angle and, after dilation, to examine the haptics. My surgical approach would aim at stabilizing the IOL or exchanging it. Using topical anesthesia and with a fully dilated pupil, I would start with a temporal 20-gauge paracentesis. This would allow easier manipulation and better visualization. I would then inject a cohesive OVD to fill the anterior chamber and open the sulcus for 360 degrees. Using a push– pull hook, I would examine the ciliary sulcus and posterior capsule all around and deliver the superior haptic into the anterior chamber to examine it for a bend or fracture. If the problem is inferior zonulysis, I would go ahead with scleral fixation of the superior haptic at 12 o'clock using the Hoffman reversed scleral pocket technique,1,2 starting in the corneal periphery at the base of the iridectomy. The superior iridectomy would allow perfect visualization of the needle during its passage to exit the sclera. Next, 10-0 or 9-0 polypropylene sutures mounted on double-armed long curved needles would be used. The IOL would be rotated so the superior haptic is at the 12 o'clock position. The temporal paracentesis would be enlarged to a 2.0 to 2.4 mm incision to allow introduction of the first needle with a microforceps. I would pass the needle behind the haptic and exit it 2.0 mm behind the limbus through the conjunctiva. A high-viscosity OVD would help open the space between iris and capsule and protect the latter from being punctured. Then, the second needle would be passed in front of the haptic and exited at the same location. Using a Sinskey hook, I would retrieve the suture ends through a scleral pocket after cutting the needles, tighten a triple knot to fixate the haptic in the proper position, and bury the knot in the pocket. I would wash out the OVD, hydrate the wound, and inject an intracameral antibiotic. This technique would provide the least amount of manipulation and induction of wound-related astigmatism, if any, keeping in mind the patient had only 0.5 D of astigmatism and excellent visual potential.
847
If the haptic is markedly damaged, the IOL would have to be exchanged after the wound is enlarged (PMMA, 6.0 mm optic). A new IOL with an overall diameter of 13.0 mm would be implanted in the sulcus and suture fixated to the sclera. Finally, the wound would be closed with 2 interrupted 10-0 nylon sutures. Yehia Salah Mostafa, MD Cairo, Egypt REFERENCES 1. Hoffman RS, Fine IH, Packer M, Rozenberg I. Scleral fixation using suture retrieval through a scleral tunnel. J Cataract Refract Surg 2006; 32:1259–1263. Available at: http://www.finemd.com/ reprints/Scleral%20Fixation%20Using%20suture%20Retrieval% 20Through%20a%20Scleral%20Tu.pdf. Accessed March 3, 2014 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 March 3, 2014
- There are 3 points to consider regarding this case; that is, the implantation of the IOL in the ciliary sulcus; the obvious rotation, shown by the haptic's intermittent presentation in the iridectomy; and the material and design of the haptics. Immediately after implantation of an IOL in the ciliary sulcus, the IOL can rotate if its diameter does not fit the sulcus dimensions. Twenty-three years after implantation, IOL rotation or decentration can occur only if the structure of the sulcus and/or the capsule changes. I believe 2 situations are the most likely causes of the problem. First is erosion of the peripheral zonular fibers or a zonulysis by the haptic, especially if the material is polypropylene. If the end of a haptic finds its way through such a defect, it may cause slight IOL decentration and bleeding or pigment dispersion from the iris or ciliary body. With 1 loose haptic within a zonular defect, backward and forward IOL rotation can occur after abrupt movements of the head or eye. Concomitant bleeding might cause an increase in IOP. The second situation is that after years, a polypropylene haptic can break, causing IOL decentration and bleeding if the end of the haptic penetrates the iris or ciliary tissue. Bleeding may also result from posterior synechiae between the iris and capsule passing through the positioning hole. After abrupt head movements, the synechiae may rupture and cause bleeding. With UBM, it may be difficult to detect the real position of the haptic end. Another option, although invasive, is to use an endoscope designed for endocyclophotocoagulation for diagnostic purposes if the patient agrees to a surgical solution of the problem
