During this live surgical demonstration, we will discuss the techniques used to surgically manage a dislocated IOL. This will include safe and reproducible vitrectomy results, removal of dislocated IOL, and scleral wall fixation of a new IOL. In particular, the gortex suture method of scleral fixation will be demonstrated, with attention to avoiding complications. (Level: Advanced)
Lecturer: Dr. David Miller, Ophthalmologist, Retina Associates of Cleveland, USA
>> DR. MILLER: Hello, everyone. Welcome to Cybersight, and I’m Dr. Miller here at the Cleveland Eye and Laser Surgery Center here in Cleveland, Ohio, and we’re already in a case because we’re running over a little bit. We have a presentation today for you. The next patient is a dislocated IOL, with removal of the IOL, and suturing, fixation of the IOL, which I plan on doing by Akreos, but we’re running over here a little bit this morning. The first case was a recurrent ID with PDR. And this patient a diabetic with dense vitreous hemorrhage. We just pulled that all off. And you can see the disc is bleeding here a little bit. Not much. That’s helped out quite a bit to contract the neovascularization, you can see the significant ischemia out here, and I will make comments about this case. You see me lasering kind of close to the macula, perhaps, but look at these vessels, they’re completely white. This is nonviable retina, anyhow, it’s ischemic and we’re better off lasering it off:
The patient already had pretty good PRP in place, so you’re seeing a lot of old pigmented scars there. We’re going to wrap this up. Can you bring down the pressures, Mike?
We had the pressure up quite a bit, we had it at 60 during that lasering, because there was some bleeding in the eye, once we pulled off all the massive … elevated pressure for a couple of minutes seemed to have slowed down the bleeding and we’re in pretty good shape. So we’ve got a nice clear view. No significant brisk bleeding, and we’re going to wrap it up.
So what we’re going to do here is while we’re getting him patched up and the room turned over, I’m — you have a .12 there? Let me show them this. I’m going to pull this out and you might not see this later, but you can see right where the wounds are at, if you press above the wound, not in the wound, but on top, it kind of collapses that tunnel. I’ll try to show you over here. This cannula went in on an angle like this, so if you can imagine, there’s a — you can just see the wound right there, so I’m going to go just posterior to that, just inferior to that, and I press pretty hard, enough to make a little bruise on the sclera there. And we’re good on the pressure, right?
We’re down, same here, as we pull out the infusion cannula, and again, here’s the wound, right here, so I don’t press on the wound, but I press on top of the wound. The wound is angulated, and just press and you collapse that, and that is it. There’s no leaks on these wounds.
This is a 25-gauge sutureless, and we’re set here. So I’m going to break out of my case here, and the team’s going to turn everything over for me.
And we’ll kind of jump into our lecture for the dislocated IOL.
Thanks, everyone, for waiting there. Sorry we ran over a little bit.
So — I prefer my mask off while they’re switching the room over. So welcome everyone, we have a team of here including Mike Carson from Retina Associates, and our fellow, Dr. Schully, is with me, too. So we will walk our way through a little lecture presentation and that will take maybe ten minutes. The room will turn over about that time. So Rachel, if we can start the lecture, that would be great.
There we go. It’s coming up. Rainy day here in Cleveland. But that’s one of our offices there at Retina Associates, that’s in the West Lake location. We have 14 offices and 15 surgeons in the group.
Title of my presentation here is: There It Goes: IOL Dislocation and Replacement.
So the causes of IOL dislocation and I did read through a lot of the questions I got ahead of time … This is one of the questions. What’s the cause?
Well, surgical complication of cataract surgery, ocular trauma, pseudoexfoliation syndrome, zonular dehiscence, broken scleral sutures, and prior vitrectomy surgery. And what we’re seeing a lot is my own patients coming back and patients of the other surgeons in the group who have had a prior vitrectomy or retinal detachment and it seems like the advent of we’re getting more zonular dehiscence and lysis. So especially patients who’ve had two or three vitrectomies, we’re seeing dislocation five, ten years later, and I’m sure it’s related to the zonular dehiscence and multiple wounds being created.
Symptoms of IOL is a sudden change in vision, loss of vision, hinged IOL, you know, sometimes the lens implant is only dislocated from 270 degrees and the lens implant will kind of hinge up and down so if they’re sitting upright they can see and if they lay down, their vision goes out. They also can get glares, halo, and diplopia from a partial dislocation.
