William E. Smiddy,
Harry W. Flynn Jr.
RETAINED LENS FRAGMENTS
Lens fragments may fall into the vitreous cavity during lens removal due to zonular dehiscence or posterior capsule rupture during lens removal. It is usually imperative to remove retained lens material (especially the nucleus) because it typically incites an inflammatory response. The estimated incidence of posteriorly displaced lens fragments is 0.3%, but is higher while surgeons are learning phacoemulsification.[1,2] The displaced lens fragments may involve the entire lens or any fraction of it. Once posterior capsule rupture occurs, the surgeon must proceed with extreme caution. One option is to use a limbal approach or convert to a larger incision to retrieve displaced lens fragments, using a lens loop or forceps before the nuclear fragment migrates posteriorly. If the fragment falls into the midvitreous, there is a high chance of further complication if limbal retrieval attempts are continued. Some surgeons advocate vigorous attempts at retrieving the lost lens nucleus from the limbal cataract incision by probing posteriorly with a lens loop or other instrumentation or by using high volumes of infusion fluid to create vortex currents to float the lens fragment anteriorly.[3] Such maneuvers have been associated with inducing giant retinal tears which have a poor prognosis for visual acuity.[4] Anterior vitrectomy, as needed, to clear the limbal wound of vitreous and permit intraocular lens (IOL) insertion if adequate capsular support exist is a more common approach.[5] Capsulorhexis techniques usually result in the peripheral anterior capsule largely intact, so sulcus fixation of the IOL is often possible. Defiitive care of the displaced lens remnants can be rendered using pars plana vitrectomy techniques.
CLINICAL FEATURES
Posterior displacement of lens fragments is usually recognized intraoperatively. Occasionally, patients present with retained lens fragments manifesting as chronic intraocular inflammation and no visible fragments in the posterior pole. The degree of intraocular inflammation is generally dependent upon the size of the retained lens fragment, whether it is nuclear or cortical in nature, the time since cataract surgery, the individual's inflammatory response, and the extent of other intraocular manipulations. Associated clinical signs including corneal edema, glaucoma, uveitis, and vitreous opacities frequently improve, at least temporarily, in the immediate postoperative interval. However, eyes with more severe inflammation may lead to other complications such as retinal detachment causing profound visual loss.[6,7]
SURGICAL TECHNIQUES
A variety of techniques have been described for use by the anterior segment surgeon at the time of lens fragment loss. Although some cases may be satisfactorily managed through a limbal incision, pars plana vitrectomy techniques allow removal of formed vitreous in a closed system and better retrieval of all lens fragments in most cases.[8-12,16-19] Three basic surgical techniques for lens fragment removal using a pars plana approach are (1) ultrasonic fragmentation, (2) mechanical crushing of the nucleus between two instruments, and (3) limbal extraction of hard nuclear fragments. The availability of modern phacofragmentation generally precludes the need for the latter two techniques.
There are four key elements in safe and effective lens fragment removal. First, adequate initial vitrectomy avoids unintended vitreous traction during phacofragmentation (Fig. 186.1). Second, reducing fragmentation power (to as low as 5% or 10% of maximum for smaller fragments) allows more efficient extraction by continuous occlusion of the suction port. This minimizes the risk of mechanical retinal trauma from projectile fragments although these fragments rarely strike the retina with sufficient force to damage it. Third, fragments should be cautiously aspirated from the retinal surface and moved to the midvitreous before activating ultrasonic fragmentation to avoid suction or ultrasonic damage to the retina (Fig. 186.2). A fourth element that might minimize postoperative retinal detachment is inducing a posterior vitreous detachment if one does not already exist. Frequently one already exists, or develops spontaneously as the surgery proceeds.
