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Suture fixation secures dislocated IOL to iris

Every cataract surgeon should be prepared to suture the haptics to the iris in cases with complications.

Rarely the IOL can dislocate after cataract surgery, particularly in cases in which there has been capsular compromise or another complication. If we have a patient with a three-piece IOL, we can easily suture the haptics to the posterior surface of the iris. This is a technique that every cataract surgeon can learn to perform.

For example, a patient had cataract surgery performed with the complication of a ruptured posterior capsule. A three-piece hydrophobic monofocal acrylic IOL was placed in the sulcus, and the patient did well initially. However, after a few months the IOL became dislocated, and it was determined that there was some capsular support but not a sufficient amount for long-term stability (Figure 1).

The critical first step of the surgery is to make sure that the IOL does not fall back into the vitreous cavity. You do not want the pupil widely dilated; rather, you want it to be 5 mm or less in diameter. The optic of the IOL should be prolapsed into the anterior chamber and held above the iris while the haptics are below the iris in the sulcus.

dislocated three-piece IOL
Figure 1. This patient has a dislocated three-piece IOL due to capsular compromise during the original cataract surgery. This large degree of dislocation is negatively affecting the patient’s vision, and suture fixation of the IOL to the iris is a good option.

Source: Uday Devgan, MD

Multiple paracentesis incisions can be made for access. There is no need for a large main incision because the three-piece IOL is already in the eye. Viscoelastic is put behind the IOL optic to help support it and then in the anterior chamber to protect the corneal endothelium and prevent it from collapsing.

Using the spatula or other instrument to tent up the optic will allow you to see the outline of the haptics, and it makes suturing them easier. Using a 10-0 (or 9-0) polypropylene monofilament suture with a long needle (curved or straight), a pass is made in the mid-periphery of the iris, not near the pupil margin. At this point, the second suture can be passed around the other haptic. Note how we keep the first needle in the eye to support the first haptic while we pass the second needle under the second haptic (Figure 2).

optic is prolapsed through the pupil while the haptics are under the iris
Figure 2. The optic is prolapsed through the pupil while the haptics are under the iris. Using a long needle, 10-0 polypropylene suture is passed through the iris mid-stroma and under the haptic, close to the haptic-optic junction.

Before cinching down the knots (a 3-1-1-1 knot is recommended), be sure to pull the pupil margin centrally to avoid incarcerating excessive iris tissue in the suture. This is the key to avoiding the ovoid pupil. As you can see in the postop picture, the pupil is still reasonably round and functions normally (Figure 3).

In an eye with a prior vitrectomy (anterior or posterior), iris fixation of the IOL is better if there is at least some degree of capsular rim support. If there is zero capsular support, just relying on these two sutures may not be sufficient to hold the IOL and the IOL may dislocate after just a few years. These IOLs tend to slip out of the knots, and the extra weight of the IOL can cause the iris to become hyper-mobile, leading to further issues. In these eyes with zero capsular support, a scleral-fixated IOL may be a better option.

In many countries, there are IOLs that can be clipped to the iris, to either the anterior or posterior surface. In particular, the placing of an iris claw lens against the posterior surface of the iris can give great results. This lens option is not available in the U.S. because none have secured FDA approval.

postop appearance shows a well-centered IOL
Figure 3. The postop appearance shows a well-centered IOL, a reasonably round pupil and sutures that are securing the IOL haptics.

A properly positioned anterior chamber IOL can also have excellent results, and many studies have shown the long-term outcomes are similar to iris- or scleral-fixated posterior chamber IOLs. While the video for a sutured posterior chamber IOL may be more fun to watch and the surgery more challenging, never underestimate the potential benefit from an anterior chamber IOL.

The case shown was performed by a senior resident with about 200 cataracts of experience. Certainly, just about any ophthalmologist should be able to learn this technique.

A full video of this technique can be found at CataractCoach.com, which is a free teaching website.

