Live Surgical Demonstration: Evaluation and Surgical Correction of Dislocated Intraocular Lens

Dislocated intraocular lens is becoming a more frequent long-term complication following cataract surgery. Risk factors will be discussed and evaluation with management choices explained. This surgical demonstration will show safe and reliable techniques of dislocated intraocular lens removal with secondary IOL placement. We will also discuss post operative issues and risks to surgery as well.

Surgeon/lecturer: Dr. David Miller, Retina Associates of Cleveland, USA

Transcript

DR MILLER: Okay. Let ’em in. There you go. Put it down for me. Good morning, everybody. I’m David Miller from Retina Associates in Cleveland. I hope you can hear me. We’re just finishing up a case. A tractional retinal detachment, diabetic. And putting in the gas bubble. And we’re gonna start the lens dislocation suturing case. Next. Let me fix the microphone here. Gotcha. Welcome again, to Cleveland, Ohio. Just starting our cases here. And we’re in the middle of turnover. Just finished a case on a diabetic tractional detachment. And maybe a few of you saw the end of that. Maybe you didn’t. But anyhow, welcome. And we’re working at the Cleveland Eye and Laser Surgery Center. Again, I’m David Miller, Rachel here is helping me with questions, Jordan is in the room, Jenny on the Block is back with us, one of our PAs, and Aubrey is our new PA in training. James, our scrub nurse. Jordan was our circulator. Grace is helping turn the room. So while we’re getting ready for the next case, I’m going to go through some slides here, the didactic, on dislocated IOLs. And repositioning or suturing IOLs. So we’ll do that. The PowerPoint. Right there. There you go. There’s your PowerPoint. Great. So evaluation and surgical correction of dislocated intraocular lens. I want to give a shout out to Dr. Hull, one of my partners, on the title slide there. He created the slides and gave this presentation a year or so ago, and added his slides to mine, and I did these a little bit. Next slide. So IOL dislocation is a serious but rare complication of cataract surgery. We don’t see it very often, but we are seeing it more often. So over the past… If I go back 10 years ago in my career, it seemed like we did a couple a year. Now I’m doing a couple a month, really. And part of that is that more people are doing these procedures and more get referred to you, but there’s definitely an increase of prevalence in these dislocated IOLs. Risk factors for IOL dislocation and inadequate capsular support include pseudoexfoliation, abbreviated here as PXE, blunt trauma to the eye, as a child or an adult or even after cataract surgery. Prior vitreoretinal surgery. A lot of my patients come back, where they’ve had multiple vitrectomies for diabetes or retinal detachments. The implant goes in, and then a year or two later, the lens implant is dislocating. We think this is because of the zonules being damaged during all the vitrectomies. So when you go in and out with the pars plana wounds, you’re probably lysing some zonules. The more difficult the case is, with multiple reops, the more zonules we’re probably losing. Making the entire lens capsular bag complex insecure. Uveitis is another risk factor for IOL dislocation. So the dislocated IOL. So normally the natural lens of the eye sits right here. And the lens implant in this case is placed in the bag. The bag is the gray. The darker gray. The lens implant is the lighter gray. And here you can see the zonules I was talking about. Kind of suspending that bag. Like a trampoline. And these little zonules can be damaged by wounds coming into the eye here for retinal surgery. They can cut some of these. Or from trauma. Right? Or pseudoexfoliation, the zonules are weak and can break away from the bag. Most often what we see is the entire bag-lens complex will dislocate together and fall to the back of the eye. Occasionally, we’ll see just the lens implant itself fall out of the bag. So IOL lens implant rescue or repositioning. We can use an intact anterior or posterior capsule with adequate support. This is often repaired by the anterior segment surgeon. What you’re looking at there is if the anterior capsule — this bag is intact and the zonules are intact and just the lens implant dislocates or moves or falls through a posterior capsule opening, we can take the lens implant, pick it up, put it back in the sulcus area in front of the zonules and rotate it to a secure position. That’s the easiest. That’s the easiest maneuver. Quite often we still do those cases. If the lens implants in a spot where the cataract surgeon or anterior segment surgeon can reach it, we don’t get involved. But quite often the lens implant is in the vitreous or halfway into the vitreous. We clean that up first, take out the anterior vitreous, do a posterior vitrectomy, elevate the lens under the sulcus, and rotate it into a spot that’s secure. More often, the cases I get involved in, and what we’re doing today, is an IOL exchange. There’s a lens implant in the eye already that’s dislocated with the bag. We’re gonna try and go in, take that lens implant, and bag complex out of the eye, bring it up off the retina, take it out of the eye, try and bisect it. If it’s the type of lens that can be cut. And then place another lens implant into the eye. And in this case, we’re looking at using an anterior chamber IOL, iris fixated PC IOL, or scleral fixated PC IOL. We’re trying today to do a scleral fixated PC IOL. If that’s not possible, there’s always a backup plan of using an anterior chamber IOL. So you want to come to the operating room prepared with more than one type of lens implant. The scleral fixated IOL — we’re set to go. But if that’s not working, we also have the lens calculations and the model ordered to put in the anterior chamber IOL. So an anterior chamber IOL on the screen here shows a lens implant laying over the pupil. The haptics oriented like this. Kind of swings back this way. You don’t see the last curve here. You want to make sure you get these in the correct orientation, because these lenses do have a concavity to them. If you get them upside down, they’re pushing against the iris and can be quite inflammatory. So the pros of anterior