Lecture: Secondary Intraocular Lens (IOLs) in Aphakia

Well, good morning to everyone. It’s a pleasure being here again with you today. Today, we’re going to talk about secondary intraocular lenses in aphakia. These are my financial relationships. None of them related to this talk. So when we look at the causes of secondary IOLs, this is a review I did of my patients between 2003 and 2011 which were 57 cases. The most common cause was ocular trauma followed by congenital cataracts, complicated cataract surgery or complicated aphakia and subluxated lenses. Intracapsular extraction, vitrectomy and subluxated IOLs. Reviewing the causes between 2011 and 2023, I found the most common cause again was ocular trauma followed by vitrectomy and complicated cataract surgery. These are the most common causes in which a primary IOL is not being able to implant and then we have the need to, in a second procedure, fixate an intraocular lens. What moves us or what forces us to implant a secondary IOL? The first is aesthetic reasons. As you know patients that have aphakia need high-powered lenses and this obviously has an impact. These are very thick lenses that magnify images and that magnification leads to a lot of difficulties in day to day life. Like walking or like estimating distances. So that forces us to analyze our patients and see if they need a secondary IOL. The other reason is we always try to fit these patients that have aphakia with contact lenses. But you know, fitting contact lenses in elderly people, especially, it’s a little bit cumbersome. Many of them have difficulty putting them in or removing the lenses. And also that leads, if they have dry eye, they might become intolerant to contact lenses and that also forces us to correct their aphakia. So metropia is another cause. If there is one eye that isn’t able to get an implant, patients won’t be able to tolerate a highly plus lens in one eye and a lower prescription in the other eye. Cases like this one, we need to do anterior segment reconstruction. We need the solve the issues with the anterior segment before doing it so the graph will stay in place and that is another cause. What do we do with patients that need secondary IOL? First, we have to evaluate the corneal transparency. We need to make sure that the endothelial cell count is good enough to sustain secondary procedure. That will be long and need a lot of manipulation inside of the eye. We need to make sure the endothelial cell count is good enough for us to do that. Yesterday, I saw a patient in my practice that had a corneal transplant. She had a cataract surgery but she was left with a minus 5, minus 4 outcome and she wanted, I actually did a transplant in her in her right eye, a deep anterior — and I did a contact with a toric IOL and her vision is quite good out of that eye. So she wants me to fix her other eye. Doing an endothelial cell count, she has 500 cells per square mm. We discussed the options of doing a piggyback I’ll to correct her astigmatism and with 500 cells you really think twice because in the future you would be forced to do an endothelial keratoplasty. In case we have low cell counts and you’ll see this during the webinar, sometimes I tell the patients let’s do a de-sec and fixate a secondary IOL. In the preop we need anatomical integrity of the anterior segment. These cases are tough when we go in we want to make sure that we know what we’re looking into. We really need to know if there’s breaches in the anterior chamber. We need to know how the pupil stands, regular or irregular, synechiae or capsular remnants and if there are, use it to place the IOL. Features of the anterior chamber and make sure the retina is healthy enough for a good visual prognosis. And all of these things we do, obviously, by our slit lamp examination. By doing endothelial cell count. By doing — if we’re not able to see adequately the retina and make sure that everything is fine before we even suggest to our patients that we’ll do a secondary IOL implantation. So what types of IOLs can we implant. We have intraocular lenses that go in the anterior chamber. Here we have angles supported IOLs or iris fixated IOLs. Within the angle supported we have the Baikoff lens that we will see in the future. I don’t like it all that much and we’ll see why. We have the Artisan iris claw lens that is fixated in the iris and it’s a very good option for secondary IOL. Then we have the posterior chamber IOLs. In this, we’ll basically implant three-piece IOLs, an MA60, Tecnis1, inFocus or Artisan is a good option. We can also use single piece IOLs. There are a few surgical procedures and we can use single piece IOLs like the flanged technique or the Canabrava. We can suture to the iris or the sclera or fixate to the sclera or gluing or just fixating them. First, what happens when we have, we examine the patient and see there’s a capsular remnant, like in this case. This is a patient that had an ocular trauma. The cornea was sutured and the cataract or the lens was aspirated. And then he comes from a secondary IOL. As we can see, we have a very nice anterior segment with a clear central cornea. And we have a good capsular remnant. In this patient, the best option would be to implant the secondary IOL in the capsule, in the remnant that we have. But first we need to make sure that we’re able to remove the posterior synechiae and here I’m going to pause, it’s important as you saw that we go and not only liberate the synechia formed on the pupil but it’s important that we go behind the iris. Because the synechiae not only forms on the pupil but also forms in the mid iris. If we don’t liberate all that synechiae, then when we implant the lens, it will not sit right. It will be difficult to position it. And that’s why as you can see, I go with this viscoelastic spatula to liberate the synechiae. And then we use a 3-piece IOL. It’s a very good option. This is the MA60 lens that has an acrylic optic and it has PMMA or haptics that we can place very well. As you can see over here, there’s slight synechiae, so again, I tried to reposition the optic so the lens sits very well in the sulcus, again, with very good centration. And then we can go ahead and suture the iris