IOL Subluxation Top 5 Pearls for Management David G. Hwang, MD, - - PowerPoint PPT Presentation

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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

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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

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Disclosure

Shire – Consultant Not relevant to this talk. I have no proprietary interest in any devices, drugs, or techniques discussed.

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#1 – Dynamic Examination

Examine in different gaze positions
Examine sitting, supine, face forward
Portable slit lamp helpful

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#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

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#2 – Posterior Approach Needed?

At risk for posterior dislocation intraop?

– Highly mobile IOL – Vitrectomized status

At risk for retinal tear/detachment?

– Haptic caught in vitreous base – High myopia, history of tear/detachment

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#2 – Posterior Approach Needed?

Posterior approach

– Dissect vitreous adhesions – Retrieve lens if falls posteriorly – Place instruments via posterior sclerotomy (forceps, endoscope)

Lim MCC. JCRS 2006;32:533-535 Hwang/UCSF

#3 – Refixation vs Exchange

3-piece vs 1-piece PCIOL

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#3 – Refixation vs Exchange

1-piece acrylic

– Sulcus not an option (Chang DF, 2009) – In-bag sulcus fixation – Explant/exchange

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#3 – Refixation vs Exchange

3-piece

– Sulcus, bag, sulcus/bag capture – McCannel fixation – In-bag sulcus suture fixation – Explant/exchange

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#4 – 3-piece lens options

< 4 clock hours capsule remnant

– Pupil capture of optic – Midperipheral haptic fixation to iris

McCannel suture or Siepser slip knot
Consider 3rd or 4th suture to supplement

classical 2-point fixation

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Optic Elevation and Stabilization

Elevation of IOL into pupil plane
Pupil capture to support optic
Straight needle to support optic

– Translimbal 9-0 Prolene needle

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Supplemental McCannel Suture

Daoud Y , Stark WJ. ASCRS Eyeworld 2011

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Translimbal 9-0 Prolene Needle

Hwang DG

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Supplemental McCannel Suture

Daoud Y , Stark WJ. ASCRS Eyeworld 2011

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Supplemental McCannel Suture

Daoud Y , Stark WJ. ASCRS Eyeworld 2011

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Supplemental McCannel Suture

Daoud Y , Stark WJ. ASCRS Eyeworld 2011

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Supplemental McCannel Suture

Daoud Y , Stark WJ. ASCRS Eyeworld 2011

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Supplemental McCannel Suture

Daoud Y , Stark WJ. ASCRS Eyeworld 2011

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#4 – 3-piece lens options

≥ 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

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Sulcus + Iris Transfixation

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#5 – One-piece IOL Management

One-piece acrylic

– Bulky haptics – Co-planar

One-piece PMMA

– Haptic manipulation can result in breakage

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One-piece Acrylic IOL

If subluxated relative to capsular bag

– Explant and exchange

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One-piece Acrylic IOL

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

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Transscleral Bag Fixation

Hoffman RS. ASCRS Eye World 2010.

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Hoffman Pocket Technique

Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF

Hoffman Pocket Technique

Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF

Hoffman Pocket Technique

Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF

Hoffman Pocket Technique

Hoffman RS. JCRS 2006;32:1907-1912

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Hoffman Pocket Technique

Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF

Hoffman Pocket Technique

Hoffman RS. JCRS 2006;32:1907-1912 Hwang/UCSF

#5 – Refixation of Scleral- Sutured PCIOL (Broken Suture)

One-piece PMMA w/ haptic eyelets
Spontaneous lysis of 10-0 Prolene

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Ab Externo Double-back Technique to Resuture Haptic

Straight 9-0 Prolene needle
Thread through eyelet
Restores fixation back to original

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Refixation of Subluxated Transsclerally Sutured PCIOL

Hwang DG, Lin CT Hwang/UCSF

Refixation of Subluxated Transsclerally Sutured PCIOL

Hwang DG, Lin CT Hwang/UCSF

Refixation of Subluxated Transsclerally Sutured PCIOL

Hwang DG, Lin CT Hwang/UCSF

Refixation of Subluxated Transsclerally Sutured PCIOL

Hwang DG, Lin CT

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Refixation of Subluxated Transsclerally Sutured PCIOL

Hwang DG, Lin CT Hwang/UCSF

Refixation of Subluxated Transsclerally Sutured PCIOL

Hwang DG, Lin CT Hwang/UCSF

Refixation of Subluxated Transsclerally Sutured PCIOL

Hwang DG, Lin CT Hwang/UCSF

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5 Pearls for IOL Subluxation

1. Dynamic examination of IOL-capsule
2. Is a posterior approach appropriate?
3. Refixation or exchange?
4. Management of 3-piece lenses
5. Management of 1-piece lenses

Questions? david.hwang@ucsf.edu

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Thank You

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IOL Style Important

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IOL Style Important

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Transscleral Bag Fixation

Ahmed IK. Ophthalmology 2005;112:1725-1733. Hwang/UCSF

Transscleral Bag Fixation

Ahmed IK. Ophthalmology 2005;112:1725-1733.

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Transscleral Bag Fixation

Ahmed IK. Ophthalmology 2005;112:1725-1733. Hwang/UCSF

Transscleral Bag Fixation

Ahmed IK. Ophthalmology 2005;112:1725-1733. Hwang/UCSF

Transscleral Bag Fixation

Ahmed IK. Ophthalmology 2005;112:1725-1733. Hwang/UCSF

Transscleral Bag Fixation

Ahmed IK. Ophthalmology 2005;112:1725-1733.