EyeWorld India December 2014 Issue

December 2014 16 EWAP FEATURE Fixing dislocated lenses and IOLs by Vanessa Caceres EyeWorld Contributing Writer Anterior segment surgeons need tools, techniques to tackle this challenge D islocated natural lenses and IOLs require constantly evolving tools and surgical approaches. The causes behind a dislocated natural lens or IOL can vary, said Minu Mathen, MD , senior consultant, cataract and refractive surgery services, Chaithanya Eye Hospital & Research Institute, Trivandrum, Kerala, India. “In my experience, the common causes of dislocated or subluxated natural lenses are congenital causes, pseudoexfoliation, trauma, and hypermature cataracts,” Dr. Mathen said. “With IOLs, the causes are implantation without adequate capsule support, placement of haptics into the area of zonular dehiscence, pseudoexfoliation, trauma, high myopia, retinitis pigmentosa, and in post- vitrectomized eyes.” Other causes include a hypermature cataract, megalophthalmos, and any other cause of preoperative phacodonesis, said Soosan Jacob, MS, FRCS, DNB , senior consultant ophthalmologist, Dr. Agarwal’s Eye Hospital, Chennai, India. Surgeons also see cases where 10-0 Prolene was used as the suture to keep a prosthetic element attached to the sclera, said Richard S. Hoffman, MD , clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Eugene, Ore., U.S. Fast forward 7 to 10 years later, subluxation occurs. “We now use Gore-Tex or 9-0 Prolene. Gore- Tex won’t break, and no one has reported 9-0 Prolene breaking yet,” Dr. Hoffman said. A study published last year involving 61 eyes found that high myopia was a common cause of late in-the-bag IOL dislocation. 1 Anterior segment surgeons may see dislocation more frequently in the future. “I think we’ll see more of these cases as patients with pseudoexfoliation live longer. Not everyone has this happen, but the longer they live, the greater the chance of the lenses coming loose,” Dr. Hoffman said. Surgical approaches The surgical approach to a dislocated natural lens or IOL depends on what has happened in the eye and the surgeon’s preference. Here’s how Drs. Mathen, Hoffman, and Jacob handle these cases. For an IOL completely dislocated into the vitreous, Dr. Mathen calls an in-house AT A GLANCE • Dislocated natural lenses or IOLs can have a number of causes, including trauma, congenital conditions, high myopia, hypermature cataracts, or older 10-0 Prolene suture use. • Surgeons may see more dislocated IOLs as patients with pseudoexfoliation live longer. • The surgical approach to fix a dislocated lens or IOL can vary greatly depending on the exact problem and surgeon’s preference. • Some familiarity and training with a pars plana approach is helpful for anterior segment surgeons. Figure 1. CTR and IOL in the bag subluxated Figure 3. Capsular bag stripped off the IOL Figure 5. 9-0 Prolene pass under one haptic Figure 7. Knots on haptic within AC with two MST forceps Figure 2. CTR explant after snipping bag near eyelet Figure 4. Optic captured above iris Figure 6. 9-0 Prolene under other haptic Figure 8. Well-centered IOL with round pupil Source(all): Minu Mathen, MD vitreoretinal surgeon to perform a pars plana vitrectomy and bring up the IOL. When there is good capsule support and a multi-piece IOL, he places the IOL in the ciliary sulcus. With no capsular support, he places the haptics exteriorly via sclerotomies placed under a partial-thickness scleral flap and tucks them into scleral pockets. He then remains sutureless by closing the scleral flaps with fibrin glue. For a single-piece IOL, Dr. Mathen will bisect and explant the IOL and then perform sutureless