like in this case to reconstruct the pupil. Again, very simple technique using a 10L proline suture and using a — knot with the modified RD Walt technique. Instead of doing three passes, we do four passes and that fixates our knot perfectly with good apposition of the iris. And again, with one knot, that is enough. We don’t need to do any other more suturing in the pupil. Getting a very nice and clean reconstruction as you can see. Just one knot is enough. Again, by doing four passes it stays in place. And this is the test that it stays in place, both the IOL and iris suture with a very nice reconstruction. When we have a good 360-degree or 200 or 180-degree remnant of the capsular bag, it’s a good option to fixate it on top of the capsule and reconstructed the anterior segment. The other option with aphakia is an anterior chamber angle supported IOL. This is a one-piece lens. It has a 5 mm optic and fixated on the angle. Four points of contact. And the advantage, it’s easy to implant. Disadvantage is because it’s positioned on the angle, it could produce a uveitis, glaucoma hyphema situation with increasing intraocular pressure, cells in the anterior chamber and even bleeding. The problem with these lenses is it’s one size fits all. And as you know anterior chambers are not all the same. If it’s again, a larger Y to Y distance, the lens tends to move and that can affect the endothelium. If it’s a short Y to Y distance, the compression or the pressure against the angle will produce glaucoma. These lenses I don’t like and this might be a bias that the patients that I see generally come like this patient with a decompensated cornea. So I would think that the only option in which would be a good idea to implant these lenses is in elderly patients in which life expectancy is limited. And again, will ensure we could place the lens and the patient will not live long enough to have a corneal decompensation. Because I don’t implant these lenses, I don’t have a video implanting it. But I do have the expectation of one of these lenses. Again, if you know how to extract them, you know how to implant them. It’s really not all that difficult and in this case I’m going to explant a Baikoff IOL that is moving, subluxed and I’m going to remove it and replace it with an Artisan aphakia lens. Because these lenses are 5 mm in diameter, we should open our wound, we can do it corneal or limbal. But we should open to 5.5. In this case because I’m implanting in an Artisan aphakia lens, I open to 6.5 mm. As you can see, this lens, the haptic is PMMA, you can remove it. It was behind the iridectomy so basically, you just can move it. Sometimes these happen picks if the anterior chamber is small and the Y to Y distance is small, these lenses might get entangled in the iris and if that happens a good option to remove them is just to cut the haptics with some scissors and proceed and explant the lens. Then this lens is replaced by an Artisan aphakia lens and we’ll talk about these lenses in the next slide. Artisan aphakia lenses are very good options. They have been around for a very, very long time. To give you an idea, the first of these lenses were called Wurst lenses because they were invented by Wurst in Holland in the 1970s. The first lens, the first of these lenses was implanted in 1980. They’re called iris claw lenses because the haptics have a little opening that has like a lobster claw in which we entangle the mid iris. Because they’re sitting in the mid iris and not in the angle, they have lower complications. They don’t have glaucoma or hyphema syndrome. They can still lead to corneal decompensation and we’ll see that in a few slides. But again, easy to implant, we’ve been implanting them since 1998 with good experience. And as aphakia lenses, very easy to implant and again we need to make sure the iris is well enough to hold the lens. So it there has to be iris integrity. As I said, again, because they’re in the anterior chamber, they can lead to corneal decompensation. This can be compensated by doing a retro pupillary implantation which is not difficult to perform because the lens has involved. You invert the lens and fixate it underneath the iris with a spatula and it holds very, very, well. This is the implantation. It’s a simple procedure. This was my preferred lens, probably between 2007 and 2012, when I shifted to iris fixated IOLs. Again, we do, we can do a corneal incision or we can do a scleral tunnel. The size of the lens, as I said is a 6 mm optic, so our incision needs to be 0.5 mm larger. The advantage of doing a scleral incision is that we can manage astigmatism in a much better way. We make two paracentesis that we do the — of the iris. The lens goes in fairly easy with cohesive viscoelastic. We close the wound with two suture, leave a central opening for the manipulation and the fixation of the optic when we do the fixation. It is important that once we center the lens, we shift it slightly downward as you can see and we go in with the fixation needles and go under the iris and fixate the lens to the iris claw, to the haptic. It’s important to take a good chunk of iris, around a millimeter so that will allow the lens to sit very well and be very stable. Very simple procedure to do once we aspirate the viscoelastic, we just hydrate the incision and the case is finished. Again, very good option. You can do this inverted and under the iris. It is also important because they are positive lenses that we do an iridectomy. In this case I did do an iridectomy but I had, initially I wouldn’t do them because of the — of the lens but then I had a pupillary blockade and I needed to do it as an emergency. And after that, I always do a peripheral iridectomy. These lenses are thick, so the odds of the optic blockading the pupil are high. This is another case of the same type of aphakia lens in a Marfan’s syndrome. This is a subluxated crystallin — you not only have to do it as a secondary procedure but you can do it as a primary procedure like in this case. I will remove the subluxated lens. This is a young, she was like 16 years old with Marfan’s syndrome. Again, removing the cataract or the crystallin lens is a little bit difficult. Although these are easy to