Glued IOL technique and a new challenging case

ByUday Devgan, MD

For the Aug. 31 blog entry, I presented a difficult case of sectoral iris loss and aphakia with no capsular support. After doing my homework and reading the excellent comments to the blog entry (thank you), I felt that the best restorative surgery would be suturing the iris defect as best as possible using the patient's ptosis to my advantage, then placing a three-piece IOL intrasclerally using a combination of the Agarwal glued IOL technique and the Scharioth tunnel technique. The results were good, but not perfect - and that's what we expected since there's no way to give completely normal form or function to an eye that has suffered such trauma.

Iris capture with the haptic of a single-piece acrylic IOL.

Here are some of the pearls that I learned. In the preop photo, it's clear that the iris has suffered significant trauma and that it is avascular and atrophic. This means that elasticity of the normal iris is gone, and the remaining iris tissue is more friable than usual. A large defect of more than a couple of clock hours is unlikely to be closed primarily with sutures. Instead, I opted to bring the nasal iris tissue superiorly to create a U-shaped pupil since the superior portion of the cornea is blocked by the patient's ptosis. The intrascleral IOL techniques are quite elegant, but there are some challenges. In making the scleral flaps, access is easier if the hinge is made at the limbus. The 25-gauge or 23-gauge hole that is used to bring the haptic transsclerally is slightly larger than the diameter of the haptic so it may leak, particularly in a post-vitrectomy eye. Placement of a 10-0 nylon suture at this site was helpful to tighten this aperture and stop any leak, which is required prior to placing the tissue glue.

The surgery went well, and I expect the patient to have a very good result. When I returned to my clinic later in the afternoon, I saw another patient who will require a restorative re-operation. The patient is a 69-year-old man with a history of recent cataract surgery in both eyes about 2 months ago. He has achieved a best corrected vision of 20/20 in the right eye and 20/25 in the left eye but notes that the left eye is constantly red, irritated and sensitive to light. Corneas are spherical in both eyes, with a plano refraction in the right eye but 2 D of astigmatism in the refraction of the left eye. At the slit lamp, you note that the IOL is partially within the capsular bag and partially above the iris.

What would be your specific surgical technique?

Get more expert perspective from Dr. Devgan live at Hawaiian Eye 2010, to be held January 17-22, 2010 at the Grand Hyatt Kauai. Learn more at OSNHawaiianEye.com.