EyeWorld Asia-Pacific March 2021 Issue

FEATURE EWAP MAR C H 2021 17 FEATURE there is a knob at the end of the haptic, and what the IOL material is, Dr. Chee said. If you need to open the capsule and free the haptics, Dr. Chee recommended inserting the OVD cannula between the anterior capsule and the IOL anterior surface. Begin injecting the OVD, but if this is not possible, she said to use a micro-grasper to lift up the anterior capsule to allow the OVD cannula to slip between the anterior capsule and IOL and inject the OVD. She said to avoid using graspers that have a sharp end, as the capsule may rip. If the haptics are adherent and do not come free with OVD and dissection, Dr. Chee said to lift the optic out of the bag and cut out and remove the central third. You could also cut the optic in half, which allows you more room to attempt to free the IOL without stressing the zonules. Dr. Chee said she prefers to reposition or exchange a lens that is fully in the bag earlier rather than later (and before fibrosis sets in), but she would hardly consider any IOL too late to reposition or exchange. IOL refixation Dr. Rocha noted that if the lens still looks good and the patient has good vision, this is a scenario when you can plan to use the same lens and refixate it. If you’re keeping the same lens, she said it’s important to determine if the patient was able to see well before with this lens and to rule out any IOL damage and determine if the patient needs a vitrectomy. There are some single-piece IOLs that you can refixate, she said, adding that she likes to use a belt loop technique, which she noted is described in depth by Cathleen McCabe, MD. Dr. Rocha will use 6-0 Prolene with this technique and scleral fixation. She then loops the IOL haptics to the scleral wall. If the patient has a three- piece IOL in the eye, one technique that is popular is the Yamane technique, Dr. Rocha said. She uses a toric marker at 6 and 12 o’clock and a secondary mark 2.0 mm from the limbus. Two angled scleral tunnels are made parallel to the limbus at the marked locations using two needles; she uses either a 30-gauge TSK ultra- thin wall needle for the CT LUCIA lens (Carl Zeiss Meditec) or a 27-gauge needle for the AR40E SENSAR IOL (Johnson & Johnson Vision). She then feeds the needles using micro-forceps and pulls the haptics. 1 those tend to calcify if you do a secondary procedure. “If the lens is dislocated with no capsule support, I’m going to cut it and take it out [and do a] pars plana vitrectomy and a Yamane technique,” he said. It works well to “clear everything out,” he said, because then you know you have the right power with a fresh lens. When you lasso an old lens-bag complex, it can be full of “junk,” Dr. Safran said, like Soemmering’s ring material, fibrosis, etc. Additionally, Dr. Safran said that if you have a dead bag, it’s important to take this out because the bag is so fragile, and once you start passing sutures, it will likely fall apart. When choosing to remove the IOL, Dr. Chee said she will use only dispersive OVD to maintain space and protect the endothelium, which is often weak in these complex eyes. “Furthermore, some OVD can safely be left in the eye without incurring a pressure spike,” she said. When removing an IOL, Dr. Chee said she prefers to cut it rather than refold it inside the eye. She specifically discussed removal of silicone IOLs, which can be more slippery. “I grab the haptic or capsule if they are dislocated posteriorly to levitate them, rather than attempting to grasp the optic,” she said. “I prefer to explant them, as they do not stay still when attempting to iris fixate.” She’ll use serrated IOL forceps to grasp the IOL when cutting. “If you fail to hold the IOL firmly with your lens forceps, try the conjunctival forceps, which are serrated and will hold them firmly for explantation,” Dr. Chee said. It’s important to know the IOL you’re explanting, where the positioning hole is or whether The lens-bag complex is dislocated in this eye with a “dead bag.” Despite being more than 10 years postop, there is no fibrosis of the capsular bag. The capsule is very thin and diaphanous, and the zonules are almost nonexistent. It is not advised to lasso the lens-bag complex in these cases; instead, the whole complex was removed and replaced with a Yamane intrascleral haptic fixation lens. Source: Steve Safran, MD