A Monday morning symposium sponsored by the International Intra-Ocular Implant Club (IIIC) focused on lens-based surgery, including complications, new technology, and advanced techniques.
One presentation given by David F. Chang, MD, involved the referral of a monofocal IOL patient who experienced visual distortion after uncomplicated cataract surgery 5 months prior. A complicating factor for this patient was time; she was scheduled to leave for the Bahamas, where she would remain for 2 months, the following week. Upon examination and surgical exploration, this patient’s lens was centered, but iTrace (Tracey Technologies) was showing 8 D of refractive cylinder, and her corneal cylinder was about 2.3 D.
Dr. Chang said he went in and saw the haptic folded in on itself. He saw the rhexis but not the rest of the bag. “I think she’s got zonular dialysis or something,” he said. Dr. Chang removed the lens and implanted a T6 toric. He used digital alignment and placed the haptic away from the area of zonular dialysis. His thought was that he could try a toric and if he couldn’t get the right alignment, he would take it out and put a three-piece lens in the sulcus. The patient went to the Bahamas as planned, and 2 months later was 20/30 and happy.
Another case was presented by Brandon D. Ayres, MD. It involved a traumatic cataract with iris repair. Dr. Ayres said that a retina colleague was on hand in case nuclear fragments were dropped during the procedure. Given the density of the lens, which he described as black like a bowling ball, he used miLOOP (Zeiss) and was able to get four pieces, while still maintaining the capsular bag, to his surprise.
He physically pushed the lens pieces to the phaco tip and said with careful use of OVD, there was no significant endothelial cell loss. A lens was put in the bag in line with the zonulopathy. Dr. Ayres said the haptics added power to the CTS he had placed. He had put in an Ahmed segment with off-label GORE-TEX, adding tension until the IOL looked centered.
Then he did a small anterior vitrectomy and prepared to address the traumatically dilated iris. He used a cerclage suture all the way around the pupil, eventually exiting through the paracentesis from which he had entered. He tightened until he got a 3.5–4 mm pupil.
Boris Malyugin, MD, PhD, shared surgical steps that he recommends for intraocular astigmatism correction in patients with small pupils.
“We know proper IOL placement and rotational stability are very important to achieve a good refractive result and that definitely belongs to toric IOLs,” Dr. Malyugin said. “When we have a pupil that’s restricted, that reduces our visualization of the optic axis marks, and that makes our placement quite challenging.”
His surgical steps using a Malyugin in these cases are as follows:
- Align the toric IOL in the standard fashion following implantation.
- Aspirate OVD from the retro-lenticular space, leaving the Malyugin ring in place.
- Under irrigation, realign the toric IOL to its intended axis. With the OVD removed prior, the lens position remains stable.
- Reintroduce a small amount of cohesive viscoelastic in front of the lens for safe disengagement and removal of the Malyugin ring.
- Remove the cohesive OVD from the anterior chamber.
Dr. Malyugin and his colleagues conducted a small study of cases that followed these steps, finding that the algorithm helps reduce rotation of the lens and the need for additional manipulations at the end of the surgical procedure.