|
|
|
|
FIGURE 186.1 Attention to complete central vitrectomy allows access to retained lens fragments. |
|
|
|
|
FIGURE 186.2 Low ultrasonic fragmentation power allows more controlled removal of fragments. |
The use of perfluorocarbon liquids to float the nucleus anteriorly to facilitate removal has been described,[20,21] but is not routinely necessary. Techniques for reattaching the retina when associated with retained lens fragments are similar to those for other complex retinal detachments,[22,23] but perfluorocarbon liquids may be useful in selected cases.[24]
Recommendations to the anterior segment surgeon is to clear the wound of vitreous, place the IOL in the posterior chamber if there is sufficient capsular support, to use suture fixation techniques[5,25-36] as indicated if support is insufficient, or to place an anterior chamber IOL (AC/IOL) and to close the limbal wound in the usual fashion. If the cataract surgeon is reluctant to insert the IOL primarily, it may be inserted at the time of the subsequent vitrectomy. Various maneuvers have been introduced to facilitate IOL placement, including the use of a mirror[37] or transillumination[38] to position the suture in the ciliary sulcus. Scleral suture fixation techniques for posterior chamber IOL (PC/IOL) placement may increase the risk of retinal detachment,[39,40] and transscleral sutures may offer a conduit for late postoperative endophthalmitis[41] (although techniques that allow burying the knot or covering it[42] may obviate this concern), and cystoid macular edema (CME).[43] AC/IOL insertion in other settings has been found to be at least as successful as sutured PC/IOLs[35,44] and is a viable option in the absence of sufficient posterior capsular support. One series reported a higher rate of at least 20/40 fial vision (80%) in eyes with PC/IOLs compared with those with AC/IOLs (62%),[12] but most other series have not reported a difference.
OUTCOMES AFTER VITRECTOMY
The visual results of managing such cases are generally good (Table 186.1).[8-12,16-19,45-48] Postoperative visual acuity of 20/40 or better has been achieved in the majority of patients in many series. The earliest series report only a 41% rate of 20/60 or better,[6] but the most recent series report 60-82% rates of 20/40 or better.[9-12,16-21,45-48] This apparent improvement may reflect changing patterns of cataract surgery technique, since a poorer prognosis has been suggested with a dropped lens nucleus when extracapsular cataract extraction techniques are used compared with phacoemulsification.[8]
TABLE 186.1 -- Outcomes of Vitrectomy for Retained Lens Fragments
|
IOP = 30 mm Hg (%) |
|||||
|
Series |
# Patients |
VA = 20/40 (%) |
Before PPV |
After PPV |
Better VA with earlier PPV |
|
Fastenberg[18] |
11 |
82 |
69 |
27 |
|
|
Gilliland et al[11] |
56 |
50 |
52 |
25 |
No |
|
Lambrou and Steward[17] |
8 |
88 |
|||
|
Kim et al[12] |
62 |
68 |
46 |
13 |
No |
|
Hutton et al[16] |
24 |
42 |
- |
33 |
Yes |
|
Blodi et al[8] |
32 |
41[?] |
30 |
31 |
Yes |
|
Borne et al[10] |
121 |
68 |
32 |
11 |
No |
|
Kapusta et al[19] |
25 |
71 |
60[?] |
No |
|
|
Vilar et al[9] |
126 |
60 |
37 |
3 |
No |
|
Margherio et al[46] |
126 |
44 |
52 |
25 |
6 |
|
Al-Khaier et al[47] |
89 |
69 |
35 |
17 |
17 |
|
Hanssen and Larsson[48] |
66 |
53 |
NA |
18 |
11 |
|
Scott et al[45][*] |
343 |
56 |
25 |
2 |
13 |
|
Smiddy et al[51] |
100 |
53 |
No |
||
|
Abbreviations: IOP, intraocular pressure; PPV, pars plana vitrectomy; VA, visual acuity; NA, not available. |
|
* |
Better prognosis with surgical intervention before 3 weeks. |
|
? |
?20/60. |
|
? |
?25 mm Hg. |
Postoperative complications related to vitrectomy surgery may be difficult to differentiate from those attributable to complicated cataract surgery and may include corneal edema, glaucoma, persistent intraocular inflammation, and new retinal detachment.[49] Retinal detachment coexisted with retained lens material in 5.8% of reported series, and retinal detachment has been reported after vitrectomy for removal of retained lens fragments in 6.5% of reported series (Table 186.2). The incidence of associated postoperative retinal detachment is decreasing,[50] however, and this might be due to improved surgical techniques as outlined above or relaxed indications for surgical intervention.[51] Thus, it is of critical importance to evaluate the retina throughout the perioperative course in such patients. One author suggested prophylactic scleral buckle in patients undergoing vitrectomy for retained lens fragments,[52] but we do not suggest this because greater than 80% of eyes would be operated on needlessly.
