Prevention, Management of Subluxated Crystalline Lenses and Iols Glued Endocapsular Ring, Glued IOL, and IOL Scaffold Techniques May Address These Issues

Prevention, Management of Subluxated Crystalline Lenses and IOLs Glued endocapsular ring, glued IOL, and IOL scaffold techniques may address these issues.

By Soosan Jacob, MS, FRCS, DNB; and Amar Agarwal, MS, FRCS, FRCOphth

n cataract surgery, avoiding subluxation or enlarge- frank dialysis has not yet occurred. The endocapsular ment of an existing subluxation of the crystalline lens is ring expands and stabilizes the capsular bag during of prime importance. Similarly, intra- or postoperative cataract surgery. It creates centrifugal forces that result subluxation of an IOL is a complication that all sur- in redistribution from stronger to weaker areas. The Igeons wish to avoid. Basic principles in pre- and intraop- endocapsular ring also makes the capsule taut and gives erative planning can help greatly to minimize the risk of counter-traction to all traction maneuvers. The surgeon these events and to manage them if they occur. may opt to place capsular hooks initially to stabilize Preoperatively, factors that can predispose a patient the bag and then implant the endocapsular ring after to intraoperative subluxation should be evaluated and cortex aspiration. dealt with appropriately. These include conditions that If, despite these precautions, subluxation does occur, convey zonular weakness, such as pseudoexfoliation, it should be managed according to the degree of zonular trauma, Marfan syndrome, ectopia lentis, hypermature dialysis. Smaller subluxations (up to 3 or 4 clock hours) cataract, high myopia, megalophthalmos, postvitrectomy can be managed by inserting an endocapsular ring. Larger status, and any other cause of preoperative phacodonesis. subluxations require scleral anchoring of the capsular bag Additionally, any cataract that is expected to entail difficult and its contents; we prefer to do this through the use of and complicated surgery can lead to an increased risk of a glued endocapsular ring. Extremely large subluxations intraoperative subluxation secondary to surgical trauma. with dangling nuclei are often best managed with removal The key is to be prepared in such cases and take all precau- of the entire bag. Progressive forms of subluxation require tions to avoid subluxation, including creating the rhexis care- either two endocapsular rings fixed 180° apart or lensec- fully, performing maneuvers within the eye gently, avoiding tomy with implantation of a glued IOL. intracapsular procedures that can place stress on the zonules, and taking care to avoid sudden shallowing of the anterior ENDOCAPSULAR RING chamber during maneuvers such as removing the phaco If the surgeon has decided to place the IOL in the bag, probe. IOL implantation should be done carefully without surgery proceeds accordingly. Anterior vitrectomy is exerting stress on the zonules. performed first in the event of prolapsed vitreous. Next, During surgery, it is important to watch for zonular dialysis the capsulorrhexis is constructed, which is always chal- so that appropriate corrective action can be taken at the ear- lenging in subluxated cataracts because the lax capsule liest sign. Subluxated cataracts are a challenge at every step, does not offer adequate counter-traction. The surgeon from rhexis construction to IOL implantation. Successful sur- should ensure that the rhexis is as central as possible. gical management of a subluxated cataract requires knowl- Care should be taken to not tear too close to the capsu- edge of the basic tenets to be followed during surgery. lar fornix and to have an adequate anterior capsular rim all around. SURGICAL STRATEGIES The rhexis should be started in a direction toward An endocapsular ring may be implanted in eyes in the dialysis, avoiding additional stress on the zonules. which zonular weakness is likely to be present, even if If this is difficult with the cystotome, the rhexis may be

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to lie within the capsular fornix. The engaging mechanism has Malyugin ring-like double scrolls,3 which engage the rim of the rhexis between the scrolls. The haptic is a peripheral extension of the device, which is exteriorized through a 20-gauge sclerotomy made under a scleral flap in the area of dialysis. Excess length is trimmed, and the haptic is tucked into an oblique (coat hanger) intrascleral Scharioth tunnel4 made at the edge of the scleral flap with a 26-gauge needle. Once the bag is anchored in position, the surgeon can proceed with phacoemulsification, cortex aspiration, and in-the-bag IOL placement. At the end of surgery, IOL centra- Figure 1. The glued endocapsular ring/segment has two arms, a double-scroll tion is verified and, if required, mechanism, and a haptic. adjusted by changing the degree of tuck of the haptic within the tunnel. continued with microrhexis forceps. The next step is to Vitrectomy is done under the flap, which is glued over the perform good cortical cleaving hydrodissection, making haptic using fibrin glue. The conjunctiva is also closed with sure this is done gently to avoid stress to the zonules. glue (Figure 2). The surgeon must then determine which type of ring to implant. In cases with small subluxation, we prefer to GLUED IOL insert a normal endocapsular ring to provide counter- In the event of a large subluxation with dangling nucleus, traction for all maneuvers and prevent further extension we prefer the glued IOL technique described by Amar of the zonular dialysis. Agarwal, MS, FRCS, FRCOphth.5,6 With this approach, scleral flaps are created 180° apart, and an anterior chamber main- GLUED ENDOCAPSULAR RING OR SEGMENT tainer or an infusion cannula is fixed. The subluxated cata- If the extent of the zonular dialysis is greater than 3 ract is removed either by lensectomy or by bringing it out clock hours, we prefer to implant a glued endocapsular through a corneoscleral section. The posterior assisted- ring (Epsilon) designed by Soosan Jacob, MS, FRCS, DNB.1,2 levitation technique described by Chang and Packard7 This ring is made of a single piece of polyvinylidene fluo- can be used to levitate the lens into the anterior chamber. ride (PVDF) with three contiguous parts: a ring portion, a Twenty-gauge sclerotomies are made under the scleral rhexis-engaging portion, and a haptic (Figure 1). The ring flap, and a three-piece IOL is implanted using the glued portion has two arms that are inserted under the rhexis IOL technique. Alternatively, a foldable three-piece IOL is A B C D

