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Bag-in-the-lens a forgiving technique if explantation is needed
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We present an example of a patient who underwent bag-in-the-lens cataract surgery with a monofocal lens. Six weeks postoperatively she came back complaining of visual disturbance due to residual astigmatism of –1.75 D and told us she strongly wished to be without glasses or contact lenses. Because the BIL technique offers a relatively easy method for IOL exchange, we offered to exchange the lens for a toric IOL.
Surgical technique
The 90° and 180° meridians were marked while the patient was in the upright position. Surgery was performed under topical anesthesia with a 2.8-mm corneal incision and a 1-mm paracentesis. An intracameral anesthetic was injected, and the chamber was filled with an ophthalmic viscosurgical device (Healon, Abbott Medical Optics). The first step in luxating the IOL is to disengage the lens capsule from the inter-haptic groove. This was done with an IOL rotator spatula (Bausch + Lomb) and the OVD cannula. A cushion of OVD was injected behind the IOL, preventing vitreous prolapse. The rest of the IOL was disengaged from the capsule and prolapsed into the anterior chamber. The lens was cut using an IOL cutter (Moria) and removed through the main incision using coaxial forceps. The replacement BIL was injected and manipulated into the capsule opening. An injection of intracameral Miostat (Alcon) was used to prevent iris capture. Residual OVD was aspirated, and the corneal wound was hydrated.
Take-home message
As cataract surgeons, we always aim to get our surgeries correct the first time, but sometimes the best course of action is lens explantation. The BIL has no haptics, and therefore, when it has to be released from the capsular bag, it is more forgiving than a standard lens. This is a helpful feature when dealing with refractive surprises, particularly in post-RK patients and in keratoconus, in which targeting emmetropia can be challenging.
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