Surgery: IOL Implantation in Challenging Cases

This video demonstrates IOL implantation techniques in a few challenging cases.  Dr. Masket explains all the steps in detail while implanting the lenses and dealing with the challenges.

In the first surgery, a posterior capsular rent was managed and an IOL was placed in the sulcus.  The patient was then referred to the vitreoretinal surgeon for the management of the retained intravitreal nucleus.

The second patient had pseudoexfoliation and diffused zonulysis.  The phacoemulsification was performed after placing the capsular support hooks.  A Henderson modified capsular tension ring was used and a single piece acrylic lens implanted in the capsular bag.

The third patient had a progressive zonulopathy, years after an IOL was inserted in the capsular bag.  The IOL along with the capsular bag complex was centered by fixating it to the sclera using sutures.

In the fourth patient, the IOL was improperly placed with the inferior optic in front of the bag, inducing marked damage to the inferior iris and repeated microhyphema.  The IOL was repositioned in the bag and therefore preventing any further iris damage.

The fifth patient had a significantly-subluxated PC IOL after a complicated cataract surgery.  The IOL was explanted and a 6mm, 3-piece acrylic lens was placed and secured to the iris using sutures.

The sixth patient presented with a lens-induced Z-Syndrome.  The IOL was explanted and a 3-piece Collamer IOL was placed inside the capsular bag.

Surgeon: Samuel Masket MD, Advanced Vision Care, David Geffen School of Medicine, UCLA, USA