chamber lens implants, good when there’s no capsule support, good option for more patients. Many surgeons are more familiar with it. The downside of anterior chamber IOLs is contact with the anterior chamber angle may lead to aggravation of glaucoma. Iris chafing and rubbing may lead to uveitic glaucoma, hyphema syndrome, and corneal touch. The lens implant does bow a little bit, so you’re closer to the corneal endothelium, which can create corneal failure over time. Suture fixated IOL to the iris is also more of an anterior segment surgeon’s game. They use sutures. As demonstrated here. Incisions to the cornea, back and forth, the implant to the iris, the haptics of the IOL are behind the iris. You can see it in this diagram here. But the sutures are going through the iris, grabbing that, and tying it to the iris, as so. The downside to this type of procedure, as you can imagine, is iris trauma, chronic inflammation, and irritation. But it can work quite well. Many patients tolerate that. And what we’re trying to do today is the suture fixated to the scleral wall. This is a diagram of the procedure we’re gonna try and do, using a Bausch and Lomb Akreos AO60 lens. It has foot plates or haptics. The reason I like this particular lens is for four-point fixation. I’ve used PC IOLs with curved linear haptics before, for many years. Including in the Yamane procedure. But the lens implant can get some tilt to it. It’s only fixated in two locations. So it can kind of twist on that axis. Whereas if you have four points, it’s harder for the lens implant to twist. You have a flat plane of the lens in the eye. Here we’re making sclerotomy incisions on either side of the eye, nasally and temporally, going in the eye, doing our surgery with the vitrector, the infusion cannula here, then we’re going to thread the lens implant outside the eye with some Gore-Tex suture. Fold the lens implant. Insert it. And pull the sutures out through the sclerotomy sites on the temporal and nasal side. I hope to get the lens centered. So this is somewhat suture dependent. Some people have been using for years 9-0 polypropylene, was the suture of choice. But these can tend to break. Quite easily. Usually by rubbing of the suture and the haptic area. Gore-Tex sutures are kind of the suture of the past few years. High tensile strength. Greater longevity. I’ve never had a Gore-Tex suture break. I’ve only been using them maybe five or six years. The problem with suturing lenses in general is the irritation of the suture. If it erupts through the conjunctiva, then you could have breaking of the suture or future dislocation. Another transscleral haptic fixation technique is the Yamane technique, first introduced by Shin Yamane in 2014, using externalized haptics. Laced into the lumen of a thin walled 30 gauge needle, the haptics are externalized, and we use cautery to create a terminal ball. Here you see the beginning of the case, marking of the sclerotomy locations, 180 degrees apart. There’s the lens implant in the eye. You can see the lens implant, the haptic here, being externalized, and melted with cautery to make a little ball and done here to make a blue little melted bulb on the tip so it cannot slide back through so easily. And secure the lens. The one thing about this, if you’re trying to use a 30 gauge needle to guide those haptics, you have to make sure you have the right needle. So the haptic, the Zeiss lens, for instance, is 0.15. So you need a bigger lumen than that. Normal 30-gauge needle is a little too small. But you can order special 30-gauge models, 30 GTW, which has a big enough lumen to accommodate that haptic and you do a handshake technique where you dock the haptic in the needle and pull the needle out with the haptic. Just showing the needle tips there. Any three piece IOL may be used. But of course you want one with flexible haptics. The Zeiss CT Lucia 602 is a hydrophobic acrylic lens that’s good for this purpose. So in summary, surgical techniques to correct eyes without capsular support include inserting an AC IOL, inserting a PC IOL with iris fixation, or inserting a PC IOL with scleral fixation, either by sutures or by sutureless technique, using the haptics themselves and the terminal bulbs. So we’re going to, I think, stop the screen sharing at this point. I’m happy to take any questions at this point. While we’re waiting for our patient to roll in. The room has been turned over. I’m just gonna put my mask up, I guess, since we’re opening up all the sterile equipment. And I’ll put my microphone on my gown right when we’re ready to go. I’ll walk you through the case. You’re gonna get to see the case here from start to finish. Whenever we’re ready. Absolutely. Yeah. So they’re gonna be bringing her in, and we’ll get the patient blocked and prepped. And this will probably take about… Oh, maybe 5 minutes total here. Let them come through. All right. So Betty is with us today. And Betty lost her vision actually several years ago. Didn’t seek medical attention. Finally went to see her eye doctor. Was thought to be aphakic. Went and saw one of my partners, Dr. Hull, who discovered that her lens-bag complex had dislocated. And Tom was gracious enough, knowing that we were trying to schedule a case of this sort, coming up to let me work with Betty to take out her lens implant and place another one in, with the Gore-Tex sutures. So typically what we do is we do these cases under monitored anesthesia care or MAC. We don’t do general anesthesia. They will give her a little bit of fentanyl and some Versed here, through the IV. I’ll be doing a retrobulbar block on the left eye. And we’ll then get her prepped and draped. If there’s any questions from the audience, I know that people asked some earlier questions, when they were signing up. Things like the causes of IOL dislocation. I think the most common that I see is actually zonular trauma, either from cataract surgery that was complicated years ago, or from multiple retinal surgeries. We don’t see as much pseudoexfoliation, though that happens too. I do think AC IOLs are a reasonable option for many, many patients. Studies trying to determine whether a PC IOL or AC IOL is better — it’s always been a bit complicated to say with confidence one way or the other.

