Considering the clinical picture, this is a case with an unstable sulcus-fixated IOL with friction to the back of the iris (pigment epithelium and blood vessels). This is causing recurrent attacks of secondary glaucoma. I would like to ask the patient whether she has a history of trauma to the eye.
Considering the older age of the patient and the displacement of the IOL inferiorly, as seen in Figure 1, a cause could be an inferior zonulysis. Another possible cause is a bend in the superior IOL haptic near the haptic-optic junction. Also, there is a small iridodialysis at 3’clock, which could indicate a somewhat compromised angle. I would add gonioscopy to the clinical examination to study the angle and, after dilation, to examine the haptics.
My surgical approach would aim at stabilizing the IOL or exchanging it. Using topical anesthesia and with a fully dilated pupil, I would start with a temporal 20-gauge paracentesis. This would allow easier manipulation and better visualization. I would then inject a cohesive OVD to fill the anterior chamber and open the sulcus for 360 degrees. Using a push-pull hook, I would examine the ciliary sulcus and posterior capsule all around and deliver the superior haptic into the anterior chamber to examine it for a bend or fracture. If the problem is inferior zonulysis, I would go ahead with scleral fixation of the superior haptic at 12 o’clock using the Hoffman reversed scleral pocket technique,1,2 starting in the corneal periphery at the base of the iridectomy. The superior iridectomy would allow perfect visualization of the needle during its passage to exit the sclera. Next, 10-0 or 9-0 polypropylene sutures mounted on double-armed long curved needles would be used. The IOL would be rotated so the superior haptic is at the 12 o’clock position. The temporal paracentesis would be enlarged to a 2.0 to 2.4 mm incision to allow introduction of the first needle with a microforceps. I would pass the needle behind the haptic and exit it 2.0 mm behind the limbus through the conjunctiva. A high-viscosity OVD would help open the space between iris and capsule and protect the latter from being punctured. Then, the second needle would be passed in front of the haptic and exited at the same location. Using a Sinskey hook, I would retrieve the suture ends through a scleral pocket after cutting the needles, tighten a triple knot to fixate the haptic in the proper position, and bury the knot in the pocket. I would wash out the OVD, hydrate the wound, and inject an intracameral antibiotic. This technique would provide the least amount of manipulation and induction of wound-related astigmatism, if any, keeping in mind the patient had only 0.5 D of astigmatism and excellent visual potential.
If the haptic is markedly damaged, the IOL would have to be exchanged after the wound is enlarged (PMMA, 6.0 mm optic). A new IOL with an overall diameter of 13.0 mm would be implanted in the sulcus and suture fixated to the sclera. Finally, the wound would be closed with 2 interrupted 10-0 nylon sutures.
1. Hoffman RS, Fine IH, Packer M, Rozenberg I. Scleral fixation using suture retrieval through a scleral tunnel. J Cataract Refract Surg. 32, 2006, p. 1259-1263, Available at: http://www.finemd.com/reprints/Scleral%20Fixation%20Using%20suture%20Retrieval%20Through%20a%20Scleral%20Tu.pdf
. Accessed March 3, 2014.
2. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg. 32, 2006, p. 1907-1912, Available at: http://www.finemd.com/reprints/Scleral%20Fixation%20Without%20Conjunctival%20Dissection.pdf
. Accessed March 3, 2014.