EyeWorld Asia-Pacific March 2021 Issue

FEATURE EWAP MAR C H 2021 19 FEATURE Using a glued IOL was described many years ago by Amar Agarwal, MD, Dr. Rocha said, mentioning this as another option. Choosing a technique depends on the IOL type. If the patient has a PMMA lens, this has a little hole that you can move and perform a scleral fixation with either 6.0 Prolene (the belt loop technique) or Gore-Tex CV-8. Another option is iris fixation, but she said she’s “not a big fan because we usually see a lot of pigment dispersion and sometimes CME.” With a three-piece IOL, you can do iris suture/iris fixation, if you’re using the same lens, she said. Intraoperative photograph showing a suture snare, created by threading a 27-gauge needle with a short length of Gore- Tex 7-0 suture, entering through a Hoffman pocket 1.75 mm posterior to the limbus, piercing the capsular bag and passing posterior to the IOL-capsular tension ring-capsular bag complex. The loop of the suture snare is externalized. Another length of Gore-Tex 7-0 suture is threaded through the extended loop of the suture snare. Withdrawal of the suture snare then delivers the suture to the scleral point. Intraoperative photograph showing the other end of the fixation suture being drawn out through the Hoffman pocket by the pre-threaded extended loop of the suture snare. This suture creates a belt loop around the IOL-capsular tension ring- capsular bag complex, drawing it into position when both Gore-Tex suture ends are withdrawn from the Hoffman pocket and tied. Source (all): Chee Soon Phaik, MD If the whole lens complex is dislocated but the lens is in the bag and looks like it’s a good lens, Dr. Safran said he will lasso the whole lens bag complex. He uses Gore-Tex sutures with a lasso in these cases. In most of these patients, Dr. Safran said he will also do a vitrectomy. “If you don’t do the vitrectomy, you can get burned,” he said. It’s easy to inadvertently engage vitreous when passing a suture through the capsular bag and bring vitreous forward into the anterior segment, he explained, emphasizing the importance of avoiding vitreous traction to the lens or sutures. Dr. Chee discussed using a lasso technique and said she creates belt loops around the haptics of the IOL either with or without a CTR only if they are still within the capsular bag. “I use either Prolene 6-0 suture with the McCabe technique or Gore-Tex CV-8 suture (which is off label for ophthalmic use) using the suture snare technique, employing Hoffman pockets,” she said. For both the McCabe and suture snare techniques, Dr. Chee said she uses a 27-gauge needle to pierce the capsular bag to lasso the haptic. “I use a capsulorhexis micro-forceps to grasp the capsular bag to position it when piercing with the needle,” she said. These are simple techniques to master, she added, and the position of the sclerotomies are determined by the remaining zonules (if any). When fixing both ends, Dr. Chee said they should be positioned diametrically opposite from one another. The Yamane technique or a glued IOL technique are other options for refixating the IOL. Dr. Chee said she has learned never to reuse the existing IOL for intrascleral haptic fixation. Instead, she exchanges them for either a CT LUCIA 202 or 602 with PVDF haptics or the AR40E SENSAR lens with PMMA haptics. She added that both Hoya and Santen make IOLs with longer PVDF haptics specifically for intrascleral haptic fixation, but they are only available in Japan. If some capsule support remains, the surgeon may choose to iris fixate an existing three-piece lens. Dr. Chee said she does not opt for iris fixation unless there is some capsular support. She added that one potential downside is that iris fixated IOLs may dislocate years later in patients who chronically rub their eyes. Iris fixation may also incur a cat’s eye pupil, she said. Postoperative considerations Some patients may require follow-up with a retina specialist.