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Sutureless 20-gauge vitrectomy can be used to reposition dislocated IOL
This new technique avoids additional incisions, and it reduces surgical time and IOP fluctuation.
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A postoperative dislocated or luxated IOL remains an infrequent but significant complication of cataract surgery. The management options are observation, IOL exchange or repositioning the IOL. In all the procedures, combined pars plana vitrectomy has to be done, which requires multiple wounds — either sclerotomies or clear corneal incisions.
 Amar Agarwal |
We describe a new technique of sutureless vitrectomy using 20-gauge vitrectomy instrumentation and repositioning the dislocated IOL in the posterior chamber with transscleral fixation of haptics, intralamellar scleral tuck and fibrin glue-assisted flap closure. This is an extension of the recent technique of IOL implantation in eyes with deficient posterior capsules (glued IOL).
Repositioning the dislocated IOL
Localized peritomy and wet cautery of the sclera at 3, 9 and 7 o’clock were performed. Two partial thickness limbal-based scleral flaps (Figure 1a; f1, f2) 2.5 mm by 3 mm were created exactly 180° diagonally apart and 1.5 mm from the limbus. A third scleral flap (Figure 1a; f3) was made about 2 mm from the limbus. A pars plana sclerotomy (Figure 1b) about 3 mm from the limbus was made with a 20-gauge needle under the scleral flap (f3). A polyglactin 6-0 suture was placed, and a 4-mm infusion cannula connected to a 500 mL bottle of balanced salt solution was inserted through the sclerotomy. An infusion cannula with a halogen light source (chandelier illumination) can also be used.
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Images: Agarwal A, Kumar DA |
Fluid flow was started after visualization of the tip of the infusion cannula in the vitreous cavity. Two straight sclerotomies with a 20-gauge needle were made about 1.5 mm from the limbus under the existing scleral flaps (f1, f2). The Accurus 400VS (Alcon Laboratories) surgical system was used for posterior vitrectomy. Posterior vitreous detachment was induced mechanically using suction of the 20-gauge vitrectomy probe. A thorough vitrectomy to free all the IOL attachments with the vitreous was done with the 20-gauge vitrectomy probe and endoilluminator.
When the vitreous tractions were released, diamond-coated 20-gauge intravitreal forceps (Grieshaber, Alcon) were used to hold the haptic tip. The IOL was gently lifted up to bring it at the level of the sclerotomy sites. The intravitreal forceps, holding the haptic, were then withdrawn from the sclerotomy site (f1), externalizing the haptic. With the assistant holding the tip of the externalized haptic, the other haptic was pulled (Figures 1c and 1d) through the other sclerotomy (f2) using intravitreal forceps. The tips of the haptic were then tucked through an intralamellar scleral tunnel made with a 26-gauge needle at the point of externalization (Figure 2A). Scleral flaps (f1, f2) were closed with fibrin glue (Tisseel, Baxter). Polyglactin suture and the infusion cannula were removed, and the third scleral flap (f3) (Figure 2B) was also sealed with the glue. Conjunctiva was also apposed with the tissue glue.
 Figure 2. Scleral flaps being closed with fibrin glue after tucking (a) the haptics (f1, f2) and after the removal (b) of the infusion cannula (f3). |
 Figure 3. Fundus showing technique being done in an eye with completely dislocated IOL in the vitreous. Internal illumination is from the halogen light source attached with the infusion cannula (chandelier illumination). |
Postoperative outcome
No subconjunctival bleb formation was seen in any of the port sites. No postoperative retinal detachment, retinal break or vitreous hemorrhage was noted in any of the patients. Two eyes showed grade 1 anterior chamber reaction that resolved within 24 hours after medical management. Mean postoperative central foveal thickness measured by optical coherence tomography (Cirrus OCT, Carl Zeiss Meditec) was 184.4 ± 17.1 µm at 6 months of follow-up. There was no loss of best corrected visual acuity in any of the eyes. Anterior segment OCT (Visante, Carl Zeiss Meditec), used to scan across the pars plicata region, showed no wound leak or gaping. Ultrasound biomicroscopy showed no vitreous traction or uveal incarceration in pars plicata ports in the postoperative period.
Advantages
In this method of repositioning, there is no IOL explantation; therefore, chances of corneal wound astigmatism as seen in pars plana vitrectomy with IOL explantation and reimplantation is decreased. It can be performed with dislocated rigid PMMA IOLs, three-piece posterior chamber IOLs or IOLs with modified PMMA haptics.
Unlike other methods, in this technique we have used the same pars plicata sclerotomy port for vitrectomy and for IOL haptic externalization. The reported complications of management of posteriorly dislocated IOLs using pars plana vitrectomy, such as intraoperative retinal dialysis, redislocation of the IOL, postoperative extension of a pre-existing subclinical retinal detachment, chronic cystoid macular edema and pseudophakic pupillary block, were not encountered in any of our patients with 6 months of follow-up. There was no postoperative hypotony or wound leak noted in any of the patients.
Although it is known that a sclerotomy wound can cause prolapse and incarceration of uveal tissue and retinal fragments leading to vitreous traction and iatrogenic retinal breaks, postoperative ultrasound biomicroscopy showed no vitreous traction or retinal incarceration in pars plicata ports.
We preferred this technique of IOL repositioning, as the suture-related complications of the suture-fixated IOL are reduced by this procedure. Because the IOL haptic is tucked in the scleral tunnel, it would prevent the further movement of the haptic, reducing pseudophakodonesis and minimizing slippage and late redislocation.
Corneal topographic changes were known to increase with sutured pars plana vitrectomy. Hence, by using the biological glue, the suturing of the sclerotomy wound is avoided. Moreover, the conventional 20-gauge vitrectomy instruments are used instead of special instrumentation. Even though complete scleral wound healing with collagen fibrils may take up to 3 months, as the haptic is snugly placed inside an intralamellar scleral tunnel, the IOL remains stable from the early postoperative period.
Conclusion
Dislocation of the IOL into the vitreous can occur as an early or late complication arising from posterior capsular rupture during phacoemulsification. Management of such a situation with available instruments without compromising the visual outcome remains challenging. This new method avoids additional corneal incisions or multiple sclerotomies, and it reduces surgical time and IOP fluctuation by maintaining a closed system.
References:
- Agarwal A, Kumar DA, Jacob S, et al. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34(9):1433-1438.
- Agarwal A, Kumar DA, Jacob S, Baid C, et al. Reply to letter: Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2009;35(5):795-796.
- Prakash G, Ashokumar D, Jacob S, et al. Anterior segment optical coherence tomography-aided diagnosis and primary posterior chamber intraocular lens implantation with fibrin glue in traumatic phacocele with scleral perforation. J Cataract Refract Surg. 2009;35(4):782-784.
- Prakash G, Jacob S, Ashok Kumar D, et al. Femtosecond-assisted keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation: New triple procedure. J Cataract Refract Surg. 2009;35(6):973-979.
- 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.
