April 2018


Anterior segment grand rounds (ASGR)
Going from “pseudoexaphakia” to exaphakia

by Steven Safran, MD

Video 1. Gore-Tex suture lasso of dislocated Akreos IOL/bag complex

Video 2. IOL
exchange/PPV/double needle ISHF/KDB blade

Figure 1. Dislocated Akreos lens in capsular bag complex OS

Figure 2. Pseudoexfoliation cataract in OD

Figure 3. Opacified Akreos IOL

Figure 4. 1 week postop

Figures 5 and 6. Melted haptic tips seen at the slit lamp (tip of arrows)
Source (all): Steven Safran, MD

This is an active, healthy, 79-year-old woman. She has been referred for a dislocated IOL capsular bag complex in the left eye and is 10 years out from her original cataract surgery in which a hydrophilic acrylic one-piece lens with four loop haptics (Akreos A060, Bausch + Lomb, Bridgewater, New Jersey) was placed. In this eye, she has a history of pseudoexfoliation glaucoma and has an IOP of 21 on topical timolol and travoprost drops. On slit lamp exam the eye appears to be aphakic with no IOL or capsular bag visible, but after being maximally dilated the top of the IOL/bag complex can be visualized bobbing around in the anterior vitreous (Figure 1). She is currently wearing an aphakic soft contact lens with which she sees 20/25, but she has difficulty putting it in and taking it out. Her endothelial cell count is excellent in both eyes, and she has no significant glaucoma damage on OCT imaging of the optic nerves. In the right eye she has a 20/70 cataract and evidence of pseudoexfoliation syndrome as well (Figure 2).

Steven Safran, MD,
ASGR editor

Management of patient with pseudoexfoliation syndrome 10 years post-cataract surgery who is now functionally aphakic and has a symptomatic cataract in the other eye

I asked my colleagues on Keranet and the ASCRS listserv, “What would you do for this patient and in what order would you suggest doing it?” Here are some of the responses I received.
Steven Rosenfeld, MD, Delray Beach, Florida, said, “I would recommend a cataract extraction with a three-piece silicone IOL (LI61AO, Bausch + Lomb) in the right eye, since the left eye with the dislocated PC IOL and capsular bag complex has 20/25 vision with an aphakic CL. Once the right eye is healed with stable vision, I would remove the Akreos IOL/capsular bag complex and perform a vitrectomy, insert a three-piece PC IOL, and secure it in the sclera without sutures using intrascleral haptic fixation.”
Matthew Ward, MD, Provo, Utah, commented, “I presume she is tolerating the aphakic SCL OK. If so, I would focus on the cataract eye first and would perform phaco/IOL with CTR; she appears to dilate well enough not to require a Malyugin ring. I like the CTR there as it makes suturing easier in case she starts to dislocate. I would not preemptively support the capsule with a sutured device unless there is significant lens mobility during surgery.
“If all goes well with the cataract surgery, I would proceed with IOL exchange in the other. I would lay the patient back in the exam lane to see if I can tell whether there is posterior migration of the IOL in a supine position. If the IOL drifts posterior, I would involve a vitreoretinal colleague to retrieve the IOL from the back. I wouldn’t attempt to suture the existing Akreos IOL, but would remove it and suture in an enVista IOL [Bausch + Lomb] using 7-0 Gore-Tex.”
Richard Schulze, MD, Savannah, Georgia, observed, “This is a challenging case of an active 79-year-old with pseudoexfoliation in both eyes, a dislocated IOL/capsule complex in the left, a cataract in the right, and glaucoma secondary to pseudoexfoliation in both eyes that is apparently well controlled without any evidence of optic nerve damage on OCT. I would focus my efforts on rehabilitating the left eye before addressing the cataract on the right. As I see it, there are three reasonable alternatives for reestablishing pseudophakia in the left eye.
“First, perform four-point scleral suture fixation of the Akreos IOL through Hoffman pockets or a scleral groove. This might be my first choice since the loops of the Akreos are already there, virtually crying out to be supported with sutures.
“Second, exchange the Akreos for an EC-3 PAL [Carl Zeiss Meditec, Jena, Germany] placed via a Yamane technique.
“Last, exchange the Akreos for an anterior chamber lens. Although an AC IOL may perhaps not be ideal, one must recognize that not every surgeon has the necessary skill for a sutured posterior chamber lens. Attempting an infrequently used technique with unfamiliar instrumentation can lead to unanticipated problems that can make things far worse, thus violating the first rule of medicine: Do no harm. If sized properly, an AC lens can be well tolerated, provide excellent vision (no dysphotopsias), and has the virtue of simplicity, falling well within the skill set of the average surgeon. One must remember to place a PI at the time of AC IOL insertion. A PI can easily be placed with a vitrector in IA/cut mode using a super slow cut speed and one snip. Alternatively, if no vitrectomy is performed (it is possible to do a case like this without needing a vitrectomy if dispersive OVD is used to tamponade the vitreous prior to removing the existing IOL), a Fugo blade can be used to perform a clean PI without risk of hemorrhage since the plasma energy of the Fugo provides hemostasis.”
Kamran Riaz, MD, Chicago, noted, “I would first ask her which eye bothers her more. I suspect it would be her right eye given the VA and the fact that she sees reasonably well with her CL in the left eye.
“I would proceed to do CE + IOL with CTR placement in the right eye. I would preemptively place an EC-3 PAL in the bag as it is a three-piece IOL, and if the bag/IOL were to dislocate later, one could suture the CTR, or if things became similar to the left eye, I could remove the bag and use the Yamane technique for scleral fixation with this IOL. Intraoperatively, I would use Shugarcaine to augment pupil dilation. I would also have two CTS available in case there was large zonular dialysis that would require additional capsular support. Depending on her IOP/HVF, I would also do a MIGS procedure, such as an iStent [Glaukos, San Clemente, California] at the time of surgery.
“After allowing for the right eye to heal, I would discuss surgical options for her left eye. If she wished to proceed with surgery, I would remove the Akreos/bag complex and perform a thorough vitrectomy, then use the Yamane technique to scleral fixate an EC-3 PAL in this eye. Also depending on her IOP/HVF in this eye, I would consider a MIGS procedure such as a Kahook Dual Blade [New World Medical, Rancho Cucamonga, California].

