CATARACT 18 EWAP SEPTEMBER 2023 cutting or folding the original IOL. “A second instrument, such as a Kuglen hook or spatula, can be used to keep the IOL away from the cornea while it is removed,” she said. Dr. Micheletti recently published about the “modified twist and out” technique. 1 With this method, once the IOL is in the anterior chamber with one haptic externalized, an additional paracentesis is made 180 degrees away from a side port and “the shaft of a 25- or 27-gauge cannula is threaded across the AC to connect these incisions.” According to the paper, this technique “frees both hands to use forceps within the incision, grasp the IOL, and rotate it around the forceps.” The technique allows for “smaller, more controlled movement than the large, 1-handed pronation” originally described. The technique is completed by withdrawing the forceps-lens complex “with one efficient movement.” What to exchange for The second IOL for replacement depends on the reason for the original IOL’s removal as well as the patient’s age, other ocular comorbidities, the patient’s goals, and the patient’s anatomy, Dr. Schockman said. If the reason for exchange is a refractive miss, Dr. Teichman said he’ll exchange for the same IOL with the correct spherical power/ toricity. “If the patient is having an IOL exchange to replace a multifocal for a monofocal IOL due to visual disturbances, it may be a straightforward in - the - bag IOL exchange. In such a case, the most important aspect of the IOL exchange is to set realistic patient expectations prior to surgery,” Dr. Schockman said, adding later, “The decision on what IOL to insert is directly dependent on the best intraocular placement for a stable IOL. It is a good idea to have multiple types of IOLs available prior to surgery to allow for different scenarios.” For example, she said placing an IOL in the bag is optimal, but sometimes it is not a viable option, and the surgeon should have different IOLs available to them for these scenarios. “It’s most important to ensure the patient’s primary problem with the IOL is addressed,” Dr. Micheletti said. “If the problem is a refractive miss, it’s straightforward. If the issue lies with the characteristics of the lens, then it’s a more complex discussion with the patient to determine the next best IOL for them. For example, one could change from a continuous range of vision multifocal to a segmented bifocal or to a non-diffractive EDOF or small aperture optic or, as a final fallback, to a monofocal IOL. The Light Adjustable Lens [LAL, RxSight] is also a good option. The adjustability of the LAL is beneficial in nailing the outcome and because the LAL is a 3-piece IOL, you can place it in the sulcus and optic capture in cases where the posterior capsule is already open. That does commit the patient to having to return more frequently for postop adjustments, so it’s important to discuss this possibility with the patient if the LAL is used as a backup intraoperatively for an unexpected capsular break.” Final best practices Dr. Micheletti mentioned the IOL calculators on ASCRS.org. “There are some calculators that can be used given the patient’s postop refraction and biometry to say what the power and orientation of the new lens should be,” he said. Dr. Schockman said her additional best practices for IOL exchange include obtaining an endothelial cell count (ECC) and a macular OCT. The ECC, she said, helps determine if an AC IOL is a reasonable option, if needed, and it allows for better counseling if there might be a future need for keratoplasty due to reduced endothelial function. Dr. Schockman also said that it might be necessary to remove an IOL and leave the patient aphakic. “IOL exchanges can be challenging, and surgeons should optimize their chances at success by taking their time, improving visualization whenever possible, and having several backup plans at their disposal. The use of iris hooks for direct visualization can be invaluable,” Dr. Schockman said. EWAP Reference 1. Duncan NB, Micheletti JM. Modified adaptation of the twist - and - out technique for intraocular lens exchange. J Cataract Refract Surg. 2022;48:1469 – 1471. Editors’ note: Dr. Micheletti practices at Berkeley Eye Center, Houston, Texas, and declared no relevant financial interests. Dr. Schockman practices at Cincinnati Eye Institute, Cincinnati, Ohio, and declared no relevant financial interests. Dr. Teichman practices at Prism Eye Institute, University of Toronto, Toronto, Canada, and has interests with Aequus, Alcon, Allergan, Bausch + Lomb, Labtician Thea, Novartis, Santen, Shire, and Sun Pharma.
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