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Glued IOL scaffold can be used to manage Soemmering’s ring
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Soemmering’s ring was first described by D.W. Soemmering and is considered to be a type of regenerating lens substance that has a peripheral disposition and often goes unrecognized unless it is centrally dislocated or the pupil is widely dilated. The incidence of Soemmering’s ring formation is higher in pediatric cases after cataract surgery. Retention of lens fibers between the anterior and posterior capsules is considered to be the possible etiology. The adhesions of the anterior and posterior capsules prevent the exposure of these lens fibers to the aqueous and the surrounding environment, promoting uninhibited growth of lens fibers.
Removal of Soemmering’s ring is essential followed by proper placement of an IOL because the presence of Soemmering’s ring may induce an IOL tilt in addition to occupying the space in the capsular bag. Various procedures and techniques have been described for the management of Soemmering’s ring. Glued IOL scaffold is a technique described by us for managing a posterior capsule rupture with non-emulsified nuclear fragments in the presence of inadequate capsular or iris support. After levitation of the nuclear fragments in the anterior chamber, a three-piece foldable IOL is injected beneath the lenticular fragments and a glued IOL procedure is performed. The pre-placed IOL acts as a scaffold and allows safe emulsification of the nuclear fragments. In cases of Soemmering’s ring with associated posterior capsule rupture, we use the glued IOL scaffold procedure for safe emulsification of Soemmering’s ring material.
Procedure
Two partial-thickness scleral flaps are made 180° opposite each other, as in a glued IOL surgery. Sclerotomy is done with a 20-gauge needle about 1 mm from the limbus beneath the scleral flaps (Figure 1). After the introduction of infusion into the eye, thorough vitrectomy is done to clear the vitreous in the pupillary space and anterior chamber (Figure 2). A three-piece foldable IOL is loaded and injected into the eye beneath the Soemmering’s ring material. Glued IOL forceps are introduced from the left sclerotomy incision, and the tip of the haptic is grasped (Figure 3), followed by its externalization after the entire IOL has unfolded inside the eye. The trailing haptic is flexed inside the eye, and the “handshake technique” is performed until the trailing haptic is externalized. Scleral pockets are made with a 26-gauge needle, and the haptics are tucked. Vitrectomy is done at the sclerotomy site to cut down all the vitreous strands.
Figure 1.Two partial-thickness scleral flaps are made 180° opposite each other. Trocar infusion is introduced into the eye. Sclerotomy is done with a 20-gauge needle about 1 mm from the limbus, beneath the flaps.
Figure 2. Vitrectomy is done with a 23-gauge vitrectomy probe introduced from the sclerotomy site.
Images: Agarwal A, Narang P
Figure 3. A three-piece foldable IOL is injected beneath the Soemmering’s ring material, and the tip of the leading haptic is grasped.
Figure 4. Iris hooks are introduced to enhance the visualization of Soemmering’s ring.
Figure 5. Phacoemulsification of the Soemmering’s ring material is performed.
Figure 6. Fibrin glue is applied, and the scleral flaps and conjunctival incisions are sealed.
Iris hooks are then applied, and the Soemmering’s ring material is dislodged from the periphery into the center (Figure 4). After complete dislodgement of Soemmering’s ring, the iris hooks are removed and the phaco probe is introduced into the eye for emulsification of the Soemmering’s ring material (Figure 5). Removal of the hooks prevents any accidental dislodgement of the Soemmering’s ring material from the edges around the IOL optic into the vitreous cavity. Stromal hydration is done, and the corneal wound is sutured with 10-0 nylon. Fibrin glue is applied, and the scleral flaps are sealed (Figure 6).
The glued IOL scaffold effectively compartmentalizes the anterior and posterior chambers. The size of the pupil plays a crucial role in this procedure. During the process of emulsification of Soemmering’s ring material, it is recommended to have a pupil size that covers the optic completely, irrespective of the previously dilated size of the pupil. Intracameral pilocarpine can be used in cases of widely dilated pupil, or if iris hooks were employed previously to dilate the pupil, then they are removed. Narrowing on the size of the pupil enhances the safety margin of the surgery because it safeguards against posterior dislodgement of the Soemmering’s ring material. Adequate coating of the endothelium can be achieved by use of appropriate ophthalmic viscosurgical devices during the surgery.
Irrespective of the size and type of Soemmering’s ring — complete or incomplete, central or peripheral, thick or thin — this technique is applicable in all cases of Soemmering’s ring with associated posterior capsule rupture.
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Amar Agarwal, MS, FRCS, FRCOphth, is director of Dr. Agarwal’s Eye Hospital and Eye Research Centre. 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; email: dragarwal@vsnl.com; website: www.dragarwal.com.Priya Narang, MS, can be reached at Narang Eye Care & Laser Centre, 2nd Floor, AEON Complex, Vijay Cross Roads, , Ahmedabad, 9. Gujarat, India; 91-79-26420034; email: narangpriya19@gmail.com. Disclosure: No products or companies that would require financial disclosure are mentioned in this article.