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Chandelier illumination and bimanual vitrectomy used to remove dislocated IOL
A wide-field lens and xenon light source provide good visualization of the IOL haptic in relation to the retina.
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| Amar Agarwal |
Numerous advances in microsurgical techniques have led to highly safe and effective cataract surgery. Two of the current trends in the evolution of modern cataract techniques include increasingly smaller surgical incisions associated with phacoemulsification (eg, sub-1-mm incisions as in microphakonit), as well as the movement from retrobulbar and peribulbar anesthesia to topical anesthesia, and even no-anesthesia techniques. Despite such advances, the malpositioning or dislocation of an IOL due to capsular rupture or zonular dehiscence remains an infrequent but significant sight-threatening complication for contemporary cataract surgery. The key to the prevention of poor visual outcome from this complication is its proper management.
Managing malpositioned IOLs
Disturbing visual symptoms such as diplopia, metamorphopsia and hazy images are associated with a dislocated IOL (Figure 1). If not properly managed, a malpositioned IOL may also induce sight-threatening ocular complications, including persistent cystoid macular edema, intraocular hemorrhage, retinal breaks and retinal detachment. Contemporaneous with advances in phakonit microsurgical techniques for treating cataracts, a number of highly effective surgical methods have been developed for managing a dislocated IOL.
Chandelier illumination
Chandelier illumination in which a xenon light is attached to the infusion cannula gives excellent illumination and visualization, and it allows one to perform a proper bimanual vitrectomy as it is not necessary for the surgeon to hold an endoilluminator in the hand (Figure 2). A reinverter system has to be used if a wide-field lens (Volk or Oculus) is used. The Volk SuperMacula lens (Figure 3) helps give better stereopsis so that one will not have any difficulty in holding the IOL with diamond-tipped forceps (Figure 4). When using a chandelier illumination system, one hand can hold the IOL with the forceps and the other hand can hold a vitrectomy probe to cut the adhesions of the vitreous, thus doing a bimanual vitrectomy (Figure 5). Two forceps can also be use to hold the lens, thus performing a handshake technique (Figure 6). The lens is then brought out anteriorly and removed through the limbal route (Figure 7).
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Images: Agarwal A et al |
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IOL brought out anteriorly through the limbal route. Notice in the upper right and left corners infusion cannulas fixed. One is for infusion and the other for the chandelier illumination. One can also have the same infusion cannula with the chandelier illumination fixed in it. |
Reinverter system
When we use the wide-field indirect contact vitrectomy lenses we have to use a reinverter as without it the image is seen inverted. The reinverter rights the image so the surgeon does not have difficulty operating. We use a model from Zeiss that works at the press of a foot switch.
One can also use the Volk reinverting operating lens system, which has a unique single-element prism design. This installs in the Zeiss and other microscopes. It offers surgical visualization ranging from high magnification of the macula to panoramic viewing up to and including the ora serrata.
Wide-field lenses
Wide-field indirect contact vitrectomy lenses are essential for performing proper bimanual vitrectomy. We use the Mini Quad Volk lens or the Oculus lens when we do a vitrectomy for a dropped IOL. These lenses give the view of the retina up to the ora serrata. We use the SuperMacula Volk lens when it is time to pick up the IOL with the diamond-tipped forceps. This lens gives very high magnification. Another advantage of this lens is better stereopsis which shows where the IOL haptic is in relation to the retina. These lenses come with a handle so that the assistant can hold the lens comfortably.
Bimanual vitrectomy
The advantage of the bimanual vitrectomy set-up is that the hand which normally holds the endoilluminator is free, so one can use two instruments to manipulate the dropped IOL. The chandelier illumination system we use is from Synergetics, and the machine is the Photon. Sophisticated filtering techniques within the Photon and its associated fiber optics are used to provide higher illumination levels.
For Your Information:
- Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Group of Eye Hospitals, trains surgeons internationally in phacoemulsification, phakonit, LASIK and retinal lasers. Dr. Agarwal is author of several books published by SLACK, Incorporated, publisher of Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery, and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; fax: 91-44-28115871; e-mail: dragarwal@vsnl.com; Web site: www.dragarwal.com.
References:
- Agarwal A, Agarwal A, Agarwal S. No Anesthesia Cataract Surgery. In: Agarwal A. Phacoemulsification, Laser Cataract Surgery and Foldable IOLs. 2nd ed. New Delhi, India. Jaypee Brothers; 2000.
- Agarwal A, Agarwal S, Agarwal A. Phakonit. In: Agarwal A. Phacoemulsification, Laser Cataract Surgery and Foldable IOLs. New Delhi, India. Jaypee Brothers; 1998.
- Chan CK, Agarwal A, et al. Management of dislocated intraocular implants. Ophthalmol Clin North Am. 2001;14(4):681-693.
- Chan CK. An improved technique for management of dislocated posterior chamber implants. Ophthalmol. 1992;99:51-57.
- Chang S. Perfluorocarbon liquids in vitreo-retinal surgery. Int Ophthalmol Clin. 1992;32(2):153-163.