October 2018


Device focus
Implanting an IOL in the sulcus

by Michelle Stephenson EyeWorld Contributing Writer

Enlarge the main incision prior to implanting a three-piece IOL into the sulcus to avoid unnecessary pressure.

Dialing three-piece IOL into the sulcus

Well-centered three-piece IOL in the sulcus; all wounds are sutured closed (to prevent vitreous tracking to the wound) and round pupil (no peaking)
Source (all): Sumit “Sam” Garg, MD

Selecting the correct lens and proper placement are key to a good outcome

Occasionally, such as in the setting of a posterior capsular tear, lenses need to be placed in the sulcus instead of in the capsular bag. Choosing the correct lens and proper placement can help to ensure a good outcome.
“When we find that there’s not adequate support within the bag, we will look to the sulcus as the next best place to implant a lens securely,” said Sumit “Sam” Garg, MD, Irvine, California. “Typically, you want to make sure that you’re putting a three-piece lens into the sulcus. A one-piece lens is never indicated for the sulcus. I generally will use one of two lenses: the Tecnis ZA9003 [Johnson & Johnson Vision, Santa Ana, California] or the CT LUCIA 602 [Carl Zeiss Meditec, Jena, Germany]. The reason for choosing one over the other depends on the eye. If I think there’s a high likelihood that the lens is going to slip in the future, I gravitate toward the CT LUCIA lens because the haptics on this lens are more amenable to scleral fixation.”
Elizabeth Yeu, MD, Norfolk, Virginia, agreed. She said that the ideal lens for sulcus placement is a three-piece lens with a round anterior edge. The only round-edged anterior optic lenses available in the U.S. are the Sensar AR40e hydrophobic acrylic three-piece IOL (Johnson & Johnson Vision) and the CQ2015 collamer three-piece IOL (STAAR Surgical, Monrovia, California). “The square edge of the anterior optic can rub against the posterior aspect of the iris and lead to chafing and varying degrees of inflammation and/or UGH syndrome. Additionally, you can use certain three-piece lens choices if you are going to do a piggyback lens technique in order to help manage a refractive miss,” Dr. Yeu said.

Multifocals in the sulcus

Dr. Garg said to use caution when placing a three-piece multifocal lens in the eye. “One of the challenges with placing a lens in the sulcus is ensuring centration. Because there is more space in the sulcus than there is the bag, the lens can gravitate off center more easily. Centering a multifocal lens in the sulcus can be challenging. That’s where something like optic capture comes into play, where you can ensure centration, especially if your anterior rhexis is well centered,” he said.
Dr. Yeu agreed and noted that she would only implant a multifocal lens in the sulcus in very specific situations. “If you have a compromised posterior capsule to the point where your only option would be placing the three-piece multifocal in the sulcus, I wouldn’t do it unless you had a perfectly centered rhexis that was created by a femtosecond laser, so you could place it into the sulcus and do an optic capture into the bag. However, the lens is only going to be available in the high add powers. The three-piece option is not available in the low add multifocal lens powers. No one should place the currently available one-piece lenses in the sulcus,” she said.

Power of the implant

When implanting a lens in the sulcus, the power of the IOL may need to be adjusted, depending on the power of the lens. According to Dr. Garg, lower powered lenses (below 14 D) do not necessarily require a change in lens power. “As you move a lens into the sulcus, the lens power effectively increases, so you will need to decrease the lens power accordingly,” he said. “In patients with lens powers between 18 and 23, I usually take 0.5 D off the lens power. If the lens power is above 24, I take 1 D off the lens power as I move it forward.”
Michael Greenwood, MD, Fargo, North Dakota, said that he would use optic capture in patients who have a posterior capsule break. “If I’m planning to implant a lens in the sulcus of a patient who has a nicely centered capsulotomy with good anterior capsule support, I’ll put the lens in the sulcus and optic capture the optic. The reason for optic capture is that it stabilizes the lens, so I don’t have to worry about that lens dislocating or moving in the future,” he said.

Learning curve

According to Dr. Garg, placing a lens in the sulcus is not commonly performed. “I encourage our residents to practice placing three-piece lenses in intact capsular bags because placing a three-piece lens into the bag requires a little more nuance and sort of gymnastics with the haptics and how the lens acts in the eye compared with a one-piece lens. A one-piece lens is usually forgiving and goes into the eye easily. With a three-piece lens, depending on the model that you’re using, you have to twist and turn as you go in to make sure that it comes out in the right orientation. I would recommend practicing on eyes when things have gone well,” he said.
Dr. Garg also recommended practicing with different three-piece lenses. “With some lenses, there can be a little bit more pressure getting through the wound. In an eye with a capsular tear, putting pressure on the wound can sometimes promote vitreous coming forward. I recommend enlarging the wound a little bit so that when you go into the eye, you’re not causing any undue pressure,” he said.
Dr. Greenwood agreed, noting that it requires a different skill set to put a lens in the sulcus. “You don’t want it to be your first time or your staff’s first time using a three-piece IOL when it’s in the heat of the moment and you’re a little nervous because you had a complicated cataract, it’s taking a little longer, and the patient is a little less comfortable. Make sure that you and your staff are comfortable loading and injecting three-piece IOLs,” he said.
Dr. Yeu added that new sulcus- based technologies are needed. “It would be helpful to use sulcus-based technologies to create zero accommodation or a pinhole effect to improve presbyopia correction in someone who is already pseudophakic. There are options that we have not explored with current technologies, but it is a procedure that we generally reserve for when we are either fixing a refractive miss or because there’s a capsular bag compromise. But I do think the sulcus space holds potential for ways that we can help patients in the future once we have technologies that are compatible with living in the sulcus space,” she said.

Editors’ note: Dr. Garg has financial interests with Johnson & Johnson Vision and Carl Zeiss Meditec. Dr. Yeu has financial interests with Johnson & Johnson Vision. Dr. Greenwood has no financial interests related to this article.

Contact information

: gargs@uci.edu
Greenwood: Michael.greenwood@vancethompsonvision.com
Yeu: eyeu@vec2020.com

Implanting an IOL in the sulcus Implanting an IOL in the sulcus
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