In this lecture, Dr. Masket discusses the root causes for early and late malpositioned and malfunctioning IOLs and various methods for refixating or replacing them.

Lecturer: Dr. Samuel Masket, Advanced Vision Care, Clinical Professor, David Geffen School of Medicine, UCLA


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DR MASKET: Good morning or good afternoon, wherever you happen to be. I am Samuel Masket. I practice in Los Angeles. I’m a clinical professor at the UCLA Stein Institute, and I work in private practice with Advanced Vision Care, also in Los Angeles. Now, some of you may know of me. Others may not. I’m the past president of the American Society of Cataract and Refractive Surgery, and I’ve also been on the Board of Trustees of the American Academy of Ophthalmology. I’m the consultation section editor for the Journal of Cataract and Refractive Surgery. It’s evening here in the United States, on the West Coast, so I’m gonna speak to you this evening about malpositioned and malfunctioning IOLs, and how we manage them. I know that some of you have sent in some questions ahead of time. I’ve looked those over, and the great majority of those will be answered during the presentation. You’ll also have the opportunity to ask questions later on. And we have a lot of materials to share with you, so we’ll try and move directly. I do have some disclosures with respect to relationships with manufacturing sector, although I don’t think any of these are particularly significant in this evening’s presentation. I’m gonna start off with a question. So the chief cause for early malpositioned IOLs is: Pilot error, pseudoexfoliation syndrome, small pupil, glaucoma, or all of the above. So the chief cause for early postoperative malpositioned IOL. Pilot error, pseudoexfoliation syndrome, small pupil, glaucoma, or all of the above. So let’s take a look at what I consider the answer to be. I notice that we have a 50/50 split between pseudoexfoliation and pilot error. Actually, pseudoexfoliation syndrome is part of a condition or a combination of agents or conditions with progressive zonulopathy. As we’ll see when we see the late malpositioned IOLs. But pilot error early after surgery is the chief cause. Iatrogenic causes. Specifically of capsule rupture, missing the capsule bag with one or both of the haptics, damaging the zonules, or damaging the IOL. Endogenous zonulysis or previous trauma are secondary causes, but pilot error tends to be the first cause. Let’s take a look at late malpositioned ones. So the chief cause for late malpositioned IOLs is: Glaucoma, pilot error, progressive zonulopathy, high myopia, or high hyperopia. Again, chief cause for late malpositioned would be glaucoma, pilot error, progressive zonulopathy, high myopia, or high hyperopia. And let’s see. You suggested, the majority of you, that progressive zonulopathy would be in fact the cause. And I do tend to agree with you. When we consider those conditions that lead to progressive zonulopathy, they include pseudoexfoliation syndrome. For some reason I can’t move the slides forward. Here we go. So late is mostly due to fibrometaplasia of the anterior subcapsular lens epithelial cells, as you can see here, this fibrous tissue surrounding this malpositioned lens, and you have the Soemmering’s Rings, a patient with pseudoexfoliation. And that fibrometaplasia tends to cause a fibrosis, leads to phimosis, and we think that leads to zonulysis. And the most common conditions are pseudoexfoliation, uveitis, trauma, retinopathy of prematurity, retinitis pigmentosa, and what’s becoming a much more frequent observation, postvitrectomy eye. We’re not sure whether it’s lysis of the zonules at the time of vitrectomy, or what all of those conditions tend to have in common is a common breakdown of the blood-aqueous barrier. Take a look here at the importance of LEC fibrometaplasia. The slide on the left here shows a patient with a lot of fibrosis of the capsule. It’s already been subjected to laser relaxing incision, and we can see the single-piece acrylic haptic is distorted. We compare that to the eye on the right, and we can see that the capsule is barely, barely visible. These are two eyes of the same patient, who had a chronic intermittent uveitis with pars planitis. In the slide on the right, no cleaning the LECs were done at the time of cataract surgery, whereas here in the example on the right, extensive cleaning the LECs were carried out at surgery, and while this eye is about three years postoperative, this is about a year postoperative. You should note a marked difference in the fibrometaplastic change of the LECs, because they’re essentially gone. And we hope — we think — that this might be a factor in preventing late malpositioning. So here I’m using a Shepherd-Rentsch curette, once the nucleus and cortical material has been removed from the capsular bag, and I’m cleaning vigorously the undersurface, undersurface of the anterior capsule, to remove the anterior subcapsular LECs. And we can do this where we can see the capsule. You can’t do this at the equator, because those cells have tight junctions to the lens capsule bag. And once the lens is in place and remove the OVD, we can note how just remarkably clean that capsule appears. I do this in all my surgeries, although some