Figure 2. (A) A subluxated cataract of about 180º is seen. A lamellar scleral flap and sclerotomy are created in the area of dialysis. Once the rhexis is complete, the arms of the device are introduced into the anterior chamber under the rhexis. The haptic is then exteriorized through the sclerotomy (B) and cut to an appropriate length and tucked into an intrascleral Scharioth tunnel. (C) Phacoemulsification is performed and the IOL is implanted. (D) A coat-hanger type intrascleral tuck hooks the haptic onto the sclera. Fibrin glue is applied, and the flap is sealed over the haptic. The conjunctiva is closed with fibrin glue.

20 Cataract & Refractive Surgery Today Europe November/December 2012 cataract surgery Bonus Feature

8 implanted with the handshake technique if lensectomy has A been performed or a rigid IOL may be used in the event of an extended corneoscleral section. Once both haptics have been exteriorized, vitrectomy is performed under the scleral flaps, and the haptics are then tucked into intrascleral limbus-parallel Scharioth tunnels. IOL centration is assessed, and any required adjustments are made by changing the degree of tuck of the haptics into their tunnels. The scleral flaps and the conjunctiva are glued using fibrin glue (Figure 3).

IOL SCAFFOLD TECHNIQUE B Another option to maintain a small incision in the case of a dan- et be .n

gling subluxated soft crystalline tu e

lens is the IOL scaffold technique ey described by Dr. Agarwal.9 This technique is also highlighted in this eyetube.net/?v=goral month’s Inside Eyetube.net column on page 15 and in a video at eyetube.net/?v=goral. With this approach, scleral flaps are created 180° apart. The lens is brought into the anterior chamber and made to rest Figure 3. (A) The foldable IOL is injected into the anterior on the iris. Anterior vitrectomy is performed, and intra- chamber and the tip of the haptic is held with microforceps. cameral acetylcholine chloride is instilled to constrict the While the IOL is injected slowly, the microforceps holding the pupil. Under cover of a dispersive ophthalmic viscosurgi- haptic are withdrawn so that the haptic is now exteriorized cal device (OVD), a three-piece IOL is injected so that the through the sclerotomy. The second haptic trails outside the leading haptic rests on the iris under the crystalline lens. wound. (B) The second haptic is exteriorized through the The trailing haptic can also be inserted over the iris if it opposite sclerotomy. A 26-gauge needle is used to has a good tone and a small pupil is present. In the case create limbus-parallel intrascleral tunnels, and both haptics of a floppy iris or nonconstricting pupil, the second hap- are tucked into these tunnels. Fibrin glue is used to seal the tic is left trailing outside the wound. We prefer to operate flaps and the conjunctiva. with gas-forced infusion provided by an air pump10 con- nected to the infusion bottle. The nucleus is emulsified lar maneuvering with long, thin needles is not required. while the IOL is used as a scaffold to prevent nuclear The fibrin glue seals the flaps hermetically and decreases fragments falling into the vitreous. Finally, using the hand- the chances of postoperative complications such as wound shake technique, the haptics of the IOL are grabbed and leak and endophthalmitis. sequentially exteriorized through sclerotomies under the The glued endocapsular ring is made of the same mate- two scleral flaps. They are then tucked intrasclerally, and rial (PVDF) and has the same dimension as some IOL the flap is glued (Figures 4 and 5). haptics. It can be inserted into the anterior chamber using the fishtail technique of Angunawela and Little11 or can ADVANTAGES be inserted with arms first and haptics last. With either The glued endocapsular ring and glued IOL techniques method, there is no need to tie sutures to the device, obviate the need for sutures, providing an inherent stabil- which increases the speed and ease of surgery. Because the ity and longevity that may not be attained with sutured haptic is exteriorized through a sclerotomy, there is no risk IOLs and capsular tension rings. Problems associated with of the glued endocapsular ring falling into the vitreous. sutures such as suture degradation, erosion, knot unraveling, Elastic memory allows the ring to regain its shape once it is knot exposure, and late IOL subluxation can be avoided. in the anterior chamber. PVDF has been shown to be inert Additionally, the degree of pseudophacodonesis that is intrasclerally in our experience with glued IOLs,5,6 and the seen with sutured fixation is not seen with the glued tech- same was also reported by Scharioth et al.4 niques. Because the haptics lie within intrascleral tunnels, The double scroll engaging mechanism is atraumatic. The the glued IOL and glued endocapsular ring are stable and device ensures intraoperative and postoperative horizontal offer great ease of adjustability. Surgery is easier and more and vertical stability of the bag as well as expansion of the rapid than with suture methods, as complicated intraocu- capsular fornix. The robust intraoperative support that it