TABLE 186.2 -- Incidence of Retinal Detachment Occurring Before and After Vitrectomy for Removal of Retained Lens Fragments
|
Series |
Initial Co-Existing RD |
RD After Vitrectomy |
Combined |
|
Hutton et al[16] |
5/26 (19%) |
5/26 (19%) |
10/26 (38%) |
|
Fastenberg et al[18] |
3/13 (23%) |
2/11 (18%) |
5/11 (45%) |
|
Blodi et al[8] |
4/36 (11%) |
3/32 (9%) |
7/36 (19%) |
|
Gilliland et al[11] |
4/56 (7%) |
4/56 (7%) |
8/56 (14%) |
|
Kim et al[12] |
2/57 (3.5%) |
2/57 (3.5%) |
4/57 (7%) |
|
Borne et al[10] |
8/121 (6.6%) |
11/121 (9.1%) |
19/121 (16%) |
|
Vilar et al[9] |
11/126 (8.7%) |
11/126 (8.7%) |
22/126 (17.5%) |
|
Kapusta et al[19] |
0/25 (10%) |
0/25 (10%) |
0/25 (10%) |
|
Margherio et al[46] |
NA |
NA |
20/126 (15.9%) |
|
Hansson and Larsson[48] |
2/66 (3%) |
5/66 (8.0%) |
7/66 (11%) |
|
Scott et al[45] |
25/343 (7.3%) |
19/343 (5.5%) |
44/343 (12.8%) |
|
Smiddy et al[51] |
4/100 (4.0%) |
4/100 (4.0%) |
8/100 (8.0%) |
|
Totals |
55/943 (5.8%) |
61/943 (6.5%) |
144/1009 (13.52%) |
|
Abbreviation: RD, retinal detachment. |
Increased IOP is associated with retained lens fragments in 30-69% of series, but in only 3-31% after vitrectomy and removal of the retained fragments (see Table 186.1).
SUMMARY
Recommendations to the anterior segment surgeon experiencing the complication of posterior dislocation of lens fragments include:
|
1. |
Attempt lens fragment retrieval only if fragment is readily accessible. |
|
|
2. |
Perform anterior vitrectomy as necessary to avoid anterior vitreous prolapse into the limbal wound. |
|
|
3. |
If possible, insert PC/IOL using residual posterior capsule or AC/IOL, as merited by the situation. |
|
|
4. |
Close the cataract wound in a standard fashion and remove viscoelastic. |
|
|
5. |
Prescribe frequent postoperative topical antiinflammatory treatment and IOP-reducing agents. |
|
|
6. |
Refer the patient for vitreoretinal consultation within a few days for initial evaluation. |
If the opportunity exists for the vitrectomy and retrieval of displaced lens fragments to be performed at the same operation, this treatment is ideal.
Recommendations for the vitreoretinal surgeon managing a typical case include:
|
1. |
Consider initial observation for eyes with minimal inflammation if lens fragment is small. |
|
|
2. |
Continue or initiate topical anti-inflammatory and antiglaucoma agents. |
|
|
3. |
Surgically intervene if inflammation or IOP is not controlled, or if the fragment is estimated to represent 25% or less of the original nucleus. |
|
|
4. |
Delay surgery as necessary to allow for an initial treatment of postoperative inflammation and to allow clearing of corneal edema. |
|
|
5. |
Perform adequate core vitrectomy before attempting phacofragmentation. |
|
|
6. |
Use low fragmentation power settings (5-10%) for more efficient removal of small fragments. |
|
|
7. |
Induce or complete posterior vitreous detachment introperatively. |
|
|
8. |
Be prepared for secondary IOL insertion in aphakic eyes. |
|
|
9. |
Examine peripheral retina for possible retinal tear or detachment. |
IOL DISLOCATION
Inadequate posterior capsular support from capsular or zonular rupture is usually the basis of IOL dislocation. Postoperative decentration of PC/IOLs is more common, occurring in 0.2-1.2% of cases and usually does not require treatment.[53,54]
CLINICAL CHARACTERISTICS
The clinical presentations of dislocated IOLs range from asymptomatic lens decentration to complete luxation into the vitreous cavity.[54] The presenting visual acuity with aphakic correction may be very good, but is commonly decreased to a moderate degree despite best spectacle correction. Decentration usually refers to mild malposition with the optic still covering more than half of the pupillary space. In many cases of decentration, one haptic is in the ciliary sulcus and the other is in the capsular bag. Progressive decentration may become apparent with progressive capsular fibrosis. Patients at this, the milder, end of the spectrum, usually present several weeks after cataract extraction with good visual acuity, with normal IOP, and without inflammation. Visual symptoms usually are mild and may be related to glare from the edge of the optic. Minor decentration may be more commonly symptomatic with the smaller IOLs. The terms luxation and subluxation are frequently used interchangeably but, technically, are different. A luxated IOL is dislocated completely into the vitreous cavity and often is mobile, whereas a subluxated IOL remains visible at the slit lamp and is at least partially attached to anterior structures. Patients with luxated or subluxated PC/IOLs are usually symptomatic because of the variable position of the optic in the visual axis. In addition, a mobile PC/IOL may also generate unique floater-like symptoms or even lead to pupillary-block glaucoma.
The advent of foldable IOLs has changed the presentation and management of such patients, although not drastically.[55] Silicone plate haptic IOLs have been redesigned with larger positioning holes in an attempt to allow more stabilizing fibrosis.[56] Dislocation may be apparent intraoperatively or within the first few days or weeks as a result of unknowingly placing the IOL through a posterior capsular defect onto the anterior hyaloid, or spontaneous IOL haptic rotation out of a zone of thin posterior capsule remnants. PC/IOLs completely dislocated into the vitreous cavity are typically diagnosed within the first week after surgery (26 of 32 cases in one series[57]); less commonly, they occur many months after surgery. Late dislocation is less common and may be due to traumatic[57] or spontaneous loss of zonular support, such as in eyes with pseudoexfoliation syndrome.[58,59] A presentation that is characteristic of foldable IOLs is dislocation following YAG capsulotomy[60]; this may be due to release of tension from progressive capsular fibrosis.
Various reports have detailed IOL fixation options with suboptimal posterior capsular support.[25-36] A multiplicity of techniques have been proposed for treating such cases and are reviewed later.[61-67]
MANAGEMENT OPTIONS
There are three general categories of management options for dislocated IOLs: observation, IOL removal with or without IOL exchange, and IOL repositioning.[61-67] The management plan and timing are formulated based on clinical factors such as the type of IOL and any observed secondary complications.
Relatively clear indications for surgical intervention include: substantial intraocular inflammation, retinal detachment, or CME, especially when associated with vitreous to the cataract wound or iris. Although a completely dislocated IOL may be well tolerated in many patients, the difficulties in visual rehabilitation usually necessitate surgical intervention. Subluxated IOLs may be operated via a limbal or a pars plana approach. Patients with less extensive subluxation can be managed through a limbal incision with minimal or no anterior vitrectomy if the posterior capsule is largely intact. However, if there is a large posterior capsular rent, vitrectomy using a pars plana approach may offer optimal control to achieve the goals of surgery and address intraoperative complications.
