EyeWorld India December 2020 Issue

EWAP DECEMBER 2020 17 FEATURE site she wanted to tighten to, and then released and pushed against the sclera to make sure they are well-covered by conjunctiva. Again, she said that it’s very important to perform peripheral iridectomy to prevent reverse pupil block. This procedure uses a 27-G needle, 6-0 prolene suture, and low- or high-temperature cautery. Case 4: No bag In this case the IOL had fallen onto the macula and Dr. Chee was assisted by a vitreoretinal specialist. After pars plana vitrectomy, she explanted the IOL—partly cutting it in half, she pulled the cut half of it through then rotated it out of the incision, while her second instrument ensured the IOL avoided the endothelium. She then performed peripheral iridectomy. She injected the replacement 3-piece IOL completely into the anterior chamber. With twin 27-G needles, she marked the 2 mm sclerotomy position back from the fixation point and introduced the needle 2 mm away creating a scleral tunnel circumferentially before entering the eye perpendicularly. She grabbed the haptic, threaded it into the bevel, and released the hub of the needle from the syringe. She repeated this at the diametrically opposite site (2 mm away from incision point at the opposite side). She pulled the two needles symmetrically and as the haptics are exposed she flanged the tips using cautery—but did not yet push them back into the eye. She checked the position of the IOL and adjusted until she was happy with the position. She then tapped the haptic tips in, released the conjunctiva to make sure the haptic tips were completely buried, and removed the viscoelastic. For this procedure, Dr. Chee recommended using two 27-G needles and either the Zeiss CT Lucia 2020 or Johnson & Johnson Vision AR40e. Postoperatively, the patient had 6/7.5 unaided vision and a very quiet eye. Case 5: Easy AssiAnchor Finally, Dr. Chee demonstrated the use of an AssiAnchor (Hanita Lenses) in a case that had a toric IOL she wanted to preserve. She began with pars plana vitrectomy holding onto the IOL, marking the eye to show the axis at which the IOL should be positioned. She supported the IOL in position with iris hooks and opened up the capsular bag with dispersive viscoelastic. She pulled a little too hard on an iris hook, resulting in a rip in the posterior capsule, but proceeded instead, preloading the AssiAnchor, as a capsular tension segment which supports the bag at the capsular fornix could no longer be used. “I like to fixate it from the stem,” she said. With the flanges tucked behind the capsule so that it is inside the capsular bag, a suture snare (bent 27-G needle pre- loaded with a short segment of Gortex 7/0 (CV-8)) is inserted above the IOL complex 1.75 mm posterior to the limbus through a corneo-scleral pocket (Hoffman pocket). A loop of the suture snare is extended using a Kuglen hook and use to lasso the end of the suture preloaded into the AssiAnchor. The snare is pulled out of the eye, bringing the suture with it. This step is then repeated. The other end of the suture is retrieved, pulled through a Hoffman pocket using a Sinskey hook, and tied with a 2-1-1 knot, adjusting tension to ensure the IOL is properly positioned. At the end, the IOL is well-centered and aligned on-axis. Dr. Chee used a 27-G needle, AssiAnchor, and CV-8. Many ways In summary, Dr. Chee said that she prefers fixing to the sclera for stability. Iris fixation is stable if some capsular support is present, and she thinks it is the easiest and perhaps safest technique for her registrars to learn. “For iris fixation, you’re just attaching it to the back of the iris, if you do adequate vitrectomy behind the iris so that when you pass your sutures, you don’t actually suture any strands of vitreous, you’ll be fine,” she said. In contrast, if scleral fixation is preferred, then a very good vitrectomy is required. In either case, she emphasized the importance of proper vitreous management—“completely remove it and don’t snag it,” she said; this can be done by using a pars plana approach and staining with triamcinolone. “There are many ways of fixing an IOL,” Dr. Chee said. “It really depends on whether you wish to save the IOL or not, on whether the bag is present, and the type of IOL, whether it can be fixated.” EWAP Editors’ note: Dr. Chee has financial interests with various ophthalmology companies including Carl Zeiss Meditec and Johnson & Johnson Vision.