EyeWorld Asia-Pacific December 2019 Issue

EWAP DECEMBER 2019 21 FEATURE may move separately. Careful examination at the slit lamp is critical in differentiating this and determining a surgical plan.” Dr. Schockman has the patient look in all directions in a “dynamic” slit lamp exam to maximize visualization. She suggested having the patient look into extreme side gaze then À>«ˆ`Þ wÝ>Ìi œ˜ ̅i iÝ>“ˆ˜iÀ½Ã ear. “As the globe comes to a stop, if the IOL and bag are not moving as a unit together, they will decelerate at different moments,” she said. The relative positions of the IOL and capsular bag are often obvious LÕÌ “>Þ Li `ˆvwVÕÌ Ìœ iÛ>Õ>Ìi in a small pupil. Dr. Khandelwal suggested dilating the pupil some more or using a pupillary expansion device in the OR. Dr. Fram suggested ultrasound biomicroscopy in cases of a small or poorly dilated pupil to evaluate IOL and haptic position, capsule bag, and Soemmering’s ring. 4GƂZCVKQP D[ +1. V[RG /…i LiÃÌ >««Àœ>V…Ìœ ÀiwÝ>̈œ˜ “is unique to each patient situation,” Dr. Schockman said. º7…i˜ ̅iÀi ˆÃ >˜ ˆ˜Ì>VÌ " É capsular bag complex, the lasso technique for sutured scleral wÝ>̈œ˜ ܜÀŽÃ Üi] «>À̈VՏ>ÀÞ when a CTR or three-piece IOL is present.” Dr. Hoffman agreed that care must be taken with single-piece IOLs as too much tension on the sutures may cause them to slip off and “cheese-wire” through the capsule. “A single- piece IOL should probably ˜œÌ Li wÝ>Ìi` ̜ ̅i ˆÀˆÃ LÕÌ > three-piece IOL with adequate posterior vitreous or capsule ÃÕ««œÀÌ V>˜ Li wÝ>Ìi` ̜ ̅i iris safely,” he said. “If the IOL is completely dislocated into the posterior segment, it will require a pars plana vitrectomy and retrieval and is then best dealt with by performing an IOL exchange for a scleral wÝ>Ìi` ̅Àii‡«ˆiVi " °» “However, in rare instances in which it is important to minimize incision number and size, ÀiwÝ>̈˜} > œ˜i‡«ˆiVi >VÀޏˆV IOL may be in the patient’s best interest,” Dr. Schockman continued. “In such situations, radial incisions for the lasso suture should be used. If there is an intact capsulorhexis with some capsulorhexis margin wLÀœÃˆÃ] -ˆi}i >˜` œ˜`œ˜ describe an elegant technique to suture the anterior capsule to the iris. 1 This can be a very useful tool in eyes with large blebs where conjunctival real estate is limited.” Dr. Khandelwal noted that dislocations usually occur due to issues with the zonules or bag. Meanwhile, care must be taken ܅i˜ ÀiwÝ>̈˜} ̅Àii‡«ˆiVi " à whether to the iris or sclera as the haptics may be weak. Iris vs. sclera The physicians tend to favor ÃViÀ> wÝ>̈œ˜ œÛiÀ ˆÀˆÃ wÝ>̈œ˜p although the latter can work “if there is an intact anterior or posterior capsule that allows support for the optic,” Dr. Khandelwal said. “There can be a PC tear or an AC tear or both, but the key is to avoid this technique in eyes without any capsule support especially those that are vitrectomized. These eyes tend to get pseudophakodonesis and UGH.” º ÀˆÃ wÝ>̈œ˜…>ň}…iÀ ÀˆÃŽ œv corectopia and CME,” Dr. Garg Ã>ˆ`° ºƂ``ˆÌˆœ˜>Þ] ˆÀˆÃ wÝ>̈œ˜ generally requires Prolene suture. It is known that this suture can degrade with time.” He added, “In general, I have gravitated toward intrascleral …>«ÌˆV wÝ>̈œ˜ Q - R œÛiÀ ˆÀˆÃ wÝ>Ìi` " ð 7ˆÌ…ˆ˜˜œÛ>̈œ˜Ã such as the glued IOL and Yamane ISHF techniques, I w˜` ̅>Ì ÃiVœ˜`>ÀÞ wÝ>̈œ˜ of IOLs has become fairly straightforward.” º ˜ >“œÃÌ > V>ÃiÃ] w˜` ÃViÀ> wÝ>̈œ˜ ÃÕ«iÀˆœÀ ̜ ˆÀˆÃ wÝ>̈œ˜ vœÀ LœÌ…" ÃÌ>LˆˆÌÞ and long-term safety,” Dr. Schockman said. “Over time, a polypropylene suture encasing both the IOL haptic and iris tissue can result in pressure necrosis or cheese-wiring of the iris. This then reduces the vÀˆV̈œ˜ ܈̅ˆ˜ ̅i wÝ>Ìi` Ž˜œÌ and results in haptic movement and IOL instability. Subsequent repeat dislocation or UGH syndrome may then ensue, resulting in increased IOP, hyphema, vitreous hemorrhage, among other complications.” “If I was going to exchange the IOL, I would perform sclera wÝ>̈œ˜]» À° œvv“>˜ Ã>ˆ`° º œÀ ÃÕLÕÝ>Ìi` V>«ÃՏ>À L>}É IOL complexes I prefer sclera wÝ>̈œ˜ ܈̅>ÃÜ ÃÕÌÕÀið v > three-piece IOL is subluxated within the sulcus, with vitreous or posterior capsular support, I VÕÀÀi˜ÌÞ «ÀiviÀ ˆÀˆÃ wÝ>̈œ˜ ܈̅ either 10-0 or 9-0 Prolene.” Describing her algorithm for IOL exchange, Dr. Fram said that she will use anterior or posterior V>«ÃՏi wÝ>̈œ˜ œv > ̅Àii‡«ˆiVi IOL if she can. “This requires .QCFKPI UWVWTG HQT ƂZCVKPI ;COCPG KPVTCUENGTCN ƂZCVKQP VGEJPKSWG