aspirate. Again, they have no, or very little somula support and that makes it difficult. Here, what I’m doing is I do a small capsular rhexis and center the lens with a iris hooks. Again, because the capsule in these young patients is highly elastic. There is basically little risk of rupturing the capsule. The lens is then aspirated with a phaco. Again, because they’re soft lenses, you don’t need to use the phaco tip, you can use a bimanual technique with a cannula or a 25 gauge aspiration cannula. As you can see, very simple to aspirate. I’m going to advance this a little bit. Very simple to aspirate. Very simple to aspirate, advancing a little bit. Again, it just takes time. It’s important to put some viscoelastic because the superior capsule tends to come forward. It’s just a patient. And I like to do it within the bag. We don’t want to do it, again, in the anterior chamber as some of these lenticular remnants. Once aspirated, I like to leave the bag and not remove it. Again, these patients with Marfan’s syndrome have large eyes. There is a risk of retinal detachment. The less we interfere with the — the better. Then we do our paracentesis and fixate the lens. Important to constrict the pupil and that makes it easier to center the lens. And we fixate and do an iridectomy and close the wound. And the case is finished. This is the postop. As you can see the capsule retracts. We have a good fixation of the lens with a millimeter of iris — in the optic and the capsule basically retracts. If it doesn’t, we can do an early capsulotome. Again, that is a better option than having to do a vitrectomy in these cases. Then other, a little bet more complicated case. This is a highly subluxed, very dense cataract. This is a patient that has a posterior vitrectomy with a detachment. The retinol gist said he will develop a cataract. You will see he removed the cataract. He came from Panama and he came with this dangling cataract with a vitrectomy eye. I decided to do an extraction of the cataract. It’s a very dense — so trying to bring the lens forward and fixating the cataract is a little bit difficult. So here I go. I just open the eye. For those very young surgeons that haven’t seen this, again, you take your cryo probe and just hold on the capsule and very gently do a sideways movement until the crystallin comes out. Again, very good option. It’s important that we use that fixated suture so the cornea doesn’t come in contact with the cryo probe. And then I’ll go in and fixate an Artisan aphakia lens. Again, great option for this patient. Very easy to do. This is a fixation forceps that basically comes with these lenses. As you can see it has these tip that stabilizes the lens or the optic. We can do it in complex cases like this one that had some capsular remnants. The iris wasn’t all that good. But if the lens sits well and the cornea is good enough, we can do the implantation. So that is the anterior chamber IOLs. Now we move to the posterior chamber IOLs and the different techniques to fixate them. The first technique we’re going to see is the iris suture IOL. It was first described by McCannel many, many years ago. The one, the technique I’m going to show you is a modified McCannel in the McCannel technique. What you did is put the IOL, you hold it, not in its longitudinal axis but in the horizontal axis. So we have the haptics basically cross one another. And then the lens is inserted with a forceps. We use a spatula to make sure that the lens doesn’t go to the vitreous canopy. Once we do that we let it open and the lens is fixated or captured in the AC but the pupil. And then we can see that the haptics basically are, we can see them through the iris. And then we’ll just pass a suture, a proline suture underneath the haptics capturing the haptics with the iris. And McCannel used to make an incision in the eye to — the suture and tie. But we can do a modified — to do the same technique in the anterior chamber. This is a — the technique. This video was done in the flying eye hospital in a program I did with Orbis in Panama. The surgeons wanted to see intraocular fixation of lenses. So here the lens is already inside. It’s fixated. You can see the haptics, again, underneath the iris. And then we pass a proline 10-0 suture with a straight needle. Again, this is a very easy needle to manipulate. It’s a very thin needle. So the advantage is that, again, the hole that it makes on the iris is very small. Then we exteriorize the suture with a hook and then we can do, again, a suture. Back in these days, I wasn’t acquainted with the — knot. So I used to suture it inside of the eye and doing three knots and then cutting them. As you can see and as I showed you in the pupillary reconstruction, basically we pass a suture, exteriorize it and leave, again, the trailing suture and just doing four passes and tying the knot. With four passes the knot will sit in place and it will be easy. Once both haptics are sutured, we basically move the optic to the retro pupillary plane and the lens is fixated in place. Obviously, the question that we always have with these cases is if the proline will be reabsorbed. As you know the reabsorption of proline is very, very low over time. But it happens. The advantage is that some fibrosis generates underneath the haptic so they tend to sit in place. It’s a good option as a primary procedure if we have a patient that we weren’t able to place the lens. And I think it’s a much better option than implanting and angle supported IOL. We just go ahead and fixate the suture, the IOL to the iris with a proline suture. The other option is to suture the IOL to the sclera. This is what was known as the Lewis technique. Basically, what we do, again, use a proline suture. We create two opposing scleral flaps, 50 percent of the scleral thickness. Generally, they’re triangular flaps that we’ll see in the video. We do 2 mm from the limbus, we pass our straight 10-0 proline suture and pass a 27-gauge insulin needle, again, 2 mm from the limbus underneath our scleral flap and we basically pass the needle into the insulin needle and exteriorize both sutures and then we go with a hook and bring, again, the suture through the wound depending on the size of