February 2012




Anterior segment grand rounds

Golfer gets a new bag

by Steven G. Safran, M.D.


Case presentation

This is a very young and active 85-year-old gentleman who is an avid golfer. He was referred to me 5 years after his cataract surgery with an SI40 implant decentered within the capsular bag. He was complaining of glare and decreased vision in his left eye. He has no problem with the other eye, which is also pseudophakic and 20/20 uncorrected.

On examination, his vision in this eye is 20/50 but corrects to 20/25-2 with a plus 1.0 refraction. His implant is completely within the capsular bag, but is decentered 2 mm to 3 mm superiorly within the confines of the bag. There is significant posterior capsule haze, and the anterior and posterior capsules are fused inferiorly from 4:00 to 8:00. His cornea topography is unremarkable, his macula optical coherence tomography is completely normal, and he has an endothelial cell count of 2,400. He does not wear distance glasses nor does he wish to start.

Steven G. Safran, M.D., ASGR editor

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Figure 1. Slit lamp image of his left eye at presentation

Figure 2. The patient looked like this post-op day 1

Roundtable discussion

To discuss this case, I am fortunate to have an experienced and erudite panel of superb anterior segment surgeons:

Uday Devgan, M.D., Robert Nasser, M.D., Garry Condon, M.D., Baseer Khan, M.D., and Dan Goldberg, M.D.

Dr. Devgan commented: "From the photo, it appears that one haptic of this three-piece IOL is above the capsulorhexis edge and in the sulcus. This asymmetric placement of the IOL, with one haptic in the bag and the other in the sulcus, very often leads to IOL decentration and excessive capsular bag contraction and fibrosis.

"Since the patient desires surgical correction of the vision in this eye, the treatment must address IOL centration as well as residual refractive error. In this situation, the IOL can be brought out of the capsular bag and placed entirely within the sulcus to help center the IOL as well as provide a more anterior positioning of the optic, which would likely result in a near plano post-op refraction. The alternative would be to explant this IOL and place a new, appropriate-power sulcus IOL."

Dr. Nasser also felt that the implant appeared to have an "in and out of the bag" configuration based on Figure 1. "I suspect the IOL has one haptic in and one out of the bag. I'd exchange the IOL rather than reposition as the lens power needs to be addressed (+1 versus plano other eye). A properly sized sulcus lens is likely the best choice. I suspect the capsule has fused and will be difficult to open fully, but if one can tease open the capsular leaves and be sure of in-the-bag placement, I would place a lens in the bag. I'd use both topical NSAIDs and steroids pre- and post-op.

"If the posterior chamber had not been able to be cleaned at surgery, 6 to 8 weeks post-op I'd YAG the capsule."

Although an "in and out" syndrome, one haptic in the bag and one haptic out, can certainly look much like this implant does, in this case I was able to ascertain at slit lamp exam and with gonioscopy that both haptics (as well as the optic) were completely within the confines of the capsular bag.

Dr. Condon commented: "The IOL appears to be completely in the bag. It looks as though its edge might well be covered by the pupil if it wasn't dilated pharmacologically. It's not likely a new or recent IOL placement. So the key question is whether his symptoms arose as the PCO [posterior capsule opacification] developed. If there are prior records suggesting longstanding decentration, then that's more support in favor of trying simple YAG as the initial step. That still leaves the option of recentering with a suture or a more involved repos or exchange. Since the IOL is in the bag, I'm not convinced trying the YAG first burns any bridges.

"Also if YAG does not help, moving the IOL from the bag to sulcus and suturing haptics to the iris to stabilize would be something I'd think about. That might also help get him closer to emmetropia."

Dr. Khan was willing to consider the possibility of doing a YAG capsulotomy here as a first option under certain circumstances: "My first question to the patient would be if he was happy with his vision after surgery, at least for the first few months. I'd be trying to establish if the tilt and the edge effect of the IOL or spherical error of the lens is bothersome to him or whether it is the PCO that is bothering him.

"If the complaint of visual disturbance is more recent, suggesting PCO as the cause of his unhappiness, then I might consider doing a YAG capsulotomy. If there is clinical suspicion that the tilt and error is contributing to the patient's symptoms, then I would plan to do a repositioning. With the lens partially in the bag, it would be reasonable to assume that one could reinflate the bag and reposition the IOL in the bag. If for whatever reason the bag cannot be reinflated, my fallback position would be to amputate the haptics, explant the optic, and place a Sensar lens [Abbott Medical Optics, AMO, Santa Ana, Calif.] in the sulcus. In both of these scenarios, I would perform a YAG capsulotomy after a minimum of 1 month after surgery."

