FEATURE EWAP DECEMBER 2023 9 at high risk for postoperative uveitis - glaucoma - hyphema (UGH) syndrome,” he said. “The tilt can also induce astigmatism and/or coma. The ideal scenario would be a small AC rent that happens to coincide with the steep axis of corneal astigmatism. This would allow the physician to orient the toric IOL such that the haptic-optic junction is around the area of the rent, and both haptics will be entirely secured under the remaining capsulorhexis edge.” A single-piece IOL may also be an option in the setting of a posterior capsule rupture (PCR), provided the posterior capsule surface area is large enough to support the IOL long term. “If the surgeon is able to keep the PCR small and controlled throughout the remainder of the surgery, a single-piece IOL is certainly a plausible outcome; in that scenario, a toric IOL should be considered,” he said. “This is especially true if the PCR can be converted to a posterior continuous curvilinear capsulorhexis. If the PCR is large and the surgeon thinks that the remaining posterior capsule cannot support an IOL, a common IOL placement is in the sulcus (with or without optic capture). In this scenario, the surgeon should not place a single-piece toric IOL in the sulcus due to the increased risk of UGH syndrome. Instead, a three-piece IOL with PMMA haptics should be used. An alternate option for placement of a single-piece IOL in the setting of a PCR is reverse optic capture; a single-piece IOL can be placed with the haptics in the capsular bag and the optic anterior to the capsulorhexis opening. This technique of reverse optic capture would allow a surgeon to still implant a single-piece toric IOL in a compromised capsule.” If capsular support is entirely insufficient, Dr. Rai also mentioned anterior chamber IOLs, iris-sutured IOLs, scleral- sutured IOLs, and intrascleral haptic fixation as possibilities. Jonathan Rubenstein, MD, shared his thoughts on what to do when there is a compromised capsule and a toric IOL was planned. If there is a PC tear, he said you need to make sure you can visualize the entire extent of the tear to ensure that it won’t tear out, producing instability. If it’s localized (and ideally round), Dr. Rubenstein said it’s unlikely to tear out, and thus OK to place a toric IOL, provided the zonules A toric IOL on axis, placed after a localized posterior capsular tear. Source (all): Jonathan Rubenstein, MD are still good. “During placement, avoid further extension of the posterior capsule, using OVD to protect the capsular bag,” he said. Dr. Rubenstein said if it’s not advisable to place a toric IOL, you can still address astigmatism in the OR. If you’ve planned for it or have a nomogram and the proper equipment available, you could perform limbal relaxing incisions (LRIs), he said. He added that he doesn’t think many surgeons are comfortable or have the equipment/information available to them in the OR to perform this procedure, if they weren’t already planning for it. Postop management of astigmatism, if a monofocal IOL was placed due to the compromised capsule, includes glasses, toric contact lenses, or a refractive procedure, such as corneal refractive surgery, LRIs, astigmatic keratectomy, and opposite clear corneal incision. Dr. Rubenstein said these are options for patients who had a three-piece lens in the sulcus or placed with optic capture. He lets these patients stabilize for 3 months post-cataract surgery because “at that point, it’s refractive astigmatism rather than astigmatism based on corneal measurement.” The physicians also addressed the patient counseling aspect of this complication. “The discussion,” Dr. Rubenstein said, “is: ‘Our first
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