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CONSULTATION SECTION
during the same procedure. It is possible to visualize the location of IOL haptic with the endoscope and then rotate the IOL into position with safe capsule and zonular support. If this is not possible or safe during surgery or a broken haptic is the problem, the IOL should be explanted and replaced by a 3-piece IOL with a 7.0 mm optic diameter, PMMA haptics, and a total diameter of at least 14.0 mm. If fixation is still not stable, I would fixate both haptics with transscleral sutures. Theoretically, retropupillary iris fixation of a reversed Artisan-style PMMA IOL in the space between the iris and posterior capsule is another option; however, because of poor control of posterior iris fixation, pseudophacodonesis, and the risk for pigment dispersion, I would not chose this as a primary solution. Gandolf Sauder, MD, PhD Stuttgart, Germany
- The reported pain, blurred vision, episodes of anterior segment Tyndall phenomenon, pressure spikes, and erythrocytes in the anterior aqueous in the left eye of this patient strongly suggest the presence of the full triad of the UGH syndrome. This syndrome was first presented in 1977 by Ellingson in a patient with an aphakic AC IOL.1 However, it has also been described years after the implantation of PC IOLs.2 The biomicroscopic photograph of the left eye shows a slightly inferiorly displaced 3-piece PMMA lens and a centrally clear posterior capsule. Also, a smooth-edged round peripheral iridectomy can be seen. The edge of the anterior capsule can be seen on the inferior side of the IOL only. It is likely a Dshaped anterior envelope capsulotomy was performed and most likely followed by extracapsular cataract extraction. The incision scar seems too large
for a first-generation phacoemulsification procedure. During expression of the nucleus, a limited superior zonulysis or posterior capsule rupture occurred. The peripheral superior iridectomy was probably made to prevent pupillary block glaucoma due to vitreous prolapse. The 3-piece acrylic IOL was probably implanted with both haptics in the sulcus. The superior haptic presumably moved slightly anteriorly as a result of irregular anterior capsule remnants or vitreous prolapse, causing unstable sulcus fixation. Anterior segment optical coherence tomography would give more accurate information on the position of the IOL in relation to the back of the iris and possible tilting of the IOL. I would presume that the prolonged chafing of 1 or both haptics against the posterior iris and possibly the ciliary body could cause recurrent microscopic bleeding in any patient. The slight peripheral iris atrophy that can be seen temporally could also be an indication of prolonged iris erosion. However, it is very likely that the bleeding was exacerbated by the use of an anticoagulant or aspirin-type medication, which is often used by elderly patients. The patient could also have a bleeding disorder. If there is no way to reduce the tendency toward bleeding and the patient is motivated to have surgery, the IOL could be removed. I would create a 6.0 mm superior incision just peripheral to the limbus with 2 additional 1.5 mm stab incisions on either side. The explantation of the IOL should be straightforward with an untoothed capsule forceps and a mydriatic pupil. I do not expect adhesions of the IOL to the capsule; however, any vitreous loss could be managed by anterior vitrectomy through the pupil opening as well as via the peripheral iridotomy. Then, 0.5 cc of 3- to 4times diluted pilocarpine 2.0% can be instilled in the anterior chamber followed by horizontal implantation of a rigid aphakic Artisan-style iris-fixated AC IOL with needle enclavation. Fortunately, this eye already has a peripheral iridectomy, so no extra precautions
Figure 2. Left: Undilated eye. Right: Dilated eye. After 1 IOL loop is sutured to the nasal ankle of the preexisting coloboma at 12 o'clock, the IOL is recentered and stably fixated. Note that the position of the suture knot does not change with the pupil fully dilated. No incidences of bleeding with blurred vision or IOP rise have occurred since.
J CATARACT REFRACT SURG - VOL 40, MAY 2014
