EyeWorld India March 2018 Issue

track posterior to the optic, you can begin viscodissection of the haptic-optic junction, which Dr. Fram said can be an area of sig- nificant fibrosis. One should avoid rotating the IOL to reduce stress on the zonules and gently lift up instead. Afterward, prolapse the IOL into the anterior chamber. Dr. Fram said the IOL can be folded, using forceps, over a long spatula 180 degrees away from the main 3mm incision or the haptics can be amputated with microsurgical scis- sors, taking precautions to remove the optic only and leave the cut end of the haptics in the bag. “Interestingly, manipula- tion and removal of the retained haptics is easier once the optic is removed,” Dr. Fram said. “If the entire IOL is removed, the surgeon should remember to dissect and reinflate the capsular bag with OVD to ensure it is open to the equator. If the previous haptics must remain, the new IOL can be placed in the sulcus with optic cap- ture as long as the anterior capsule remains curvilinear and properly sized.” After freeing the optic and haptics, Dr. Al-Mohtaseb said she uses a Sinskey hook in addition to the OVD cannula to lift the lens into the anterior chamber. She prefers to cut the lens in half, while holding it with forceps, and leaves one haptic out of the wound to avoid losing it until it’s removed through the wound. Sometimes, Dr. Al-Mohtaseb will insert the new IOL underneath the original one to act as a platform during the cutting of the old lens. If it’s a toric IOL, websites like astigmatismfix.com or other devices can help surgeons decide whether the lens needs to be rotat- ed or exchanged. If it needs to be exchanged, Dr. Fram said the ideal time is between 1 and 3 weeks postop. Dr. Al-Mohtaseb said prior to rotating a toric she’ll mark its current axis and the new axis. Dr. Fram added that the key to toric IOL exchange is removing all OVD. For this reason, she prefers ProVisc (sodium hyaluronate, Alcon, Fort Worth, Texas) because it comes out easier than a dispersive and it can be used with intraoperative aber- rometry, she said. Fixating a new IOL In some cases, the new IOL cannot be placed within the capsular bag, necessitating another fixation tech- nique. Dr. Al-Mohtaseb mentioned research that showed similar out- comes among iris sutured, scleral sutured, and anterior chamber IOL techniques. 2 Her preferred technique is the flanged intrascleral double-needle technique pioneered by Shin Yamane, MD, Yokohama, Japan. Benefits of this technique are its small wound; its potential to use an already implanted three-piece lens or other off-the-shelf lens; and its elimination of potential suture exposure, among other reasons. If the bag cannot be saved with a capsular tension ring or ring seg- ments, Dr. Fram said her fixation technique depends on the degree of capsule support. If there is dif- fuse zonulopathy and an intact anterior or posterior curvilinear capsulorhexis, one could place hap- tics in the sulcus and optic capture through the anterior or posterior capsulotomy as described by How- ard V. Gimbel, MD, and popular- ized by David F. Chang, MD, and Lisa Brothers Arbisser, MD. 3 If there is more than 270 de- grees of capsule support and poor zonules not amendable to a CTR or optic capture, a lens could be put in the sulcus, and haptics sutured to the iris using 10-0 polypropyl- ene in a McCannel or Siepser fash- ion, which Dr. Fram said would ensure centration of the IOL over time. Finally, if there is no capsule viability and it needs to be re- moved, Dr. Fram advised a triamci- nolone-assisted pars plana anterior vitrectomy and intrascleral haptic fixation, using either the Yamane or glued IOL technique or scleral suture fixation with off-label Gore-Tex. Final tips for young eye surgeons In cases of IOL exchange, Dr. Fram said one should go slowly and have a plan A, B, and C at the ready. New techniques should be prac- ticed with a simulated eye model before heading to the OR, she added. “The most important thing is to know your own limits,” Dr. Al-Mohtaseb said. “If there is sig- nificant zonular loss or if the IOL I want to remove is too dislocated (which I can tell when I lay the pa- tient back in clinic), I ask my retina colleagues to do a combined case with me in which they remove the lens and I insert the secondary IOL using the Yamane technique. It is always better to be safe than heroic in these cases.” EWAP References 1. Kim EJ, et al. Refractive out- comes after multifocal intraocular lens exchange . J Cataract Refract Surg . 2017;43:761–766. 2. Brunin G, et al. Secondary intraocular lens implantation: Complication rates, visual acuity, and refractive outcomes. J Cataract Refract Surg. 2017;43:369–376. 3. Gimbel HV, et al. Intraocular lens optic capture. J Cataract Refract Surg . 2004;30:200–6. Editors’ note: The physicians have no financial interests related to their comments. Contact information Al-Mohtaseb: zaina@bcm.edu Fram: nicfram@yahoo.com 36 EWAP CATARACT/IOL March 2018 IOL exchange - from page 35