EyeWorld Asia-Pacific March 2013 Issue

29 EWAP CATARACT/IOL March 2013 University of Minnesota, Minn., would choose the option of anterior optic capture to “lock” the lens in place. “While keratorefractive procedures could be considered, they do not solve the basic problem of the lens being out of position, and the lens may continue to be unstable and rotate down the line. The photograph shows a well- positioned toric IOL in the bag with good overlap of the anterior capsule over the optic (at least for the 270 degrees or so that I can see). After viscodissecting the IOL free, I would prolapse the optic in front of the rhexis (reverse capsule capture) and rotate it to the proper position on the steep axis. This can be done quite atraumatically with minimal risk.” Because I have no personal experience with anterior optic capture, I was a bit uncomfortable with the idea of purposefully putting part of a single-piece AcrySof implant (Alcon, Fort Worth, Texas, USA/Hünenberg, Switzerland) anterior to the rhexis where it could potentially contact the iris. I asked about experience with reverse optic capture (ROC) using the single-piece AcrySof platform on the ASCRS chat board and got this response from Jason Jones, MD , medical director, Jones Eye Clinic, Sioux City, Iowa. “ROC is a capsule fixation technique where the haptics of the IOL are posterior to the anterior capsule and the optic is brought forward (captured) by the intact CCC. Several anatomic elements must be respected here. The CCC must be intact, smaller than the optic, and well centered. The zonules must be stable. And the CCC must be free of any vitreous (if the PC has been breached). Ideally the configuration of the iris relative to the capsule should be assessed; I don’t have any numbers to recommend here, but there should be good clearance to avoid iris-optic contact. Given that the cataract has been removed and the IOL occupies much less space, I feel it is reasonable to assume most (not all) eyes will avoid such contact. In the case of repositioning a toric with ROC, this can and should be considered. Once the lens is rotated into position then the optic can be brought forward to obtain capture. … Now, I have not had an opportunity to use ROC for a misbehaving toric lens. But I have implanted a series of AcrySof single-piece acrylic IOLs using ROC. In these cases the PC was damaged during primary surgery, and I elected to use this technique. All of my patients have done very well with clear visual pathways, no UGH syndrome, no RD, no decentration, and with up to four years or more follow- up in select cases. This is not sulcus fixation, and the issues that AcrySof SPA IOLs in the sulcus have encountered should not be conflated with ROC.” Dr. Jones’ experience with this technique should be comforting to those who may consider it. In a follow-up email, Dr. Lane did add that he has done ROC “twice with good results and no iris chafe.” I do have the personal experience of having treated six cases of pseudophakic reverse pupillary block that caused contact between the iris and IOL leading to iris chafing and pigment dispersion. I reported and discussed this phenomenon in the ASGR column of the January 2012 issue of EyeWorld , “Reversal of misfortune.” All patients were vitrectomized high myopes (as is the case here) so I believe that if one wishes to consider ROC in a vitrectomized high myope, one should also consider placing a peripheral iridotomy to prevent the possibility of reverse pupillary block occurring, which could lead to the iris being pushed back against the optic, leading to chafing. In this case I chose to simply wait five weeks and reposition the lens. My own experience is that if you reposition the lens immediately, it is very likely to rotate again. If, on the other hand, you wait a few weeks for some fibrosis to occur, the bag will shrink wrap a bit around the lens, and the lens will not rotate a second time. Although a CTR could have been used, I discussed the option with the patient who wished not to have one placed unless I felt it was absolutely necessary. In this case I did not feel that it was so we chose not to use it. The patient ended up with a 20/30 final outcome and no repeat rotation (Figure 2). One does not want to wait so long that the haptics become so strongly fibrosed in place that they are impossible to free up but long enough that there is some shrink wrapping of the bag around the lens so that the lens is not likely to rotate a second time. Although we don’t know the exact timeframe for this, it is likely that waiting five to six weeks post-op from the original cataract surgery is a pretty safe play. One tip is that if you know the axis the lens is at, you don’t need to mark the patient sitting up. For example, in this case the lens was measured at an axis of 67 degrees at the slit lamp, so I simply made a mark 33 degrees in the counterclockwise direction under the surgical microscope knowing that this would be exactly 100 degrees and then I rotated the lens to this point. I like to use a flat tip LASIK cannula (Katena K7-5106, Denville, NJ, USA) to get under the edge of the anterior capsule and initiate viscoelastic dissection. When you reopen the bag there is no need to “hyperinflate” with viscoelastic but rather to reopen just enough to easily facilitate rotation. The capsular bag exhibits a slightly different stiffer feel at six weeks out then it does at the time of initial cataract surgery due to fibrosis, and I believe this is what prevents the lens from rotating again. After rotation the viscoelastic is removed and the case is completed. Again, the CTR turned out not to be necessary. If I were to treat a patient who was not willing to consider waiting 4 to 6 weeks for a rotation then I would definitely use a CTR, but if you can wait a bit to do the repositioning, a CTR is probably not needed. If this lens were to rotate again, I would consider adding a CTR, and finally if it rotated a third time, reverse optic capture with a laser iridotomy could be considered as a final option. EWAP Editors’ note: Drs. Arbisser, Jones, Lane, and Wong have no financial interests related to this article. Dr. Safran has financial interests with Bausch + Lomb. Contact information Arbisser: drlisa@arbisser.com Horn: jeff.horn@bestvisionforlife.com Jones: jasonjonesmd@mac.com Lane: sslane@AssociatedEyeCare.com Safran: safran12@comcast.net Wong: mwong2020@gmail.com