CATARACT EWAP SEPTEMBER 2022 31 lens in the sulcus space and tucks the optic of that lens underneath the anterior capsule. This technique provides a secure position for the IOL and reduces the likelihood of the lens moving around in the sulcus. The refractive outcome will also be comparable to placing the lens in the capsular bag. Sometimes there may not be enough of an anterior capsule to safely perform optic capture. If the surgeon is in doubt of the lens stability in the sulcus, he or she could place a suture to secure the haptics of the lens to the iris for additional support. Dr. Venkateswaran noted that some surgeons, in cases where the PCR is small and central, will create a primary posterior capsulorhexis and perform posterior optic capture, where the IOL is placed in the bag and the optic is captured in the posterior capsulorhexis. This provides additional stability for the IOL, but it’s also tricky and will only work if a truly round posterior capsulorhexis can be made out of a small P RÆ it will not work if there is a large radial PCR. Dr. Venkateswaran also mentioned reverse optic capture, which she said can be useful if there is a PCR particularly in the setting of a premium lens. This could provide the patient the opportunity to still get the premium technology they want in a safe way. Ultimately, these lenses, when optic captured, are extremely stable, Dr. Venkateswaran said. “I think there are issues when a surgeon places a three-piece lens in the sulcus, and they’ve lost a large portion of the anterior capsule. These lenses can move around quite a bit and can potentially dislocate, and that’s why fiÝating these lenses to the iris is a more stable option.” If the surgeon doesn’t think there is enough support for a three-piece in the sulcus, Dr. Venkateswaran recommended either putting an anterior chamber lens in or staging the procedure and coming back when the eye is quieter to perform a secondary lens fiÝation. Dr. Behshad said that timing of the PCR and residual capsular strength is what will help determine IOL placement. “When there is a stable residual anterior capsule remaining, placement of a three-piece IOL in the ciliary sulcus would be the most acceptable option,” he said. “Reverse optic capture can be performed in this scenario to provide further IOL stability, but if the anterior capsulotomy is too small or large, it may not be possible in all cases.” He said that if the PCR occurs after placement of a one-piece in the capsular bag, and the posterior rent or tear is stable with an intact anterior capsule, optic capture with the anterior capsule can be performed. Care and time should be taken to ensure that the IOL is stable in this configuration. “If there is any concern for stability, the one-piece IOL should be removed and a three-piece placed in the ciliary sulcus,” he said. “It is never OK to place a one-piece IOL in the ciliary sulcus, as this will lead to 1G syndrome.” Placement of an ACIOL has been shown to lead to complications down the line, including glaucoma and corneal decompensation. Therefore, it may not be the best long-term option for patients, Dr. Behshad said, adding that other IOL placement techniques are dependent on surgeon skills. These techniques include suturing a three-piece IOL to the iris, suturing a three-piece IOL or PMMA IOL to the sclera, or intrascleral IOL fiÝation using a three-piece IOL with haptics made of polyvinylidene yuoride, such as the CT LUCIA 602 (Carl Zeiss Meditec). Following IOL placement, care should be taken to do a complete anterior vitrectomy to ensure all prolapsed vitreous is removed from the anterior chamber, Dr. Behshad said. Dilute triamcinolone or acetylcholine should be Preoperative photograph demonstrating existing posterior capsular weakness. The patient was referred for a cataract; YAG vitreolysis was performed for a symptomatic posterior vitreous detachment. Source: Soroosh Behshad, MD, MPH
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