the lens that we’re implanting now, we do acrylic lenses. But if we do a PMMA lens, for example or a CZ lens that has, again, the holes for passes the suture, then we have to do a larger wound. Or if we’re going to implant an optic iris lens that has, again, an iris prosthesis, we do a larger wound. But if we’re going to do an MA60 lens, a 3 mm incision should be enough. We exteriorize the suture and cut it in half, fixate the haptics and introduce, then we pull the sutures and suture it to the sclera. So this is this technique. This is a case, again, that had a corneal transplant. In this case, as you can barely see, there’s a remnant of the capsule inferior and temporal. I’m just going to fixate the IOL or the haptic in the area where there is no capsular support. I’m going to place the lens and haptic in the sulcus and fixate the other haptic, again, to the sclera, I thought it was a nice video to show. I do a triangular scleral flap 50 percent of thickness. The base of the flap is around 2 mm. I go in 2 mm from the limbus into the posterior chamber. And I put an insulin needle and I basically pass the needle into my insulin needle, my probing needle into the insulin needle and exteriorize it. Here it comes out. And again, if we’re going to fixate both haptics, what we do is pass that insulin needle through, underneath the opposing scleral flap. Then I’m going to do my wound incision, this is a transplant. I prefer to do it in the limbus. Again, I exteriorize it. I suture the haptic or I tie the suture to the trailing haptic. Then I’m going to introduce the lens, it’s folded with forceps. Here we can see that the suture is fixated in — exactly in the middle of my haptic. Then I basically put the lens in the posterior chamber. We can see now better the remnant of the haptic. I’m going to rotate the lens clockwise and as I rotate it, then I’m going to put the trailing haptic in or over or in the sulcus over the capsular remnant. I’m going to basically move it and I can put the haptic, again, over the capsule. Basically, rotate the lens. Pull very gently the suture and the lens as you can see will rotate and end up where it’s supposed to be. When we’re doing this technique, again, in fixating in opposing sides, it’s very important that we know where the suture is. I think the most difficult part of this technique is having all these sutures tangling around. We need to make sure which one is the trailing haptic and the leading haptic. So we won’t have, again, the suture behind the lens and everything entangled inside of the eye. Once we know that the lens is in place, we will just pass the suture in the sclera, underneath the flap and then pass it, leave a loop and suture it and fixate it. It is very important that we do a flap. And the reason is, proline, the proline tends to stick out and if there is no scleral flap, it will basically start eroding the conjunctiva and then the patient is prone to having endophthalmitis and again, it becomes very uncomfortable for the patient. Foreign body sensation and the risk of having endophthalmitis is higher. It’s important that we cut the proline, you know, very close to the knot. And we cover this knot with our scleral flap. The flap is easy to close, just one suture should be enough. And we’re finished. We close the conjunctiva and aspirate and see that the lens is sitting very well in place. This is an old video, 2015. If I did it today, I will probably suture the pupil to make it aesthetically better. There is the glued IOL technique. This is nowadays my preferred technique for secondary IOLs. Again, if you’ve done sutured IOLs to the sclera, basically modifying the technique is simple. So that transition between suturing the IOL to fixating the IOL through a scleral tunnel is quite simple. What you do is create two square three-by-three mm scleral flaps of 50 percent thickness. Opposing one another. We make a 3 mm, 3.2 mm incision. We’re going to use, if you use the MA60 lens, basically we’re going to use the B cartridge. We start inserting the lens. We use the serrate forceps to hold the lens and introduce it through the sclerotomy that is done 2 mm behind the limbus with the V lens. Then we introduce our Serrate forceps and hold the tip of the leading haptic and exteriorize the haptic through the sclerotomy. And it’s called the handshake technique because basically we’ll hand the trailing haptic to a seratta forceps in the anterior chamber and 2 mm behind the limbus and we basically hand it to the other forceps and exteriorize both haptics. Once exteriorized, we introduce them in a tunnel that we previous have done with a 27 gauge needle and glue the flaps and the case is finished. This is the glued IOL technique. Introduced by — a few years back and it’s my preferred technique. First, it’s important that we mark the cornea in the center. That way question create our flaps and make them exactly 180 degrees apart. One of the reasons why this procedure is so successful and there’s no tilt in the lens is because if we do our markings and we place the haptics exactly where they’re supposed to be, opposing 180 degrees one another. Here we create a flap. We can use a 15-degree blade. We can use a diamond blade. We can use a crescent blade. We do, again, 3 by 3. We’re going to do a — of the flap. And then we go at 50 percent and we dissect it until we go to the limbus. We measure 2 mm with a caliber behind the limbus. It’s important that we do the marking and we do a little mark on the edge of the sclera, of that flap. And then we introduce a bent 27-degree, 27 gauge insulin needle. We bend it 90 degrees and create a little tunnel. And then we do two opposing paracentesis to manipulate inside of the eye. We can do an inferior one if we’re going to use an anterior chamber maintainer. This we use if there is a vitrectomy. If there is no vitrectomy, there is no need to use the anterior chamber. We use a V lens to do the sclerotomy. Introduce the forceps and make sure they go in quite easily. There is nothing worse than having the lens inside and the forceps — we’re having difficulty introducing the forceps. We use the B cartridge and again, exteriorize the leading haptic. It’s important that we don’t pull on the