CATARACT 16 EWAP SEPTEMBER 2023 T here are many motives and methods for IOL exchange. While a rare need, the physicians who spoke with EyeWorld said it’s important to be familiar with the indications for exchange, removal techniques, and considerations for IOL replacement. “Thankfully, the need to perform an IOL exchange is relatively uncommon in modern ophthalmology,” said Samantha Schockman, MD. Morgan Micheletti, MD, remembers IOL exchanges being portrayed as “a scary, complex, and challenging surgery” when he was a medical student. While these cases aren’t routine, he said that ophthalmologists are now more comfortable with the surgery. Joshua Teichman, MD, said the decision to exchange is a joint one between the surgeon and patient. “A surgeon who performs more IOL exchanges will have a low complication rate and likely offer this earlier than a surgeon who does not,” Dr. Teichman said. “It is important that those who implant IOLs more prone to dissatisfaction be comfortable with IOL exchange. When a patient is unhappy from something that is clearly attributable to the IOL and exchange has a reasonable chance of improving this, I think an exchange is warranted. It is important that other issues be ruled out first. If patients are unhappy with presbyopia - correcting IOLs immediately postoperatively, one can generally assume that this is not from posterior capsule opacification, and a YAG capsulotomy should be avoided. IOL exchange in the presence of an open posterior capsule increases the risk and may be surgically more challenging. One should be prepared to Contact information Micheletti: morgan.micheletti@gmail.com Schockman: sschockman@cvphealth.com Teichman: josh.teichman@gmail.com Making Practice Perfect for IOL exchange by Liz Hillman Editorial Co - Director perform a vitrectomy in these cases, and if the capsular bag integrity is compromised, be prepared with a 3-piece IOL for sulcus placement and/or flanged double needle intrascleral haptic fixation (Yamane).” Why exchange and when According to the physicians, there are several reasons for IOL exchange: refractive miss, dysphotopsias, intolerance to presbyopia - correcting designs, dislocation/subluxation, IOL defects/damage/opacification, and secondary issues (e.g., corneal edema from AC IOLs, UGH syndrome, etc.). “If you know it’s a miss, and you know there is stability, and you know it’s not an unusual situation like post-RK, but for whatever reason you’ve had a refractive miss, you can exchange relatively early on,” Dr. Micheletti said. “Relatively early I would say is within a month. If they’re not improving and they have a documented refractive error that’s large, I would go back in pretty quickly.” If the patient is off by less than a diopter, the patient is a good candidate, and it isn’t a rotational issue with a toric lens, Dr. Micheletti added that he’d consider a LASIK enhancement instead of intraocular surgery due to the risks. Dr. Schockman said when there is a mechanical or anatomical issue causing complications, the decision to proceed with an IOL exchange is relatively straightforward. “It can be less clear when an IOL This article originally appeared under the title “IOL exchange 101” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. IOL cut in half in anterior chamber. Source: Joshua Teichman, MD, MPH
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