>> Dr. Miller, we have a few questions, if you want to open up the Q and A. You can look at those.

DR MILLER: I do see that, yep. So I see one of the questions is about the different suture materials you can use. So I’m using Gore-Tex here, because it’s non-erodible. Polypropylene 9-0 has been used for many, many years. And I think that suture — I’ve had quite a few patients come in with those breaking and being cut, probably from the roughness of the haptic eyelets. Those bigger lenses with eyelets on the haptics and the suture rubs and gets cut in that choke point. So I do like the Gore-Tex quite well. There’s even some cases where you can rescue the lens implant in the eye. If it’s the right type. Using Gore-Tex suture. Without removing the lens. What about iris fixated IOLs like the Artisan? I’m not that familiar with the different lens implants, necessarily. All the different models. I do think you can do iris fixation. If that’s a claw type IOL, I think that’s fine too. Again, those lenses have been associated with recurrent hyphemas and uveitis. Sometimes corneal endothelial decompensation. So probably not my favorite. I really prefer suturing… Having a sutured IOL or a sclerally fixated IOL over AC IOLs myself. As far as trying to practice these techniques yourself, in a wet lab… I don’t know that that’s gonna be… I don’t really have a wet lab model for doing this. Definitely it’s a more complicated ophthalmic surgery. I think one of the most complicated. And my own techniques have evolved over the years. Correcting problems that were recurring over and over. Ready to block the patient? Let’s get going here. We’ll block the patient. Okay, Betty. We’re gonna get you going. You doing okay?

>> We’re working on the left eye. She has no allergies.

DR MILLER: So what we’re gonna do here is use a retrobulbar solution of lidocaine. I think just lidocaine only, right? Lidocaine and what? Oh, lidocaine and 0.75 marcaine. Betty has a prominent and sunken eye. That’s gonna present its own challenges. Just a little pinch here. Gonna inject 5 CCs here. A little burning, Jenny. Betty. A little burning. I’m gonna inject a little bit more there, trying to raise her eye up, which is what we did, to kind of bring it out of the orbit, make it more accessible. Okay. Very good. Thanks. So while Jenny on the Block there is getting our prep on Betty, which will only take a couple minutes, we can answer a few more questions and tell you what we’ll be trying to do. I’ll be using… So I’ll answer a few more questions and describe the beginning of my case a little bit. One of the questions would be: What would be your plan in the rare case of an IOL exchange failure? So if the lens is failing, if I can’t get it to suture properly or I can’t get the sutures to pass or something is wrong, you know, there have been cases where you just abandon the procedure. Do not suture in the IOL. At that point, I generally try to place an AC IOL, unless there’s something worse going on, like a choroidal hemorrhage. These cases are more liable for those types of problems, like choroidal hemorrhages, because you don’t have as good control of intraocular pressure. Other complication of these surgeries include refractive surprises, because you’re making corneal incisions with sutures. Also you’re trying to get lens measurements ahead of time. And consideration of what the prior lens implant was. And how the eye may have changed. Infection risk is a little higher. Bigger wounds in these surgeries. Long-term infection risk too, because if you’re using sutures, or even the Yamane technique, you have a track through the sclera into the eye. So something bacterial gets subconjunctival, the bacteria can easily find their way into the intraocular contents. One of the questions here is: Can we use vicryl suture? No, it’s a dissolvable suture and that won’t hold the lens implant. There’s no way for the lens implant to scar up. Any experience with floppy iris? I don’t do any cataract surgeries. I don’t really pay much attention to floppy iris syndrome. And the medications that cause that. And for the most part, it doesn’t affect my procedure. So we just work through it. This patient is… Target refraction is… Emmetropia is one of the questions. So we’re gonna try to make her emmetropic. Use the lens implant that gives her a minimal refraction per distance, then using reading glasses — it’s what she has in her other eye. So we’re gonna get started on the procedure here. I’m gonna get myself scrubbed up. I’ll just talk while I’m getting my gown and things on. What we’ll do first is… Get the conjunctiva down. Temporally and nasally. And that will allow us to examine the sclera and find our locations for our suturing. So we’re gonna measure where the scleral fixation sutures are gonna be first, before we make any incisions or sclerotomies in the eye or try to make the incision to get the lens implant out, which is an extra incision too. There we go. You know what? Can you get my microphone? Can you tie this first? And I’ll get my microphone pulled out and put on top. I’ll just let her… Just reach in and grab that. Hopefully this will help with the sound here. Are we good? Okay. Great. Okay. Thank you, Jenny. I’ll lower the bed a little bit. Again, the bottle — I’ll talk about some general vitrectomy techniques as we’re going here. We generally want the eye to be — at least the bottle at the level of the drip chamber, to keep the intraocular pressure where we want it. Okay. This patient has a shunt, a glaucoma shunt here. A suture over here. I’ll take the conjunctiva down like we talked. Nasally and temporally. Just gonna adjust the lid speculum here a little bit. Put it back open. There we go. Make the temporal incision the same as the nasal and the conjunctiva here. You can use cautery or not. I don’t get too much into cautery myself. I like to just kind of mark the eye. We’re gonna make our incisions… Holding the lens implant 4 millimeters back from the limbus. The reason we do this… It kind of simulates a bag placement of the intraocular lens. There’s 4 millimeters. Try and make these marks right on the horizontal to start out. And then we’re gonna go two above and two below that. These sutures are placed 4 millimeters apart. Going through those haptics. So… Use it as my middle point. Here’s 2 millimeters. And here’s 2 millimeters. And then we’ll make a quick check to see if they’re both 4 from the limbus. You’ve got a pen there. Blue pen. You dry this for me? You need a blue pen. Dry the bottom one there. Right there. And let’s dry this one up here. This one is also at 4, nicely. Dry that one for me, before it bleeds. There you go. So there you go. Now you have two marks, 4 millimeters apart. 4 millimeters off the limbus. More or less nasal, directly nasal. So we’re gonna do the same thing temporally. Here you want to line these up. You can use a toric marker perhaps to get 180 degrees apart, or you can kind of eyeball it, which is my preferred method. I think that’s gonna put us about right there. Okay? And a small palpebral fissure, which makes the case a little more difficult than some others. We’re gonna be fighting that the whole day, it looks like. Or the whole case. And… This one is a little in front of the dot. We’ll fix that. This one is right on. Okay. And this one is a little in front. Right there. The point being: If these sutures are lined up nicely — this is one of the mistakes you can make with this case — everything builds, like everything else in ophthalmic surgery, every step is important. And if these are off a clock hour, these are moved up here and these are moved here, the lens implant is gonna be decentered. If you keep these 180 degrees apart, so you don’t want to rely on the toric marker too much. You always want to use the eyeball test a little bit here. If you use the toric marker, you would say… Wow. That is pretty straight across. Jenny, what do you think? I always ask Jenny. She has a good eye too. So there we go. So now we’re gonna put in our sclerotomies. Okay? This one is the infusion. We know this is 4. So I don’t need to be 4 back, by the way, for this. I’m gonna put this one in here right there. We’re gonna work through this sclerotomy right here. We’re gonna make an extra one right now. Sometimes I’ve toyed with not even using the cannulas here. Because they’re a little bit bigger. And that makes the wounds leak a little bit more. Sometimes you can get away without suturing if you don’t use the cannulas like I did here. There’s all the wounds for the sutures that are created. And now we’re gonna plug in our infusion cannula. By the way, I’m using a Dutch Ophthalmic or DORC… Infusion on, please. And then the light pipe. Using a DORC Ophthalmic 25-gauge sutureless vitrectomy system. And we’ve got a little bit of corneal edema here, I know. Hopefully it won’t impede the view too much. I don’t have it up yet. There we go. And so here we start the vitrectomy. You can see one of the haptics right there. There’s the edge of the lens implant. The view may not be that great. It’s really up in the edge. Lens implant right here, actually. Dislocated posterior, some. Put the Eibos up. So it’s kind of just sliding around here.