haptic. We just hold it until the lens goes in and once the lens goes in the eye, then we can exteriorize it. We introduce the trailing haptic and hand it as a handshake technique, one to the other. We hold it on the tip and we exteriorize it. It’s important to hold it on the tip. That way we don’t bend the haptic and it comes out easily through that sclerotomy. Once, this is the importance of marking, we introduce the haptic in the tunnel that we created in both sides. And as you can see, by introducing it, the lens basically sits very well with no tilt. And then we’ll go on and use a tissue, a glue to fixate the flap and to fixate the conjunctiva. Here you can see how well the lens centers. By doing all these measurements and introducing the haptic through the tunnel, basically the lens will sit very well in place without any tilt. The formulas that I use in doing this are the formulas that I generally use, the Barret universal two formula is the one that sits very well in the eye. The SRKT formula. And the predictability of the lens is very high if we place it exactly 2 mm behind the limbus. This is another video showing the same technique. Here, we have an iris, sorry, a lens. It’s the same technique. This video is slightly accelerated, again, in time. We do basically the same. And this technique we do in patients with subluxated lenses. Here, in hindsight I could have done in this case, put a capsular tension ring. Back then I thought, you know, if I fixate the lens to the sclera, it will be stalled forever and ever. And that’s the reason I didn’t put a capsular tension ring and IOL in the bag. But it could also be a very good option. As you saw in the first case, when we do the aspiration of the lens, a lady with poor vision. The vision was 20/70 and she ended up very, very good with 20/20 vision. There was no reason for her not to see very well. And then we aspirate the lens. The aspiration is simple. We stabilize the lens with the iris hooks. Put a little bit of viscoelastic. And once we finish, we put some viscoelastic in the AC and go in and do the sclerotomy 2 mm behind the limbus. By having the capsule in the eye, there is no vitreous coming to the AC and we minimize complications like retinal detachment. We go in, increase the wound to 3.2 mm. Test that our sclerotomies are big enough for the forceps to go in. And to the lens. These opposing scleral flaps, my experience is we should do always a supra nasally slightly and slightly supra temporal. That allows for better manipulation inside of the eye. If we do a nasal and temporal at 9 and 3 o’clock, sometimes the nose, it makes it difficult to manipulate the forceps. By doing it slightly supra nasal and supra temporal, it’s easier to man nip lit in the eye. Here we go in and do the handshake technique. Take the tip of the haptic. Exteriorize it. Once the lens is well centered, we fixate it. Introduce the haptic on our previously created tunnel. As you can see the lens sits very, very well in place. It’s very well centered. If we want to center it even more, we can just introduce the haptic. And this, I’m going to pause it because this is a modification of the glued IOL technique. I found that in patients F you don’t have access to tissue glue or because of the cost, it’s a high cost, we can basically go in and suture the sclerotomy with a — it’s called an X suture. We make two passes. We close the suture and then we go, again, we pass it again underneath the haptic and suture it. It will make an X suture as you’ll see. Having a twofold purpose. One is closing the sclerotomy and the other is holding the haptic in place. That minimizes the risk of a subluxation and we close the flap, close the conjunctiva. As you can see the lens centers very well. We aspirate the viscoelastic and it’s a good outcome. Then, there are tougher cases. This is a patient that came toll me. She had a subluxated lens. They did her cataract. They put a capsular tension ring. And then an IOL in the back. And the patient comes, again, with a subluxated IOL tension ring went bad. That’s the reason that when we have the subluxated lenses, I would rather do a scleral fixated IOL instead of putting in a capsular tension ring because this happens from time to time. And so here what we do, again, the same procedure. We do our markings. The pupil is dilated. There is phimosis of the anterior capsule. The lens is highly subluxated. We do, again, the same technique. The planning is the same. We do our scleral flaps. If you do — this part of the procedure is very simple to do. I always tell my glaucoma associates that I used to do her cataracts and she used to do the trabeculectomies and for me I was like a fellow. I learned to do them. And again, it’s quite [inaudible] it has helped me to do my scleral flaps. Again, what is sometimes difficult is to estimate the depth. Then we mark 2 mm behind the limbus. We use again, an insulin needle. Important that we don’t hold against the flap when introducing the needle. You can see I’m holding the conjunctiva, we don’t want to rip the flap. The other thing I do is mark, put some glue in the needle to make sure where the flap is and then do the paracentesis and go in with the V lens and create a sclerotomy. Generally, if you increase the size of the sclerectomy a little bit, it’s easier to explant the haptics. We do it very small. The haptic, the tip of the haptic might get entangled and it will be hard. Here I need to explant this lens. I’m cutting the phimosis. Here what I see is as I go in, the posterior capsule is broken. As you can see, I introduced some viscoelastic. You can see the lens basically moves, or tilts slightly backward. I decide that I’m going to grab it with my forceps. It’s a one-piece IOL. I’m going to bring it to the anterior chamber here. We can see I’m using the spatula. I bring it to the anterior chamber. And once my lens is in the anterior chamber, I can go ahead and explant it. I increase the size of the wound to 3 mm. And I will go in and hold the haptic and use a scissor to cut the radius and rotate and explant. Then we put some viscoelastic and grasps the capsular tension ring and explant it. Now, if we have removed that lens. Because we have a sclerotomy