So your surgical approaches here are, one is do nothing, if it’s minimally mobile, you know, there’s certainly no retinal damage. These lenses are so feather-light, if you’re in a location where it’s just frankly impossible to retrieve the lens, it’s just economically or technologically not possible or, you know, the skills aren’t there, you know, you can leave a lens implant in the eye. If it’s not moving around, it may not even bother the patient at all. And then you can go with a contact lens, spectacles, thick glasses, or you may even consider replacing a second IOL without removing the original. I’ve seen it a few times, even here, where a surgeon will go back where the anterior segment, in a more rural area, maybe leave the lens where it is, in the vitreous base and they come in and slide a lens implant right into the anterior chamber.
Other approaches for surgical approach would be a repositioning in the sulcus. Assess anterior capsule support, assess the zonules. If you’ve got 7, 8 hours of support, it’s very nicely that a nice 3-piece lens can sit in there. It can’t be a single-piece lens. I think actually my second case today may be a candidate for that, so we actually have two patients lined up. The first one has a dislocated IOL. That’s an Akreos dislocated in the eye. It was previously sutured in the bag. And the second one is a lens implant, it looks like there may be enough capsule support to remove the single-piece lens and replace it with the three-piece lens. We’ll check and if there’s time for you guys to hang out for both cases.
I tend to go superior, because I’m sitting superior as a retinal surgeon. We make that wound right into the clear cornea. The advantage of that is you’re well above the iris. Iris prolapse is very difficult to deal with in these more complicated cases and so really want to avoid iris prolapse. We make larger wounds around 6mm for solid wounds such as PMMA. Some of these lens implants are 15, 20, 25 years old and that was the most common lens back in that era. Or sometimes we use a smaller wound, we can bisect the lens in the eye and take it out in halves or as a Pacman technique, either way, we can take it out through a smaller wound and we can insert the Akreos in that smaller wound.
So the replacement choices. Factors include things like age, corneal condition, anatomy, and glaucoma.
The patient’s now in the room, actually. And so the team is prepping the patient now and getting the block done for me.
We can also do a surgical approach. Iris fixation of many model IOLs, so that’s sewing the lens to the iris. I don’t do that procedure myself. I’m not as big a fan of that. I’ve had to take a few out for different surgeons because of chronic inflammation or recurrent hyphemias, and it’s from the sutures rotating through the iris, they’re rotating sutures and they’re causing recurrent bleeding or inflammation, so not my favorite way to fix an IOL.
Scleral fixation without suture. 3-piece lens. The common name for this is the Emami procedure. I have a colleague who does a beautiful Emami procedure, but I don’t I can tell you that they are quite a bit different and the skills you develop to do each one are different. So I’ve been doing the Akreos for quite a few years now and have gotten very comfortable. I’ve been very impressed with the elegance of it, but there’s certainly a learning curve when you watch those cases in terms of distorting those and getting them in the right location.
The one advantage of scleral fixation without suture is you’re not worried about the suture breaking, so here’s a little video showing them making those locations tunneling a location, picking up the lens that’s already in the eye and explaining the ha haptics. You can cauterize the tips there a little bit, to make them more bulbous, they don’t indeed go backwards and suture things up. You can see that lens implant is nicely secure, that was the one already in the eye, and you end up with a subconjunctival blue proline haptic there, right? As you can see on the screen a little blow-up view there. Again, this is the haptic. There’s some risk about that eroding in the eye, but if you do this procedure with a little more modern technique. This is an old video of mine, actually. You can actually get that haptic to be more intrascleral and less risk of erosion.
So the surgical approach I’m going to talk about today — I’m going to put my mask up, just because we’re opening the case and want to keep things, you know, clean in the room.
So the surgical approach we’re going to talk about today is scleral fixation, I use the Akreos AO60. In the past I have used a CZ70BD. It has eyelets for the sutures. The problem with this lens is it’s only two-point fixation, so the lens can tilt, you know? Also, the sutures that go through here in the past have been proline and there’s a roughness to these eyelets where that proline will break, usually they break between 5 and 10 and the lens is hinged and falling down again. So I’ve kind of move offed to the Gore-Tex suture, which is a nonresorbable suture, monofilament, very strong tensile strength, it’s also thicker. We don’t need needle in most cases.
Very difficult to pick up once it heals in, it’s kind of sclera-colored. There’s one on each side, about 4mm apart where it enters the eye.
