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Iol Dislocation After a Fall a After Dislocation Iol Cataract & Refractive Surgery Today Europe

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Iol Dislocation After a Fall a After Dislocation Iol Cataract & Refractive Surgery Today Europe s CATARACT SURGERY CASE FILES IOL DISLOCATION AFTER A FALL With one haptic in the anterior chamber, how would these surgeons proceed? BY AUDREY R. TALLEY ROSTOV, MD; QUENTIN B. ALLEN, MD; S. ASHA BALAKRISHNAN, MD; ALAN S. CRANDALL, MD; H. BURKHARD DICK, MD, PHD, FEBOS-CR; AND ALANNA NATTIS, DO, FAAO CASE PRESENTATION A 73-year-old woman presents with a complaint of decreased vision in her right eye since a fall several weeks ago. The patient underwent uneventful cataract surgery approximately 10 years ago. BCVA is 20/200 OD. A slit-lamp examination reveals inferior corneal edema and a dislocated three-piece IOL (Figure). The inferior haptic and the inferior portion of the optic are located anterior to the iris. Some heme is visible at the inferior border of the pupil. The cornea and sclera are intact, and a dilated fundus examination and B-scan ultrasound of the retina show no retinal detachment. How would you proceed? —Case prepared by Audrey R. Talley Rostov, MD Figure. The inferior haptic of a three-piece IOL is located in the anterior chamber. the other haptic is also in the capsular bag, I would attempt to remove it from the bag after viscodissection for repositioning in the sulcus, because returning the IOL to the bag at that QUENTIN B. ALLEN, MD point would typically be impossible. S. ASHA BALAKRISHNAN, MD Moreover, trauma might have Obviously the IOL should be significantly weakened the zonular Based on the level of trauma, repositioned. The real issue is whether or apparatus such that the bag may not repositioning and scleral fixation of not there is an intact zonular structure be intact or able to withstand sulcus the IOL are advisable. Preoperative to support sulcus repositioning. placement of an IOL. If that is the case, administration of a steroid and sodium Fortunately, the IOL is a three-piece lens, it may be possible to fixate the IOL via chloride hypertonicity ophthalmic which could make its relocation to the iris fixation or the Yamane technique ointment 5% (Muro 128, Bausch + ciliary sulcus possible. I would plan to after the implant has been dissected Lomb) will help to reduce intraocular attempt sulcus repositioning under local from the capsular bag, or the lens- inflammation and optimize the view anesthesia with a retrobulbar block. I capsular bag complex can be removed through the cornea. would also be prepared to perform an and an anterior chamber IOL (ACIOL) Scleral fixation can be achieved with anterior vitrectomy because vitreous placed. Because of the long-standing a transscleral needle technique and/or prolapse around the capsular bag is endothelial trauma from the dislocated a PTFE lasso suture (Gore-Tex, W.L. common in cases such as this one. haptic, there is increased risk of corneal Gore & Associates, off-label indication). After instilling a dispersive OVD, decompensation with this option, but For a transscleral needle technique I would inspect the capsular bag to given this patient’s age, an ACIOL could using a TSK 30-gauge needle, I use a determine if there is capsular support. If be a consideration. toric marker to mark the cornea at 20 CATARACT & REFRACTIVE SURGERY TODAY EUROPE | JULY/AUGUST 2019 CATARACT SURGERY CASE FILES s 0º and 180º for the main incisions. I Even though ultrasound showed no corneal opacification. A surgical then pass the needle through the sclera retinal detachment, I would obtain solution is required, and sooner rather 2 mm posterior to the limbus, with a an anterior segment OCT scan to than later. 2-mm tunnel, before introducing the identify where the remainder of the Maximal medical mydriasis (topical needle into the posterior chamber. IOL–capsular bag complex sits. This but not necessarily intraoperative) will I thread both haptics through the imaging can also help to identify a be required for optimal visualization of needle before externalization. Once cyclodialysis cleft. If no new defects all relevant structures. After the topical externalized, the haptic ends are are evident, then I would plan to application of medications to achieve cauterized to create bulb ends, which I reposition the IOL. corneal dehydration, an inferior tuck into the sclera. It will be important to have backup epithelial debridement may become For a lasso approach, I reposition surgical plans. If the remaining zonules necessary. the inferior portion of the IOL behind are intact, and if the complex is simply I recommend using an OR the iris and perform conjunctival repositioned posteriorly and is stable, microscope with a stereo coaxial peritomies around the haptics. With a then the iris can hold the lens after it is light beam in order to achieve a sideport blade, I create sclerostomies placed in the