Dislocated Intracoular Lens (IOL) |
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and Dropped Nucleus |
8.1 Dislocation of the IOL with Capsular Bag due to Zonulolysis
The PPV for a dislocated IOL should be performed by an advanced surgeon because the complication proÞle is high.
DVD
Video 11a, b Luxated IOL and subluxated IOL
Surgical preparation: The surgery should take place under general anaesthesia as it is not a routine surgery and the complication proÞle is high. After removal of the capsular bag, you can suture the IOL to the sclera. One can suture a 3-piece IOL as well as a 1-piece IOL to the sclera. Alternatively, an iris-claw lens can be implanted.
Instruments
1.4-Port trocar
2.120D lens
3.2× Eckardt forceps
4. Polypropylene 10-0 suture with curved needle (i.e. Alcon Polypropylene, blue monoÞlament, double-armed; 8065307601)
Tamponade
Intra-operative: PFCL
Post-operative: None
Individual steps
1. Opening of the conjunctiva at 3 and 9 oÕclock + 4-port trocar
2.Core vitrectomy
3.PFCL bubble as macular protection
4.Grasp the IOL and cut the capsular bag
5. Two sclerotomies (1.5 mm posterior to the limbus) at 3 and 9 oÕclock
6. Extraction of a haptic at 3 oÕclock, place a suture onto the haptic and push it back into the eye. The same procedure at 9 oÕclock
U. Spandau, H. Heimann, Practical Handbook for Small-Gauge Vitrectomy, |
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DOI 10.1007/ 978-3-642-23294-7_8, © Springer-Verlag Berlin Heidelberg 2012 |
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8 Dislocated Intracoular Lens (IOL) and Dropped Nucleus |
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Fig. 8.1 A dislocated IOL with capsular bag. After removal of the capsular bag, the IOL can be sclera-Þxated
7. Suture the haptic suture in a snake shape to the sclera 8. Removal of PFCL and closure of conjunctiva
1. Opening of the conjunctiva at 3 and 9 o’clock + 4-port trocar
Open the conjunctiva at 3 and 9 oÕclock to make space for one sclerotomy and a scleral suture, i.e. approximately from 2 to 4 oÕclock and from 8 to 10 oÕclock. Then cauterise the bleeding vessels. Insert the trocars and the chandelier light as usual for the 4-port trocar system.
2. Core vitrectomy
3. PFCL for macular protection
4. Grasp the IOL and cut the capsular bag
First, vitrectomise the central vitreous. ConÞrm the presence of a PVD or create a PVD before injecting PFCL. Then inject a small PFCL bubble at the posterior pole to protect the macula (Fig. 8.1). Hold the IOL bimanually with the forceps and cut the capsular bag with the vitreous cutter (Figs. 8.2Ð8.4).
5. Two sclerotomies (1.5 mm posterior to the limbus) at 3 and 9 o’clock
6. Extraction of a haptic at 3 o’clock, place a suture onto the haptic and push it back into the eye. The same procedure at 9 o’clock
In case of a 3-piece IOL, fasten the suture in the middle of the haptic, and in case of a 1-piece IOL, at the end of the haptic (Fig. 8.5).
In the area of the sulcus, 1.5 mm posterior to the limbus, perform an approximately 1.3-mm sclerotomy (Fig. 8.6). The sclerotomy must be perpendicular (i.e. approximately 90¼ to the sclera) in order not to harm the anterior chamber. Via the sclerotomy at 3 oÕclock, grasp a haptic with an Eckardt forceps (Fig. 8.7) and pull it out of the eye. Cut a 10-0 polypropylene suture with two curved needles in two halves. Then place a
8.1 Dislocation of the IOL with Capsular Bag due to Zonulolysis |
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Fig. 8.2 Bimanual technique. Grasping the Þbrotic capsule with a serrated-jaw forceps and removing it with a vitrector
Fig. 8.3 If the Þbrotic capsule is too hard for the vitrector, you may either remove it with the Fragmatome or luxate it into the anterior chamber. Perform a 2.75-mm tunnel and remove the hard capsule. Do not extract the IOL
Fig. 8.4 Now, the 3-piece IOL is positioned with a forceps in the middle of the vitreous cavity area, and the residual capsular bag is removed with the vitreous cutter
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8 Dislocated Intracoular Lens (IOL) and Dropped Nucleus |
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Fig. 8.5 A luxated 1-piece IOL can also be scleraÞxated. It is important that the suture is fastened to the end of the haptic
Fig. 8.6 After opening the conjunctiva, two sclerotomies at 3 oÕclock and 9 oÕclock are placed 1.5 mm behind the limbus. It is important to perform a perpendicular (90¼) sclerotomy; otherwise you will damage the anterior chamber
Fig. 8.7 In this step, one haptic of the IOL is grasped and extracted through a sclerotomy at 3 oÕclock. The photo shows how the Eckardt forceps grasps a haptic in order to extract it
8.1 Dislocation of the IOL with Capsular Bag due to Zonulolysis |
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Fig. 8.8 The haptic was drawn outside with Eckardt forceps. In the picture, a 10-0 polypropylene suture is tied to one haptic. Subsequently, the haptic is pushed back into the eye, and the suture is sutured in 5 snake-shaped stitches without a Þnal knot to the sclera
Fig. 8.9 Drawing of the |
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suture technique. Suture 5 |
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snake-formed stitches in and |
Infusion |
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out the sclera and cut the |
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suture without a knot |
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Cmolter |
Endoillumination
10-0 Prolene suture to the haptic (Fig. 8.8) and insert the haptic back into the eye. Perform the same manoeuvre at the 9-oÕclock sclerotomy. After the haptic has been pushed back, centre the IOL by pulling carefully on both sutures.
7. Suture the haptic suture in a snake shape to the sclera
Different techniques are now possible. One can place Þve U-shaped sutures in the shape of a snake to the sclera and then cut off the suture without a knot. A knot can cause a disturbing foreign body sensation to the patient (Fig. 8.9). Alternatively, you can prepare a scleral ßap, fasten the suture to the sclera and place the knot under the scleral ßap.
8. Removal of PFCL and closure of conjunctiva
Aspirate the PFCL. The conjunctiva is closed with an Vicryl 8-0 suture. The sclerotomies do not need to be sutured.