people reserve this for those patients who are at risk of pseudoexfoliation and what have you. Now, this device is referred to as a Singer Sweep. For those of you who play golf, it kind of looks a little bit like a 7 iron. But today I actually used this through a series of side port incisions, instead of the Shepherd-Rentsch curette. So management strategy. We talked a little bit about cause. We have to take an individualized approach to all the eyes we face. We want to work under the least amount of light possible, so we don’t induce photic maculopathy. Microsurgical instruments are helpful. And the skills that we’re gonna need to have in our bag, so to speak, are the ability to reopen the capsule bag, to stabilize and capture the IOL, either through pars plana, anteriorly, we’re also gonna need to have the skills for vitrectomy, whether they’re done either anteriorly or pars plana approach. Removing lenses, cutting them, folding them, and then fixating IOLs either to the capsule bag or to the sclera are also important tools in our bag of tricks. In our office, we have kind of a treatment algorithm for malpositioned IOLs. If it’s a single-piece acrylic and it’s in the sulcus, that we know is a no-no. We always must remove a single-piece acrylic from the sulcus. Those patients are what we call a time bomb with a fuse of variable length. And they will cause an UGH syndrome, uveitis-glaucoma-hyphema, because of the thick haptics, which also tend to have an abrasive, sticky quality to them. Single-piece acrylic in the bag — we can lasso those to the eye wall. If it’s a three-piece lens and it’s in the sulcus, we have adequate capsule support, then I think we prefer to fixate those to the iris or iris suture fixation. Without capsule support, the lens may have a tendency for late malposition, even sutured to the iris. And then we will either fixate it to the sclera, either in what’s called the glued technique, or now the Yamane Flange technique. If it’s in the bag, then we can lasso it through the bag with scleral suture fixation. So let’s talk a little bit about suturing. Here’s your next question. Which suture material is most likely to deteriorate over time? 8-0 Gore-Tex? 10-0 polyester? 10-0 prolene? 9-0 prolene, or perhaps all of the above? Once again, which suture material is most likely to deteriorate over time? Gore-Tex 8-0, polyester 10-0, prolene 10-0, prolene 9-0, or all of it? Let’s see how you respond. We have some mixed responses here. Actually, Gore-Tex suture is non-absorbable, and actually becomes incorporated in body tissue. We like it a lot. It’s used in cardiovascular surgery. And while the package itself says not to use in the eye, we found that it is probably the best material, or among the better materials. I also like 10-0 polyester. It’s a little more difficult to work with. It’s also non-biodegradable. But currently off the market. 10-0 polypropylene is the most likely to deteriorate, either through hydrolysis or friction. And so we no longer recommend the use of 10-0 prolene for fixating IOLs. 9-0 prolene can be used, but 10-0 prolene we advise against. And here you can see some examples. The Gore-Tex on your left. The CV-8, which is TTc-9 needles, is our current agent of choice. 10-0 prolene we reserve for iris suturing, not suturing to the sclera. There’s also 9-0 prolene. A few different manufactures. And this is the Alcon polypropylene, which is presently not available. Now, the Hoffman pocket is a method that was devised for suturing IOLs to the eye wall, that would enable you to do this without dissecting conjunctiva, most typically valuable for patients who have had prior glaucoma surgery or retinal surgery, with a lot of conjunctival scarring. We want to make sure we avoid conjunctival surgery, if they would need to have future glaucoma filtering surgery. So here we put a marking device on the cornea. And we’re gonna mark exactly 180 degrees apart on the same axis as the loops of this three-piece lens. A peripheral groove, 300 microns deep, is made in the cornea. Clear cornea specifically. And then a crescent blade is used to dissect near the equator of the eye, or posteriorly. One wants to make sure they can see the blade through the tissue, so that we’re not too deep, but also we don’t want to be too superficial. Monitor the procedure field. Now, here, a 27-gauge needle is passed across the Hoffman pocket, and from an opposing paracentesis, the needle of the Gore-Tex suture is docked into the 27-gauge needle. Now that same needle is passed through the Hoffman pocket, this time anterior to the capsule bag and loop complex, and the double-armed suture is then passed through that same paracentesis, docked into the 27-gauge needle, and then brought out of the eye, creating a lasso or a loop of suture material through the bag around the loop of the lens. And when you pull on that, you see the lens move. Once both sides have been sutured, you then reach into the pocket and bring out the free end of the Gore-Tex suture. And we tend to then make a slipknot, and we don’t tension it fully until we do the same thing on the other side, and then progressively tension the knot until we have good centration of the lens. Then we finish our 3, 1, and 1 knot, and once the knots are completely tied, they’re cut and allowed to