EyeWorld India March 2021 Issue

20 EWAP MAR C H 2021 FEATURE “All these complex surgeries that incur vitreous removal can pose a risk to the retina,” Dr. Chee said. “I generally will give the patients the necessary advice and screen their retinas starting as early as 10 days postoperatively and at almost every consult. I only refer if I am suspicious of a retinal problem.” She added that when dealing with a highly myopic eye that is at an increased risk of IOL subluxation, she prefers that the retina surgeon screen the eyes for retinal breaks prior to surgery. “I also perform OCT of the macula if the vision is not as good as expected to detect and treat CME early.” Dr. Chee said it’s also important to look out for raised IOP, persistent inflammation, and endothelial cell loss, in addition to retinal issues. In terms of medications to use, Dr. Chee said that with intrascleral haptic fixation, the One important thing to know when planning to cut IOLs is that it is hard to cut a PMMA lens, Dr. Rocha said. However, for hydrophilic or hydrophobic lenses, you can cut them in the anterior chamber and remove them through the small incision. To remove PMMA lenses, Dr. Safran said he makes a 6-mm scleral tunnel on the steep axis with a self-sealing incision. You can put pars plana trocars in and an infusion line to keep the eye firm, he said. If it’s PMMA, it should come out in one piece, Dr. Safran said. Though he said that he sometimes will cut the haptic and go after those separately. Dr. Safran said that “all of the foldable lenses,” including hydrophilic acrylic, hydrophobic acrylic, or silicone, should cut readily. Dr. Chee also shared some tips for cutting IOLs. If possible, she said to mobilize the IOL into the anterior chamber to cut in order to avoid capsular injury. She also said to ensure that the entire capsular bag is bowed posteriorly with OVD to prevent both anterior and posterior capsule injury, as OVD may be lost during the cutting process. “This is especially important when cutting the optic if the entire IOL cannot be mobilized into the anterior chamber,” she said. “Make sure that the tip of the scissors does not cut the capsulorhexis rim.” Another technique for reducing the risk of posterior capsule injury is to insert the new IOL into the capsular bag, under the old IOL. Dr. Chee said the new IOL acts as a scaffold to protect the posterior capsule while the old IOL is being cut in the anterior chamber. She said to use intraocular scissors that are intended for the purpose and ensure they are sharp. Grasp the IOL firmly with intraocular forceps when cutting. Or you could provide a counterforce opposing the cutting force to prevent the IOL from slipping. Dr. Chee said to ensure that no sliver of the IOL is left in the eye during the cutting process. Dr. Chee said that the IOL can be cut into two or three pieces, depending on the incision size desired. “A useful technique that avoids the need to rotate one half of the IOL during explantation to avoid the haptic snagging the intraocular structures is to use the ‘Pacman’ method,” she said. “This involves cutting the IOL three- fourths across and rotating the cut section followed by the rest of the IOL out through the incision.” The way an IOL behaves when cut also depends on the IOL material. Dr. Chee said the AcrySof IOLs (Alcon) tend to be thinner, softer, and easier to cut than the thicker, more rigid TECNIS IOL (Johnson & Johnson Vision). She added that hydrophilic IOLs are softer, thinner, and easier to cut across and can be removed through a smaller incision than hydrophobic IOLs. However, silicone IOLs are slippery and thick and are the most difficult to explant. Cutting IOLs inflammation resolves within a month, and using topical steroids, antibiotics, and a topical NSAID for 1 month is adequate. With iris fixation, these eyes require the same medications but sometimes for 3–4 months after surgery. Dr. Rocha noted that she uses the same drops that she uses for regular cataract patients. But she watches for CME postop especially in iris fixated lenses, she said, adding that it’s also important to monitor for IOP spikes. EWAP Reference 1. Rocha KM, et al. Combined flanged intrascleral intraocular lens fixation with corneal transplant. Am J Ophthalmol Case Rep. 2018;13:1–5. Editors’ note: Dr. Chee practices at the Singapore National Eye Centre, Singapore, and has interests with Carl Zeiss Meditec, Johnson & Johnson Vision, and Hoya Surgical Optics. Dr. Rocha is Director of Cornea and Refractive Surgery, Medical University of South Carolina, Charleston, South Carolina, and declared no relevant financial interests. Dr. Safran practices in Lawrenceville, New Jersey, and has interests with Johnson & Johnson Vision and Cynosure.