Occasionally we’ve had to go back and release an IOL like that where the patient had a subsequent retinal detachment years later. Went back to cut it out, and those sutures are so tight in the sclera, suture doesn’t even need to be knotted at that point.
So the advantage of the Gore-Tex, you can have insertion through small corneal incisions. The strength of the Gortex,
And here’s how the lens implant’s kind of threaded with the Gore-Tex, I’ll show you in each case. One suture on each side. In different places you can use four-point fixation. I’ll be doing more using diagram B, where we use the sclerotomies here and here. But you can move those incisions, so depending on what’s going on in the eye, scar-down conjunctiva, glaucoma implants or shunts, blood, you can move the incision sites to make it work.
So I’m going to — let’s see how long this video is. We’re going to show you here — now, here again you’re seeing the lens implant in the eye, make a corneal incision, again, kind of high in the cornea, a little over 3mm, you’ll see me kind of carve that a little bit open on the corners, and we’re going to grasp that forceps with the forceps or the retractor itself, that’s a single-piece kind of lens. We’re going to grab it, and pull it out through the wound, so I will I’m going to be showing you all of this live today in just a few minutes. They’re getting ready. That comes out, there’s the Akreos, this is obviously a very edited surgical video, so things look very quick, but you’ll see in the — it’s a handshake technique, pass it off from one hand to the other, grasp it — and I preplace the two lower Gore-Tex sutures and then I put the last two in after we put the lens in the eyes, so now we got the lens in the eye, you can see the spaghetti effect in there, that can be a bit of a mess. We’re going to avoid that today.
Kind of the technique — again, there’s a learning curve and you learn how to avoid some of the problems early in the case. And here we see us externalizing the sutures and the haptics will center up real nicely.
I’m going to jump ahead here and not get too much into these for right now. And we’ll take questions in between. So postoperatively, etc. We’ll come back to that.
We’re ready to start the case, so we’ll jump to our live surgery. Collapse that down for me, and I’ll see you over at the microscope camera.
Time out? Yup. Removal of lens, Akreos, right eye and that’s what we’ve got, no allergies, 17.5, all good.
OK, so just getting gloved up here. Getting the gowns on. And we’ll get started in just a moment.
So assisting is a surgical nurse, and also, administrator, who doesn’t come into the room very often, and we get Dawn, who is our expert business manager, and also our videographer.
Keep coming down, right about there. I’d like the eye to not be any higher than the drip chamber. What I’ve realized if it’s higher than, the eye can soften. The eye pressure versus the retractor pull power doesn’t match up.
You can see the lens implant there, kind of sitting, the profile of it sitting on edge, we’re looking at the haptic right here. Take the Westcott scissors, Dr. Schuley is assisting us here, very brilliant fellow and retinal surgeon, after completing his residency in Kansas. Now, he’s already done a few of these cases for me as a primary surgeon and maybe we’ll come back someday in a future and watch him do a case here on Cybersight with my instruction, but today I’m going to be the primary surgeon.
And there we go.
So I’m just cutting down the conjunctiva. Making a nice — I’ll take the calipers and I’ll mark them and I’ll set them. So I go to 4mm, so the first question is, how far back to you go? Well, a lot of the articles and stuff you see in the journals say 3 and what I’ve found with 3 is, one, it works, and it’s supposed to be equivalent of in-the-bag calculations, which is nice, but the problem with 3 is sometimes the haptics of the lens implant or the sutures are rubbing against the iris.
So we measure 4mm back, so I use an extra mm, which I’ve found to work really well. Then we’re going to go to 2 here. That didn’t look right to me. Always make sure it makes sense, I thought I had it at 2 and I did not.
So we’re going to measure at 2mm at each side of that metal mark. We’re going to confirm that they’re 4mm back. Again, 4 to me is really key, having had troubles with the current CME I’ll take a trocar and a cannula here.
And we are we’re going to put this one here and we’re going to make this while we’re here. That’s also at 4, it’s nice and they’re about 4 apart, see? So always make that incision, and I will I’m going to mark that one, because sometimes it’s tough to find later. We’ve got the blue pen. You can cauterize here, there’s no harm, I just prefer not to if I can get away with it. I just mark it so I can find it later.
We got the infusion cannula, let’s take that while we’re dancing around. No, I mean just the cannula.
