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Consultation section

December Consultation # 2

Braunstein, Richard E. MD

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Journal of Cataract & Refractive Surgery: December 2007 - Volume 33 - Issue 12 - p 2013-2014
doi: 10.1016/j.jcrs.2007.10.004
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This case presents several problems related to sulcus placement of a 1-piece AcrySof ReSTOR IOL in the setting of a broken posterior capsule and vitreous prolapse in the left eye. It is likely that sulcus placement of the IOL is responsible for the low-grade intraocular inflammation and pigment cells in the anterior vitreous, which are the result of contact of the IOL edge with the iris pigment epithelium.1 The 1-piece AcrySof ReSTOR IOL is unstable in the sulcus, which may be responsible for the reduced and fluctuating vision in that eye. Retinal acuity meter and OCT testing suggest that the best corrected distance acuity should be 20/20 rather than 20/40. Manifest refraction shows myopic astigmatism resulting in blurred uncorrected distance acuity, which is due to failure to adjust the IOL power for sulcus fixation.

The current refractive outcome in the right eye is appropriate and desirable for bilateral AcrySof ReSTOR IOL implantation. As the patient has expressed dissatisfaction with his current visual function in the left eye, it is unlikely nonsurgical management will improve the situation. Before surgical planning, I would obtain an endothelial cell count to determine the relative risk for endothelial decompensation with additional surgery in this eye. My preoperative discussion with the patient would include the surgical option of removing the current IOL, performing an anterior vitrectomy, and replacing the AcrySof ReSTOR with a larger sulcus-fixated IOL or, if necessary, an iris suture-fixated IOL. I would offer the patient the option of a multifocal or monofocal IOL, with the patient's understanding that final uncorrected near acuity will likely be reduced with a monofocal IOL.

I would perform surgery in the left eye using peribulbar rather than topical anesthesia. Before attempting to remove the IOL, I would perform an anterior vitrectomy to ensure the vitreous face is posterior to the posterior capsule and the haptics are free of vitreous. To do this, I would create a side-port incision inferiorly and carefully fill the anterior chamber with a dispersive ophthalmic viscosurgical device (OVD) to protect the endothelium and tamponade additional vitreous prolapse. A second side-port incision will be needed superiorly for access with the unsleeved vitrectomy handpiece. I would place an anterior chamber maintainer (ACM) in the inferior side-port incision. Although the IOL appears to have adequate support to prevent dislocation into the posterior segment, I would not open the infusion before I had a second instrument in the eye to support the IOL, should it appear necessary. I would carefully perform an anterior vitrectomy, ensuring that I gently elevate the IOL to work through the posterior capsule tear to completely free the lens of vitreous entrapment. Once I was certain the anterior chamber was free of vitreous, I would remove the ACM, instill additional OVD underneath the IOL, and carefully rotate the IOL into the anterior chamber above the iris plane.

My preferred technique for foldable IOL removal is to refold the lens in the anterior chamber. This is easily accomplished with a cyclodialysis spatula placed 180 degrees from the main incision and a lens folding forceps in the cataract wound. To proceed with this, a new side-port incision should be created 180 degrees from the original cataract wound and the original temporal incision opened with a keratome, extending the incision to approximately 3.5 mm. The IOL is gently folded in half over the spatula, taking care not to place additional force on the capsular bag. The spatula is then removed, and the IOL is delivered through the original cataract incision with the forceps. After IOL removal, the anterior chamber should again be swept for the presence of vitreous strands with a cyclodialysis spatula through a side-port incision.

I would place a 3-piece foldable acrylic IOL with a 6.0 mm optic and 13.0 mm overall length in the ciliary sulcus. Biometry would have to be repeated if the patient's original measurements and IOL power were not available. The IOL power should be adjusted for sulcus fixation as described by Warren Hill (doctor-hill.com); that is, 0.50 or 1.00 diopter (D) less than for in-the-bag fixation, depending on the IOL power. If the patient opted for a multifocal IOL, I would select the AcrySof ReSTOR 3-piece lens, which is also appropriate for sulcus fixation. The haptics would have to be oriented at 6 o'clock and 12 o'clock where, based on the clinical photograph, adequate capsular and zonular support is most likely present. If the IOL does not appear to center correctly or support is questionable, I would suture fixate the IOL to the midperipheral iris using a small-incision foldable IOL insertion technique with a modified McCannel suture.2,3

REFERENCES

1. Wintle R, Austin M. Pigment dispersion with elevated intraocular pressure after AcrySof intraocular lens implantation in the ciliary sulcus. J Cataract Refract Surg. 2001;27:642-644.
2. Stutzman RD, Stark WJ. Surgical technique for suture fixation of an acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg. 2003;29:1658-1662.
3. Condon GP, Masket S, Kranemann C, et al. Small-incision iris fixation of foldable intraocular lenses in the absence of capsule support. Ophthalmology. 2007;114:1311-1318.
© 2007 by Lippincott Williams & Wilkins, Inc.