retract into the Hoffman pocket, and so we have precluded the need for conjunctival dissection. And we have a nice stable and centered lens. This is a little bit different approach. Many of us have abandoned the Hoffman pocket, because it’s a little bit difficult to titrate the tension on the loop and hence the centration. This is a patient with retinitis pigmentosa, one of the conditions that we know is responsible for late decentration of the lens. We can see some fibrotic change in the anterior capsule. You can see this loop goes over here, but notice that the inferotemporal loop has been kind of doubled back on itself, because of the fibrosis in the bag. Now, to remove this lens would require a big incision, because it’s made of 7 millimeter PMMA. So here I’m using another marking device, so we can be exactly 180 degrees apart, and I’m going 3 millimeters posterior to the limbus and making the mark, and then passing again the same Gore-Tex suture through the Hoffman pocket, underneath the loop of the lens, through the capsule bag, and docking it into a 27-gauge needle. I straighten out the Gore-Tex needles, so they’re not too curved. Less of a tendency to strike the endothelium. And then a millimeter and a half anterior to that I go through with a 27-gauge needle. This is full thickness sclera. After taking down the conjunctiva, we then turn the suture around, and we have a loop now of suture material that goes around the loop of the lens through the bag. And as we pull it, we notice that that lens moves. If the lens doesn’t move when you cinch up on the suture, it means either both passages of the suture are in front of or both behind the lens, and that’s not gonna get the job done. So you must have a loop around the loop. One pass goes underneath. One pass superficial to the loop. We pull it up, and we watch the lens move, and we know. Once the lens moves, good. Then we know. Now I’m gonna do a slipknot, a 1-1-1 slipknot, and again we’re gonna tension this. Now we can be a little bit more exacting with our tension than in the Hoffman pocket, but notice I did dissect the conjunctiva. Now, once I have completed the knots, it is very important to bury the suture ends into the scleral tissue, or the exposed knots will eventually erode. Risk factor for endophthalmitis. And I’m using fibrin adhesive to close the conjunctiva, although it could be sutured, rather, or coapted with cautery. Okay. So now we have another question for you. Am I more audible at this level? Good. So let’s take a look at risk factors for late zonulysis. Pseudoexfoliation, retinitis pigmentosa, retinopathy of prematurity, postvitrectomy, or all of the above. So what risk factors are there for late zonulysis. Pseudoexfoliation, retinitis pigmentosa, retinopathy of prematurity, postvitrectomy, or all of the above. So again, divide it half and half between pseudoexfoliation and all of the above. As I showed in the slide earlier, pseudoexfoliation is the most common cause for late zonulysis, but every one of these conditions will definitely induce late zonulysis and are responsible for late malposition of the IOL. But pseudoexfoliation is the most common. But all of them are responsible for a progressive fibrosis, phimosis, and zonulysis. And again, that’s one of the reasons we like to clean the LECs as extensively as we can. Now, I mentioned postvitrectomy, and we’re not really certain why the postvitrectomy eye is more likely to have progressive zonulopathy. But we know that we see this. And so the question is why. Is it due to the vitreoretinal surgeon lysing the posterior zonular fibers? Or is it due to some change perhaps in the blood-aqueous barrier? We’re really not sure. But all those conditions — uveitis, pseudoexfoliation, postvitrectomy, ROP, and RP all tend to have chronic breakdown of the blood-aqueous barrier. So in an eye that is postvitrectomy, one of the concerns about a loose IOL is that when the zonular fibers let go, that lens falls very quickly. And an anterior segment surgeon is going to be very, very hard pressed to prevent that. So I developed a method of making a little basket or safety net underneath the intraocular lens before you try to manipulate it. So I notice that there are some questions. Let me see what your questions are. Can we use Gore-Tex suture and Hoffman pocket safely in children? And my answer to that question is absolutely yes. One of the problems that we run into, however — I’ll answer live here — one of the problems that we run into is that some institutions do not allow us to use Gore-Tex suture, because it is printed on the package “Not for use in the eye”. And this is the same question. But yes, I do use it in children. I think it is the best material to use in children, because so long as you bury the knot, you have lifelong safety with it. So what do we do? I’m back to the postvitrectomy eye, where there’s no buoyancy underneath the lens to keep it from falling rapidly, should the remainder of the zonular fibers go while you’re trying to manipulate the lens and control its position. So I developed a basket safety suture. Let’s take a look at this. Let’s freeze this for a moment. So we had here a one-eyed patient who lost the other eye following retinal detachment. What we notice here is that there is extensive conjunctival