EyeWorld Asia-Pacific December 2015 Issue

December 2015 20 EWAP FEATURE Non-capsular IOL fixation by Maxine Lipner EyeWorld Senior Contributing Writer AT A GLANCE • Use of anterior chamber lenses can be a simple approach for handling non-capsular IOL fixation but can have complications in the long run. • Suturing the lens to the iris or sclera are effective options for cases where capsular fixation is not possible. • Gluing an IOL in place is gaining traction as an approach that minimizes movement. Moving beyond the usual bag of tricks W hile typical cataract cases are usually a no-brainer for practitioners, in instances where there is a tear in the posterior capsule, pseudoexfoliation, or no capsule remaining inside the eye at all, innovative strategies are needed. Here are some of the leading techniques experts recommended for handling cases of non-capsular IOL fixation. Richard Hoffman, MD , clinical associate professor of ophthalmology, Oregon Health & Science University, Portland, finds there are a variety of approaches from which to choose in such cases. Anterior chamber lens Putting in an anterior chamber lens can be the simplest approach but is not for every patient. “I still do this on occasion when I have an older patient,” he said, adding that potential complications associated This case involving a dislocated IOL/ capsular bag complex is ideal for sclera fixation using sclera pockets. Scleral tunnels created adjacent to scleral flaps for IOL haptic capture in a case involving the glued IOL technique Source: Amar Agarwal, MD Iris fixation using Dr. Hart’s innovation, which makes pupil ovalization less likely. Source: Richard Hoffman, MD with anterior chamber lenses include endothelial compromise, iritis, and glaucoma. Still, there are patients who have had these lenses in for 40 or 50 years who haven’t had any trouble, Dr. Hoffman said. “If a 50-year-old patient came in and needed a secondary IOL, I don’t think I would use an anterior chamber lens. But if an 80- or 85-year-old came in and I thought the case might be complicated, I might go ahead and put an anterior chamber lens in that patient.” Fixation fixes For cases involving posterior chamber lenses with no capsule support, Dr. Hoffman uses a different approach. If the lens is already in the eye and is decentered, his preference is to iris fixate the lens. “In my opinion it’s less invasive and you don’t have to suture to the sclera or create scleral pockets or tunnels or mess with the conjunctiva,” he said. However, if the entire capsular bag with a lens inside is loose but approachable from the anterior, Dr. Hoffman will usually scleral fixate both the bag and the IOL using pockets. “It’s very simple to do, and you’re fixating the IOL haptic through the capsular bag to the sclera,” he said. The iris fixation technique itself is very simple, Dr. Hoffman said. He uses the double-needle iris-IOL fixation modification demonstrated by John C. Hart, Jr., MD, at the 2015 ASCRS Film Festival. This entails first cleaning up any vitreous that is present and prolapsing the optic in front of the iris. The practitioner constricts the pupil so that the lens will stay centered in front of the iris. With the haptics placed behind the iris, the practitioner takes a double- armed needle and cuts off one of the needles so that just a very long suture remains on the other needle, Dr. Hoffman explained. Next the practitioner takes a needle without a suture attached to it and passes that through a paracentesis. This goes through the iris underneath the haptic. “That lifts up the haptic and makes it much more obvious where this is behind the iris,” Dr. Hoffman said. The idea is to take the second needle that has the suture on it and pass it through the same paracentesis this time taking as small a bite of the iris in the periphery and passing that through the cornea and removing it. The first needle that initially held up the haptic is also removed. The beauty of this technique is that you don’t get ovalization of the pupil, he said. In cases involving fixating the bag to the sclera, Dr. Hoffman uses a different technique. “With this technique you pass a double-armed suture through a paracentesis and pass one suture behind the IOL haptic 180 degrees away through the capsular bag,” he said. The other suture is placed in front of the capsular bag so that when the surgeons pulls that one out of the sclera, it is lassoed around the haptic because it is double-armed. “I do that through a Hoffman pocket so that I don’t have to dissect the conjunctiva,” he said. These Hoffman pockets are made 180 degrees away from each other, overlying where the haptics are. The surgeon