63.6Subluxated Lens

If, according to the patient, the lens still allows acceptable vision, there is no need to intervene. If there is signiÞcant interference with vision,6 removal is indicated. How the lens is extracted depends on many factors (see Chap. 38).7 However, if there is vitreous prolapse into the AC Ð and this needs to be evaluated using TA8 Ð this must be addressed Þrst.

¥Use an AC maintainer.

¥Through a temporal paracentesis, remove the vitreous using the probe. The port should not be directed downward to avoid injuring the iris.

ÐIf the vitreous is strongly adherent to the iris or the endothelium, do not force its complete removal; just be sure that you severed the connection between the remaining vitreous and the gel behind the lens/iris (see the comments under

Sect. 47.2.2).

63.7IOFB

63.7.1 AC

Whether and how the object is removed depends on many factors; in general, it should be removed unless it is small, inert, smooth, noncontaminated, and outside the visual axis (see Fig. 39.3).

¥If the IOFB needs to be extracted, the paracentesis for delivery should be at some distance (typically, minimum 90¡ away) from the location of the object.

¥Very rarely, an AC maintainer, occasionally even visco, may be needed to maintain the depth of the AC and avoid iatrogenic injury to the lens (see Fig. 39.4). None of these, however, should be default options; it is truly exceptional that either is needed.

¥Depending on the iron content of the IOFB, a small IOM or forceps needs to be used.

6Even monocular diplopia is possible.

7The one caveat that is important to emphasize here is to not use a capsular tension ring; even if all looks great at the end of surgery, the remaining, possibly also injured, zonules are now under increased tension and may subsequently break (see Table 3.3).

8An air bubble can also show the presence of vitreous in the AC (see Sect. 31.3).