scarring. He’s had a prior scleral buckle and vitrectomy. He’s got 360 degrees of conjunctival scarring. So we might want to think about using the Hoffman pocket here to fixate the lens. But we will also note that this lens is markedly subluxated, with very, very few zonular fibers. So anything we attempt to do might cause those few fibers to lyse, and the lens falls then, into the posterior segment, making this a much more complex surgery. So what I’ve done here is I’m gonna take a straight polypropylene 10-0 suture needle and come from one side. And I’m gonna dock that needle into a 27-gauge needle, coming across — again, 2 millimeters posterior to the limbus — from the other side. And I’m gonna dock that suture into that needle, and bring it out. And about 2 or 3 millimeters apart, I will take the second arm of the double-armed 10-0 prolene suture, and again take a 27-gauge needle, and then dock the 27-gauge needle, and 10-0 prolene suture needle together, and then bring the two-needle complex out of the eye. And so now I have a horizontal mattress suture underneath the lens in the horizontal meridian now, here I bend the needle, and I’m demonstrating that, so that when I dock it, now we’re doing it in the vertical meridian. When I dock that 10-0 prolene suture into the 27-gauge needle, I want to have firm friction, so that the needle will not slip out of the 27-gauge hypodermic needle, so we bend it and pass it across. And then you can see this gives us now a lens that is sitting on a safety suture net, and we can do whatever we choose. We can remove it. We can suture fixate it. Depending on our preference. Here we’ll demonstrate another case. This is a patient who sustained complicated cataract surgery. I refer to this as triphakia, because she actually has 2 intraocular lenses, an anterior chamber lens and a posterior chamber lens placed at the same time, about three weeks ago, and we’ll also see subsequently she has some nucleus in the back of the eye. So she has three lenses. I refer to this as triphakia. So here again — this is the 10-0 STC-6 — 10-0 polypropylene, that we’re going to dock into a 27-gauge needle, 180 degrees apart, and I was doing this surgery in combination with a vitreoretinal surgeon who requested that I do this. But I don’t ordinarily do it in a non-vitrectomized eye. There usually isn’t a need. If the lens is very loose and subluxated, I will do it. Usually I reserve this safety basket technique for the postvitrectomy eye. But in this situation, I placed it only in one meridian, not in two meridia, and now I’m going to use triamcinolone to stain the vitreous that’s in the anterior segment and remove the vitreous from around the intraocular lenses, so that we can safely remove both of them before I turn the patient over to the vitreoretinal surgeon, who will do a pars plana vitrectomy and remove lens material from the posterior segment. So I have made a superiorly oriented crown-shaped incision. I’m placing a Sheets glide, and sliding out the anterior chamber lens. And now I’m going to remove some more vitreous from around the posterior chamber lens, and this is a single-piece acrylic lens. I really can’t tell you what the surgeon was thinking when he implanted both of these, but obviously the capsule was ruptured when he was placing the posterior chamber lens, and he thought it was going to fall into the posterior segment, so he placed an anterior chamber lens at the same time. So now the single-piece acrylic posterior chamber lens is being freed from its attachments in the back of the eye. And it will then also — once the vitreous adhesions are managed, the lens will then also be brought out through the superior incision. Here we’re placing some hydroxypropyl methylcellulose on the cornea for protection and better visibility. Once both lenses have been removed, a synechiolysis is performed, and the patient is then turned over to the vitreoretinal surgeon, in order to do a pars plana vitrectomy and remove the lens material. Now, I’m going to fixate to the sclera with Gore-Tex suture a Bausch and Lomb hydrophilic A060 lens. And the reason we can do this is the loops on that lens will allow us to have a continuous loop of Gore-Tex or 10-0 prolene suture. So here we’re gonna use what we call needleless recovery. The needles have been removed from the Gore-Tex suture, and it is looped through the positioning holes in the intraocular lens. We reach through sclerotomies that are 4 millimeters or 5 millimeters apart. 2.5 millimeters posterior to the limbus, using 2 microsurgical instruments in a hand to hand manner. And the continuous loop of the Gore-Tex suture is then — both sides brought out. The lens brought in through the incision. And then again making slipknots with gradual tensioning, the lens is centered in the posterior chamber. Now, this material is hydrophilic, and there have been reports of this lens turning opaque when subsequent gases put in the eye should be necessary either for corneal lamellar surgery, such as the DSAEK or DMEK, or if the patient needs gas for vitreoretinal surgery. There’s an iatrogenic hole in the iris. I’m trying to remove some of the lens material via the vitrector. And so that is being closed with a CIF-4 10-0 prolene suture. Now, this 10-0 prolene is fine for closing iris defects, but