EyeWorld India December 2014 Issue

December 2014 18 EWAP FEATURE Methods for secondary lens implantation by Ellen Stodola EyeWorld Staff Writer Surgeons discuss types of secondary IOL implantation, suture use, and postop medication W ith secondary lens implantation it is important to consider specific techniques, the best IOL, sutures, and medication regimens. Richard Davidson, MD , associate professor and vice chair for Quality and Clinical Affairs, University of Colorado, Aurora, Colo., U.S.; Natalie Afshari, MD , chief of cornea and refractive surgery, Shiley Eye Center, University of California, San Diego, La Jolla, Calif., U.S.; and Bryan S. Lee, MD , assistant professor, Department of Ophthalmology, University of Washington, Seattle, Wash., U.S., discussed their preferred methods for these procedures. Preferred method It depends on the patient when choosing a method of secondary IOL implantation, Dr. Davidson said. It depends on the patient’s anatomy, age, refractive error, if the patient has any comorbidities, and what hardware is in the eye, he said. “But in general, I prefer to either do a Hoffman pocket, which is a way to scleral fixate the IOL, or I’ll suture the IOL to the iris.” Dr. Lee said that he prefers iris fixation if the iris is able to support the lens, and his second choice is scleral suturing. “Although modern anterior chamber IOLs are good, suturing an IOL to the iris or sclera is still safer for the corneal endothelium,” he said. Compared to scleral fixation, iris fixation has several advantages, including that all the sutures are internal, you do not need to worry about doing a very peripheral vitrectomy, you avoid the possibility of a leaking sclerotomy, and there is less risk of a vitreous hemorrhage that can slow down visual recovery, Dr. Lee said. The glued IOL technique is also a possibility. “Although I think it’s attractive, I’d like longer- term follow-up, plus a lot of the advantages of iris fixation are still applicable,” he said. Dr. Afshari said she uses a PC-IOL if there is anterior capsular support because it is a more natural option. Otherwise, she decides on a case-by-case basis, with other options including a sutured PC- IOL or an anterior chamber IOL. “I feel that the new anterior chamber IOLs have quite good designs as well,” she said. IOL choice For iris or scleral fixation, Dr. Davidson said he uses the STAAR AQ5010V (STAAR Surgical, Monrovia, Calif., U.S.) for low diopter powers or AQ2010V for regular powers. These IOLs are silicone, 3-piece lenses that work well for scleral fixation gluing or with iris fixation, he said. Dr. Lee likes the STAAR AQ2010 for iris fixation because it has a large optic and a rounded edge, but it is not always available in his OR. The AcrySof MA60AC (Alcon, Fort Worth, Texas, U.S.) also tends to work well. “For a scleral sutured IOL, I use the Alcon CZ70BD and go through the eyelet with 9-0 Prolene or make a hitch around it with CV-8 Gore-Tex,” he said. Sutures It is important to consider the types of sutures for these cases. For iris fixation, Dr. Lee uses a 9-0 Prolene suture on a long curved needle with a Siepser or McCannel knot, depending on where the incisions and suture passes are. For scleral fixation, he is transitioning from 9-0 Prolene to CV-8 Gore-Tex. “For both iris- and scleral-fixated IOLs, the MST snare [MicroSurgical Technology, Redmond, Wash., U.S.] makes retrieving sutures through a small incision easy,” he said. Dr. Davidson said his choice for sutures depends on what is being done. He uses a 10-0 Prolene when he is suturing to the iris. For this, he also uses the CIF-4 needle, a long, curved needle. However, for suture fixation to the sclera, he prefers 8-0 Gore-Tex if it’s available. Dr. Davidson noted AT A GLANCE • Surgeons use different types of suture depending on the patient’s condition; CV-8 Gore-Tex, 9-0 Prolene, and 10-0 Prolene are used often. • When performing a vitrectomy, physicians sometimes perform these on their own and other times consult a retina colleague. • Attending wet labs and courses at meetings can be helpful for the cataract surgeon who is uncomfortable performing secondary IOL implantation. Dr. Lee demonstrates one technique for iris xation of an IOL. A spatula supports the IOL while the suture is passed. His rst pass uses a Siepser sliding knot, and he uses the Condon modi cation of the Siepser sliding knot, which he thinks makes it easier to tie the knot. Source: Bryan S. Lee, MD continued on page 22