Well… So lens implant is unstable. I’m debating whether we should just try to reposition it, as opposed to taking it out. Because what you can do here is work with the one you got. Just picking up some of the capsule on the lens implant. That looks pretty well secured, to be honest. So I kind of don’t see the point… Of trying to reposition that. Hm. Let’s take another look. So we’ve got pretty good optics right through the center of the IOL. There’s no real need to suture this lens and remove this one. We can just reposition it a little bit. Let’s bring the Eibos up. Paracentesis site. So we’re gonna try to change the game plan here. And what we’re gonna go with is… Kind of checking the lens implant from the top here. About repositioning. So we already kind of moved the lens implant quite a bit with the vitrector. And you can use a side port incision there, like we just did. Doing a case like this, we can rotate the lens implant to a new position… Because those generally center up better. Usually it’s a haptic being contracted by a phimosis in the capsule, something of that sort. So we rotate it about… Rotated about half a turn there. Kind of positioned itself a little nicer. It’s a big lens implant. Sulcus style. An MA60 AC would be my guess, just by looking at it. Turn the vitrector down here. That’s about it. We’re gonna fix this here. There we go. We’re fine. Okay. So actually the case is gonna be rather abbreviated. We’re not gonna suture or cut this lens out. We’re just gonna reposition it in the sulcus. And that’s fine. Take a quick look around the periphery. Okay.. Never a bad idea to take a look around the retinal periphery, make sure there’s no retinal tears or detachments. There’s one of your cannulas from the vitrectomy. There you go. I’ll take a look on this side again. Make sure there’s no retinal tears or detachments. Take a look here. So begin, if you can use a lens implant in the eye, you can see it’s well centered. Now you can see both haptics. One is right here. One is over here. Lens implants perfectly centered. Even by scleral depressing, one test you can check a lens implant — when you’re depressing, if the lens implant stays well centered when you’re done, it doesn’t dislocation, you’re inflicting some trauma on the eye, I guess, with some scleral depression. If the lens implant stays stable, you’re in a pretty good spot. So we’re gonna clean up a little bit more in the vitreous here. And we’ll be out. So… It’s always nice to… Always nice if we can to (audio drop) when we spun the lens around. It’s always nice if we can to avoid sutures or any type of scleral fixation. It’s always the first choice. If you can get into the sulcus with a well situated IOL that’s not causing iris chafing or pupillary block, that’s ideal. And that’s where we’re at in this case. So these cases are always a little bit… You don’t know until you get here. But if we can avoid the stitches… To hold the lens implant in place, avoid the long-term risk, I just need the sutures, vicryls… You can see how small these wounds are, right? Here’s the infusion wound right there. Eye is holding pressure pretty well, actually. We’re gonna use some vicryl to hold the conjunctiva up. And we actually had two patients lined up with this condition today. But the second patient just canceled on Friday. Late last week. So we’re just down to this one lens implant case today. And a handful of retinal detachments and macular holes and so on. So always again… Simpler is always better. Better outcome for her not to have that removed and sutured. You notice, we’re not suturing the sclerotomy wounds. Because all those looked tight enough. The hole. So for those who are really looking forward to seeing the suturing technique of IOL maneuver… I apologize for that. We’re gonna have to look for another such payment, schedule up a day, perhaps, in the future with Cybersight. But we’re always gonna do what makes sense in the case, of course. So always keep your options open and be flexible. And these cases really… More than others… Need that mindset. Because you really can’t approach it… They’re all a little different. You’re working all the way across the eye. She even has a glaucoma procedure here. You want to avoid that bleb and so on. Related to that shunt. And she did very well. So this is good news, Betty! We got the lens implant — the old one — right where we want to put it. You don’t need a new one. That makes the procedure easier for you. There we go. This is 7-0 vicryl we’re putting in here, by the way. Just putting the conjunctiva back up. Some BSS to reform the eye. Just putting some fluid into the eye to reconstitute it. Bring the pressure up. We’ll check the wounds after that. Oh, see… There it goes. Now, wait a minute. Oh. See, now it’s not stable again. Now it’s going back. You’ve got to be kidding me. See what it’s doing?

