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Suction-based levitation of dislocated IOL prevents contact with retina
A sleeveless-extrusion cannula is placed on top of the IOL and suction is increased to 300 mm Hg, enabling the surgeon to lift the lens to the pupillary plane.
Suction-based levitation with a sleeveless-extrusion cannula may be an alternative to the conventional method of removing dislocated IOLs from the vitreous cavity, according to a study.
The novel technique, performed in tandem with 23-gauge transconjunctival sutureless vitrectomy, requires no grasping of the dislocated IOL or contact with the retina, according to lead author Ashvin Agarwal, MD.
Ashvin Agarwal
The technique involves standard 23-gauge three-port pars plana vitrectomy. After cutting the vitreous and removing the silicone oil, the surgeon places the cannula on the center of the IOL optic, sets the vacuum to 300 mm Hg and lifts the IOL to the pupillary plane. The IOL is grasped by end-opening forceps; the surgeon removes, repositions or exchanges the implant.
“Addressing the IOL with an extrusion cannula without sleeves gives a larger surface area to be adhered to the IOL,” Agarwal and colleagues wrote in the study, which was published in the British Journal of Ophthalmology.
Study design and results
The retrospective study included 10 eyes of 10 patients who underwent suction-based levitation of a dislocated IOL. The main outcome measures were reliability, reproducibility, and intraoperative and postoperative complications.
IOL levitation was performed within the first week of IOL dislocation in all cases.
Six cases involved a three-piece foldable acrylic IOL, three cases involved a one-piece foldable acrylic IOL, and one case involved a plate-haptic IOL.
IOL exchange was performed in four eyes, and the same IOL was repositioned in six eyes; of those six eyes, two underwent sulcus repositioning and four underwent glued intrascleral fixation.
Patients were examined postoperatively at 1, 3 and 7 days, weekly for the first month and monthly for 9 months.
Figure. A dislocated IOL resting on the retina (a). A sleeveless-extrusion cannula lifts the silicone oil from the retina using traction after vitrectomy, so that no vitreous is present (b). Once the oil is brought to the anterior vitreous, one of the haptics is grasped with 23-gauge forceps (c). The IOL is maneuvered into the sulcus or glued in place, depending on the presence of a rhexis (d).
Image: Agarwal A
Intraoperative suction loss and subsequent IOL dislocation occurred in one eye. Intraoperative corneal edema was identified in one eye but resolved after surgery.
Intermediate and late complications included one case of macular edema that resolved with medical management.
No cases of postoperative vitreous or retinal hemorrhage, retinal break or retinal detachment were reported.
Agarwal noted that he had no complications in 30 to 40 recent procedures.
“If you cut the vitreous, there aren’t going to be any complications, whereas in the traditional technique, I used to struggle in terms of retinal edema. By touching vessels from the retina, you’re going to cause a bleed,” Agarwal said.
Pearls on surgical technique
Agarwal said that the technique differs from traditional methods only in that vitrectomy is performed completely above the dislocated IOL.
Vitrectomy should be performed with extra caution in cases with double-loop lenses, Agarwal said.
“Just make sure that there are no tags of vitreous, especially between the double-loop lenses,” he said. “If you have a single-haptic lens, you will not struggle too much. The only problem starts when you have a double-loop lens and you have vitreous stuck in between the two loops. That’s when you have to be a little more cautious when doing a vitrectomy.”
Agarwal warned surgeons against rushing the procedure.
“If you’re in a hurry to pull up, it may cause traction,” he said. “You only want to assure that there is no traction into the retina. That is the biggest difference for someone who is trying the technique for the first time.”
Agarwal also advised right-handed surgeons to hold the left side of the optic, not the right side or center.
“When you try to grab the left side of the optic and you elevate your hand up to bring it in the pupillary space, you bring the haptic into the pupillary space. At that point, the amount you have to supinate your hand will be very little,” Agarwal said. – by Matt Hasson
Reference:
Agarwal A, et al. Br J Ophthalmol. 2014;doi: 10.1136/bjophthalmol-2013-304700.
For more information:
Ashvin Agarwal, MD, can be reached at 19 Cathedral Road, Chennai-600 086, India; 91-44-28116233; fax: 91-44-2811-5871; email: agarwal.ashvin@gmail.com.
Disclosure: Agarwal has no relevant financial disclosures.