IOL Subluxation Top 5 Pearls for Management David G. Hwang, MD, FACS Professor and Vice Chair Kimura Endowed Chair in Ophthalmology Director, Cornea Service and Refractive Surgery Services University of California, San Francisco December 2016 Hwang/UCSF Disclosure Shire – Consultant Not relevant to this talk. I have no proprietary interest in any devices, drugs, or techniques discussed. Hwang/UCSF Hwang/UCSF 1
#1 – Dynamic Examination • Examine in different gaze positions • Examine sitting, supine, face forward • Portable slit lamp helpful Hwang/UCSF Hwang/UCSF #1 – Dynamic Examination • Anatomy of IOL-bag complex – IOL type; CTR? – Haptic type and location – Capsule and rhexis anatomy – Cortical material, PXF? – IOL relation to bag – Stability vs mobility Hwang/UCSF Hwang/UCSF 2
Hwang/UCSF Hwang/UCSF Hwang/UCSF Hwang/UCSF 3
#2 – Posterior Approach Needed? #2 – Posterior Approach Needed? • At risk for posterior dislocation intraop? • Posterior approach – Highly mobile IOL – Dissect vitreous adhesions – Vitrectomized status – Retrieve lens if falls posteriorly • At risk for retinal tear/detachment? – Place instruments via posterior sclerotomy – Haptic caught in vitreous base (forceps, endoscope) Lim MCC. JCRS 2006;32:533-535 – High myopia, history of tear/detachment Hwang/UCSF Hwang/UCSF #3 – Refixation vs Exchange #3 – Refixation vs Exchange • 3-piece vs 1-piece PCIOL • 1-piece acrylic – Sulcus not an option (Chang DF, 2009) – In-bag sulcus fixation – Explant/exchange Hwang/UCSF Hwang/UCSF 4
#3 – Refixation vs Exchange #4 – 3-piece lens options • 3-piece • < 4 clock hours capsule remnant – Pupil capture of optic – Sulcus, bag, sulcus/bag capture – Midperipheral haptic fixation to iris – McCannel fixation • McCannel suture or Siepser slip knot – In-bag sulcus • Consider 3 rd or 4 th suture to supplement suture fixation classical 2-point fixation – Explant/exchange Hwang/UCSF Hwang/UCSF Optic Elevation and Stabilization Supplemental McCannel Suture • Elevation of IOL into pupil plane • Pupil capture to support optic • Straight needle to support optic – Translimbal 9-0 Prolene needle Hwang/UCSF Daoud Y , Stark WJ. ASCRS Eyeworld 2011 Hwang/UCSF 5
Translimbal 9-0 Prolene Needle Supplemental McCannel Suture Hwang DG Hwang/UCSF Daoud Y , Stark WJ. ASCRS Eyeworld 2011 Hwang/UCSF Supplemental McCannel Suture Supplemental McCannel Suture Daoud Y , Stark WJ. ASCRS Eyeworld 2011 Hwang/UCSF Daoud Y , Stark WJ. ASCRS Eyeworld 2011 Hwang/UCSF 6
Supplemental McCannel Suture Supplemental McCannel Suture Daoud Y , Stark WJ. ASCRS Eyeworld 2011 Hwang/UCSF Daoud Y , Stark WJ. ASCRS Eyeworld 2011 Hwang/UCSF #4 – 3-piece lens options Sulcus + Iris Transfixation • ≥ 4 clock hours capsule remnant – Viscodissect sulcus space – Retract iris, use light pipe – Place haptic where ≥ 4 clock hours capsule – Iris transfixation to one or both haptics Hwang/UCSF Hwang/UCSF 7
#5 – One-piece IOL Management One-piece Acrylic IOL • One-piece acrylic • If subluxated relative to capsular bag – Bulky haptics – Explant and exchange – Co-planar • One-piece PMMA – Haptic manipulation can result in breakage Hwang/UCSF Hwang/UCSF One-piece Acrylic IOL Transscleral Bag Fixation • If centered in capsular bag – Explant and exchange – In situ fixation • Transscleral capsule fixation (esp. if CTR present) • Iris fixation of anterior capsule with peripheral iridectomy Hoffman RS. ASCRS Eye World 2010. Hwang/UCSF Hwang/UCSF 8
Hoffman Pocket Technique Hoffman Pocket Technique Hoffman RS. JCRS 2006;32:1907-1912 Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF Hwang/UCSF Hoffman Pocket Technique Hoffman Pocket Technique Hoffman RS. JCRS 2006;32:1907-1912 Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF Hwang/UCSF 9
Hoffman Pocket Technique Hoffman Pocket Technique Hoffman RS. JCRS 2006;32:1907-1912 Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF Hwang/UCSF #5 – Refixation of Scleral- Ab Externo Double-back Technique to Resuture Haptic Sutured PCIOL (Broken Suture) • One-piece PMMA w/ haptic eyelets • Straight 9-0 Prolene needle • Spontaneous lysis of 10-0 Prolene • Thread through eyelet • Restores fixation back to original Hwang/UCSF Hwang/UCSF 10
Refixation of Subluxated Refixation of Subluxated Transsclerally Sutured PCIOL Transsclerally Sutured PCIOL Hwang DG, Lin CT Hwang DG, Lin CT Hwang/UCSF Hwang/UCSF Refixation of Subluxated Refixation of Subluxated Transsclerally Sutured PCIOL Transsclerally Sutured PCIOL Hwang DG, Lin CT Hwang DG, Lin CT Hwang/UCSF Hwang/UCSF 11
Refixation of Subluxated Refixation of Subluxated Transsclerally Sutured PCIOL Transsclerally Sutured PCIOL Hwang DG, Lin CT Hwang DG, Lin CT Hwang/UCSF Hwang/UCSF Refixation of Subluxated Transsclerally Sutured PCIOL Hwang DG, Lin CT Hwang/UCSF Hwang/UCSF 12
5 Pearls for IOL Subluxation 1. Dynamic examination of IOL-capsule 2. Is a posterior approach appropriate? Questions? 3. Refixation or exchange? david.hwang@ucsf.edu 4. Management of 3-piece lenses 5. Management of 1-piece lenses Hwang/UCSF Hwang/UCSF Thank You Hwang/UCSF Hwang/UCSF 13
IOL Style Important IOL Style Important Hwang/UCSF Hwang/UCSF Transscleral Bag Fixation Transscleral Bag Fixation Ahmed IK. Ophthalmology 2005;112:1725-1733. Ahmed IK. Ophthalmology 2005;112:1725-1733. Hwang/UCSF Hwang/UCSF 14
Transscleral Bag Fixation Transscleral Bag Fixation Ahmed IK. Ophthalmology 2005;112:1725-1733. Ahmed IK. Ophthalmology 2005;112:1725-1733. Hwang/UCSF Hwang/UCSF Transscleral Bag Fixation Transscleral Bag Fixation Ahmed IK. Ophthalmology 2005;112:1725-1733. Ahmed IK. Ophthalmology 2005;112:1725-1733. Hwang/UCSF Hwang/UCSF 15
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