CATARACT 24 EWAP SEPTEMBER 2022 he probably would not do this. “You don’t want to be doing unnecessary steps that could cause complications, especially if you’re not used to doing it. It could be fiÝed later by someone who is skilled at doing that.” Dr. Mamalis shared a few possible preventative strategies as well. He said to make sure the capsulorhexis is an adequate size. This removes some lens epithelial cells, and he mentioned that some people advocate for polishing the capsule. If you start to see the capsulorhexis shrink over time (capsular phimosis), some suggest doing an anterior YAG capsulotomy with four small radial incisions 1–2 mm outward from the edge of the rhexis, relieving the phimosis that pulls on the zonules. “[Another] thing physicians talk about is should we be putting a capsular tension ring in the bag to help prevent late postoperative dislocation? I don’t know the answer to that. We’d need to put that in a large number of patients, follow them for 10 years, and see what it does,” he said. “But I can say be vigilant in following [patients who have pseudoexfoliation or who’ve had vitrectomy]. If the IOL-capsular complex begins to dislocate, you want to recognize that early on when there is a chance to suture the complex to the ciliary sulcus.” He said that in the laboratory, he has received spontaneously dislocated IOLs where there is a beautifully centered capsular tension ring within the capsular bag, but the complex still dislocated. Another tactic, if there is known, diffuse zonulopathy, is to put the IOL in the sulcus and capture the optic in the capsulotomy, Dr. Mamalis said, noting that there are not studies to support that this prevents late dislocations. When late lens-bag dislocation occurs, Dr. Safran said there are a number of ways to handle it, depending on the presentation and other factors. He said he would lasso the lens-bag complex under certain conditions: if the patient was happy with the lens before, if it was the right power and undamaged, etc. He will not scleral fiÝate hydrophilic acrylic lenses due to their propensity to calcify over timeÆ he’ll take those out. He would also take out lens-bag complexes that have a lot of Soemmering’s ring material because it’s pro-inyammatory. If the lens is sitting on the retina, if it’s a Crystalens (Bausch + Lomb), or a plate-haptic lens, he said he’ll usually take it out. He’ll also take out a dead bag, which he explained is so diaphanous it shreds if you try to do anything with it. “The capsular bag itself has to have enough fibrosis to hold,” he said. When it comes to putting in a new IOL, Dr. Safran will generally do the Yamane double-needle intrascleral haptic fiÝation technique. There are rarer indications where he’ll use GORE-TE8 sutures. While there are techniques to fiÝ dislocated lens-bag complexes, Dr. Safran said they’re not things surgeons should “dabble in.” “If you’re only going to do this once or twice a year, I wouldn’t mess around with it because there is a lot of potential to cause problems if you don’t do it correctly,” he said. “A lot of the ones referred to me are revisions of cases other people tried to do, and they’ve dug a deeper hole for the patient. … If it’s not something you plan on doing frequently or do on referral, consider referring to someone who does a lot of them.” Dr. Safran said while patients might notice a change in their vision or a bobbing of the IOL, sometimes it’s the physician who notices the lens-bag complex is beginning to dislocate. If it’s not fully dislocated and not impacting the patient’s perception of their vision, it’s reasonable to wait to repair this until the patient becomes aware of symptoms or develops a problem related to the IOL dislocation. “Ophthalmologists often think that there is an urgency to these procedures because the lens may dislocate posteriorly. However, it’s easier to justify surgical repair on a patient once they’ve developed symptoms related to the dislocation because they’re more accepting of having a surgical procedure and all that comes with it,” Dr. Safran said. “Also, there are excellent techniques for dealing with IOL bag complexes that dislocate posteriorly so really there is no urgency for these patients to have surgery unless they have a visual problem or uveitis-glaucoma-hyphema syndrome related to the IOL.” EWAP Reference 1. Culp C, et al. Clinical and histopathological findings in the dead bag syndrome. J Cataract Refract Surg. Ó0ÓÓÆ4n\£ÇÇq£n4. Editors’ note: Dr. Mamalis is Professor of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah. Dr. Safran practices ophthalmology in Lawrenceville, New Jersey. Neither disclosed any relevant financial interests.
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