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Early in the course of phacoemulsification in this patient with pseudoexfoliation it is evident that there is a large posterior capsule rent and vitreous prolapse. Triamcinolone, assisted by manual vitrectomy, is carried out anteriorly, after which a three-piece acrylic lens is inserted into the ciliary sulcus, with the loops carefully placed above the capsule. Additional vitrectomy is carried out, and the optic is then prolapsed behind the anterior capsule, creating posterior optic capture. The incision is then closed after additional vitrectomy carried out, and the patient referred for vitreoretinal management of the retained intravitreal lens nucleus. In this patient with pseudoexfoliation and diffuse zonulysis, it is evident during the attempted capsulotomy that the lens is significantly loose, as evidenced by the corrugation of the capsule on attempted peeling. In this case, the capsule was stained to increase its visibility later in the surgery, during placement of capsule support hooks, which were a likely necessity in this case. Here, under viscoelastic tunnels, capsule support hooks are then placed underneath the anterior capsule, creating an artificial zonule and allowing phacoemulsification. Careful, gentle, but copious hydrodissection is carried out to free the nucleus and the cortex from the capsule bag. My preference is vertical or quick chop of the lens nucleus into several pieces, prior to their removal. Note that there is little to no movement to the capsule bag, as a result of the capsule support hooks that are specifically designed for patients with zonulopathy. Once the lens nucleus is removed, cortical clean-up is in process. However, it is noted that the inferior capsule is disinserted from the zonular apparatus. A Henderson type CTR is called for, and by manual aspiration of the cortex, is carried out. The Henderson modification of the CTR has scalloping to facilitate removal of the cortex. However, in this case, cortical removal has already been accomplished. The capsule tension ring is placed within the confines of the capsule bag, and extensive polishing of the anterior subcapsular lens epithelial cells is carried out to prevent late capsule contraction and fibrosis with metaplasia of the subcapsular cells. A single piece acrylic lens is then positioned into the capsule bag. The OVD is removed in bimanual fashion, and given stability of the lens, no further action is necessary. Intraoperative Seidel test assures firm sealing of all incisions. Now, this patient has had placement of a single piece PMMA lens into the confines of the capsule bag many years earlier. However, he’s undergone progressive zonulopathy, and here, 180-degree marks are made in the peripheral cornea, followed by 300-micron-deep peripheral corneal grooves, and then a crescent blade is used to create the Hoffman pockets. A 10-0 polypropylene suture on STC-6 needle is then passed through pars plana and docked into an opposing 27-gauge needle in the horizontal meridian to create a basket safety suture underneath the IOL, to prevent further posterior subluxation. As the pupil is small in this case, capsule iris hooks are used to enhance visibility. An MDR blade is passed through the Hoffman pocket, through the fibrous tissue, between the optic and the double encircling loop. That is replaced with a microforceps, and from an opposing paracentesis, a Gore-Tex suture is passed from hand to hand, and then brought out through the Hoffman pocket. The other end of the Gore-Tex suture is then passed peripheral to the loop, creating a lasso around the loop of the IOL, inferiorly, and the same procedure is then repeated superiorly. First iris retractors are placed, an MVR blade is then passed through the Hoffman pocket, underneath the IOL, and then pierces the capsule between the lens loop and the optic, and then from the opposing paracentesis, a Gore-Tex suture is passed first beneath the loop, and then here above the loop, again creating a lasso. The Gore-Tex sutures are then removed from the Hoffman pocket, and tied in temporary slipknots, which are then progressively tightened, creating firm fixation and centration of the capsule bag IOL complex. The OVD is then removed with the vitrector, in case any vitreous has prolapsed anteriorly. The safety suture is removed. Intraocular pressure checked at physiologic levels. And fibrin adhesive then passed into the Hoffman pockets. A bandage contact lens is applied for corneal protection in this diabetic patient. This thick-edged three-piece acrylic meniscus lens was improperly placed five years earlier, with the inferior optic in front of the bag, inducing marked damage to the inferior iris and repeated microhyphemas. Here the optic is rotated out of the casual bag, and the adhesions between the anterior and posterior capsules lysed with OVD and then blunt dissection with a spatula. The adhesions on the temporal side are somewhat more tenacious, and one can note zonular stress. Therefore the anterior capsule edge is held open with a Sinskey hook, while the adhesions between anterior and posterior capsule are lysed by blunt dissection. Once the capsule bag has been open fully for 360 degrees, the optic can then be repositioned in the confines of the capsule bag, therefore preventing any further iris damage. Once the OVD is removed, the incisions are tested with fluorescein dye and noted to be watertight, completing surgery. This patient had unfortunately complicated cataract surgery, with damage to the posterior capsule. Here one can note a three-piece acrylic lens, significantly subluxated posteriorly, and essentially on its edge. Under the protection of OVD, a microforceps is used to grasp the edge of the lens, through a paracentesis, and the lens is then elevated with the assistance of the spatula coming from an opposing paracentesis. Once the optic is brought into a normal position using a Sinskey hook, the lens is then rotated into the anterior chamber, allowing its removal. Had the lens been properly powered, it would have or could have been fixated to the iris. However, from preoperative measurements, it was ascertained that the lens power was improper. And then here, after the lens is freed from its adhesions to the peripheral capsule bag, the lens can be transected and then removed in step-wise fashion. The lens is now positioned in the anterior chamber. Vitrectomy carried out through an anterior approach. A 19 gauge Chang-Packer scissor is then used to partially transect the optic while it is being held with a serrated microforceps through a paracentesis. The optic is then rotated in order to complete transection of the optic. Each piece can then be brought out through the incision, and an appropriately powered lens then selected. Given marked capsule damage, the lens needed to be secured either to the iris or the eye wall, at the discretion of the surgeon. The temporal corneal incision is enlarged to approximately 3.8 to 4 millimeters. A 6-millimeter three-piece acrylic lens is folded in bucket handle position, and then with lens-holding forceps, the loops are passed behind the pupil, and the optics supported anterior to the pupil, creating a pupil capture of the optic temporarily, for fixation purposes, allowing the loops then to be sutured to the iris. Here 10-0 polyester suture is being used to secure the loop to the iris, and then the same thing on the opposing side. In standard McCannel fashion, paracentesis are fashioned, and using Bonds microhooks, the two ends of the 10-0 suture are brought out through a common paracentesis, completely a McCannel suture. The suture is then tied snugly in a 3, 1, and 1 fashion, and the suture drawn into the paracentesis, where the knot is cut close to its origin. Once both sides have been suture-fixated to the iris, the optic is then prolapsed into the posterior chamber, with spatula, being careful not to rotate the lens as to free the loops from the iris. Here the iris is teased centrally to enable the pupil to remain round. Following this, the OVD is removed from the anterior chamber, and the incision closed with two 10-0 nylon sutures, pressure checked at physiologic levels, antibiotic instilled into the chamber, and surgery then completed. This patient has sustained a Z syndrome, and attempts to ameliorate the situation failed. The patient developed iris prolapse, and has marked iris damage, along with the Z syndrome of the Crystalens. The goal of this surgery is to remove the lens and replace it with an in-the-bag lens in order to correct the marked lens-induced astigmatism from the Z syndrome. It is very difficult to free the adhesions of the Crystalens from the peripheral capsule bag, owing to the design of the lens. So, in this situation, it is often better to cut the haptics with microscissors, which is being done through a paracentesis, and a 23-gauge microscissor, while the lens is held with a serrated forceps. Once both of the haptics are freed from the optic, the temporal incision is recreated, the optic transected, and then brought out through the 3-millimeter incision. In this case, it was possible to free the distal haptic and loops from the capsule bag. However, the proximal was held too tenaciously. Nevertheless, it was possible to open the capsule bag for 360 degrees and place a three-piece Collamer lens in the confines of the capsule bag. The previously created incision is closed with one suture, and all incisions then tested with fluorescein dye, completing surgery.


February 21, 2018

Last Updated: October 31, 2022

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