So here we go. And this — that’s going to be away from these two so it’s not in the way and that one I kind of tunnel in, as you probably saw that. Tunnel meaning putting in obliquely all the way through. This can always be your first cannula sometimes. I don’t worry about it too much unless it’s a prior vitrectomized eye. I don’t use a trocar marker. It’s just another instrument. We do have those here but I never really found it useful. The eyeball test here in terms of symmetry, it works pretty well. I know we were right there, I want to be directly across, and 4mm again right there and we’ll confirm it with our eyes before we place our sutures, just to make sure things are about where we want them.
That’s the first mark. I want to make the 2mm one. I’m going to rotate the calipers a little bit anterior and then I’m going to recheck with my caliper here that this is 4. It’s a little back. I’m going to go right there. You got the cannula there?
DR. MILLER: Going to go right in front of that one and then we’re going to come over here and see the 4 right there. Now, it’s about right — we like that one.
And you got the marker again. So once we have all the incisions in, before we throw any sutures at this guy, we want to make sure that everything looks about symmetrical. So if you go like this real quick, take a look at how the eye is set up, and you got these two across from each other, these two. Right here, and right here, across from each other, and that passes the eyeball test. You know, it’s pretty much right on without getting too measurement-obsessed.
OK, we’re going to start our vitrectomy here. Using a Leica miscroscope. And we’re going to do the vitrectomy first, so things to get in trouble with, are pulling out these lens implants when they’re wrapped in vitreous, and the retina can tear and of course you get a detachment right then or a few days later. Very disappointing. So if we can get the vitreous out of that eye and you can see we want to get the vitreous first so we can do this surgery safely.
And that includes even a vitreous separation, ideally. So — and I’m not really worried about the lens implant falling here. I want to make sure it’s not entangled. That’s more important. If it falls, then I know it’s free of entanglement.
And we’re going to try and make sure there’s no vitreous remaining back here. Typically there is not, but here there is. The vitreous is still attached.
So I’m using the aspiration on the cutter, to pull the Weiss ring, kind of engage it, hook it with the retractor. You can maybe see the shadow coming up there. This is a tougher view, I think, for the camera.
You can see the shadow of the vitreous there, and it’s dripping out quite nicely. And there you can see the Weiss ring come up, the advantage there is now I know I’ve got the vitreous, that’s not going to get snarled up in sutures or a lens insertion and tying, etc., so I just feel much more comfortable in an eye that has a complete — what I call a complete vitrectomy. And you can see the lens implant shaking and moving again because of those vitreous attachments. That’s why you don’t want to just grab it and pull it.
And it still hasn’t fallen yet, but I know there’s quite a bit of anterior capsule in this particular case, but I’m working my way around.
In the peripheral retina. I do have the cutter pointed — I wouldn’t say directly at the retina, but nor do I have it pointed apartment the middle of the eye. It’s kind of sideways, just to engage some of that peripheral retinal skirt. These cutters do such a nice job of not pulling so hard to tear at the retina, even when the port is faced towards the retina. The 20-gauge cutters, that was a much bigger risk, because they would grab more vitreous per bite. We’re going to switch hands here. We’re fine. You don’t have to move it.
I always start my vitrectomy with the temporal hand. I always come back over to the other side, because the vitreous can be a little more difficult to reach on the side you’re on, so I come across. Again, this is a pseudophakic eye. It’s going to be much more difficult than a phakic eye. Don’t want to bump the lens, but as you can see, we’re just kind of making sure all of that vitreous is out of our way, which gives us a much better shot of doing this without a complication. We will check for those complications, of course, whoops — let’s get that over there.
Give us a slash on the cornea there. And who has a Q-Tip? Just kind of grab some of this out of there. It’s Halloween, so this kinda fits.
Little extra … there we go.
So give me a splash in that cornea, take some of that off. There you go.
This is not good capsule in terms of like trying to do a capsule support. If anything I’ll try and remove it and get out the rest of the cataract at the same time.
Let’s lose a little residual cortex there.
You can see us pulling out the residual cortex, which I don’t like to leave either, because at the end of the day, it’s very inflammatory. So if we can get that out … then you saw the lens implant drop back there.
What maybe we can get it on aspiration, or a vacuum, Mike? Let’s change those things on the machine to pull a little stronger. Thanks.
What you’re going to do when you grab the iris like that is you want to make sure you don’t have the cutter on it, you don’t want to make extra PIs, you know?
Sometimes we can see it a little bit better like this.
Let’s put the — because at this point we’re just kind of making blind passes at the — yup, thanks.