What was done

I offered this patient the choice of which eye to tackle first, and she wanted to fix the dislocated lens in the left eye. My original plan was to lasso this Akreos lens/bag complex with Gore-Tex sutures using the same technique I used in a previous case with success (see Video 1).
Unfortunately, the patient in this video came in 2 years postoperative—and 1 week after I saw the patient we are currently discussing—and his lassoed hydrophilic acrylic had opacified leading to a decrease in vision. The same week, I was referred another patient with a history of trabeculectomy, RD repair with silicone oil (subsequently removed), and a previous YAG capsulotomy with an opacified Akreos as well (Figure 3).
At this point, I was already aware of reports of opacification of Akreos lenses after placement of an air bubble in the eye to perform endothelial keratoplasty, but neither of these two patients had a history of such procedure so it became clear to me that these hydrophilic acrylic IOLs may opacify over time in complex eyes even without the placement of an air bubble to perform DSAEK or DMEK. With this concern, I decided to abandon my plan to lasso the Akreos lens and instead remove the IOL/capsular bag complex completely by elevating it up into the anterior chamber from a pars plana approach, performing pars plana vitrectomy, cutting and entirely removing the complex and performing a Yamane style double needle intrascleral haptic fixation of a three-piece hydrophobic acrylic EC-3 PAL lens. I also planned to do a goniotomy with a Kahook Dual Blade to help control the IOP (see Video 2).
At 1 week postop her vision in this eye was 20/20-2 uncorrected with an IOP of 16 (Figure 4). Figures 5 and 6 demonstrate what the melted haptic tips look like at the slit lamp; they are flush and barely visible.
At 1 month the vision remained at 20/20, and IOP was 16 on topical timolol only, so a decision was made to do the cataract surgery in the other eye. This was performed uneventfully using a Symfony lens (Johnson & Johnson Vision, Santa Ana, California) along with placement of a CTR resulting in 20/20 uncorrected vision. The patient was very happy with the final outcome.
I chose to present this case to highlight the fact that hydrophilic acrylic IOLs can opacify over time in eyes that have a history of secondary procedures, and those procedures do not necessarily have to include placement of air or gas in the eye. I think this makes these implants an inappropriate choice for use in complex eyes even though they are relatively easy to suture fixate. It is clear to me that we now have with the Yamane intrascleral haptic fixation approach another alternative that can be used safely through a small incision and that requires no conjunctival dissection. With this technique, we can utilize a hydrophobic acrylic lens that has no history of opacification or degradation over time. I think that this is the safest and most stable current option for these patients that we have available to us.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

: kamranmriaz@gmail.com
Rosenfeld: srosenfeldmd@gmail.com
Safran: safran12@comcast.net
Schulze: richardschulze@comcast.net
Ward: mattsward@gmail.com

Going from “pseudoexaphakia” to exaphakia Going from “pseudoexaphakia” to exaphakia
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