>> Mm-hm. Slipping.

DR MILLER: It’s gone. The lens implant is not gonna stay, it looks like, actually. We’re gonna go in and get it. Well, I guess… This is what happens. Sometimes you get here and you find out… That’s what I was doing the scleral depression for. Trying to avoid that. So we’re gonna go back and get that. Yeah. So… We are gonna take this lens implant out. It’s just not gonna be stable. So it’s moving around on her quite a bit, and it’s about halfway down right now into the vitreous. So we were able to rotate into a secure spot. But then just by injecting the BSS, the eye got a little softer. And it wasn’t that much. Not even half a CC. But the movement in the eye and the needle going in and out means this lens implant is not gonna stay where Betty needs it, lifelong. So we’re gonna use the same incisions we already made. And we’re gonna get another set of cannulas. We got everything set up, right? Just need the cannulas.

>> Yeah.

DR MILLER: So give us a minute. Not even that. A second here. Just use the cannulas… And we’ll almost start… Well, we’ll start from a head start, because we’ve already got the incisions. We’ll use the same ones, in fact. I’ve got the infusion cannula incision right here. That one’s gone. Right here? Was the infusion you? Switching the infusion? It’s the same type?

>> Are these peel packed ones?

DR MILLER: These are peel packed ones.

>> These are the old ones.

DR MILLER: I have to match the infusion cannula with the transscleral cannula. So yeah. Change out the infusion cannula too. Can I have a second forceps? We’re gonna put this cannula on. Gonna turn it on for a second. Actually… Maybe it does… It’s not gonna come out. It’s pretty tight. So infusion on again. It’s not running. Just give another pack. Where is the infusion? Can you turn it on? Okay. Second forceps. Infusion on, please. Keep it on. Where is the pressure at?

>> 35.

DR MILLER: Can we get to where we’re supposed to be? I’ll take a look around the back. Have a vitrector. Okay. We’re gonna take a look here with the vitrector. Make sure everything looks okay in the back before we proceed with suturing the lens implant. So there’s our lens implant. So the patient has had a prior vitrectomy. Can you get the pressure up to 100? What’s going on? Can you take it up to 5? Having a little problem with the infusion here. In that the eye was getting softer in the vitrectomy there at the very start of that. And so we’re gonna make sure we’ve got proper fluid dynamics here. To continue the case safely. I’m gonna grab these air bubbles. And I’m testing it now. The aspiration of the vitrector. It is maintaining pressure. What is the pressure at now?

>> 35.

DR MILLER: Okay. Good. All right. Can we make a corneal incision here? I’m just gonna keep working at 12:00. There’s a shunt in here. But we’re just gonna go over… Maybe we’ll go a little to the side. As opposed to getting in this… I don’t want to get into this conjunctiva here. I think we’re gonna come over this way a little bit. And we’re gonna tunnel this into the cornea. Just make it a little bit bigger… 3 millimeter keratome, Kim? 3.2, right? Make that a little bit bigger. Saw me saw with it a little bit. I’m gonna grab this with an MST, the vitrector, and a light pipe, and the MST scissors. I need two MSTs. One is a scissor. One is a forceps. Got the side port incision already over here. Let me see — make sure I can find the side port incision. Right there. Okay. What we’re gonna do is use the vitrector to aspirate the lens implant up and hand it off to a forceps. These lens implants are so light. You can do… Well… Pick it up. Yeah. I can see. So we’re holding the lens implant. Max grip forceps. So what we’re gonna do now is get the lens implant in a position where we can… Get a second MST forceps.

>> Cutter?

DR MILLER: Give me the cutter. I want to get… Well, maybe that’ll work.

