Chopstick forceps help implant IOL in ciliary sulcus

Amar Agarwal

It is a challenge to implant an IOL in the ciliary sulcus in a setting of posterior capsular rent without experiencing IOL-related complications such as drop or tilt.

There have been numerous techniques described in the literature for a safe, stable positioning of the IOL with deficient capsular support. In this column, we describe a new instrument that allows easy implantation of the IOL in the ciliary sulcus in cases of capsular compromise. Surgical manipulation is reduced to a minimum, allowing placement of the IOL even in instances of a torn capsulorrhexis and discontinuity in anterior capsular support. The IOL may be implanted in the same sitting or as part of a secondary procedure.

Chopstick forceps are especially helpful when implanting a posterior chamber IOL in the sulcus in cases that have a large anterior capsular rhexis, a small pupil in which the rhexis margin is not visible or the anterior rhexis margin is torn. In such cases, one can implant the posterior chamber IOL by mistake posterior to the anterior capsular rhexis rather than anterior to it. One should also remember not to implant a single-piece acrylic lens in such cases as it is better to implant a three-piece IOL.

Agarwal-Katena chopstick forceps

The instrument, known as Agarwal-Katena forceps, consists of 18-gauge lens forceps (Katena Products). The forceps (Figures 1a to 1b) consist of a handle, the ends of which are rounded over at the end. The tip of the forceps consists of two flanges, 5 mm in length and opening anteriorly to a maximum inter-flange width of 0.75 mm. The forceps work on the mechanism of “reversed action.” This allows the flanges of the forceps to be in apposition when at rest (Figure 1a). When squeezing the handle of the forceps, the flanges open (Figure 1b).

Figure 1. Agarwal-Katena forceps. The flanges are opposed at rest (a). When the handle is squeezed, the flanges are separated and the forceps open (reverse action) (b). Images: Agarwal A

IOL implantation in sulcus

In the event of a posterior capsular rupture during phacoemulsification, the surgeon first ascertains that a thorough anterior vitrectomy is done to first free the anterior chamber of any vitreous. The clear corneal section is then enlarged.

The surgeon then checks the adequacy of the anterior capsular rim to facilitate implantation of an IOL in the ciliary sulcus. The IOL intended to be implanted is then gripped by the Agarwal-Katena forceps by opening the forceps by squeezing the handle. The handle is then released.

In the position of rest of the handle, the IOL is firmly held in place by the forceps (Figure 2a). The IOL is then introduced into the eye, stabilizing the globe by means of a rod introduced through the side port (Figure 2b). The leading haptic of the IOL is maneuvered into the ciliary sulcus. In case of a torn rhexis, care is taken to introduce the haptic away from the site of capsular defect. All the time, one flange of the forceps supports the IOL posteriorly. Thus, the IOL is held in a “chopstick” fashion (Figure 2c) until it is in position. After the leading haptic is in place, the handle is squeezed to release the grip on the lens. The same forceps can be used to place the trailing haptic of the IOL into the sulcus. Any type of IOL, rigid or foldable, can be implanted safely with the forceps.

Figure 2. The IOL is gripped with the forceps, after which the surgeon can ease the pressure on the handle (a). The IOL is introduced through the limbal incision (b). The IOL is supported posteriorly by one of the flanges of the forceps (c). IOL is well-centered and stable in the sulcus (d).

Advantage of reverse action

The advantage of the forceps is that unlike other instruments being used for IOL insertion, the mechanism is that of “reversed action.” This allows the flanges of the forceps to be in apposition when at rest. On squeezing the handle of the forceps, the flanges open. This allows the IOL to be gripped stably without any effort of the surgeon once the IOL is placed between the two flanges of the forceps. The forceps then act like a pair of chopsticks to give adequate posterior support to the IOL during its implantation until the surgeon is absolutely sure of its stability in the sulcus (Figure 2d).

Because the IOL is supported adequately throughout the implantation, the risk of posterior dislocation is prevented. Surgical manipulations are reduced to a minimum.

Conclusion

Supporting the IOL in the ciliary sulcus when there is a large posterior capsular defect is one of the options that many cataract surgeons choose to adopt. The special chopstick forceps help the surgeon in these situations. The lens is firmly held in place, and the surgeon may shift his focus to maneuvering the lens into place without the danger of causing an inadvertent IOL drop.

• Amar Agarwal, MS, FRCS, FRCOphth, is director of Dr. Agarwal’s Eye Hospital and Eye Research Centre. Prof. Agarwal is the 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.