OBSERVATION
IOLs with simple decentration are usually managed by observation. Observation may also be recommended even for luxation if other superceding medical or ocular problems prohibit further surgery. Occasionally, management with topical miotics can reduce symptoms, especially for minor subluxations. In a series of 15 patients with dislocated anterior chamber or iris plane IOLs that were observed, a visual acuity of 20/40 or better was reported in 60%, but retinal detachment occurred in two patients.[61] Like other eyes with posterior capsular rupture, eyes with IOL subluxation may be associated with an increased incidence of CME, whether or not there is vitreous incarceration anteriorly. A prolonged delay in therapy for CME may limit ultimate visual rehabilitation.
REMOVAL OR EXCHANGE
The IOL is usually removed when there is damage to the IOL (e.g., broken haptic), if available instrumentation to effect repositioning is lacking, or if highly flexible lens styles make the IOL unsuitable for sulcus fixation.
IOL exchange is commonly considered for certain silicone IOLs.[68] Silicone IOLs are slippery and more difficult to grasp than polymethyl methacrylate IOLs, but they can usually be engaged and elevated from the retinal surface with a vitreoretinal pick or a lighted pick or the suction force of a fragmatome[69] or sutures.[70] Serrated or diamond-dusted forceps may be necessary, but care should be exercised to avoid scratching the center of the optic if the IOL is to be repositioned. Although silicone plate haptic IOLs are extremely floppy and difficult to manipulate, and the dimension of the IOL is designed for capsular fixation, it can usually be satisfactorily repositioned onto the anterior capsular remnants.[71] Various techniques have been reported to remove the IOL more safely; replacement with an AC/IOL has been advocated for both its technical simplicity and its proven effectiveness.[72-76] In fact, IOL exchange is increasingly performed for indications other than dislocation.[70] However, explanting and reimplanting an IOL may risk more corneal endothelial cell trauma compared with repositioning techniques. Exchange for an AC/IOL may be less traumatic to the corneal endothelium and may be easier and faster to accomplish. Newer AC/IOL designs reportedly avoid complications caused by the mechanical side effects of earlier AC/IOL designs compared with PC/IOLs, but the results can presumably be extrapolated to dislocated IOL management.[77] In general, scleral suture fixation with a PC/IOL is preferred by the authors over AC/IOL implantation. However, the possibility of either PC/IOL or AC/IOL implantation should be anticipated with proper IOL power calculations before surgery.
A less commonly used option is implantation of a second IOL for visual rehabilitation (usually AC/IOL) without removal of the dislocated IOL.[78-80] This is usually not the preferred option because of potential future complications from the dislocated IOL.
REPOSITIONING
IOL repositioning completes the initial surgical objectives of the cataract surgery and is the most commonly elected surgical approach. Generally, implantation or repositioning can be accomplished without scleral suturing when at least 180 degrees of peripheral capsular material is intact. More extensive support is necessary, however, when the capsule is absent inferiorly or if the residual rim of capsule where IOL haptics are to be placed is too narrow. There are three basic approaches to IOL repositioning: (1) IOL repositioning without sutures using residual peripheral anterior or posterior capsule, (2) iris suture fixation, and (3) scleral suture fixation.
Subluxated IOLs associated with a mostly intact posterior capsule may be repositioned from an anterior approach if there is only moderate subluxation of the IOL. A pars plana approach is optimal for patients with large posterior capsule defects, for patients with IOL luxation into the vitreous cavity, and for patients with coexisting ocular complications such as retinal detachment. Good visibility and exact haptic placement are also vital to secure haptic placement during repositioning attempts.