not the sewing to the sclera. And once that is tied, and the pupil looks round, then the surgery is completed. And now she has only one lens. And a microscissor is used to cut the 10-0 prolene suture. And here we are checking to make certain that the incision is watertight, using a drop for a Seidel test, and again using fibrin adhesive to close the conjunctival incision. Now, many people around the world are using a form of intrascleral fixation where the loop of a three-piece lens is brought out through a flap, and then through a Scharioth tunnel, the loop is passed into a scleral tunnel, and then the flap is closed with glue. The glue technique has been popularized by Amar Agarwal, but we’ve seen some issues with this technique in our office, and here you can see a loop that’s almost poking its way through the conjunctiva. So a more recent technique is the Yamane Flange Method, developed in Japan by Dr. Yamane. And here again, we’re marking the eye 180 degrees apart. And in this technique, we’re going to fixate an intraocular lens to the eye wall, a three-piece lens, and we’re going to heat the haptics to make a little flange, and then that flange is going to be placed in the scleral tissue itself and folding it by friction. So we mark 2 millimeters posterior, and then 2 millimeters inferior to the left side, and 2 millimeters superior to the right side. I’m placing trocars now, to do both vitrectomy and infuse the eye. It is necessary to remove enough vitreous so that when you place the lens, you’re not tugging on the vitreous face. Here the patient’s pupil is somewhat updrawn from congenital cataract surgery. This is a 21-year-old. You can see there’s some inferior capsule through which we could deport the lens. But we notice that there’s no superior capsule. So we want to fixate the lens symmetrically, so we will fixate it to the sclera. This is diluted triamcinolone that we’re using in order to do a vitrectomy and enable us to see where the vitreous is. It stains the vitreous. I’m testing now the paracentesis to make sure it’s at an angle with which I’m comfortable, in preparation for grasping the loops of the lens. And here I’m testing that these loops on this three-piece lens will fit into a special 30-gauge needle. So once I know that, I know that I can fixate this lens through that needle. So the lens is inserted, leaving one loop externally, and then passing this 20 degrees angle and 5 degrees posteriorly, it’s gonna have about a 2 millimeter intrascleral path. We see the needle. I reach in. And I take a microforceps, and then tuck that suture into the 30-gauge needle. And feed a good bit of it in. I then remove the syringe from the needle, and just ignore the needle, and then move to the fellow haptic. So now we have the distal haptic in the loop. So here I’m going back 2. I’m going to have a 20-degree angle toward the limbus. And 5-degree angle posteriorly. And then enter in through the pars plana, through the pupil. And now I’m going to bring the trailing haptic now into the special wide bore 30-gauge needle. And here we feed it in. And we’ve got it at an angle that works well. That’s why we checked the paracentesis. And then we bring these out of the eye. Whichever end comes out first should be held, grasped, and then cauterized. So here one comes out. We’re going to hold onto it. Leave the other one alone for the moment. Then we can pull the other one out, and we’ve got both of them free. And now we cauterize the end, make a little ball, and the lens of choice today is really the Zeiss lens that has PVDF or Kynar haptics. They tend to make a more… Or a larger mushroom to fit into the sclera. More robust. Now I’m just testing to make sure that that lens is nice and stable by pushing on it. And then I will try and remove that iris from that old superior incision from the congenital cataract. We can see the previous iridectomy is now in full view, and we’re going to remove the OVD from the chamber, and then suture the incision, if necessary. And so that’s the Yamane Flange Technique, which we use either for aphakia or a replacement lens. Setting pressure at physiologic levels, and then I like to do intraoperative Seidel testing on all incisions to make certain that they are watertight. Let’s talk about exchanging lenses. We’ve dealt mostly with malpositioned and loose lenses. Indications for lens exchange would be late malpositioned lens that wasn’t satisfactory in the first place or was in the wrong place. But we also have to deal with lenses that opacify, wrong power lenses, multifocal lenses where the patients fail to successfully neuroadapt, to dysphotopsias, UGH syndrome, and eyes that have tenderness to touch, typically from anterior chamber lenses. One of the skills that is necessary in order to remove and replace an intraocular lens is the ability to open the capsule bag. Let’s look at this patient. Five years before this picture was taken, the patient had routine cataract surgery. But at the time of surgery, a pilot error occurred, and the temporal loop of this lens did not get in the capsule bag. As a result, the inferior part of the lens was anterior to the capsule bag, while the superior part of the lens is in the confines of the capsule bag, as is the loop on the nasal side. Now, this is a very low power acrylic