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Scaffold technique simplifies IOL exchange
Surgeons explain how to deal with post-cataract refractive surprises caused by IOL problems.
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We collaborated with Roger F. Steinert, MD, and Brian Little, MA, DO, FRCS, FRCOphth, on an IOL scaffold technique to facilitate IOL exchange. They have significantly contributed to its development and have successfully employed it in their patients with post-cataract refractive surprises.
Need for IOL exchange
Unpredictable refractive error after cataract surgery can be a major cause of patient dissatisfaction. In such a scenario, IOL exchange to correct the refractive surprise becomes imperative. Improper IOL power calculation, incorrectly labeled IOLs, intraoperative error by the surgeon in placing the IOL at a different position than determined preoperatively during the IOL power calculation or an error on the part of an assistant while delivering the IOL to the surgeon can account for some of the potential reasons leading to an IOL exchange.
Figure 1. Viscoelastic is injected inside the eye.
Figure 2. The edge of the optic is lifted with a rod.
Figure 3. IOL is manipulated out of the capsular bag.
Figure 4. The offending IOL is lying in the anterior chamber, and the corrective IOL is injected into the capsular bag.
Images: Agarwal A, Narang P
Figure 5. The offending IOL is cut across its optic, along the longitudinal axis.
Figure 6. The offending IOL is rotated, and the optic is bisected.
Figure 7. The bisected IOL is pulled by its haptic and explanted.
Figure 8. The offending IOL is completely removed from the anterior chamber. The corrective IOL is safely placed in the bag.
IOL scaffold is a technique that facilitates emulsification of the nuclear fragments in cases with inadvertent posterior capsule rupture wherein the IOL is preplaced beneath the nuclear fragments, thereby acting as a scaffold. In cases of IOL exchange, after levitating the offending IOL from the capsular bag, the corrective IOL can be preplaced in the bag before the offending IOL is cut and explanted out of the eye. In this way, the corrective IOL acts as a scaffold when the offending IOL is cut, and it also prevents any inadvertent damage to the posterior capsule during bisection of the offending IOL. The IOL power is recalculated using formulas that have been described in the literature. Availability of the patient’s case sheet, which denotes the power of the previously implanted IOL, can be of great help, and it can facilitate in determining the corrective power after taking residual refractive error into consideration.
The technique
A corneal tunnel incision is framed, and viscoelastic is injected into the eye (Figure 1) to adequately coat the endothelium. In long-standing cases, adhesions between the margin of the anterior capsule and the optic of the IOL can be encountered. These adhesions can be broken down after passing a rod-like structure or an iris spatula beneath the anterior capsule margin.
Once the adhesions are freed, an adequate amount of viscoelastic is injected beneath the optic of the IOL to create a space between the posterior capsule and the posterior surface of the IOL. The edge of the optic is lifted with a Y-shaped rod (Figure 2), and the offending IOL is slowly manipulated out of the capsular bag (Figure 3). The foldable corrective IOL is loaded onto the cartridge and slowly injected beneath the offending IOL to place it in the capsular bag (Figure 4). The corrective IOL is dialed into position.
With IOL cutting scissors, the offending IOL is cut along its longitudinal axis, across the optic (Figure 5). The IOL is rotated 180° and is again cut along the precut axis so as to divide it into two pieces (Figure 6). The edge of the haptic is grasped, and the cut hemisection of the IOL is pulled out of the eye, followed by removal of the residual hemi-section (Figures 7 and 8). Bimanual irrigation and aspiration is performed, and the viscoelastic is removed from the eye. Stromal hydration is performed, and a 10-0 nylon suture is used to seal the corneal section, if needed.
This procedure serves as an effective tool to facilitate the explantation of an IOL. In eyes with a shallow anterior chamber, adequate attention should be imparted to the endothelium due to the proximity of the offending IOL to the cornea. Adequate coating of the endothelium with dispersive viscoelastic is recommended in such cases.
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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: Agarwal and Narang have no relevant financial disclosures.