>> If you want to…

DR MILLER: That’ll work. You can give me a McPherson. I want to try to get the lens implant a little bit better positioned in my hands so I can cut and use this side over here. Need some viscoelastic too, of course. Hold the cannula over here. Okay. That’s fine. Viscoelastic. Have to get some corneal protection in here. MST.

>> The cutter or the regular?

DR MILLER: The regular forceps.

>> Sorry.

DR MILLER: So we’re gonna use the two hand technique. One instrument to hold the lens implant. Right there. One to cut. We bisect the lens. Don’t have to go all the way through. If anything, you can go 3/4, maybe a little bit farther through. And then you can hopefully have it follow through. One side to the other, staying connected. Like so. So it comes out as one piece. So lens implants out… We’ve got this corneal defect here from the start of the case. It’s been with us. We’ll take a look around. And here is the lens implant. Forceps out of the way. Here’s the lens implant we just took out. You can see the bisection cut I made right there. This haptic is still on. This one came off when it came through the wound. Now the lens implant is out. And that’s the reason you can cut this lens. It’s that type of lens. It’s an acrylic material. Or silicone. But acrylic — this one is. Where you cut it right through there, and it just kind of folds up. There we go. Okay. Now we’re gonna try and put our little… Again, gonna take a look at the vitrector. In the back, to make sure we didn’t create a problem in the back. Retinal tearing, retinal bleeding. Hang on there. Don’t drop me. There you go. Thank you. No choroidal hemorrhages, things of that sort. So you always want to kind of be aware… Maybe do a quick check… In this case, I’m also gonna grab the rest of this bag out here, so it’s not in our way. So maybe I’ll grab it out with the forceps. Even better yet. We lost the cannula over here. It’s on the machine. I don’t need it. So what we’re gonna do is… Take out the capsular bag here… And that is the capsular bag right there. That way, it won’t get caught up in our sutures, as we’re trying get the case done here. Now it’s a much cleaner eye. We’re gonna go forward from there. Lens implant. We’re gonna use this Akreos AO60 with the Gore-Tex sutures. So this is the lens implant here. Give me a rinse. Not quite sure what happened there. There we go. I’d like to thread these in this fashion. The sutures are always on top of the optic orientation for myself. Okay. Fair enough. So that’s one suture, kind of pre-placed. I’m gonna grab it. I find it easier almost to drive this one. Drive the haptic to the suture, as opposed to the suture to the haptic. And they’re a little sticky. So sometimes the assistant will grab it like so. Keep pulling. It’s wrapped around my forceps. Hang on. Keep pulling. You’ve got it around my forceps. There you go. I’ve got it. Now they’re both threaded. Now we’re gonna preplace some of these sutures. Take this one for me. And I have the MST forceps. Take that for me. Yep. Max grip forceps. So we’re gonna preplace the two inferior sclerotomy sites. Sutures. You can see the iris almost wants to be difficult with the wound. I would like to stay high in the iris wound to avoid that problem, which is what we did here. Otherwise you’re fighting iris prolapse the whole time if your incision is in this area. So I like to come up into the cornea and then go in. That’s a big help. These are all things you kind of pick up, as you do more and more of these cases. And also sometimes it can be hard to reach in and get the suture. Get that for me there. Let me get focused a little bit better so I can find my forceps more easily. There we go. A little hard to get the view. What we’re gonna do here… Because the angle is tough with the nose… We can oftentimes bend these forceps a little bit. That’s what we’re gonna do. Bend the forceps. Make a nice little curve. Sometimes you break the forceps. They are disposable. Not as much as I need. No. So Jenny thought I broke the forceps. Right. I did not break the forceps. But I have before. So it happens. You know. The curve allows you a much nicer… Not as deep in the eye there, see? Now you can see what you’re doing. Kind of just making mad grabs. The suture comes through. So I like to place two. And place two after we get in. So we’re now gonna fold the lens and insert it. Viscoelastic again. And… Lens folder here. Extra little gadget. The McPherson there. Give it a little push so it folds the right direction. You’ve got the inserter. And this holds the lens together with the McPherson again. I like to have her pull up on the suture a little bit to take the slack out as we’re going. You’ve got yours. Pull a little bit. I don’t like these crossed. There you go. It’s a little hard to sometimes get these started. There we go. And it goes. And there it is. So Jenny kept her slack up. Saves a lot of twisting. You get a spaghetti effect in the eye otherwise, and it can be pretty difficult to manipulate the lens implant if it gets… These sutures get spaghettied around the haptics and the lens implant. You’re trying to tangle things around in the eye. Dumped the implant farther back in the eye, so it’s out of the way. And… There you go. Here’s our curved forceps again. Keep getting my wounds a little farther over. This is tricky for me today, even. Placing the wound more nasal, superonasal. More in that glaucoma area. Just getting my lens oriented in the eye so I can see it everywhere. And we’re gonna get one more suture to place. It’s this one. And gonna push the lens implant back. We’ll do that again from this side, even. Because we want to keep the suture on top. You always want to keep your orientation and things lined up correctly. And this one goes through. Now you can see the lens implant — now I have the four sutures externalized. We’re gonna grab this with the Bonaccolto. So we don’t pull the suture through, we hang on to the suture at the other end and take off that cannula. Take a Bonaccolto again.