November/December 2012 Cataract & Refractive Surgery Today Europe 21 cataract surgery Bonus Feature

A B IOLs. There is a reduced chance of uveitis-glaucoma-hyphema syndrome, as compared with scleral-fixated IOLs, and less chance of long-term endo- thelial cell loss because the IOL is placed far from the endothelium. An advantage of the IOL scaffold technique is that the procedure can be completed via small incisions. The optic C D of the IOL blocks the pupil, preventing nuclear fragments from falling into the vitreous. The optic compartmental- izes the eye, preventing hydration and prolapse of the vitreous and aspiration of the vitreous into the phaco probe. Although the same can be achieved with a Sheets glide,12 the HEMA contact lens described by Mehta et al,13 or perfluoro- Figure 4. (A,B) The dangling lens is brought up into the anterior chamber and emulsified carbon liquid,14 all of these procedures using the IOL as a scaffold. (C) Both haptics are sequentially removed from their position require implantation of a material or above the iris and exteriorized through sclerotomies. (D) The haptics are tucked into device that must eventually be removed scleral tunnels and the flaps and conjunctiva are glued down using fibrin glue. from the eye. The Sheets glide also requires extension of the incision, and provides allows safer performance of intracapsular maneu- PFCL flotation and emulsification of the nucleus requires vers such as in-the-bag nucleus chopping. Explantation, if the assistance of a vitreoretinal surgeon. The IOL scaffold required, is also relatively simple. This requires the surgeon technique utilizes the IOL to be implanted, thereby advanc- (under cover of OVD) to grasp the edge of the double scroll ing its placement to an earlier time point in the surgical and pull the device through the main port. The flexible procedure. device can easily be explanted in this manner. The glued IOL also has inherent advantages, includ- SUBLUXATED IOLs ing greater IOL stability and lack of pseudophacodone- The management of subluxated IOLs follows essen- sis compared with sutured scleral-fixated IOLs. Surgery tially the same decision-making process as described is simple and rapid, and good centration of the IOL can above, depending on the degree of zonular dialysis. A be achieved by adjusting the tuck of the haptics. The glued endocapsular ring can be inserted into the bag after procedure can be done with any three-piece IOL and it is expanded with OVD, and the bag-IOL complex can be does not require an inventory of lenses to be main- anchored to the sclera using the technique described tained, unlike with scleral-fixated and anterior chamber above for subluxated cataracts. In case of large three- piece IOL subluxations or secondary A B repair of sulcus-fixated three-piece IOLs found postoperatively to be unstable and subluxating, a closed- globe technique of refixing the same IOL can be employed using the glued IOL technique.15 This is done by holding the IOL haptic with microforceps while performing vitrectomy to clear any vitreous traction. Each haptic is then sequentially exteriorized through the sclerotomies, then Figure 5. (A) Slit lamp photograph shows a well-centered bag-IOL complex at 6 months. tucked and glued down. (B) The blue color of the haptic can be seen under the scleral flap and conjunctiva. The In the case of a dangling subluxated coat-hanger tuck is seen, and the haptic is observed lying inert under the flap. one-piece IOL, the lens can be explanted

22 Cataract & Refractive Surgery Today Europe November/December 2012 Take-Home Message • Subluxation should be managed according to the degree of zonular dialysis. • The glued endocapsular ring and glued IOL techniques obviate the need for sutures. • The entire procedure for the IOL scaffold technique can be completed via a small incision. • The management of subluxated IOLs follows the same decision-making process as with subluxated cataracts, depending on the degree of dialysis. after partial bisection, and then a foldable glued IOL can be implanted.

CONCLUSION Zonular weakness presents challenges during cataract surgery. In the event of a subluxated crystalline lens or IOL, the surgeon must plan the type of surgery and the individual surgical steps with great care. n

Amar Agarwal, MS, FRCS, FRCOphth, is Chairman, Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Dr. Agarwal states that he has no financial interest in the products or companies mentioned. He may be reached at tel: + 91 44 2811 6233; e-mail: [email protected]. Soosan Jacob, MS, FRCS, DNB, is a Senior Consultant Ophthalmologist at Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Dr. Jacob states that she has no financial interest in the products or companies mentioned. She may be reached at e-mail: [email protected].

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