lens. Because it’s low power, it’s a meniscus design, and as a result, has a thick edge. And this thick edge here is sitting right directly against the iris, so you can see all of this iris transillumination. If you look carefully, you can see some blood here. This patient has had a chronic UGH syndrome, with multiple episodes of bleeding from iris chafing as a result of this exposed edge of this lens. Now, when we want to fix this problem, if we can reopen the capsule bag and tuck the loop and the lens back in the bag, we should be in fine stead. But if we can’t do that, we have to consider taking the lens out and putting a lens that’s kinder to the posterior iris than this acrylic lens with a thick, abrasive edge. So here we are at surgery. And notice you’ll see some blood moving around. That’s some bleeding inside the eye. We’re placing a dispersive visco agent. And the first thing I’ll do is place an agent under the IOL. And I notice this is not in the eye inferiorly, but is in the bag superiorly. So we’re using OVD to help dissect the bag open. And then we’re gonna take a Sinskey hook and just spin the one loop that’s in the bag outside of the bag, so the lens will now be in the sulcus. And now working under the lens, we’re gonna try and open up the capsule bag to 360 degrees, so we can place this lens back in the bag. Now, let me freeze this for a moment. Where a capsule is in contact with the IOL, you tend not to get firm adhesion. Where the capsule is in contact with capsule — particularly capsule edge — that’s where you can get a very, very firm fibrotic attachment. And the risks are that you could tear the anterior capsule, tear the posterior capsule, or tear the zonule. But if you were to carefully, slowly, diligently, with a good plan, you can have success. So let’s follow this through. So I’m trying now to open where the bag is fused together, where the lens is not in the bag. And I’m using OVD to try and make a tunnel, and then using a blunt spatula on one side. That’s on the nasal side. And now I’m gonna work on the temporal side. First some OVD to try and get into that space. And you’ll notice that when I try to manipulate that you’ll see the zonular fibers being stressed. So instead of stressing the zonular fibers, if we hold back the edge of the bag, which I’m doing here with a Sinskey hook, we can then use the spatula to lyse the adhesion, rather than lyse the zonular fibers. So here you can use any type of capsule support hook. But in this case, I’m using a Sinskey hook to hold back the capsule bag and not stress the zonular fibers, and even though it’s been five years since the surgery was done, one can still open the capsule bag using the appropriate blunt dissection, viscodissection, and also respecting the zonular fibers. And so now I am able to tuck both loops of the lens back in the bag, and in this fashion avoid any further damage to the inferior iris. As a matter of fact, this patient never had another episode of bleeding. And you see the lens is now inside the capsule bag. And we’re rotating it, just so it’s stable and centered. And the OVD is then removed. Single-piece acrylic lenses… Let me freeze this for a moment. Single-piece acrylic lenses are a little bit different to remove. You’ll notice in the previous one I rotated the lens in the plane of the capsule bag in a clockwise fashion, because that’s the way the loop is designed. If the loops were facing to the right instead of to the left, then we would rotate counterclockwise, but lenses are not designed that way. But single-piece lenses — it’s a little more tricky to get them out of the capsule bag, because the end bulb in the Alcon lenses tends to get a fibrous capsule, and on the AMO lenses, there’s a little elbow up here, which also will create a tension point, trying to get them out. So I use this. It’s a femtosecond laser spatula that we’re gonna use to separate the anterior capsule from the anterior surface of the lens, and then we’re gonna place some dispersive OVD. And these lenses — I tend to lift more toward the cornea, to break adhesions, rather than rotate them circumferentially. Here the lens is being elevated, and some OVD is being placed along the channel, the fibrotic channel. I’m using a microsurgical instrument to hold the loop, and then using a spatula to bluntly dissect down that channel that I’ve expanded with viscoelastic, and then it comes out. And the same thing here. A little traction, and blunt dissection will get the loop out of the channel. And then we can cut it, fold it, whatever our preference is to remove it. When we have a fibrotic anterior capsule, late after surgery, and want to remove the lens, then we have to deal with this anterior capsule. If you have a femtosecond laser available, there is a very, very nice technique here. You use a femtosecond laser to create a new anterior capsulotomy. My partner and I will soon publish a paper on this technique. And as we’ll see here, intraoperatively, once the femtosecond laser procedure has been completed, we can then remove that capsule with a microinstrument, and then remove the lens from the capsule bag, as we saw previously. So here’s that secondary anterior capsulotomy. Unfortunately, you can’t use a YAG laser to do this, because that causes relaxing incisions, and the problem with