Any of these would be fine. Now we tie. You can cut these down to like here. Yep. And same on this side. No, no, no. That’s fine. Just… It’s fine. So… We’ll pull this lens implant over. There we go. A little shorter. One, two, three. Make a throw. Not tighten it down. Because we can see the lens implant is not centered. One, two, three. On the other side. Once we get the first throw in, then we’re gonna center the lens implant. Now it’s centered again. You can see we want it about right… There. You don’t want to overtighten these. That’s a problem too. They can distort the haptics. And the optics completely. And then you can’t even get refraction in there. The lens implant gets totally contorted by suture tension, it’s pretty much… Impossible to correct. So I think we’ve got the lens implant well centered. We’re gonna throw a knot over the top here. Before we tighten it down, we’ll do the other side too. Again, just to make sure we’re well centered. Gore-Tex is such a forgiving suture. You can actually back the knots out if need be. And so you can see now the lens implant is well centered. Left and right. You can see the optic. It doesn’t have to be perfect. You know. That one is pretty close. But it does not have to be perfect. You don’t need it dead center. If you’re off a little bit, don’t fret it. You can actually take these knots out with a pair of small forceps. I’ve done that before and retied them. If I didn’t like my centration when I got to that point in the case. This has one more throw to it yet. Gore-Tex is very pliable. Quite forgiving. Now what we’re gonna do is rotate those knots into the eye. Because we’ve got one continuous suture. You can see now we’re leaking at this site. That’s typical. Just put the McPherson into the wound and that gets it rotated in. Take the tips of the McPherson forceps and put it into the sclerotomy site. You can’t just pull the suture over. You can rotate it to get it there, but you have to actually grab the knot and jam it into the eye. I’m not sure “jam it” is a real technical, surgical term. But sometimes a little force does work. Okay. The lens implant remains well centered. Here’s your Gore-Tex sutures. They’ll be subconjunctival. You can see the lens implant. Nicely suspended. Right where we want it. Now we’re gonna put the wounds back together. We’ve got to close this… Here you go. I’ll take… Something. Yeah. Typically these will leak around the sutures. Especially the superior ones. So we’re gonna do a little suturing here. And that is the medial rectus muscle we’re kind of just getting to the edge of. A little vascular. Not worried about strabismus or creating a muscle effect. Just looking for the end of this. There it is. Don’t worry too much about cutting the Gore-Tex suture. With the vicryl needle. I have done that. Actually. Done enough cases where it seems like everything has happened once. It’s unfortunate, but you can then string another Gore-Tex suture inside the eye, through the optic. What am I caught on here? And so this is just, at this point of the case, just some sewing, you know. Sclerotomy — this can… To make this as simple as upon on yourself, again, it’s kind of case planning. You want to avoid all the wounds. There we go. Nice and dry. This one is still leaking like crazy over here, so we’re gonna get a couple of throws, stitch it on this side. And this is where a small fissure kind of hurts you. Betty, how are you doing? You doing okay?

>> Fine.

DR MILLER: Yeah, Betty is awake during the case here. We’re doing just fine. So what happened… Getting this case done for you… We thought we had a simple fix. Ended up that the simple fix wasn’t gonna work. So back to the more complicated procedure. But the case has gone well, regardless.

>> (inaudible)

DR MILLER: Yeah, we’re getting there.

>> (inaudible)

DR MILLER: She must have had a lot of that bouncing around in there, you know. Depending when you caught it… We caught it in a good spot for the case. So… Q-Tip there? So typically what happens, I’ve noticed, is that the top ones leak and we sew them. The bottom ones don’t. Which is what she’s doing. She’s behaving very commonly. Which has led me to sometimes use the cannulas, and sometimes that helps. Don’t have to even put these sutures in. And so let’s grab the… We’ve got the 10-0. So this wound here is self-sealing, as you can see. We’re gonna just make sure the viscoelastic is out. It is. But I tend to always… Somehow they always get snagged on my… I typically will put a suture here. Being that I’m not the cataract surgeon making these wounds all the time, I prefer to sew this closed. Just because of the infection risk. Wound leak risk. So I’ll put one… 10-0 nylon in. A little awkward again. Because of the location. You can cut this. Oh. So we’re gonna put this 10-0 right here. I don’t mind if it’s a little tight. We’ll release it in a couple weeks in the clinic. And so it induces a little astigmatism, perhaps, being a tighter stitch, but like I said, we’ll cut that in the clinic and remove it in a couple weeks. It’s no problem. Just the scissors. Yeah. Cut those off. Rotate the knot down so it’s in the cornea there. That’s nice and tight. Right in the middle of the wound. The paracentesis site doesn’t leak. Now we’re just gonna grab the conj. Okay. So put the conjunctiva up. This is the second time we’ve done this today. And for Betty here, that’s always gonna be a little tricky. Sometimes we don’t have the best conjunctiva. I’m sure people watching have all seen that in their own surgeries. The main goal of the game with the conjunctiva is to make sure the Gore-Tex is covered. That’s what we’re after. So a little bite in the sclera, a couple of bites in the two ends of the conjunctiva. And see if we can’t elevate this conj up and over the Gore-Tex like so. You’ve got real scissors? There you go. Thank you. How are we doing on time? A little after 10:00. I guess we ran over a little bit. We also started a little late, perhaps, because the other case ran long. I’ll be done here in just a couple minutes. I’m happy to answer any questions. Rachel, you’ve got anything popping up over there on the… Yeah, go ahead. What have you got, Rachel? Anything? You can just read them out loud. Well, we’ve covered that one. It’s most commonly prior retinal surgery, vitreoretinal surgery, or trauma from cataract surgery. Complicated cataract surgery. Zonular dehiscence. And pseudoexfoliation is one condition where we know there’s weak zonules and you get zonular dehiscence and rupture. I think we’re okay. Again, so the conj here is well up over the Gore-Tex. We’re in good shape. We’re gonna pull this. Wait for that wound. I would not expect to have to put a suture in that infusion cannula wound. You can see that swelling shut already. There we go. Again, the goal here is to get… Not the prettiest conj closure, but just get the Gore-Tex covered, where it won’t be exposed. The conj can scar down. The Gore-Tex won’t even be visible under the conjunctiva in a couple weeks. Very difficult to find, even with the slit lamp. I’m just looking at the conjunctiva here. I want to get this anchored in a way that… The Gore-Tex will be covered. I had a case where the conjunctiva can be so friable from prior surgeries or scleral buckles, et cetera, where it’s really not even possible to do this type of case. You know, and certainly that’s where planning with AC IOLs comes in. There we go. You have the Westcott scissors there? Free up the conjunctiva here a little bit more. And pull it up over this Gore-Tex. I’ll probably cut this one out, even. What we’re doing here is making sure we get this conj up. A little nicer. Because we had too much of the superior suture. This will be much better. Yeah.