Disclosure: Devgan reports he owns the CataractCoach.com website, which is free and noncommercial.

Rarely the IOL can dislocate after cataract surgery, particularly in cases in which there has been capsular compromise or another complication. If we have a patient with a three-piece IOL, we can easily suture the haptics to the posterior surface of the iris. This is a technique that every cataract surgeon can learn to perform.

For example, a patient had cataract surgery performed with the complication of a ruptured posterior capsule. A three-piece hydrophobic monofocal acrylic IOL was placed in the sulcus, and the patient did well initially. However, after a few months the IOL became dislocated, and it was determined that there was some capsular support but not a sufficient amount for long-term stability (Figure 1).

The critical first step of the surgery is to make sure that the IOL does not fall back into the vitreous cavity. You do not want the pupil widely dilated; rather, you want it to be 5 mm or less in diameter. The optic of the IOL should be prolapsed into the anterior chamber and held above the iris while the haptics are below the iris in the sulcus.

dislocated three-piece IOL
Figure 1. This patient has a dislocated three-piece IOL due to capsular compromise during the original cataract surgery. This large degree of dislocation is negatively affecting the patient’s vision, and suture fixation of the IOL to the iris is a good option.

Source: Uday Devgan, MD

Multiple paracentesis incisions can be made for access. There is no need for a large main incision because the three-piece IOL is already in the eye. Viscoelastic is put behind the IOL optic to help support it and then in the anterior chamber to protect the corneal endothelium and prevent it from collapsing.

Using the spatula or other instrument to tent up the optic will allow you to see the outline of the haptics, and it makes suturing them easier. Using a 10-0 (or 9-0) polypropylene monofilament suture with a long needle (curved or straight), a pass is made in the mid-periphery of the iris, not near the pupil margin. At this point, the second suture can be passed around the other haptic. Note how we keep the first needle in the eye to support the first haptic while we pass the second needle under the second haptic (Figure 2).

optic is prolapsed through the pupil while the haptics are under the iris
Figure 2. The optic is prolapsed through the pupil while the haptics are under the iris. Using a long needle, 10-0 polypropylene suture is passed through the iris mid-stroma and under the haptic, close to the haptic-optic junction.

Before cinching down the knots (a 3-1-1-1 knot is recommended), be sure to pull the pupil margin centrally to avoid incarcerating excessive iris tissue in the suture. This is the key to avoiding the ovoid pupil. As you can see in the postop picture, the pupil is still reasonably round and functions normally (Figure 3).

In an eye with a prior vitrectomy (anterior or posterior), iris fixation of the IOL is better if there is at least some degree of capsular rim support. If there is zero capsular support, just relying on these two sutures may not be sufficient to hold the IOL and the IOL may dislocate after just a few years. These IOLs tend to slip out of the knots, and the extra weight of the IOL can cause the iris to become hyper-mobile, leading to further issues. In these eyes with zero capsular support, a scleral-fixated IOL may be a better option.

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In many countries, there are IOLs that can be clipped to the iris, to either the anterior or posterior surface. In particular, the placing of an iris claw lens against the posterior surface of the iris can give great results. This lens option is not available in the U.S. because none have secured FDA approval.

postop appearance shows a well-centered IOL
Figure 3. The postop appearance shows a well-centered IOL, a reasonably round pupil and sutures that are securing the IOL haptics.

A properly positioned anterior chamber IOL can also have excellent results, and many studies have shown the long-term outcomes are similar to iris- or scleral-fixated posterior chamber IOLs. While the video for a sutured posterior chamber IOL may be more fun to watch and the surgery more challenging, never underestimate the potential benefit from an anterior chamber IOL.

The case shown was performed by a senior resident with about 200 cataracts of experience. Certainly, just about any ophthalmologist should be able to learn this technique.

A full video of this technique can be found at CataractCoach.com, which is a free teaching website.

Disclosure: Devgan reports he owns the CataractCoach.com website, which is free and noncommercial.

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