Repositioning by capsular fixation is the most common management technique in reported series[62,67] and is the authors' first choice when technically possible. Surgical success depends on accurate placement of the haptics into the ciliary sulcus, which requires visualization of the residual capsule.[81,82] Iris hooks may be useful in selected cases to assess or utilize a residual anterior capsular rim in eyes with insufficient pupillary dilatation; usually strategic local iris retraction with a hooked instrument allows adequate visualization. A useful maneuver is to bring the IOL anteriorly and capture at least one haptic anterior to the iris (Fig. 186.3). After the IOL is stabilized in the anterior chamber, the second haptic can be guided between the residual capsule and the posterior iris surface either by rotating the lens or with an intraocular forcep via the pars plana. There are many techniques to achieve this.[83] Foldable IOLs designed for capsular fixation can be effectively repositioned into the ciliary sulcus[55,84]; long-term follow-up has demonstrated the safety os this option.[85] Repositioning a PC/IOL permanently into the anterior chamber also has been reported, but chronic chafig of the iris by the IOL and lens power considerations may be limiting factors,[86] and it is probably best reserved for exceptional cases.[87] However, this strategy is not recommendable for silicone plate haptic IOLs.[88]
|
|
|
|
FIGURE 186.3 When repositioning a PC/IOL onto residual capsular remnants, it may be useful to bring one haptic anterior to the iris to facilitate accurate visualization of haptic placement over the residual capsule. |
Iris fixation sutures were initially described for the use of dislocated AC/IOLs.[89] However, their use has been modified for fixation of dislocated PC/IOLs using a limbal or a pars plana approach.[81,90,91]Concern regarding iris-mediated chronic inflammation and the technical difficulty encountered during suture placement have led to the development of other techniques. This technique may be better suited for use in conjunction with penetrating keratoplasty ('open sky').
Scleral fixation sutures were first introduced for implantation of secondary IOLs and for primary IOL placement in the absence of satisfactory peripheral capsular support from a limbal or pars plana approach.[25-34] Early reports described pulling the haptic externally through a sclerotomy to tie a suture to a haptic before anchoring it to the deep part of the sclerotomy wound.[92-94] Subsequently, IOL repositioning using transscleral fixation sutures, via a pars plana approach mimicking the techniques of secondary IOL fixation, was described.[64] Numerous innovative modifications have made the technique technically easier and safer. Components common to all scleral suture fixation techniques include (1) retrieving of the IOL, (2) introducing a suture loop through the ciliary sulcus region into the vitreous cavity, (3) passing the suture loop around the IOL haptic, and (4) securing the suture to the sclera.
Most proposed techniques modify how the suture loop is introduced and attached to the IOL haptic. Such techniques have included umbricating the IOL haptic into the sutures used to close the sclerotomy,[95] externalizing the haptics to attach a suture,[96,97] using a needle guide to thread the suture around the haptic,[98] introducing a small needle intraocularly to capture the haptic,[99] suturing through IOL optic positioning holes,[100,101] backing a large needle into the eye to introduce a suture loop,[102] using a loop grasped by intraocular forceps,[103,104] and suturing techniques involving or introducing the suture from a third sclerotomy.[105] Other suturing techniques have been introduced.[106-110] Some other proposed variations include achieving three- or four-point fixation to lessen lens torsion[111]; using specially designed, small-gauge forceps to aid in maneuvering the loop around the haptic[112]; and using perfluorocarbon liquids to place the implant in a convenient position for suturing.[63,113-115] Most posterior segment surgeons fid the routine use of perfluorocarbon liquids unnecessary.