that is 2 mm behind the limbus, we can go ahead and do an anterior vitrectomy through the pars plana, again, removing the capsule and whatever vitreous is there. This is important that we can use to do a pars plana vitrectomy. We want to make sure there is no vitreous strands or bands in the AC. And then we go in and implant our lens. This lens I like a lot. It’s a very good option. It’s a focus matrix IOL. It has PBDA (ph.) haptic which is are better than the MA60 haptics with a C configuration. They are easier to exteriorize, the risk of rupturing the haptic is very low. And again, very easy to grab. Very easy to manipulate. And because they don’t have the haptic doesn’t have J shape but a C shape, they’re easier to introduce in our scleral tunnels. As you can see, very easy to introduce. And then the lens is sitting very well. And then we do our suturing technique, we go underneath the lens and then we do a second pass to close the sclerotomy and that will hold the lens in place and then we can go ahead and close our sclerotomy, close the conjunctiva. And always when we finish and when we do the aspiration of the viscoelastic, we see how the lens sits in place and how it’s fixated where it’s supposed to be. And it doesn’t move backwards. Again, this is the test that our lens is very well fixated. I like sometimes to put a little bit of air in the AC and that’s the end of the case. This is postop. We see the sutures closing the sclerotomy. The lens is sitting well in place. The haptics and the lens is very well centered. This is a picture showing that the lens is sitting very well in place. More complex cases like the one I showed you initially in which we’re going to do a combined procedure before doing an endothelial keratoplasty. We’re going to remove the IOL and fixate the MA60 to the sclera and then, again, once you have mastered your secondary IOL technique, it’s very easy to tangle these very complex cases. Because, basically, I like to tell in my lectures that you see them with different eyes. So this eye looks very, very bad but then you look at them and say, well, I can probably fix this eye if the visual prognosis is quite good, I will be able to remove that AC IOL and then I’m going to fixate a posterior chamber IOL. And then once I do that, I will be able to do an endothelial keratoplasty. In the complex cases I prefer to do — we’re going to see it in one of the next cases. We create our flap. Again, this is, it repeats itself. We create the flap. Sometimes they bleed a lot because, again, they’re very insolent eyes with a lot of inflammation and pannus and vascularization. We open our wound, we go ahead and untangle that IOL. We remove the haptic. It’s very important that we make sure it’s not, there is no synechia of the lens against the iris. Then we can produce an irido dialysis and that leads to having to fixate that. Then it’s important in this case that we have visualization to remove the fibrotic epithelium with the pannus that it has. That will give us better visualization of the anterior chamber. These eyes do not dilate well. It’s important that we use everything that we have in our arsenal, like the iris hooks. They way we make sure that we have better visualization of what we’re going to do by reconstructing this anterior segments. Once we open the pupil, we have better visualization. We create our little tunnels. We measure, again, always measure, measure, measure. We don’t want, again, if we do all these measurements, we make sure that the lens will sit perfectly in place and it won’t have decentration or tilt. We go in with the V lens and create the sclerotomy. It’s important that we see the tip of the V lens. Now we make sure that we’re where we’re supposed to be. Then we go ahead, handle, again, our haptic. As you can see, I don’t pull on it until the lens comes into the eye. That way we won’t, again, remove the haptic from its insertion on the optic. Because it’s a larger wound, I don’t need to do a handshake. I just can bring it in and exteriorize it. And then go ahead and tuck the haptic into my tunnel. Sometimes it’s difficult if it’s bleeding. And then again, I hate to repeat myself, but if you do your measurements and you tuck in where it’s supposed to be, we can see that the lens sits perfectly in place. In this case, again, I didn’t use tissue glue. I just passed my X shaped suture and removed my hooks. Close the wounds and close the flaps and close the main incision and aspirate the viscoelastic and the lens sits perfectly in place. Make sure there is no synechiae and the case is finished. This is postop just after the implantation and IOL fixation. You can see the haptics transilluminate through the sclera. This is after a Dsec in the same case. We see the suture. The cornea is nice and clear and we solved a difficult case. Sometimes I do a combined. We do everything. This is a patient that I had done back in 2012. Was aphakic. I planted an aphakia lens in the AC. He came back, I think 2 years back or last year with a decompensated cornea. So I told him, okay, let’s go ahead and let’s remove that lens. I can’t be sure that the cause was the aphakia lens. Again, those patients with vitrectomy have lower cell counts. But I decided the best option, if I’m going to do the endothelial keratoplasty, I better remove that lens. This is a modification of the technique that I’m going right now. Here it’s a 1.2 mm knife to create a little pocket. Then I go with the needle. That way I create like a little pocket and then I make the tunnel. So when I’m looking or trying to find that tunnel, it’s easier. I put some viscoelastic in the AC and underneath the Artisan lens. I will open it. I will remove the encapsulation of the iris. It’s a simple procedure. I go ahead with the need and will do an inverted procedure. Instead of tucking from posterior to anterior. We do it from posterior the anterior and use an inverted hook to remove the Artisan aphakia lens. I go in and place — because it’s a large wound I don’t have to bend the lens or use the injector. I place it in the AC over the iris. Then I go in with my Serrata forceps and do the handshake technique. And exteriorize the leading haptic and introduce the trailing