that is that they will tend to relax out to the periphery. Now, if we take a look at this patient here, six months postoperatively, we can see this is that secondary anterior capsulotomy, and a multifocal lens that has been replaced with a single-piece acrylic. Sometimes it’s better to cut the loop. Now, this is a Tecnis multifocal lens, and if you look carefully here, you’ll note that there’s a notch in this elbow, so to speak. And that made it extremely difficult to try to remove this from the capsule bag, and you have to pay strict attention to the zonular fibers to be certain that you don’t lyse them. So here I’m trying to get this up out of the bag and notice that I’m not having success. So what I instead do is: I will cut this loop, remove the optics, and then it makes it much easier to remove the loop from the capsule bag. So here again, despite all my attempts, I can’t get the elbow to get out of that fibrotic channel that is formed after surgery, despite my best efforts using blunt dissection. So now I’m going to expand the tunnel. I’m going to cut the loop. And then once I have removed the optic from the eye, and I have more room to work, I can reach into that capsule bag with a serrated microforceps, and then it’s just so much easier, then, to remove the loop. So sometimes it’s better to cut the lens and remove it in pieces. Here’s a case of a three-piece lens. Now, someone had written in a question about glistenings. This is a form of glistenings not that you see throughout the bulk of the optic, but this is immediately below the surface. It’s the same condition of trapped water vapor in the lens. And this is called SSNG or subsurface nanoglistenings. And the interesting thing is: In some directions of the light, the lens will look grayish-white, as here. But sometimes at different angles of the light, will actually look clear. Not many patients are as symptomatic as this woman. But this is a three-piece lens. And I encountered the same problem in trying to remove this three-piece lens, as the loops were stuck and we had to cut them. But let me just fast-forward through this, because I do want to show you an important aspect here. If you’re going to cut the loops of a three-piece lens, try to do it as flush to the optic as you can, so that — see, here I’m trying to peel it out. It won’t come out of the bag. If you leave long loops with sharp edges, they can damage the iris or damage the cornea. But if you just cut it as flush to the optic as you can, then you’re not going to run that risk. So they’re right on the optic-loop junction. And then this can be either folded or it can be cut, depending upon what you wish to do and what you wish to put back inside the eye. I want to leave enough time to talk about iris suture fixation. So let’s move forward. Now, we can sew the loops of the lens to the iris, and I prefer to do it today only in cases where we have capsule support. Otherwise it tends to be late decentration. But in the past I’ve used it for secondary implantation. But again, it’s very, very useful. It preserves conjunctiva. It’s closed chamber surgery. Again, you have to remove enough vitreous, so that when you’re managing the lens, you don’t sweep through the vitreous face. This is a patient who had a ruptured capsule, ruptured inferior zonule, and I captured the optic now. The optic anterior to the pupil, and the haptics posterior, in the posterior chamber. And I’m coming across the chamber with a 10-0 polyester suture. And we do the same thing on the opposite side. This is going to be the Siepser suture method, where we reach through a paracentesis. Now, unfortunately, 10-0 suture is difficult to see. But hopefully you have enough of a view. We’re gonna reach through and create a loop of suture, and make a three-throw loop here. One, two, and three. And then grab the free end of the suture and go across to the other side. So the knot has been made outside. Now, Amar Agarwal is now suggesting four loops, and that’s all you need. Most people make three, one, and one, having to reach into the eye again. I’m gonna demonstrate two types of iris suturing here. I tend to prefer Siepser suturing to close defects of the iris. This patient had a notch, unfortunately, in the iris, from vitrectomy surgery. So we come across a paracentesis with a 10-0 prolene or 10-0 polyester suture. We grab that needle and bring it out through a paracentesis. And now just as you saw in the previous eye, we’re gonna reach in with a microhook, or you can reach in with a microforceps. You can bring out a loop of suture material, and make your three throws, and then grab the free end and pull in this fashion. So that is the Siepser sliding knot technique. Extraordinarily useful. Some people prefer to sew loops as well as to sew iris to iris. I happen to prefer the McCannel technique. But this was a malpositioned anterior chamber lens that was stuck in a peripheral iridotomy. So we want to make our iridotomy mid-periphery, when dealing with anterior chamber lenses. And in order to prevent this from rotating back into that iridotomy, I’m going to use a McCannel suture to sew the loops even of an anterior chamber lens to the iris. So here we come through a paracentesis underneath the iris, underneath the loop, back out through the iris, and then come out