IOL Subluxation Top 5 Pearls for Management. Disclosure. David G. Hwang, MD, FACS. Shire Consultant. Not relevant to this talk.

Transcription

1 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 Disclosure Shire Consultant Not relevant to this talk. I have no proprietary interest in any devices, drugs, or techniques discussed. 1

2 #1 Dynamic Examination Examine in different gaze positions Examine sitting, supine, face forward Portable slit lamp helpful #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 2

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4 #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 #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: High myopia, history of tear/detachment #3 Refixation vs Exchange 3-piece vs 1-piece PCIOL #3 Refixation vs Exchange 1-piece acrylic Sulcus not an option (Chang DF, 2009) In-bag sulcus fixation Explant/exchange 4

5 #3 Refixation vs Exchange 3-piece Sulcus, bag, sulcus/bag capture McCannel fixation In-bag sulcus suture fixation Explant/exchange #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 3 rd or 4 th suture to supplement classical 2-point fixation 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 Daoud Y, Stark WJ. ASCRS Eyeworld

6 Translimbal 9-0 Prolene Needle Supplemental McCannel Suture Hwang DG Daoud Y, Stark WJ. ASCRS Eyeworld 2011 Supplemental McCannel Suture Supplemental McCannel Suture Daoud Y, Stark WJ. ASCRS Eyeworld 2011 Daoud Y, Stark WJ. ASCRS Eyeworld

7 Supplemental McCannel Suture Supplemental McCannel Suture Daoud Y, Stark WJ. ASCRS Eyeworld 2011 Daoud Y, Stark WJ. ASCRS Eyeworld 2011 #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 7

8 #5 One-piece IOL Management One-piece acrylic Bulky haptics One-piece Acrylic IOL If subluxated relative to capsular bag Explant and exchange Co-planar One-piece PMMA Haptic manipulation can result in breakage 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

9 Hoffman Pocket Technique Hoffman Pocket Technique Hoffman RS. JCRS 2006;32: Hoffman RS. JCRS 2006;32: Hoffman Pocket Technique Hoffman Pocket Technique Hoffman RS. JCRS 2006;32: Hoffman RS. JCRS 2006;32:

10 Hoffman Pocket Technique Hoffman Pocket Technique Hoffman RS. JCRS 2006;32: Hoffman RS. JCRS 2006;32: #5 Refixation of Scleral- Sutured PCIOL (Broken Suture) One-piece PMMA w/ haptic eyelets Spontaneous lysis of 10-0 Prolene Ab Externo Double-back Technique to Resuture Haptic Straight 9-0 Prolene needle Thread through eyelet Restores fixation back to original 10

11 Refixation of Subluxated Transsclerally Sutured PCIOL Refixation of Subluxated Transsclerally Sutured PCIOL Hwang DG, Lin CT Hwang DG, Lin CT Refixation of Subluxated Transsclerally Sutured PCIOL Refixation of Subluxated Transsclerally Sutured PCIOL Hwang DG, Lin CT Hwang DG, Lin CT 11

12 Refixation of Subluxated Transsclerally Sutured PCIOL Refixation of Subluxated Transsclerally Sutured PCIOL Hwang DG, Lin CT Hwang DG, Lin CT Refixation of Subluxated Transsclerally Sutured PCIOL Hwang DG, Lin CT 12

13 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 Thank You 13

14 IOL Style Important IOL Style Important Transscleral Bag Fixation Transscleral Bag Fixation Ahmed IK. Ophthalmology 2005;112: Ahmed IK. Ophthalmology 2005;112:

15 Transscleral Bag Fixation Transscleral Bag Fixation Ahmed IK. Ophthalmology 2005;112: Ahmed IK. Ophthalmology 2005;112: Transscleral Bag Fixation Transscleral Bag Fixation Ahmed IK. Ophthalmology 2005;112: Ahmed IK. Ophthalmology 2005;112: