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Glued IOL implantation can be combined with silicone oil removal in complicated eyes
No IOL-related complications were noted in a pilot study of the combined procedure.
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Despite recent advances, lens surgeries such as cataract extraction or secondary IOL implantation in vitrectomized eyes remain challenging. Eyes with deficient capsules with a primary vitreoretinal procedure requiring silicone oil injection often require silicone oil removal and visual rehabilitation by secondary IOL implantation. Combining silicone oil removal with glued IOL implantation in a single sitting has advantages compared with a two-step procedure. It negates a second surgical procedure for IOL implantation, which minimizes the overall treatment time, reduces the risk of anesthetic complications and achieves a faster visual rehabilitation while cutting down the total costs involved.
Silicone oil removal with glued IOL
Under peribulbar anesthesia, localized conjunctival peritomies were made at 3 and 9 o’clock hours. Two partial-thickness limbal-based scleral flaps about 2.5 mm × 2.5 mm were created exactly 180° diagonally apart (Figure 1). Infusion was maintained by a 23-gauge pars plana transconjunctival trocar cannula. After making the scleral flaps, a superior corneolimbal 2.8-mm incision was made for transpupillary silicone oil removal (Figure 1). Here a continuous controlled pressure was given on the posterior lip of the wound using the flat end of the iris repositor or vitrector, while the infusion flow was maintained (Figure 2). This flushed the silicone oil from the intraocular space in a controlled fashion through the dilated pupil. Silicone oil removal can also be performed using a 23-gauge transconjunctival three-port pars plana sclerotomy using motorized active suction with continuous infusion through the pars plana trocar. In cases of emulsified silicone oil, multiple air-fluid exchanges were performed, if possible, to ensure complete removal. In cases with silicone oil in the anterior chamber or an inverse hypopyon, a thorough wash of the anterior chamber was done with balanced salt solution after making a side-port incision.
Figure 1. Opacified IOL in an eye with silicone oil (a). Two partial-thickness scleral flaps made and 23-gauge trocar cannula infusion fixed (b). Corneolimbal incision made and the opacified IOL explanted (c and d).
Images:Agarwal A, Kumar DA
Figure 2. Silicone oil removal proceeded with transpupillary method (a). Glued IOL implantation done (b).
In eyes with a subluxated cataractous lens, lensectomy through the corneoscleral wound was performed before silicone oil removal. In eyes with an opacified IOL, the superior incision was extended and the IOL was explanted (Figure 1). After silicone oil removal, the glued IOL was performed as described originally by Agarwal et al (Figure 2). Two straight sclerotomies were made under both the flaps with a 20-gauge needle about 1 mm to 1.2 mm from the limbus. The cartridge loaded with the foldable IOL was then passed into the anterior chamber. Glued IOL forceps were passed through the sclerotomy, and the tip of the leading haptic was grasped and externalized by the glued IOL forceps. The haptic was held by an assistant or tires. The second haptic was then flexed into the anterior chamber and pulled through the opposite sclerotomy by the glued IOL forceps using the handshake technique. When both the haptics were externalized under the flaps, they were tucked into the limbus parallel to a intralamellar Scharioth tunnel made with a 26-gauge needle at the point of haptic externalization. The anterior chamber was formed by sterile air. Reconstituted fibrin glue was then injected under the scleral flaps, and local pressure was given for 10 seconds. The pars plana infusion port, if present, was then removed.
Outcomes of combined procedure
In a short pilot study of the combination procedure, we noted no IOL-related complications, such as optic capture, IOL subluxation or decentration, or clinical IOL dislocation or tilting, in any of the eyes. The major complications noted after silicone oil removal with a glued IOL were persistent glaucoma (one eye), re-detachment (two eyes), persistent corneal decompensation (one eye) and dispersed vitreous hemorrhage (one eye).
Advantages of glued IOL
Various techniques are available to implant IOLs in aphakic eyes, including anterior chamber IOL implantation, iris-fixated IOL, scleral-fixated IOL and glued IOL. Each technique has its own unique qualities, surgical difficulty level and postoperative complications. Although easy to implant, an anterior chamber IOL is generally associated with risk of keratopathy, uveitis, glaucoma and angle-related complications. An iris-fixated IOL needs a specially designed IOL and is pupil dependent. A higher risk of intraocular inflammation and pseudophakodonesis, iris erosion and IOL slippage are matters of concern. Although technically difficult, a scleral-fixated IOL has long been the mainstay for implanting an IOL in the posterior chamber, but it too is associated with complications such as pseudophakodonesis, IOL tilt and decentration, suture erosion and vitreoretinal complications. The glued IOL method reduces the common complications associated with other IOLs as described above, and no specially designed IOL is required. Both foldable and non-foldable lenses can be implanted by the glued IOL method.
References:
Agarwal A, et al. J Cataract Refract Surg. 2008;doi:10.1016/j.jcrs.2008.04.040.
Agarwal A, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.01.019.
Casswell AG, et al. Br J Ophthalmol. 1987;doi:10.1136/bjo.71.12.893.
Kumar DA, et al. Curr Opin Ophthalmol. 2013;doi:10.1097/ICU.0b013e32835a939f.
Kumar DA, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.03.004.
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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.
Disclosure: No products or companies that would require financial disclosure are mentioned in this article.