EyeWorld India September 2018 Issue

31st APACRS: ENLIGHTENMENT Reporting from the 31st APACRS annual meeting, 19–21 July, Chiang Mai, Thailand IOL Fixation, Toric IOLs popular topics for MasterClasses O ne MasterClass at the 31st APACRS annual meeting focused on ‘IOL Fixa- tion – With and Without Sutures.’ The teaching session was led by Soon Phaik Chee, MD , Singapore. Prior to the MasterClass, Dr. Chee spoke to EyeWorld about what to expect from the course, which also included faculty members Alan Crandall, MD, Salt Lake City, Utah, U.S., David Lubeck, MD, Homewood, Illinois, U.S., Mo- han Rajan, MD, Chennai, India, and Shin Yamane, MD, PhD, Yokohama, Japan. There are various options for IOL placement in the absence of zonular support, Dr. Chee said. The IOL may be supported by the iris or sclera, she said. “A well sized anterior chamber IOL placed on the iris with the footplates resting in the angles can give good long-term outcomes, but if sizing of the implant is inappro- priate, the UGH (uveitis, glaucoma, hyphema) syndrome may develop,” she said. “Alternatively, an iris claw lens may be clipped either anterior or posterior to the iris.” Dr. Chee added that this technique of IOL fixation is simple and quick, and thus a good option for the elderly patient who is unable to tolerate a long surgical procedure. “Suturing a 3-piece IOL to the iris is another good and readily mastered tech- nique of iris fixation and is mini- mally invasive,” she said. Dr. Chee also said that fixation of an IOL to the sclera provides a more stable support, and this may be done with or without sutures. “Fixation with sutures may be easily done using special IOLs with suture eyelets along the haptics used to anchor the IOL to the scle- ra,” she said. “Scleral fixation may also be performed using a standard 3-piece IOL with special suturing methods.” Intrascleral haptic fixation techniques anchor the haptics of the IOL to the sclera by tucking the haptic in an intrascleral groove without the need for sutures, she added. Dr. Chee also described how these patients may present to an ophthalmologist. Patients without capsular sup- port may present as a complication of cataract extraction surgery, a dis- located IOL, or aphakia, she said. Loss of capsular support during surgery may develop with inadvert- ent zonulysis or be discovered only during the time of surgery (pre- existing zonulysis or subluxated crystalline lens), she added. “Dislocated IOLs mostly develop years after uneventful cataract surgery,” Dr. Chee said. “In these eyes, the IOL is found within the capsular bag with partial or complete zonulysis.” She added that they may rarely present in the early postoperative period following a posterior capsule rupture. Additionally, Dr. Chee said that the majority of aphakic eyes are re- ferred following complex vitreoreti- nal surgery. “Some aphakic eyes are a result of cataract surgery which encountered significant complica- tions intraoperatively,” she said. In addition, some eyes may present either with acutely raised intraocular pressure and/or chronic uveitis due to intermittent anterior movement of the IOL/crystalline lens. Dr. Chee said that most cases are elective cases rather than a result of intraoperative zonulysis. “I usually perform 4-5 cases of IOL fixation per week,” she said. With various techniques for IOL fixation, Dr. Chee described her preferred intrascleral haptic fixation. “There are various ways of fix- ing IOLs in the absence of capsular support,” she said. “My current favorite technique is a modification of other described methods.” She added that the key points in this technique apply to other scleral fixation techniques as well. 1. Sclerostomies for IOL fixation must be 180 degrees apart for centration of the IOL. 2. Align IOL in vertical meridi- an to achieve maximal haptic length for fixation. 3. The scleral tunnel should be created mid-sclera in depth. “In essence, my technique involves creating two diametrically opposite partial scleral thickness incisions through which the hap- tics of a 3-piece IOL are retrieved, to be tucked into scleral tunnels,”