haptic and hand it to the other forceps. Then exteriorize the haptics, tuck it in. That gives a good centration. The lens is slightly decentered but as I tuck it in, I will center perfectly once I tuck it in I do my X suture. Again, suturing the sclerotomy. And then going underneath the haptic. I go underneath the haptic, again, a second pass. That makes the X suture. It closes the sclerotomy and holds the lens in place and I close the scleral flap. And then I go ahead because I have the viscoelastic, I do the — to remove the endothelium that is nonfunctional. Remove it. The reason I prefer doing a de-sec and not a D mic, there is no advantage of doing a D mic. These patients have a very limited visual acuity, prognosis. Again, if you’re going to have a 20/40 or 20/30 instead of 20/20, there is no reason to do a Dsec. The advantage of doing a Dsec is these patients are vitrectomized and fixating the endothelial transplant is easier. We can — on the transplant and put air in the AC and the case is finished. Lastly, I’m going to show a technique that I don’t do very often. The reason I don’t do it often is I tried it 4 or 5 times and it’s more difficult than what it seems and the lens tends to have tilt. It’s not as well centered as I achieved with my other techniques. This is — I’m going to lower the volume a bit. This was given to me, shared with me by a great friend who does this frequently. This is the Amana (ph.) technique. A lot of people like it and feel comfortable with it. If you feel comfortable with it, go ahead and do it. My personal experience is that it is tougher than it seems to be. And the lens tends to have a greater tilt than with the other technique. In this technique, is instead of creating the scleral flap, we basically exteriorize the haptics and then basically with a cautery, burn the tip of the haptic so it creates a little bulb preventing it from luxating inside of the eye. The advantage is that by not doing a scleral flap, it’s faster than the scleral fixation technique. What Heraldo did, instead of going in with the needle, he creates a little pocket with the, with a paracentesis, 1.2 mm knife. Creates a little pocket. Here he has removed the lens and he will go ahead and remove the capsule. As you’ll see, creates a little pocket that he introduces the needle through the pocket and he does it. Here he is removing the capsule. This, again, you can see there is traction. If you have all these ports you might as well go in and do an anterior vitrectomy and remove it. Again, with the vitrector. I think it’s much much better, creating less pulling of the vitreous with less risk. He uses a diamond knife. Presets it to 400 microns and he will do a small incision. And then he will use the V lens to create a little pocket. This is quite good because the bulb of the haptic will be underneath. Then he will go and introduce his bent 30 gauge needle. Or 27-gauge needle. Make sure that, again, you can introduce the haptic on the needle. He introduces both needles as you can see. This is the other thing I don’t like about this technique, you don’t know what this needle is doing inside of the eye. But you introduce the lens with the injector and you know, introducing this haptic on the needle is quite easy. It’s probably the simplest part of the procedure. Once you introduce it, you leave the needle inside of the eye and introduce the trailing haptic. Using an MA60 lens to do this is difficult. It’s better to use the Technis lens which is this one. The loop of the haptic is not as angled. So it’s easier to exteriorize the trailing haptic. Or the focus matrix IOL. Then, once you exteriorize the haptic, you use cautery to create this bulb. We exteriorize the haptic again and create this little bulb. Again, the problem here is to measure it, make sure that it is where it’s supposed to be. This is the problem that I have with this technique. We can see the edge of the lens here in the pupil. So the centration and the fill are my concerns with this technique. But it is, if you master it and use it and feel comfortable with it, it is a very good technique and here he shows, again, how the bulb is tucked in within the pocket that he created again. So that is a very good thing. The take home message is there are options for secondary IOL implantation. Know them, get acquainted and master one or two of these techniques and use it. Once you master it and feel comfortable with it, you can tackle most of the cases that come to you. And you can either solve them as a primary procedure if you have a complicated cataract surgery, you can go ahead and create the flaps or do the — technique and fixate the lens. Or if they come to you after complicated cataract, you can go ahead and fixate the secondary IOLs. I didn’t talk about the flank techniques. You can look for them on the internet. I don’t use them. But they’re an option. They’re an option with one-piece IOLs. Basically what you do is create with a proline fiber suture in the optic of the lens. You place four sutures. And you introduce the fiber proline and then you exteriorize it and create a bulb and that holds the lens in place. These are lenses that we have available for us, the MA60, the Technis. These we can solve most of the problems that we have. So I think we’ve gone a little bit long. It’s a little past 10. Let’s see if I can answer some of the questions. We’ll do it briefly. Any tips to constrict the pupil before implanting AC IOL or iris fixated IOL. You can use acetylcholine in the AC. That will reduce the size of the pupil. Again, nowadays I shifted and as you probably saw and I didn’t show this, but up to 2013, I believe, my preferred technique, between 2003 and 2006 or 07, my preferred technique was to suture the IOL with 10-OL proline. Easy to implant, short procedure. I showed you those older videos. As of 2013 and on, my preferred technique is to fixate into the posterior chamber using the Igerwald technique. In my view there is no sense of using fixated IOLs. The complications you see over time are high. And again, if you want to use an AC IOL use an Artisan aphakia lens and constrict the pupil with acetylcholine. So this one was answered. Can you share your experience with scleral