CATARACT EWAP SEPTEMBER 2023 17 exchange is warranted when the patient has visual complaints in an otherwise healthy eye,” she said. “When the patient is unhappy with their vision after cataract surgery, the surgeon should first make sure the correct IOL was placed, the IOL is in good position, and the eye is otherwise in good health,” Dr. Schockman said. “It is advisable to repeat IOL measurements for accuracy. Any other cause for the patient’s visual complaints should be ruled out. If there is dry eye, the ocular surface should be optimized. In the case of multifocal IOLs, the surgeon should allow adequate time for neuroadaptation to occur. Once a stable refraction has been demonstrated, laser vision correction can be considered in the case of a refractive miss. The surgeon should try optimizing the patient’s vision prior to deciding on an IOL exchange. If the patient continues to have problematic symptoms despite clinical optimization, a detailed discussion is warranted to weigh the benefits and risks of IOL exchange.” Dr. Teichman said if an exchange is being considered for incorrect IOL power or toricity, he’ll proceed once a stable refraction can be obtained. If the exchange is due to intolerance of a presbyopia - correcting IOL, some consider waiting months for neuroadaptation. Dr. Micheletti said if a patient is extremely bothered by severe dysphotopsias due to a diffractive IOL from the day of implantation, “you likely need to intervene sooner rather than later.” “I do try to go back in pretty quickly, within the first 2–3 months,” he said, noting that sometimes it means switching up IOL technology. He noted that the patient must understand what they might be giving up if they opt to exchange an IOL that they’re not entirely happy with. “You have to find out what exactly is bothering the patient and, in the case of a multifocal, if they’re willing to give up that near vision that they’re getting,” Dr. Micheletti said. “Some of my patients think about it and say, ‘I’m happy with my near vision, I don’t want to go back to glasses, I can handle this.’ That’s a very different conversation from the patient who says, ‘I can’t live like this, I’m miserable.’” How to exchange Focusing on in - the - bag IOL exchange, Dr. Teichman shared his usual process. “If the previous surgery was less than 3 months prior, I generally reopen the wound with a Sinskey hook,” he said. “If later, I will create a new wound, making sure it will not connect to the previous wound, which can occasionally reopen creating a very large unstable wound. I favor a slightly larger incision for IOL removal. The endothelium should be protected with dispersive viscoelastic and space created with a cohesive OVD (using the soft shell technique of Steve Arshinoff, MD). “It is important not to fill the anterior chamber completely as one will require additional OVD to free the IOL in the next steps,” he continued. “Next, ideally at the haptic-optic junction, dispersive OVD is injected just under the anterior capsule to begin the separation of the anterior and posterior capsule to open the bag. This can be done with a 30-gauge needle bevel down or a flat LASIK cannula. Once the separation has begun, the usual OVD cannula can be used to propagate this. This step is a combination of viscodissection and gentle manual dissection at times. The goal is to open the capsule 360 degrees. The location of the densest adhesions varies by the haptic shape and may be the proximal or distal portion. Once the IOL is partially freed, OVD is inserted posteriorly to protect the posterior capsule. Once the IOL is completely freed, it is brought into the anterior chamber, and with good protection of the endothelium and posterior capsule, the IOL is cut using intraocular IOL cutters. This is best performed with the second hand holding the IOL using micro-instrumentation. I generally completely bisect the IOL, but other techniques exist, including creating a Pac-Man or twisting maneuvers. Some surgeons will insert the second IOL posterior to the first, prior to cutting the first, to protect the capsular bag.” Dr. Schockman said having a plan and a backup plan (or two) prior to removal is important. “To remove an IOL from within the capsular bag, it’s critical to ensure viscoelastic material is used to completely free the haptics. There can be fibrosis and scarring around the haptics, and manipulation of the haptics before they are completely freed can result in zonular dehiscence or capsular rupture,” she said. “Gentle dissection can be performed, but attempts to rotate the IOL before the haptics are free should be avoided. In some instances, the haptics cannot be freed, and the surgeon may amputate the haptics and remove the optic only. A new IOL can still be placed in the bag 90 degrees away, if a toric IOL is not required.” Dr. Micheletti and Dr. Teichman also shared this advice about leaving a haptic, if it cannot be easily freed. Dr. Micheletti noted that sometimes cutting at the haptic gives the surgeon more flexibility that could lead to its removal during the case. Depending on the IOL material, the first IOL can be folded, cut, or removed whole, Dr. Schockman said, also mentioning the Pac- Man technique. Both Dr. Schockman and Dr. Micheletti discussed inserting the second IOL posterior to the original to act as a scaffold, protecting the capsule. Dr. Schockman also gave the tip of using enough viscoelastic to protect the corneal endothelium while
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