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Two-Step Technique for Posterior Optic Buttonholing of Intraocular Lens

Agarwal, Tushar*; Jhanji, Vishal*; Singh, Digvijay*; Khokhar, Sudarshan*

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Optometry and Vision Science: April 2014 - Volume 91 - Issue 4 - p S17-S19
doi: 10.1097/OPX.0000000000000180
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Phacoemulsification in subluxated lenses continues to pose a challenge to the ophthalmologists with difficulty in achieving a stable intraocular lens placement.1,2 The intraocular lens may be stabilized by the use of a capsular tension ring (CTR) or Cionni’s modified capsular tension ring.3,4 We describe a two-step surgical technique for placement of a posterior chamber intraocular lens (IOL) in cases with crystalline lens subluxation resulting from non-progressive zonular dialysis. This technique is recommended in cases where a CTR is contraindicated (posterior capsular tear) or where an anterior vitrectomy is indicated because of herniation of vitreous into the anterior chamber.



Phacoemulsification is performed under peribulbar anesthesia following standard surgical preparations. A clear corneal incision is fashioned at 12 o’clock using a 2.75-mm blade and side ports created with a microvitreoretinal blade. A continuous curvilinear capsulorrhexis is created aiming for a central location on the subluxated lens. Modified iris hooks are used to stabilize the capsular bag (wherever necessary). The lens is removed using slow motion phacoemulsification.5,6 Following cortical cleanup with bimanual irrigation and aspiration system, a 4-mm posterior capsular opening is created aiming for a central location on the subluxated lens using an automated vitrector. In cases with preexisting posterior capsular tear, the opening is extended to 4 mm diameter. Subsequently, anterior vitrectomy is done through the posterior capsular opening using a 20 G cutter (Infinity; Alcon Inc., Fort Worth TX, USA) with cut rate of 800 cuts per minute and aspiration of 250 mm Hg. At the end of the first stage of the surgery, the side ports are hydrated using balanced salt solution (BSS).

The patients are taken for secondary IOL implantation 6 weeks after the first surgery. The IOL power is calculated for a three-piece Acrysof lens (MA60AC; Alcon Inc.) with a further 0.5 D addition. The previous 2.75-mm clear corneal incision is enlarged to 3.2 mm. Healon GV (Abbott Medical optics Inc., IL, USA) is injected into the anterior chamber and below the iris to create space in the ciliary sulcus. The IOL is loaded in an injector (Monarch Injector System; Alcon Inc.) and is inserted slowly into the eye to avoid any sudden snapping in the anterior chamber. The IOL haptics are dialed into the sulcus so that their longitudinal axis is aligned with the area of intact zonules. Using a Sinskey hook, one half of the optic is pushed gently behind the posterior capsular opening. Following this, the other part of the optic is also pushed behind the posterior capsular opening. Therefore, the IOL is placed in the intended manner, whereby the optic of the IOL is placed posterior to the capsular bag, through the posterior capsular opening and the haptics of the IOL come to rest in the sulcus, anterior to the capsular bag. Subsequently, viscoelastic is removed using an automated irrigation aspiration system. All surgical ports are hydrated using BSS. Postoperatively, all patients received topical moxifloxacin 0.5% three times a day for 2 weeks and prednisolone acetate 1% QID 4 weeks. Tropicamide 1% eye drops are prescribed twice a day for the first week.


Seven eyes of seven patients (6 males, 1 female) with posttraumatic, non-progressive zonular dialysis were operated on using the aforementioned technique (age range: 10–46 years). Five cases had vitreous herniating into the anterior chamber through the zonules preoperatively while two cases had a preexisting posterior capsular tear and underwent anterior vitrectomy through the expanded existing opening. In all cases, the IOL was well centered on final follow-up (Fig. 1). Postoperative visual outcomes are shown in Table 1. In two cases with postoperative visual acuity of 20/80 (case 2 and 6), the patients had preexisting scars secondary to choroidal rupture.

Postoperative visual outcomes in cases after two-step posterior buttonholing surgery
A, Six-month follow-up after posterior optic buttonholing procedure. Intraocular lens is well centered. Haptics are placed in the sulcus (block arrow) with the optic resting behind the bag (arrow). B, Eighteen-month follow-up after posterior optic buttonholing surgery. Intraocular lens is well centered without any evidence of posterior capsular opacification in the visual axis.


Currently available options for a posterior chamber IOL placement in cases with zonular dialysis and subluxation involve the use of capsular tension rings, segments, or Cionni’s modified capsular tension ring.7–9 The CTR works by recruiting the remnant zonules to support the IOL by redistributing force among them. However, anterior or posterior tears in the capsule are contraindications for using a CTR. Cionni’s rings work partly like a CTR as they distribute the force to the remaining zonules, and this force is supplemented by the suturing of the ring to the sclera. A drawback though is the permanent placement of a prolene suture in the eye that is prone to breakage.10 Apart from this, these eyes are also known to have a high incidence of posterior capsular opacification and late decentration of the IOL.11,12

The technique for posterior buttonholing of the IOL in cases of posterior capsular tears has been described previously.13,14 However, because the haptic of the IOL are still in the capsular bag and derive their support from the bag and zonules, it cannot be used in cases with zonular deficiency because of the risk of decentration of the IOL. In our technique, placement of the optic posterior to the bag prevents anterior displacement of the IOL while the haptics lying anterior to the bag prevent its posterior displacement.

The main advantage of our technique is preclusion for an additional implant like CTR and Cionni’s ring. This technique can be used in patients with either a preexisting or iatrogenic posterior capsular tears when a CTR is contraindicated. A possible criticism of our technique can be that it entails creating a posterior capsular opening and loss of the anterior-posterior barrier function. However, we performed this technique only in cases that already had a vitreous prolapse into the anterior chamber through the zonular dialysis or a preexisting capsular rupture. We allowed time between the initial surgery and IOL implantation to allow some degree of fibrosis in the capsular bag so that the IOL implantation can be performed easily during the second stage of the surgery. Also, a two-stage surgery avoids excessive anterior chamber inflammation. We observed that none of our cases required prolonged use for corticosteroids after the first or second stage of surgery.

The main limitations of this study are short follow-up and a small number of cases. However, all patients were advised to follow up on a regular basis to look for late complications such as glaucoma. Nevertheless, we present a simple and effective technique for intraocular lens placement in eyes with non-progressive subluxation without the use of an additional implant. The technique is recommended in the presence of less than or equal to 6 clock hours of zonular dialysis and in cases with preexisting posterior capsular tear. Lensectomy and implant are fraught with challenges in patients with a history of trauma and lens luxation issues. We propose a method to minimize risk and maximize success. This should be especially appealing to all co-managing doctors and doctors within referral center practices.

Received October 14, 2013; accepted December 20, 2013.


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two-step technique; posterior optic buttonholing; intraocular lens; zonular dialysis

© 2014 American Academy of Optometry