Finally Dr. Goldberg felt (as I did) that a YAG capsulotomy would likely not be enough to solve this patient's problems. "This exceptional gentleman will not be satisfied with a simple YAG capsulotomy and fortunately has a healthy ocular surface, cornea, and retina, so he is an excellent candidate to repair the superiorly subluxed PCIOL. The IOL appears to be in the bag, and it appears that the anterior capsulotomy ring is reasonably centered and could serve as a good scaffold for reverse optic capture. A secondary benefit would be reduced hyperopia from a more anterior optic."


At the time I saw this patient I considered a few different surgical options, but ultimately chose the option that I felt would give me the best chance to correct all the patient's complaints with one procedure. I felt that a YAG capsulotomy would still leave this patient hyperopic and coping with issues related to edge glare and could make future surgical intervention more complicated. I was nervous about repositioning this particular implant because I did not know if the haptics were kinked or damaged (as I couldn't visualize them completely). I decided to replace this lens for another implant of greater power, a three-piece Tecnis Acrylic (AMO) in the capsular bag. View a video of the surgery at youtu.be/qA19XQoOOzk.

In this case I used a 26-gauge spatula-tipped LASIK cannula to enter the anterior capsule and inject viscoelastic to reopen the capsular bag. This is an ideal instrument for this because of its blunt, flat tip.

You may note at 4:51 in the video there is what looks like a posterior capsule tear, but it's actually the ring of fibrosis that was fusing the capsule together between 4:00 and 8:00 that has been pulled off the rim of the anterior capsule and is now floating free like a ring of scotch tape.

In Figure 2, you can see the ring of fibrosis that was apparent on the video now extending from the capsule and wrapping around behind the implant.If I had been a little more aggressive at the time of surgery this ring of fibrosis most likely could have been removed entirely. A YAG capsulotomy was never needed in this case. This case demonstrates that beneath the LEC (lens epithelial cell) proliferation and its associated fibrosis an elastic, clear capsular bag may be found even in an 85-year-old years after his initial surgery. The capsule itself isn't what becomes stiff and fibrotic; it is the LEC metaplastic transformation into myofibroblasts laying down collagen and connective tissue with contractile properties that transform a clear and elastic capsule into something with a substance like stucco or rubber cement layered on it. If you can strip that off you may find a virgin elastic capsule underneath. This demonstrates the importance of meticulous LEC removal at the time of cataract surgery. It also illustrates that creating a perfect rhexis (as was clearly present in this case) is secondary to removing these LECs if one is to avoid the issues of capsular phimosis, fibrosis, and contraction that will lead to problems with implant tilt and centration and to achieve predictable outcomes with current and future accommodating IOL designs.

Dr. Goldberg made the excellent suggestion of reverse optic capture, which I feel is very reasonable and something I did not consider at the time. After viewing the video of the surgery, Dr. Condon agreed: "It's also interesting how the existing IOL seemed to center nicely once you released some of the cap fibrosis. Reverse optic capturing at that point might have secured centration and induced enough myopic shift to help the hyperopia. Just a thought."

I did this case 3.5 years ago and reverse optic capture was not something yet popularized as a treatment for negative dysphotopsia (by Samuel Masket, M.D.), so it wasn't on my radar screen. Traditional optic capture in the bag with haptics in the sulcus was considered, but ultimately I felt that exchanging this lens for the exact IOL I wanted would give me a chance to correct the refractive outcome, clean out the bag, obtain the advantage of an aspheric implant, and avoid any possible problems related to a damaged haptic. It worked out well in this case with a 20/20 uncorrected visual outcome and relief of all negative visual symptoms. Depending on the desired refractive outcome, anterior optic capture or even optic capture through a posterior capsulorhexis could be considered along with other options for cases that present like this in the future.

Editors' note: The doctors mentioned have no financial interests related to this article.

Contact information

Safran: safran12@comcast.net

Anterior segment grand rounds Golfer gets a new bag Anterior segment grand rounds Golfer gets a new bag
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