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‘Sunset syndrome’ requires tailored approach

Technique is performed with the IOL remaining in the posterior chamber with a 3-mm entrance wound in a closed system.

Issue: October 1, 2007

ByThomas TJ John, MD

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“Sunset syndrome” after cataract surgery usually requires surgical intervention for the proper management of this condition. Patients with sunset syndrome, or when an IOL becomes dislocated behind the pupil, usually complain of blurred vision and often have uni-ocular diplopia.

Various surgical techniques have been described in the past, including optic capture by the pupil and suture fixation of the haptic to the iris. In some cases, the haptic is brought out of the surgical wound and after suturing of the iris, the IOL implant is then placed back in the posterior chamber.

An alternative technique includes an IOL exchange through a large entrance wound. This technique is performed with the IOL remaining in the posterior chamber at all times, in a closed system, with a small 3-mm entrance wound and a side-port wound for the second instrument. The present technique utilizes iris retractors effectively for good visualization of the subluxated posterior chamber IOL.

Step-by-step surgical explanation

General or peribulbar anesthesia with monitored anesthesia care can be used.

The pupil is not constricted or dilated (Figure 1a).

Healon GV (sodium hyaluronate 1.4%, Advanced Medical Optics) is injected into the anterior chamber (Figure 1b).

Iris retractors are used to expand the pupil (Figures 1c and 1d). A Sinskey hook is used to move the subluxated posterior chamber IOL into position (Figures 2a and 2b).

A large, curved needle is passed through the cornea, through the iris, between the inferior haptic and the capsular remnants and then through the iris to exit the cornea (Figures 2c and 2d).

The needle is then pulled through (Figure 3a ), leaving the 10-0 Prolene suture in place (Figure 3b).

An additional iris retractor is placed at 12 o’clock position for additional exposure of the superior haptic. A similar needle is passed through the cornea, iris, and in between the superior haptic and the posterior capsular remnants (Figure 3c), and then through the superior iris to exit the cornea (Figure 3d). All iris retractors are removed (Figures 4a and 4b), and Miostat (carbachol, Alcon) is injected to constrict the pupil (Figure 4c).

Additional Healon GV is injected into the anterior chamber (Figure 4d). John Super-Micro Forceps (ASICO) have a notch at the end, which facilitates tying the knots of a 10-0 Prolene suture (Figures 5a and 5b).

Healon GV is injected over the inferior iris (Figure 5c), and a Sinskey hook is used to pull the Prolene suture to form a loop within the inferior anterior chamber (Figure 5d).

The two John Super-Micro Forceps are used to tie multiple knots on the iris, without any significant traction on the iris or iris root and without coming into contact with the corneal endothelium (Figures 6a to 6d, and 7a, 7b).

The suture is cut using the John Super-Micro Scissors (ASICO) (Figure 7c). Figure 7d shows the iris suture in place fixating the inferior haptic of the posterior chamber IOL to the iris. A vitreous sweep is used to pull the superior 10-0 Prolene suture into a loop (Figures 8a and 8b), and the suture is tied, fixating the superior haptic to the superior iris. Automated, two-port anterior vitrectomy is performed using the Infiniti system (Alcon) to remove all of the vitreous from the anterior chamber (Figure 8c). The side-port wound is closed with 10-0 nylon suture (Figure 8d). The vitreous sweep is used to confirm there is no vitreous in the anterior chamber at the end of the procedure (Figures 9a and 9b).

The superior wound is closed with 10-0 nylon sutures, and the conjunctiva is approximated (Figures 9c and 9d). Under higher magnification, the iris-fixation sutures are seen (arrows, Figure 9d) and a round pupil.

Surgical regimens

Preoperatively, one drop of an antibiotic drop, such as Zymar (gatifloxacin, Allergan) or Vigamox (moxifloxacin, Alcon), should be applied four times a day for 3 days before surgery.

Intraoperatively, the surgeon should follow the usual surgical prep for any intraocular surgery.

Postoperatively, a topical steroid and a latest-generation ophthalmic fluoroquinolone are applied four times a day. For globe protection, the patient is asked to wear glasses or an eye shield during the day and a shield at night. The usual postoperative activity limitations are required.

For more information:

• Thomas John, MD, is a clinical associate professor at Loyola University in Chicago and in private practice in Tinley Park and Oak Lawn, Ill., and Hammond, Ind. He can be reached at 708-429-2223; fax: 708-429-2226; e-mail: lasikcornea@gmail.com. Dr. John has no direct financial interest in the products discussed in this article.

References:

• Chan CK, Agarwal A, Agarwal S, Agarwal A. Management of dislocated intraocular implants. Ophthalmol Clin North Am. 2001;14:681-693.
• Chan CK, Hawkins H, Lin SG. Modified haptic externalizing technique for repositioning dislocated 1-piece acrylic posterior chamber implants. Can J Ophthalmol. 2007;42:573-579.
• Condon GP, Masket S, et al. Small-incision iris fixation of foldable intraocular lenses in the absence of capsule support. Ophthalmology. 2007;114:1311-1318.