CATARACT SURGERY FEATURE STORY eyetube.net Dislocated IOL Levitation With a Sleeveless Extrusion Cannula An effective technique for a dropped IOL of any type. BY PRIYA NARANG, MS; ASHVIN AGARWAL, MS; AND AMAR AGARWAL, MS, FRCS, FRCOPHTH islocation of an IOL into A B the posterior chamber is a dreaded complication. It leads to a continuous tussle Dto optimize visual outcomes and meet the expectations of a highly demanding patient. Below we explain how to use a sleeveless extrusion can- nula to reposition a dislocated IOL atraumatically. C D Flynn et al1,2 described the technique of using a soft-tipped extrusion cannula to drain posterior subretinal fluid. In this commonly used procedure, flexible silicone tubing is attached to the end of a tapered extrusion needle and advanced into the subretinal space, through a preexisting open peripheral break or a retinotomy Figure 1. An IOL is lying flat on the retina (A). The sleeveless extrusion cannula is performed during vitreoretinal introduced into the eye, and the bore of the cannula is positioned facing the surface of microsurgery, in order to allow the IOL; suction is generated with the footpedal in position 2, and the IOL is lifted (B). atraumatic drainage of posterior Once the IOL is brought into the mid-pupillary plane, it is grasped with end-opening subretinal fluid. forceps (C). The IOL is brought into the anterior chamber and explanted or repositioned, In complicated cataract surgery, depending on the presence or absence of sulcus support and the type of IOL (D). using a sleeveless extrusion cannula to address a dislocated IOL provides a large contact vitrectomy with careful separation and removal of area with the IOL. With application of adequate suc- the posterior hyaloid face is performed prior to lift- tion, the IOL can be lifted and brought into the pupil- ing the IOL. This prevents traction on the retina in lary plane, from whence it can be grasped by forceps subsequent maneuvers. The IOL gently floats to the and removed. posterior pole of the eye once it is freed from all attachments (Figure 1A). SURGICAL TECHNIQUE The sleeveless extrusion cannula is then connected to Under local anesthesia, standard 23-gauge three- the vitreotome, and the vacuum is set to 300 mm Hg port pars plana vitrectomy incisions are created. After with the cutting function turned off. As the IOL rests releasing all vitreolenticular adhesions, complete flat on the retina, the sleeveless extrusion cannula is 38 CATARACT & REFRACTIVE SURGERY TODAY EUROPE SEPTEMBER 2014 CATARACT SURGERY FEATURE STORY slippery, and difficult to grasp,3 especially those with In complicated cataract surgery, plate haptics. using a sleeveless extrusion cannula The flexible silicone sleeve fits snugly within the rigid outer shaft of the vitrector cannula, preventing leakage to address a dislocated IOL of air or fluid and providing good access into the sub- provides a large contact area with retinal space.8 Removal of the silicone sleeve exposes a the IOL. Removing the silicone wider access of the bore of the cannula, which helps to sleeve exposes a wider access of the create effective suction around the IOL. bore of the cannula, which helps to CONCLUSION create effective suction around the The technique described et above and in a video at .n IOL. be eyetube.net/?v=uheri is safe, reliable, tu e and reproducible. Moreover, it is an ey positioned carefully to face the center of the optic; inef- effective solution for a dislocated fective contact of the cannula’s lumen with the surface IOL of any type, including plate- eyetube.net/?v=uheni of the IOL optic can lead to vacuum loss. Suction is haptic IOLs, which are often difficult then initiated and controlled with the footpedal. Linear to grasp with retinal forceps. Other advantages are that footpedal control allows vacuum to be increased when no additional device is required and availability of an needed during levitation of the IOL (Figure 1B). extrusion cannula is not an issue, as these instruments The IOL is lifted from the surface of the retina and are included in virtually all vitreoretinal set-ups. n brought into the anterior vitreous cavity in the mid- pupillary area (Figure 1C). Next, end-opening forceps, Amar Agarwal, MS, FRCS, FRCOphth, is introduced from the corneal incision under direct visu- Professor and Head of Dr. Agarwal’s Eye alization through the microscope, are used to grasp the Hospital and Eye Research Centre, Chennai, IOL, and the extrusion cannula is removed. The IOL can India. Professor Agarwal states that he has no then be managed depending on the surgical scenario; financial interest in the products or companies it can be either repositioned in the sulcus or explanted mentioned. He may be reached at tel: +91 44 2811 6233; (Figure 1D). fax: +91 44 2811 5871; e-mail: dragarwal@ vsnl.com. Ashvin Agarwal, MS, is a Senior Consultant BETTER ACCESS, EFFECTIVE SUCTION at Dr. Agarwal’s Eye Hospital and Eye Research Various methods of IOL levitation have been Centre, Chennai, India. Mr. Agarwal states that described in the literature.3-7 Retinal forceps are he has no financial interest in the products or a mainstay of treatment in vitreoretinal surgery; companies mentioned. He may be reached at however, an accidental iatrogenic retinal tear while e-mail: [email protected]. lifting an IOL from the surface of the retina is possible Priya Narang, MS, is a Director at Narang Eye with use of these instruments. Often IOLs are sneaky, Care & Laser Centre, Ahmedabad, India. Ms. Narang states that she has no financial interest TAKE-HOME MESSAGE in the products or companies mentioned. She • With application of adequate suction, a dislocated may be reached at tel: +91 79 2642 0034; fax: +91 79 2268 4556; e-mail: [email protected]. IOL can be lifted and brought into the pupillary plane 1. Flynn HW Jr, Blumenkranz MS, Parel JM, et al. Cannulated subretinal fluid aspirator for vitreoretinal microsurgery. with a sleeveless extrusion cannula. The IOL can then Am J Ophthalmol. 1987;103:106-108. 2. Flynn HW Jr, Lee WG, Parel JM. A simple extrusion needle with flexible cannula tip for vitreoretinal microsurgery. be grasped by forceps and removed. Am J Ophthalmol. 1988;105:215-216. 3. Mello MO Jr, Scott IU, Smiddy WE, et al. Surgical management and outcomes of dislocated intraocular lenses. Ophthalmology. 2000;107:62-67. • This technique can be used with any type of IOL, 4. Santos A, Roig-Melo EA. Management of posteriorly dislocated intraocular lens: a new technique. Ophthalmic Surg Lasers. 2001;32:260-262. including those with plate haptics. 5. Olson JL, Montoya RV, Erlanger M, et al. Management of a dislocated intraocular lens with a suction-based grasping tool. J Cataract Refract Surg. 2013;39:154-157. • Once the IOL is safely lifted from the surface of the 6. Jorge R, Siqueira RC, Cardillo JA, et al. Fragmatome lifting: surgical option for intraocular lens and foreign body removal. Ophthalmic Surg Lasers Imaging. 2005;36:261-264. retina, it can then be repositioned in the sulcus or 7. Lewis H, Sanchez G. The use of perflurocarbon liquids in the repositioning of posteriorly dislocated intraocular lenses. Ophthalmology. 1993;100:1055-1059. explanted. 8. Flynn HW, Lee WG, Parel JM. Design features and surgical use of a cannulated extrusion needle. Graefe’s Arch Clin Exp Ophthalmol. 1989;227(4):304-308. 40 CATARACT & REFRACTIVE SURGERY TODAY EUROPE SEPTEMBER 2014.