EyeWorld India December 2014 Issue

December 2014 17 EWAP FEATURE scleral fixation as described above. “If there’s a single or multi-piece IOL and the whole capsular bag with or without a capsular tension ring [CTR], then I would sclerally fixate it by passing 9-0 Prolene sutures around either haptic by piercing the capsular bag close to the haptic and fixating them to the sclera,” he said. For lenses decentered in the capsular bag, Dr. Hoffman will viscodissect it free and recenter the lens. If there is one haptic in the sulcus and one in the bag, Dr. Hoffman will take the same approach and place the whole lens in the bag. For lenses in the sulcus, Dr. Hoffman will perform iris fixation, fixating the haptics to the iris. “When the lens is in the capsular bag and the whole bag is loose, usually I’ll sclerally fixate the haptics to the sclera,” he said. “When the whole lens has dropped into the vitreous cavity, I will get the retina people involved.” Dr. Hoffman recommends turning any microscope light down to avoid phototoxicity to the retina. “When doing nonessential things outside of the eye, such as manipulating sutures or making flaps, use a corneal protector so the light isn’t burning the retina,” he said. Depending on the degree of subluxation, Dr. Jacob uses a CTR and a newer approach that she has developed using sutureless, transscleral fixation of a modified capsular hook—a technique she terms a “glued capsular hook.” To achieve this, Dr. Jacob will take a modified capsular hook and insert it through the sclerotomy in a plane so it comes out under the iris but over the capsular bag. The hook is then used to engage the rhexis rim and provide stability to the capsular bag. One or more hooks may be used as required in a combination of transsclerally- and translimbally- placed hooks. A capsular tension ring is then inserted either before or after completing the phacoemulsification. “The transsclerally-placed capsular hooks remain in situ at the end of surgery. They are tucked intrasclerally into a Scharioth tunnel and thus are able to provide sutureless transscleral fixation,” she said. One advantage of this approach is avoiding sutures, Dr. Jacob said. She also will use a glued IOL if needed, especially in cases of extensive subluxation or in progressive causes of subluxation. A pars plana approach? Should surgeons take a pars plana approach when managing dislocated lenses? “I think they should be familiar with it, but it depends on the surgery type,” Dr. Hoffman said. “If there’s vitreous loss, it’s usually more efficient to remove the vitreous with a bimanual pars plana approach. Sometimes, to reposition a lens, you need to go through the pars plana if the lens is decentered in the sulcus.” At a minimum, anterior segment surgeons should be comfortable with pars plana incisions, although they do not need to know how to perform complex approaches or extensive vitrectomies, Dr. Hoffman thinks. “A pars plana approach is useful in many situations,” Dr. Jacob said. “You need to be confident about your surgical skills and have some supervised training and experience. It’s safe if done the right way.” Better and finer instrumentation has made this approach easier, Dr. Jacob said. Although he does not do it himself, Dr. Mathen said that a pars plana approach can be an efficient way to clear vitreous from the anterior chamber in cases of vitreous loss or to do a VISCOAT (Alcon, Fort Worth, Texas, U.S.)-associated posterior levitation of nuclear fragments in cases of impending nucleus drop. EWAP Reference 1. Fernández-Buenaga R, Alio JL, Pérez-Ardoy AL, et al. Late in-the- bag intraocular lens dislocation requiring explantation: Risk factors and outcomes. Eye (Lond). 2013;27:795–801. Editors’ note: The physicians have no financial interests related to their comments. Contact information Hoffman: rshoffman@finemd.com Jacob: dr_soosanj@hotmail.com Mathen: minumpry@yahoo.com