30 EyeWorld Asia-Pacific | September 2024 REFRACTIVE SURGERY If the lens is loose, there is no capsular support, and you need to exchange it out, she said, this can involve taking out the entire lens-bag complex and placing a secondarily fixated IOL (scleral fixated with or without sutures). Depending on the patient and the stability of their capsular anatomy, Dr. Chen will perform either in-the-bag IOL exchanges or explantation and removal of the IOL and capsule (if compromised) with secondary IOL implantation via either flanged IntraScleral Haptic Fixation (ISHF) or scleral-sutured IOL techniques. If there is a 3-piece lens already in the eye that needs to be repositioned or scleral fixated due to dislocation or UGH syndrome, she will usually first consider re-scleral fixating the same IOL to minimize trauma to the corneal endothelium. Tips and tricks Dr. Wang recommended starting off with having a good discussion on expectations and patient goals and taking your time. It’s also important to have a surgical plan and share this with the patient. Knowing what type of lens is in the eye is key, Dr. Wang said, especially if a bit of time has passed. The way the lens gets fibrosed into the capsule depends on the shape of the lens. It’s also important to know how you want to get the lens out of the eye. There are many ways to do this. You can fold and pull it out, cut it completely and pull it out in halves and thirds, or cut it in half, fold, and pull it out. You need to make sure you have the right instruments to do it, Dr. Wang said, adding that certain lens materials can’t be cut, so it’s important to know if this is the case with the lens that you’re dealing with. Dr. Chen also mentioned the differences among types of IOLs. Different IOLs tend to fibrose and adhere to the capsular bag in different places, she said. “With enVista lenses [Bausch + Lomb], the adhesions usually occur in the triangular eyelet at the optic haptic junction. With Tecnis single-piece lenses [Johnson & Johnson Vision], the adhesions are most prominent in the cutout indented area at the optic haptic junction, and with Alcon lenses, the capsular fibrosis tends to occur at the terminal bulbs of the haptics,” she said. “When explanting these IOLs, I use a cohesive OVD on a cannula to ensure full release of the adhesions in these areas and sometimes gently lift the capsule while injecting OVD to break the adhesions and to fully open the capsular bag. “Occasionally, haptics are so fibrosed to the bag that they can’t be released without compromising the zonules. In these cases, to preserve zonular support, I will still open the bag up as much as I can but will amputate the haptics while the IOL is in the bag so that the optic is easier to remove,” Dr. Chen said. Dr. Chen said in cases where she preserves and re-scleral fixates the existing 3-piece IOL in the eye, she externalizes the trailing haptic and tests the threading of the trailing haptic into a 30-gauge wide lumen TSK needle prior to tunneling the needle for ISHF to ensure that the intraocular threading will proceed smoothly. “As a precaution, when planning a possible scleral fixation, I obtain permission from the patient’s primary care provider or cardiologist to stop aspirin and blood thinners prior to surgery if it is safe for the patient,” she added.
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