The current technique preferred by the authors is described and illustrated.[115] A standard three-port pars plana vitrectomy is performed to remove the vitreous formed and to mobilize the IOL. Partial-thickness, limbus-based scleral flaps are dissected, most conveniently in the 1 and 7 o'clock meridians to avoid the previous cataract wound and yet be accessible. A 5/8-inch, 25-gauge needle, prethreaded with a 9-0 polypropylene suture is introduced into the eye 1 mm posterior to the limbus in the bed of the partial-thickness scleral flap (Fig. 186.4). Slack is created in the suture along the shaft of the needle by withdrawing it slightly. The IOL haptic is guided through this loop using the intraocular forceps to grasp the optic. The haptic is captured in the loop as the needle is withdrawn (Fig. 186.5). A partial-thickness scleral needle pass in the bed of the scleral flap allows fixation of the scleral suture. A similar procedure is repeated for the other haptic, unless capsular fixation is sufficient (Fig. 186.6). Occasionally, it is necessary to guide the haptic through the loop by using intraocular forceps. The scleral flap usually does not require suturing, but is closed by pulling the conjunctiva taut over it. Similar techniques are applicable to foldable IOLs.[55,116-119] Although long-term stability of scleral suture fixation has been reported,[120] redislocation may occur and may be amenable to special techniques.[121,122]
|
|
|
|
FIGURE 186.4 Suture connected to one needle is threaded through a 25-gauge straight needle with a hole within the bevel of the needle. The needle and suture are introduced into the vitreous cavity 1 mm posterior to the limbus through the bed of a partial-thickness scleral flap. Under direct visualization, the haptic is threaded through the loop along the shaft of the needle. A scleral plug is placed in the unused open sclerotomy. |
|
|
|
|
FIGURE 186.5 The needle is withdrawn, and the suture is tied under the scleral flap in the usual fashion. |
|
|
|
|
FIGURE 186.6 A similar procedure is performed for the other haptic, unless the second haptic can be secured by capsular fixation. |
Histopathologic and ultrasound biomicroscopic studies have shown that little or no fibrosis occurs around sutured PC/IOL haptics,[123] but one study has shown cicatrization around the haptics.[124] Either way, it is vital to use a nondissolving suture material because it may provide the sole means of support at the ciliary sulcus.
IOL torsion and decentration can be avoided by accurate ciliary sulcus placement and by adequate excision of bulky capsular and cortical remnants. It may be necessary to exchange some IOLs that are too short from haptic to haptic for sulcus fixation. Anatomic studies have located the sulcus ?1 mm posterior to the limbus.[125] Consequently, suture placement more posteriorly may cause IOL optic torsion by forcing the circumferentially oriented haptic over radially oriented ciliary processes. Identification of the location of the ciliary sulcus can be facilitated by transillumination techniques.[38] The sutures must be placed diametrically apart for proper centration. Also, the IOL must be rotated minimally and cautiously to the center at the end of the case.
OUTCOMES OF SURGERY FOR DISLOCATED PC/IOLS
The fial visual acuity probably depends not only on preoperative macular function but also on complications from the original cataract surgery, such as CME and retinal detachment. Still, recent series report a fial visual acuity 20/40 or better in more than 90% of eyes (Table 186.3). However, surgical series are difficult to compare accurately owing to nonhomogeneity and the variety of management techniques.
TABLE 186.3 -- Results of Pars Plana Vitrectomy for Dislocated Intraocular Lens
|
Series Patients |
n |
VA = 20/40 (%) |
|
Campo et al[98] |
17 |
59 |
|
Flynn et al[61] |
25 |
68 |
|
Smiddy and Flynn[62] |
32 |
69 |
|
Chan[96] |
12 |
92 |
|
Panton et al[64] |
31 |
94 |
|
Smiddy et al[67] |
46 |
50 |
|
Mello et al[91] |
110 |
57 |
|
Abbreviation: VA, visual acuity. |
POSTOPERATIVE COMPLICATIONS
An intraoperative or postoperative vitreous hemorrhage commonly occurs because sutures are placed through the vascular ciliary body, but these are almost always self-limited and of little clinical significance.
Bacterial migration along the transscleral suture tract has been described as being the possible route for infection in cases of delayed-onset endophthalmitis.[61] The use of a partial-thickness scleral flap to cover the scleral suture knot should reduce the risk of this complication, but the suture knot may erode through the flap.
