EyeWorld Asia-Pacific March 2021 Issue

FEATURE EWAP MAR C H 2021 15 by Ellen Stodola Editorial Co-Director Pearls for refixating and exchanging IOLs Contact information Chee: chee.soon.phaik@singhealth.com.sg Rocha: karolinnemaia@gmail.com Safran: safran12@comcast.net This article originally appeared in the December 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. I n some cases, it may be necessary to refixate or remove an IOL after cataract surgery. Several surgeons discussed how they determine when this course of action is needed and techniques they use. When you have a patient with a dislocated lens-bag complex, there are a variety of factors to consider, said Steve Safran, MD. First, he noted that you could be dealing with dislocation of the whole lens-bag complex where the zonules are shot; he usually uses a lasso in these cases. On the other hand, the capsular bag could be intact but within the lens is dislocated. “Your decision will depend on whether or not you want to keep that lens,” Dr. Safran said. Choosing an appropriate option depends on the anatomy, your strategy, and if the IOL inside the eye is the one you want to keep. “Most of the time, they are lenses I want to get rid of,” he said. Dr. Safran said in rare cases, comorbidities may influence the decision. If there’s a filtering bleb, that might limit your angle of approach. If the patient is a high myope with a large eye, that will influence the decision. If the eye is bigger, it might be more difficult to do certain techniques. In terms of determining when a lens should be repositioned vs. exchanged, Chee Soon Phaik, MD, said this will often depend on the particular IOL. The design of the haptics, IOL power, and condition of the IOL all play a role, she said. The technique for fixation will also influence the decision—for example, if the IOL can be sutured to the iris or if it’s going to be intrascleral fixation. Dr. Chee said she will do a supine exam, if a couch is available. “However, if a UBM has been done, I do not need to lie the patient down because the scan gives an image of the IOL with the patient in the supine position,” she said. It’s also important to consider iridodonesis. Eyes that have undergone surgeries, such as trans pars plana vitrectomy, or patients with floppy irises are more difficult to operate on, Dr. Chee said, explaining that it is difficult to suture an IOL to a floppy iris. “These eyes have more pseudophacodonesis, postoperative inflammation, and pigment dispersion that lasts for 3–4 months regardless of whether the IOL is iris sutured or enclavated,” she said. “For this reason, I prefer intrascleral haptic fixation as the IOL is rock stable during eye movements.” Dr. Chee said if an adequate peripheral iridectomy is created, and the IOL is not tilted or decentered, there is little risk of optic capture when the pupil is dilated. Additionally, Dr. Chee said she will stop the anticoagulant to reduce the risk of vitreous hemorrhage and raised IOP when possible. Passing the needle through the iris or sclera can evoke an uncontrolled bleed and raised IOP in these compromised eyes. Dr. Chee said she will proceed without a retina specialist if she can reach the IOL safely with micro-forceps with adequate exposure for things like iris hooks and scleral indentation. She will stain the vitreous with diluted triamcinolone acetonide to ensure she does not tug on the vitreous and clear the vitreous around the IOL before moving it to the anterior segment. “Have Dislocated single-piece IOL Source: Karolinne Maia Rocha, MD, PhD