S. ASHA BALAKRISHNAN, MD S. ASHA BALAKRISHNAN, MD Scleral fixation can be achieved withachieved be can fixation Scleral Based on the level of trauma,of level the on Based inflammation and optimize the viewthe optimize and inflammation cornea.the through and/or technique needle transscleral a W.L. (Gore-Tex, suture lasso PTFE a indication).off-label Associates, & Gore techniqueneedle transsclerala For ause I needle, 30-gauge TSK a using atcornea the mark to marker toric repositioning and scleral fixation offixation scleral and repositioning Preoperativeadvisable. are IOL the sodiumand steroid a of administration ophthalmichypertonicity chloride +Bausch 128, (Muro 5% ointment intraocularreduce to help will Lomb) Figure. The inferior haptic of a three-piece IOL is located in the anterior chamber. Figure. The inferior haptic of a three-piece IOL is located given this patient’s age, an ACIOL couldACIOL an age, patient’s this given consideration.a be apparatus such that the bag may notmay bag the that such apparatus sulcuswithstand to able or intact be case,the is that If IOL. an of placement viaIOL the fixate to possible be may it technique Yamane the or fixation iris dissectedbeen has implant the after lens- the or bag, capsular the from removedbe can complex bag capsular (ACIOL)IOL chamber anterior an and long-standing the of Because placed. dislocatedthe from trauma endothelial cornealof risk increased is there haptic, butoption, this with decompensation the other haptic is also in the capsularthe in also is haptic other the itremove to attempt would I bag, for viscodissection after bag the from because sulcus, the in repositioning thatat bag the to IOL the returning impossible.be typically would point havemight trauma Moreover, zonularthe weakened significantly | JULY/AUGUST 2019 | JULY/AUGUST

—Case prepared by Audrey R. Talley Rostov, MD —Case prepared by Audrey R. Talley Rostov, MD D, FEBOS-CR; AND ALANNA NATTIS, DO, FAAO NATTIS, DO, FAAO D, FEBOS-CR; AND ALANNA h

CASE FILES QUENTIN B. ALLEN, MD QUENTIN B. ALLEN, MD

After instilling a dispersive OVD, dispersive a instilling After Obviously the IOL should beshould IOL the Obviously How would you proceed? How BCVA is 20/200 OD. A slit-lamp examination reveals inferior corneal edema and a edema and a corneal BCVA is 20/200 OD. A slit-lamp examination reveals inferior A 73-year-old woman presents with a complaint of decreased vision in her right right a complaint of decreased vision in her presents with woman 73-year-old A CASE PRESENTATION anterior because vitreousbecause vitrectomy anterior isbag capsular the around prolapse one.this as such cases in common to bag capsular the inspect would I Ifsupport. capsular is there if determine Fortunately, the IOL is a three-piece lens,three-piece a is IOL the Fortunately, theto relocation its make could which toplan would I possible. sulcus ciliary localunder repositioning sulcus attempt I block. retrobulbar a with anesthesia anperform to prepared be also would repositioned. The real issue is whether orwhether is issue real The repositioned. structurezonular intact an is there not repositioning.sulcus support to approximately 10 years ago. 10 years ago. approximately The inferior haptic and the inferior portion of the (Figure). dislocated three-piece IOL the inferior border of the heme is visible at Some iris. to the are located anterior optic and B-scan a dilated fundus examination and are intact, and cornea pupil. The retinal detachment. ultrasound of the show no eye since a fall several weeks ago. The patient underwent uneventful uneventful cataract surgery The patient underwent several weeks ago. since a fall eye With one haptic in the anterior chamber, how would these surgeons proceed? surgeons would these how one haptic in the anterior chamber, With CRANDALL, MD; S. ASHA BALAKRISHNAN, MD; ALAN S. ROSTOV, MD; QUENTIN B. ALLEN, MD; BY AUDREY R. TALLEY MD, P H. BURKHARD DICK, IOL DISLOCATION AFTER A FALL A AFTER DISLOCATION IOL CATARACT & REFRACTIVE SURGERY TODAY EUROPE

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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

