EyeWorld Asia-Pacific March 2019 Issue

66 March 2019 EWAP DEVICES Implanting an IOL in the sulcus by Michelle Stephenson EyeWorld Contributing Writer Selecting the correct lens and proper placement are key to a good outcome O ccasionally, such as in the setting of a posterior capsular tear, lenses need to be placed in the sulcus instead of in the capsular bag. Choosing the correct lens and proper placement can help to ensure a good outcome. “When we find that there’s not adequate support within the bag, we will look to the sulcus as the next best place to implant a lens securely,” said Sumit “Sam” Garg, MD, Irvine, California. “Typically, you want to make sure that you’re putting a three- piece lens into the sulcus. A one- piece lens is never indicated for the sulcus. I generally will use one of two lenses: the Tecnis ZA9003 [Johnson & Johnson Vision, Santa Ana, California] or the CT LUCIA 602 [Carl Zeiss Meditec, Jena, Germany]. The reason for choosing one over the other depends on the eye. If I think there’s a high likelihood that the lens is going to slip in the future, I gravitate toward the CT LUCIA lens because the haptics on this lens are more amenable to scleral fixation.” Elizabeth Yeu, MD, Norfolk, Virginia, agreed. She said that the ideal lens for sulcus placement is a three-piece lens with a round anterior edge. The only round-edged anterior optic lenses available in the U.S. are the Sensar AR40e hydrophobic acrylic three-piece IOL (Johnson & Johnson Vision) and the CQ2015 collamer three-piece IOL (STAAR Surgical, Monrovia, California). “The square edge of the anterior optic can rub against the posterior aspect of the iris and lead to chafing and varying degrees of inflammation and/or UGH syndrome. Additionally, you can use certain three-piece lens choices if you are going to do a piggyback lens technique in order to help manage a refractive miss,” Dr. Yeu said. Multifocals in the sulcus Dr. Garg said to use caution when placing a three-piece multifocal lens in the eye. “One of the challenges with placing a lens in the sulcus is ensuring centration. Because there is more space in the sulcus than there is the bag, the lens can gravitate off center more easily. Centering a multifocal lens in the sulcus can be challenging. That’s where something like optic capture comes into play, where you can ensure centration, especially if your anterior rhexis is well centered,” he said. Dr. Yeu agreed and noted that she would only implant a multifocal lens in the sulcus in very specific situations. “If you have a compromised posterior capsule to the point where your only option would be placing the three-piece multifocal in the sulcus, I wouldn’t do it unless you had a perfectly centered rhexis that was created by a femtosecond laser, so you could place it into the sulcus and do an optic capture into the bag. However, the lens is only going to be available in the high add powers. The three- piece option is not available in the low add multifocal lens powers. No one should place the currently available one-piece lenses in the sulcus,” she said. Power of the implant When implanting a lens in the sulcus, the power of the IOL may need to be adjusted, depending on the power of the lens. According to Dr. Garg, lower powered lenses Enlarge the main incision prior to implanting a three-piece IOL into the sulcus to avoid unnecessary pressure. Dialing a three-piece IOL into the sulcus. Well-centered three-piece IOL in the sulcus; all wounds are sutured (to prevent vitreous tracking to the wound) and round pupil (no peaking). Source: Sumit “Sam” Garg, MD