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Consultation section: Cataract

November consultation #4

Scharioth, Gabor B. MD, PhD

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Journal of Cataract & Refractive Surgery: November 2019 - Volume 45 - Issue 11 - p 1688
doi: 10.1016/j.jcrs.2019.08.027
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Late IOL dislocation is becoming a more frequently occurring event after previously uncomplicated cataract surgery. Pseudoexfoliation, status post-vitrectomy, myopia, trauma, and uveitis are the most common causes, and these are at cumulative risk.

In the presented case, a 3-piece PMMA IOL was implanted in a vitrectomized eye after trauma and retinal detachment. Considering the young age of this patient, an AC IOL is not a good option. Also taking into account the atrophic iris, I would not consider an iris-fixated IOL. Myopia and status post-vitrectomy might also cause excessive pseudophacodonesis (IOL wobbling). Transscleral suture fixation with polypropylene sutures could be considered; however, late suture erosion or suture break in this young patient will require repeated interventions.

Over the past decade, I have successfully used a sutureless intrascleral haptic fixation technique in hundreds of patients.1 In only one eye, I tried refixation of a 1-piece PMMA IOL. This failed because of the dislocation of one haptic because of the stiffness of the PMMA material. In another eye, I refixated a 3-piece PMMA IOL successfully. However, the haptics are often damaged after capsular bag shrinkage or optic–haptic disinsertion. This can result in optic rotation or tilt despite correct intrascleral haptic fixation (twisted optic syndrome). Therefore, I advocate an IOL exchange in most cases.

After careful inspection, I would open the conjunctiva in two places opposite to each other in areas of the least scleral thinning. Then, I would place a 25-gauge infusion line inferotemporally. Next, I would place two 25-gauge sclerotomies approximately 2.0 mm behind the limbus exactly 180 degrees from each other. Starting from inside, I would prepare these sclerotomies (counter-clockwise intrascleral limbus-parallel tunnels) with a 23-gauge cannula or microvitreoretinal blade. Next, I would prepare two side-port incisions and a 2-step corneal incision at the steep corneal meridian, and then I would explant the dislocated IOL together with capsular bag. If the pupil is too small, iris hooks can be used to improve control during the intraocular manipulations. I would implant a 3-piece hydrophobic acrylic IOL, temporally externalizing the haptics through the ciliary sulcus sclerotomies and then suturing the corneal incision with 10-0 nylon (Ethilon). This will reduce leakage and improve globe stability while the haptics are fixated intrasclerally. In case the sclera turns out to be extremely thin, the haptics can be sutured to the scleral surface and covered with a scleral patch. Next, I would inject a balanced salt solution through the side-port incision. If this causes a reversed pupillary block, I would perform a peripheral iridectomy to release it and reduce the risk for postoperative iris capture. Then, I would remove the 25-gauge infusion line and cannula. To prevent leakage, the sclerotomies should be sutured with 8-0 polyglactin (Vicryl). Finally, I would close the conjunctiva.

Reference

1. Gabor SG, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007;33:1851-1854.
© 2019 by Lippincott Williams & Wilkins, Inc.