D, FEBOS-CR h Editorial Advisory Board AUDREY R. TALLEY ROSTOV, MD MD AUDREY R. TALLEY ROSTOV, Editorial Advisory Board n CRST Europe CRST The patient did well postoperatively, well did patient The Cornea, cataract, and refractive surgeon and Cornea, cataract, and refractive surgeon and Associate Professor in Ophthalmology and [email protected] Financial disclosure: Consultant (Alcon) Cataract, cornea, and refractive surgeon, Cataract, cornea, and refractive surgeon, [email protected]; Financial disclosure: None John A. Moran Presidential Professor; [email protected] Financial disclosure: None Director and Chairman, University Eye Hospital, Member, [email protected] Financial disclosure: None Private practice, Northwest Eye Surgeons, Seattle Private practice, Northwest Seattle Medical advisory board, SightLife, Member, [email protected] (Alcon, Financial disclosure: Consultant Florida Vision Institute, Stuart, Florida [email protected] Financial disclosure: None Director of Clinical Research, Lindenhurst Eye Director of Clinical Research, Lindenhurst Eye Physicians and Surgeons, a division of SightMD, Babylon, New York Surgery, NYIT College of Osteopathic Medicine, Old Westbury, New York DLV Vision, Los Angeles Instagram @balavisionla John E. and Marva M. Warnock Presidential Endowed Chair; Senior Vice Chair; Director of and Cataract; and Senior Medical Director, Moran Global Outreach Division, John A. Moran Eye Center, University of Utah, Salt Lake City Bochum, Germany Bausch + Lomb) Bausch + Lomb)               n n n n S. ASHA BALAKRISHNAN, MD S. ASHA BALAKRISHNAN, MD n n n ALAN S. CRANDALL, MD n n n H. BURKHARD DICK, MD, P n n n n ALANNA NATTIS, DO, FAAO at the same time. I instilled carbacholinstilled I time. same the at Alcon). (Miostat, solution intraocular withinresolved edema corneal the and weeks. 6 SECTION EDITOR n n n n n QUENTIN B. ALLEN, MD n n n - - -

WHAT I DID: WHAT I DID: AUDREY R. TALLEY ROSTOV, MD AUDREY R. TALLEY ROSTOV, MD After a peribulbar block, I madeI block, peribulbar a After Given the significant corneal edema, Iedema, corneal significant the Given If the posterior aspect of the IOL isIOL the of aspect posterior the If isIOL the of aspect posterior the If passed so that the haptic was fixated was haptic the that so passed closedwas defect iris the and iris the to two bimanual incisions and injected ainjected and incisions bimanual two spatulaKuglen a used I OVD. dispersive rotatedOnce IOL. the reposition to beto appeared IOL the sulcus, the into withdefect iris inferior an closed I stable. waswhich suture, polypropylene 10-0 a plana vitrectomy.plana performto hesitant extremely be would anof placement with exchange IOL an explant of option the said, That ACIOL. patientthe leaving and IOL the ing dayanother return to order in aphakic IOLsecondary a of implantation the for considered. be always could still within the capsular bag and zonular and bag capsular the within still tois option one adequate, is support by bag capsular the reinflate to attempt molecularhigh a with OVD an instilling anteriorlythe dial gently to and weight theinto back haptic and IOL displaced theof integrity the however, If, bag. or compromised been has bag capsular ais there and absent is support zonular vitreousand/or dislocation IOL of risk scleralperform would I prolapse, Yamaneor IOL glued a with fixation parsa with combination in technique located in the ciliary sulcus, no vitreous no sulcus, ciliary the in located capsuleanterior the and prolapsed, has wouldI intact, are bag capsular and sul the in IOL the reposition to attempt afterhook Kuglen or Sinskey a with cus anatomyocular the inspecting carefully sul ciliary the into OVD an injecting and three- a is This chamber. anterior and cus uveitis-glaucoma-hyphemaso IOL, piece concern. a not is syndrome | JULY/AUGUST 2019 | JULY/AUGUST

CASE FILES ALANNA NATTIS, DO, FAAO ALANNA NATTIS, DO, FAAO The challenge here is determining is here challenge The A detailed discussion with the with discussion detailed A This patient experienced traumaexperienced patient This At the end of surgery, I would injectwould I surgery, of end the At the safest and most efficacious way toway efficacious most safestand the patient’sthis preserve and improve twoor plan surgical backup A vision. bestthe ensure to required often are outcome.possible realistic expectations. Because of theof Because expectations. realistic outcomes variable and complexity dislocatedreplacing and repairing of outcomesoperative potential all IOLs, includingdetail, in explained be should surgery.for need future possible a the treatment approach. Ultrasoundapproach. treatment the segmentanterior or biomicroscopy adjunctshelpful be may imaging OCT edema. corneal the given ofrisks the about required is patient aboutand surgery doing not or doing if the remainder of the IOL is withinis IOL the of remainder the if sulcus.ciliary or bag capsular the theof notation and Visualization theand centration and integrity bag’s importantare vitreous any of presence influencewill findings these because of sufficient force to dislodge andislodge to force sufficient of chamber.posterior the from IOL comprehensivea foremost, and First forlook to necessary is examination determineto and pathology additional reveal any residual strands of vitreous.of strands residual any reveal thehave would I Postoperatively, antibioticstopical administer patient weeks. 4 for NSAID an and days 3 for in the bag. Because this is a three-piecea is this Because bag. the in leaveto fine be would it however, IOL, sulcus.the in haptics the +Bausch (Miochol-E, acetylcholine tochamber anterior the into Lomb) toand round is pupil the that confirm be my preference. If visualization isvisualization If preference. my be hapticthe position would I adequate, CATARACT & REFRACTIVE SURGERY TODAY EUROPE

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