fixated IOL? Pros and cons and special advice. I think we have gone over that. My preferred technique is the Igerwald technique. I think it gives a good centration and no tilt and a little bit more difficult and cum BER system to do but I think we went over that. Do you prefer to use cryo probe or lens loop to do ICCE? I do it seldomly. The cryo probe I think is the best option. The loop, what happens with the loop and the loop works very well if the lens is luxated in — I mean if the zonule that is holding the lens is at 6 o’clock, you can go in with the loop and bring it up. A lens like this one, the loop is fixated at 12 o’clock, going underneath the lens is very difficult. What you do is basically drop the lens to the vitreous cavity. So, yes, you can use the loop if the zonular basin is at 12 o’clock or the superior portion, then the loop is a good option. How to end the knot at fixation. You pass the suture. You leave a loop and suture it to that loop. That is the way to tie the knot. You basically cut it and I think that answers the question. Do you recommend glued IOL technique for PMMA IOLs? Yes. But it has to be, again, a 3-piece PMMA IOL. It works exactly the same because the haptics are the same. And you can do it. You don’t need an acrylic IOL. The only thing to take into consideration is that it’s a 6 mm IOL so you should make your wound or your main incision 6.5 mm. But it works exactly the same. And the technique is basically the same. I have used that technique for the optic iris prosthesis IOL. It’s a big IOL, 9 mm with a colored periphery mimicking the iris. And I used that technique. That has some loops. You cannot exteriorize the loops. You have to suture it. How to tie the scleral sutures in the Lewis technique. I think I went over this. Because you exteriorize it and have a needle here, a curved needle. You go into the sclera and pass its so you have a loop. And you cut on the needle end of the suture and tie it with a loop and make four passes and cut the knots so they are very close to the knot and don’t stick out and exterior use. In a cryo probe used for ICCE, how serious is the risk of endothelial touch damage? It is but if you use that fixating suture on the cornea, it will be easy to do. The lecture wasn’t about intracapsular extraction. I just wanted to show how to fixate a lens in these cases. Pars plana core vitrectomy. You do it in a non-vitrectomized eye, yes, yes. It’s always important to do. Again, I didn’t show it. I had a case in which the lens is highly subluxated. I bring it up, I fixate it and remove the cataract. It’s important that the anterior segment surgeons we know how to do an anterior vitrectomy. That way there is no future strands or bands against the eye well or pulling. And that reduces the risk of retinal detachment. Could you repeat the name of the lens for the glued technique. I’m going to write it down because it’s the focus — there are two lenses that are very good for this. The Technis one 3-piece IOL or the focus matrix 3-piece IOL. The focus matrix 3-piece IOL is an acrylic hydrophilic IOL made in India. It has BVDF haptics. How do you change the power of IOLs? Very, very good question. When you use an AC IOL, for example the Artisan aphakic IOL, the IOL constant, if we’re going to fixate in the AC, it’s 116.0. We’re going to invert the lens and put it in the posterior and fixate to the iris but posteriorly, the constant is 117.0. If we’re going to fixate a lens to the sclera, an MA60, a Technis one or inFocus, then the constant is the same that we use for a sulcus IOL. 118.9. MA60, 119. For a Technis one 118.0 for the focus matrix IOL. So that’s how you — basically you change the power based on how you change the IOL constant. What is your preferred way of anesthesia in secondary implantation? Great question. It has to be general or sub T (ph.) or retro bulbar or peri bulbar. Many years ago I abandoned retro bulbar or peri bulbar. I do the sub — or general. There is still eye movement and this is a technique that takes 45 minutes to perform. You want the eye to stay still. Do you prefer retro pupillary Artisan lens over ante-pupillary one? What I recommend is when you’re going to do it, you have lens, you pass a suture through the haptics. That way if a lens, you know, luxates, you can bring it back up front. Then you go in and you tuck in with your forceps underneath the iris and go with a Sinski (ph.) hook and try to find out where the iris claw is and press down. The reason I prefer the anterior chamber lens is these lenses, if a patient has a blow to his head, they can luxate. If they luxate in the anterior chamber, it’s easy to repair. If it luxates to the posterior chamber you have to do a sclerotomy to push it back forward. Is it safe to dilate eyes that have Artisan lens? Yes, perfectly safe. No trouble. I dilated that eye because I needed to fixate a lens. So it’s dilated and it really has no problems. How to tie the scleral sutures in the Lewis technique. We covered that. Which one of these techniques do you recommend for resource poor setting. We can’t get all the instruments? I would say either the Igerwald modified. My modified technique in which I suture it. That would be the best option. If not, the Amana (ph.) technique. If you’re able to use it and, again, get accustomed to fixating not the leading haptic but the following haptic. That is a good technique and requires very little instruments. Just forceps, retinal forceps and a needle. Is it possible to do AC IOL with vitreous anterior chamber. You can do it. You cannot do an AC IOL with vitreous in the chamber. You have to remove the vitreous, when manipulating in the AC, always when you think of secondary IOL. Try to fixate the anterior chamber. You want to clear that vitreous and make sure there is no synechiae. Because then you’ll go in and have a very difficult time and then you’ll just feel frustrated and the outcome will be worse than what you had initially. I think I’ve answered all the questions. I think this covers our webinar. I hope you enjoyed it. And again, I will see you, we will see you in a future webinar with Orbis. Thanks a lot to Andy Chang and Lawrence Sica for helping me today and again, see you later.