Other postoperative complications are difficult to separate from those that would be expected with complicated cataract surgery. Both CME and retinal detachment have been described after IOL repositioning surgery. Retinal detachment occurs in ?2% of cases, but may be less frequent than with retained lens fragments (Table 186.4).[49] Possible reasons for the disparity include less inflammation with IOL dislocation relative to lens nuclear and cortical materials. Also, primary vitrectomy is often performed from the limbus at the time of the lost lens fragment, whereas with the dislocated IOL, this is usually less aggressively performed. Surgical approaches typically involve standard vitreoretinal surgical techniques, but the use of perfluorocarbon liquids may be helpful in selecting cases to better manipulate the IOL while avoiding retinal trauma.
TABLE 186.4 -- Incidence of Retinal Detachment Occurring Before and After Vitrectomy for Dislocated Posterior Chamber Intraocular Lens
|
Series |
Initial Co-Existing RD |
RD After Vitrectomy |
Combined |
|
Flynn et al[61] |
1/20 (5%) |
0/20 (0%) |
1/20 (5%) |
|
Smiddy and Flynn[62][*] |
1/32 (3%) |
1/32 (3%) |
2/32 (6%) |
|
Chan[96] |
0/12 (0%) |
0/12 (0%) |
0/12 (0%) |
|
Smiddy et al[67][*] |
0/59 (0%) |
0/59 (0%) |
0/59 (0%) |
|
Panton et al[64] |
0/31 (0%) |
0/31 (0%) |
0/31 (0%) |
|
Mello et al[91] |
11/110 (10%) |
7/110 (6.4%) |
18/110 (16.4%) |
|
Totals |
13/254 (5.1%) |
8/254 (3.1%) |
21/254 (8.3%) |
|
Abbreviation: RD, retinal detachment. |
|
* |
These two series are from the same institution, but they are compiled here as consecutive series without overlap of cases. |
For the anterior segment surgeon, avoiding PC/IOL dislocation depends on accurate assessment of posterior capsule status intraoperatively. With the increased use of phacoemulsification, capsular ruptures are now more commonly central, rather than peripheral as was more commonly seen with extracapsular techniques. However, the anterior segment surgeon must evaluate the integrity of the peripheral capsule carefully before implanting a PC/IOL in the presence of a posterior capsular rupture. Generally, at least six clock hours of peripheral capsular support (at least three of which must be inferior) are necessary to maintain IOL positioning. Retracting the iris may be necessary to visualize directly the extent of peripheral capsular support before placing the PC/IOL. Once it is determined to be safe to proceed with IOL placement, it is vital that the haptics placed precisely. Viscoelastic and iris retraction (again, using iris hooks, if needed) may facilitate this.
One recommendation to the anterior segment surgeon encountering PC/IOL dislocation intraoperatively is to perform an anterior vitrectomy to avoid vitreous incarceration in the wound. Postoperatively, frequent topical corticosteroids and, as clinically indicated, IOP-reducing agents should be prescribed. For most cases, vitreoretinal referral for defiitive management is advisable, but some cases as described earlier are best observed or may be amenable to management with limbal incisions. Careful attention is necessary to evaluate for other complications such as retinal detachment.
Recommendations to the vitreoretinal surgeon include careful assessment of existing capsular anatomy and coexisting complications to formulate a treatment plan in terms of timing and technique options. Generally, allowing a week or more for treatment and resolution of acute postoperative inflammation and cleaning of the cornea is advisable. The vitreoretinal surgeon should also be aware of IOL calculations from the cataract surgeon (or repeat them preoperatively) so that appropriate IOL power can be selected if necessary.
SUMMARY
Management options for patients with dislocated PC/IOLs are numerous and varied; they include observation, removal or exchange, and repositioning. Innovations in surgical technique have simplified the repositioning options, including sulcus suture fixation or placement anterior to the anterior capsule. The preferred option by the authors is repositioning even with dislocated silicone or acrylic haptic IOLs. Most foldable IOLs may be repositioned using techniques developed previously for rigid IOLs, but a larger capsular rim is necessary and scleral suture techniques may not be feasible in some cases.
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