posterior chamber. One good red reflex. I would create two 2 mm posterior to the limbus in the or more sutures may be required to paracenteses without a main incision. area around the central portions of close the defect or defects. If greater It will be important to maintain a the superior and inferior haptics. I then support is necessary, one of several stable anterior chamber and to exam- thread a PTFE suture into a 27-gauge techniques for fixation can be used. ine it for the presence of vitreous. If needle and pass it under the superior Because this is a three-piece IOL, visualization is poor, I would instill a haptic 3 mm posterior to the limbus. sound options include iris fixation small amount of purified triamcino- I retrieve the suture with forceps with a polypropylene suture (Prolene, lone acetonide to check for vitreous. (MicroSurgical Technology). Next, Ethicon) or a glued IOL technique. If vitreous is present, I would execute the suture is drawn over the haptic If there is a defect in the IOL, then a one-port pars plana vitrectomy with forceps and passed through the I would explant the lens and replace using a 23- or 25-gauge trocar with a sclerostomy to create a loop around it. If the IOL is foldable, one option is valve. Based on the Figure, I would not the superior haptic. The same steps are to cut and remove it and then fold, expect to find vitreous in the anterior repeated for the inferior haptic. I tie the insert, and fixate the replacement IOL chamber because the optic is lying suture ends to maintain IOL centration with either of the aforementioned directly on the iris and the capsular and close the conjunctival peritomies techniques or the Yamane technique. bag is not visible anterior to the iris. with either polyglactin sutures (Vicryl, An Artisan IOL (Ophtec) fixated ante- My preference in this case would Ethicon) or glue. riorly or posteriorly would be a suit- be to use a cohesive OVD because Subconjunctival injections of able alternative. I would not use an of the ease of its removal. I would antibiotics and a steroid would angle-fixated ACIOL. flush out the OVD instead of using provide immediate postoperative bimanual or monomanual irrigation inflammation control. and aspiration. The latter can lead to complete shallowing of the anterior chamber after removal of the I/A device, which can result in vitreous prolapse, especially if an Nd:YAG laser capsulotomy has already been H. BURKHARD DICK, MD, PHD, performed. FEBOS-CR The crucial next step would be to ALAN S. CRANDALL, MD return the IOL to its intended position. The slit-lamp examination reveals I would bimanually reposition the The patient presents with inferior that both the optic and the haptic inferior haptic in the ciliary sulcus. corneal decompensation encroaching are inside the anterior chamber. What To minimize stress on the zonules, on the central visual axis (probably renders the clinical situation perilous it will be essential to keep the optic explaining the decreasing vision), iris is that the haptic is in contact with from moving too much superiorly. trauma, and partial anterior subluxation the corneal endothelium. Complete The IOL is still fixated and is held by of the IOL with a haptic in the anterior corneal decompensation is more than the superior portion of the fibrotic chamber. I assume there is inflamma- a possibility—it seems highly likely capsular bag. If both haptics are in the tion along with the hemorrhage. because there is already widespread sulcus, posterior optic capture would JULY/AUGUST 2019 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 21 s CATARACT SURGERY CASE FILES be my preference. If visualization is If the posterior aspect of the IOL is at the same time. I instilled carbachol adequate, I would position the haptic located in the ciliary sulcus, no vitreous intraocular solution (Miostat, Alcon). in the bag. Because this is a three-piece has prolapsed, and the anterior capsule The patient did well postoperatively, IOL, however, it would be fine to leave and capsular bag are intact, I would and the corneal edema resolved within the haptics in the sulcus. attempt to reposition the IOL in the sul- 6 weeks. n At the end of surgery, I would inject cus with a Sinskey or Kuglen hook after acetylcholine (Miochol-E, Bausch + carefully inspecting the ocular anatomy Lomb) into the anterior chamber to and injecting an OVD into the ciliary sul- SECTION EDITOR AUDREY R. TALLEY ROSTOV, MD confirm that the pupil is round and to cus and anterior chamber. This is a three- n Private practice, Northwest Eye Surgeons, Seattle reveal any residual strands of vitreous. piece IOL, so uveitis-glaucoma-hyphema n Medical advisory board, SightLife, Seattle Postoperatively, I would have the syndrome is not a concern. n Member, CRST Editorial Advisory Board patient administer topical antibiotics If the posterior aspect of the IOL is n [email protected] for 3 days and an NSAID for 4 weeks.
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