through the cornea. So now we have both end inside the eye. We make a common paracentesis, and then bring both loops out through the common paracentesis and tie in a three, one, and one fashion, and that is the McCannel technique of sewing loops of the lens to the iris. When you generate the knot, the iris comes out through the knot. And there are modifications where we can actually slip this into the eye. Ike Ahmed has developed a technique that is referred to as the McAhmed, rather than the McCannel, because he slides it into the eye. So I want to look at one last situation, and then we’ll answer questions. I don’t know if you’re familiar with the Z syndrome, but I’m gonna ask you this. A Z syndrome is associated with which intraocular lens? Three-piece acrylic lens, one-piece acrylic lens, Artisan lens, Crystalens, or all of the above lenses? Z syndrome is associated with which intraocular lens? Three-piece acrylic, one-piece acrylic, Artisan, Crystalens, or all of the above? And I gather from your answers that many of you are not familiar with the Crystalens. The Crystalens is the only lens associated with the Z syndrome. It is a flexible plate haptic lens, designed to accommodate, but those plates of the lens may unfortunately flex asymmetrically, and the lens be double-angled, kind of in a — if you look in a cross section, look like the letter Z. So here we can see such a case. One is angled anteriorly, one angled posteriorly, and sometimes surgeons use the YAG laser to do extensive capsulotomies, to take the tension off of these flexible haptics, and the problem with that is you often allow vitreous to come around, and it often fails, and then you have to do a surgery here with vitreous in the chamber. And so again we’re gonna see a triamcinolone-assisted vitrectomy, because the lens is blocking any opportunity to reach into the pars plana. We’re gonna do an anterior vitrectomy. And these lenses have very firm adhesions to capsule, because they have a polyamide mustache-shaped haptic at the end of these plate halves. Now, silicone doesn’t fixate to capsule as well as acrylic. Or the polyamide material. So we have to cut these. And you can see that little bit of that polyamide material still inside the capsule bag. So this lens is cut. The haptics remain in the bag. The lens is then bisected. And brought out through a 3-millimeter incision. And this can be replaced by a 3-piece lens. My preference is to put a 3-piece silicone lens in the posterior chamber, and suture-fixate the loops to the eye wall. So this is the LI61 lens, going into the ciliary sulcus above the capsule bag, and then the loops will be fixated by sutures to the iris. Now, one of the problems of iris suture fixation is ovalization of the pupil. And I’ll show you a little trick before we move on to answering your question. So here again you’re going to see this is the McCannel suture technique through a paracentesis under the iris, under the loop of the lens. Brought out through a common paracentesis. The suture is then tied in a three, one, and one fashion, and then the optic is prolapsed into the posterior chamber. But notice that we have a cat’s eye. So we’re gonna try and take some of this iris that got captured by the suture, and use a microforceps to kind of tease those fibers out of that suture pathway. And it doesn’t loosen the lens suture. It just gets some of the iris material out, and then the OVD can be removed with the vitrector. I prefer the vitrector, just in case any vitreous has remained, and move forward. So I’d like to finish with — I saw there was one question. And let’s see if we can open up that question. Can we bring up that question? Or that box that enables me to see that? There it is. Okay. So I notice here: Which are your criteria for using one type of suture or the other? And I think that’s an excellent question. If I’m going to fixate to the sclera, my preference is really the use of Gore-Tex suture. Well, 9-0 polypropylene is also very strong. Its ends tend to erode through scleral pockets, and I think long-term there are more concerns about it. I think that Gore-Tex is much easier to work with, and so long as you bury the knots, I think it’s very, very safe. So for sewing to the sclera, I’m going to prefer Gore-Tex. For the iris, I only like 10-0. If you’re gonna work with 9-0 to the iris, it tends to be a little bit brittle, and that would be 9-0 prolene. It would tend to be a little bit brittle, and causes too much cheese wiring. So my preference is to use 10-0 prolene on the iris and 8-0 Gore-Tex on the sclera. I am happy to take any questions. If anyone has any questions for me. We have reached 8:00 here on the West Coast in Los Angeles. And I think that completes our evening. Are there more questions I haven’t answered? Yes, we can use Gore-Tex in children, and yes, we can use Hoffman pocket. So I think we answered all those questions. Are there further questions? If not, I hope this has been of interest and benefit to you in your daily practices. The nature of our practice is that we manage many patients with malpositioned, malfunctioning IOLs, and should any of you want to visit us in Los Angeles, feel free to do so.

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June 6, 2018

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