EyeWorld India December 2019 Issue

FEATURE 20 EWAP DECEMBER 2019 A n IOL that isn’t where it should be after surgery is a serious complication, but not the end of the world. In these cases, the surgeon may …>Ûi ̅i œ«Ìˆœ˜ ̜ iˆÌ…iÀ ÀiwÝ>Ìi or exchange the lens. EyeWorld VœÀÀi뜘`i` ܈̅wÛi iÝ«iÀÌà about this issue. Fix or exchange? º «ÀiviÀ ̜ ÀiwÝ>Ìi >˜ >Ài>`Þ present IOL whenever possible since this typically requires fewer steps and is less invasive for the eye,” said Samantha Schockman, MD. “I generally plan on an IOL exchange with ÃViÀ> wÝ>̈œ˜ ܅i˜ ̅iÀi ˆÃ > one-piece acrylic IOL or when the capsular bag does not allow vœÀ Ã>vi wÝ>̈œ˜° Ƃ ̅ˆVŽ V>«ÃՏ>À bag with a large Soemmering’s ring can potentially push the iris forward and create angle closure while an unusually friable capsule may not be strong i˜œÕ}…vœÀ > ÃÌ>Li wÝ>̈œ˜° One-piece acrylic IOLs are rather ŜÀÌ >˜` µÕˆÌi yi݈Li] Ü œœ« wÝ>̈œ˜ œv ̅i…>«ÌˆVà V>˜ Li challenged by tilt, torque, or degloving of the capsule off the haptics if tied too tight. If tied too loose, the complex can trampoline against the iris with eye movement or rubbing. There are rare anecdotal reports of in-the-bag UGH [uveitis- glaucoma-hyphema syndrome].” Sumitra Khandelwal, MD, prefers repositioning and ÀiwÝ>̈œ˜] LÕÌ Ã>ˆ` ˆÌ ºœ˜Þ ܜÀŽÃ if the current lens is the correct type of lens and the power is correct.” Repositioning a rotated but correctly powered toric IOL is a good example of this. A dislocated one-piece lens, however, might best be exchanged for a three-piece for “œÀi œ«Ìˆœ˜Ã vœÀ wÝ>̈œ˜ >˜` iÃà ˆÀˆÃ V…>w˜}] Åi Ã>ˆ`° “In general, if a patient was happy with their vision previously and the lens is amenable to repositioning, I will do so,” said Sumit (Sam) Garg, MD. He noted that a wide range of factors go into this decision: lens status, degree of dislocation, lens type, patient age, capsule status, iris state, cornea status, and patient expectations. In terms of feasibility, “if an IOL is accessible from an anterior approach it can usually Li Ài«œÃˆÌˆœ˜i` œÀ ÀiwÝ>Ìi`]» said Richard Hoffman, MD. “Single-piece IOLs that are not in the capsular bag will usually need to be removed and exchanged. Three-piece IOLs that are decentered and in the ciliary sulcus can be either ÃViÀ> wÝ>Ìi` œÀ ˆÀˆÃ wÝ>Ìi` ˆv there is still vitreous present in the posterior segment or if there is some capsule support behind the IOL to help reduce pseudophakodonesis.” “The key question to ask the patient is if they were happy with the vision prior to subluxation,” said Nicole Fram, MD. If yes, keeping the IOL is appropriate; œÌ…iÀ܈Ãi œÀ ˆv ̅iÀi ˆÃ È}˜ˆwV>˜Ì Soemmering’s ring that could lead to UGH syndrome, an IOL exchange may be best. To assess accessibility via anterior approach, she recommended examining the patient the week before surgery in upright and supine positions to assess full dislocation and see if the retina is involved. The surgeon should be comfortable with retrobulbar or sub-Tenon’s block techniques and preservative-free triamcinolone-assisted vitrectomy, and backup IOLs should be chosen preoperatively. When evaluating a patient ܈̅> ÃÕLÕÝ>Ìi`ɓˆÃ«œÃˆÌˆœ˜i` IOL, Dr. Fram asks: (1) Can I use the capsule? (2) Can I use the ˆÀˆÃ vœÀ wÝ>̈œ˜¶ ή >˜ ÕÃi ̅i ÃViÀ> vœÀ wÝ>̈œ˜¶ Locating IOL dislocation “Location is key,” Dr. Khandelwal said. It might seem like just the lens, but often these lenses dislocate in the bag and are attended by weak zonules and disruption in the bag. If an IOL is out of position, the surgeon should evaluate whether it is simple IOL dislocation or capsular bag dislocation, generally due to diffuse zonulopathy. While IOL and bag subluxation typically go hand in hand since the IOL is encased in the bag, Dr. Schockman said, “In cases in which the IOL is not within the capsule, or there is an extensive break in the capsule, the IOL or capsule )WKFG VQ TGƂZCVKQP CPF GZEJCPIG by Chiles Aedam R. Samaniego Þi7œÀ` čÈ>‡*>VˆwV Senior Staff Writer AT A GLANCE • ˜ }i˜iÀ>] ÀiwÝ>̈œ˜ ˆÃ «ÀiviÀ>Li when the correct IOL power and ÀiwÝ>Li " ÌÞ«i Ü>à ˆ˜ «>Vi ܈̅> Ã>̈Ãwi` «>̈i˜Ì «ÀˆœÀ ̜ subluxation, the IOL is accessible >˜ÌiÀˆœÀÞ] >˜` Ã>vi wÝ>̈œ˜ ˆÃ possible with the existing capsule, iris or sclera; otherwise, replace. • œÀ Ài«œÃˆÌˆœ˜ˆ˜} >˜` ÀiwÝ>̈œ˜] the IOL, haptic, and bag positions should be evaluated with direct examination using techniques to maximize visualization, with pharmaceutical or mechanical dilation and/or biomicroscopy if necessary. • ˜ ÌiÀ“à œv wÝ>̈œ˜] ܅i̅iÀ vœÀ ÀiwÝ>̈œ˜ œÀ " iÝV…>˜}i with a compromised bag, scleral wÝ>̈œ˜ ˆÃ }i˜iÀ>Þ «ÀiviÀÀi`° • Indications for IOL exchange include: decentration without bag support, damage to the IOL, patient dissatisfaction with vision or residual refractive error uncorrectable by cornea surgery or repositioning, iris optic V>«ÌÕÀi] ˆÀˆÃ V…>w˜}] `ˆÃœV>̈œ˜ into the vitreous cavity, and other conditions such as UGH syndrome. Contact information Fram: DrFram@avceye.com Garg: gargs@uci.edu Hoffman: ÀŜvv“>˜Jw˜i“`°Vœ“ Khandelwal: SKhandel@bcm.edu Schockman: sschockman@cvphealth.com This article originally appeared in the September 2019 issue of EyeWorld . +V JCU DGGP UNKIJVN[ OQFKƂGF CPF appears here with permission from the ASCRS Ophthalmic Services Corp. +TKU UWVWTG ƂZCVKQP