>> Perfect.

DR MILLER: So we took down the one suture. To allow more mobility. And push the conj over. Now it’s… So much better fit. Okay. Probably put one more here. No. So the question was: What’s our post-op routine for drops and antiinflammatories? And the answer is: Really don’t treat it any differently than any other case. We use an antibiotic drop. Four times a day? Three times a day?

>> Four.

DR MILLER: And steroids also, four times a day. Pred Forte or prednisolone eye drop, four times a day. And generally by within a week, we’re tapering that down. So… Generally not too bad for inflammation. All the lens fragments out of the eye in this type of case. Another reason to pull the bag. And those cataract fragments. Makes the need for the steroid drops even less. A little easier healing for the eye. So there we go. So the conj is well over the Gore-Tex. The Gore-Tex is way down here. The conj is way up here. We’re in good shape. So the lens implant looks good. Centered in the eye. Pressure. Yep. This time, when we put the fluid in the eye, to reconstitute the eye, the lens implant doesn’t move or start to fall backwards. It’s right where we left it. Very good. So that’s the IOL explantation, scleral fixation, four-point scleral fixation, using Gore-Tex sutures. For Cybersight. What’s interesting about this case is really how we started out with one plan, which was to go in there, and pick up an IOL and cut it up and take it out. Got in there. Thought there was a space to leave it in the sulcus and just rotate it and recenter it. But what we find when we tested it, it looked good, and we got to the very end of the case, virtually the very end of the case, the lens started to dislocate. So here we almost did two surgeries for IOL rescue or fixation or exchange, more than one. You almost saw two. You saw the simple repair, which is go in there, take out the anterior vitreous, free up the lens, and rotate it. Which we did. And it looked good. I’m a little surprised, just by injecting the BSS, how unstable it became. But it showed there was some zonule dehiscence, the lens implant started to slide right through, so we went back, opened up all the wounds, and put the four-point fixation. So kind of two cases in one here. But these types of surgeries can be more complicated. And I think you saw a very prime example of that here today. So… A couple questions. One: Do we do endothelial studies before these procedures? No, not really. I do look at the endothelium. People with a lot of guttata, I do warn them that there could be endothelial decompensation. These are usually pretty difficult cases. And patients going into it are pretty understanding. They know they’re in bad shape. These aren’t routine cataract cases. They know they can’t see coming in at all. Do you ever use triamcinolone in the anterior chamber before you close? No, not too much. I have used it to try and detect vitreous strands and residual vitreous. We do use triamcinolone sometimes to find the vitreous in the… Around the anterior chamber. In certain cases. But not in these. I don’t find a need for it. Is ultrasound biomicroscopy of any value to assess the post-op zonular status? I’ve never done it. I do not know if that would be useful or not. Generally I use the old examination techniques of looking at the lens implant, where it’s centered, decentered, where the vitreous is coming through, et cetera. I think the question here is… Can a three-piece IOL also be fixed by this technique? Any kind of that? Not so easily. The three-piece IOLs don’t really have a great place to secure the sutures. I used (inaudible) sutures on the haptics in the past, with some success. But I got quite a bit of rotation on the lens implant in too many cases, and I wasn’t satisfied with that. I definitely prefer this type of lens implant, where you can put in four-point fixation. The question is… Can a retinal detachment occur after this type of procedure? Certainly a retinal detachment can occur after any ocular surgery. I have not actually had one caused by these procedures. And the lens implant being either dislocated in the eye or going to retrieve it and remove it. But the lens implant itself, when it’s free floating in the eye, seems to be extremely well tolerated. Bounces around, but it doesn’t tear the retina or seem to damage the intraocular structures. Okay. So… I guess that kind of wraps up our lecture for the day. And our live surgery. Thank you all for attending. It’s been my pleasure to participate in Cybersight. It certainly is a great platform. And everyone have a great day. Thanks.

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March 21, 2022

Last Updated: September 12, 2022

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