We’re just trimming up the vitreous a little bit, and I can just make out some lens capsule here. I’m going to have Mike maybe turn up the aspiration again. I don’t want to get too crazy with it, because again when you’re pulling — turn it up a little for me, Mike?
Make it a little shorter, so I’ve got a bigger …
Struggling here a little bit on the capsule removal. The other choice is to grab a forcep and get it out that way, which we could do, too, but I think we’ve got it right about here. I keep thinking it’s going to release and it doesn’t. So can you get the eyeball set up for me?
You got a forcep there, a super-grip? So I’ll show you another way to grab this capsule. Sometimes we’ll just use the retinal forcep and grasp it.
If we can find it.
I kind of lost sight of it. Can I have the retractor back? This would be a part of the case you could let go, but I generally prefer to have all the remnants out.
Do you have the forcep again? The best thing about the forcep is you can pull it right out through the sclerotomy site like so. Very elastic, and it’s working its way out. There we go, just grab it and take it out.
Now we’re clean all the way around, and the advantage — can you put that down for me — is there is no cortical material left in the eye to add to inflammation later. Now is as good a time as any to take a look around the eye — and I’ll do that before we pull the lens up, I guess, make the corneal incision next and there’s the lens implant.
Just checking the peripheral vitreous again, and we’re in good shape. That lens implant will not hurt the macula lying down and vibrating a little bit.
Now we’ll make our corneal incision for explantation of the IOL. So we’re going to make this a biplanar wound. We’re in the corneal stroma there and we’re going to go dimple it and push it straight in. These are things my cataract surgeon friends taught me. I do not have the expertise on corneal wound creation, they do. I can always use a suture for that reason. Take some viscoelastic while we’re here. I do like to use viscoelastic for corneal protection.
And then what we’re going to do on this side port incision, yup, we’re going to use the side port incision, so we can put another instrument in the eye there. Like that one to bleed a little bit so I can find it later.
And so what we’re going to do is, grab this lens implant. Different ways to grab a lens implant. There’s forceps of course, I find the vitrector to be quite adequate and quite safe. Under aspiration view is a little wonky here because of the — yeah, right, because the viscoelastic. So we just grab it like so.
I don’t care which orientation it comes up. You can pick that up, yup, and now I’m going to take a pair of forceps. Also lost it. Let’s pick it up again.
So that’s OK, and that’s very common.
What you want to do is just — if we have to, we can always use forceps, like I said, but I usually find it not necessary.
OK, pick that up.
Nope, don’t have it, let’s take one more shot at it, and then we’ll go to the forceps. Just depends on the edge of the IOL.
Can you focus that for me? There you go.
OK. And splash the cornea when you get a moment.
You can see, I’m just holding the lens there. And we’re going to use these forceps through our little side port incision to grab it. There you go. Now we let go of the aspiration, and we got the lens purchased with the forceps and now I’m going to bisect it with some intraocular scissors. There’s just two of them here and we’re going to — once the scissors grab it, you can repurchase — you know, I can hand it to myself and get it a little better. So I’m going to cut it right down the middle, just behind the iris like this, and that usually works pretty well and — you can see how far I cut — do you have the McPherson forceps? You don’t get too particular on which side I’m working on or whatever. You kinda just stretch, and it follows itself out like so. So that’s our lens implant right there. So we cut it. That’s the Pacman thing they talk about, you know, and it’s like a gummy-type material.
Do you have a vitrector again? I see a little more cortex hanging out. We’re going to grab that. That’s probably just iris, yeah, a little iris pigment epithelium. So we’re going to get the next lens implant situated here, and ready to go.
We’re going to do that right here in my clean little. Field. Yup, take the lid off myself. This is our Akreos lens, can you get the McPherson’s again? And so we take out the Akreos, and the way it goes in the eye, these lenses are — have a convexity to them, right? So going backwards, so it’s kind of convexing this way, and the other thing is two of the haptics are notched and the one that’s notched right here is the upper right. I like to put my sutures in from the top and come back up, the point being I think it makes a little better chance of not rubbing up against the back of the iris, and that’s one side, they’re going to reload my Gore-Tex, for the other side, thank you. We’re going to do the same thing here. This Gore-Tex is a very forgiving suture, you can do quite a lot with it. You can untie the knot — someone asked the question, can you use a suture to save the Gore-Ttex that’s already in the eye, the answer is yes.
So I’m going to just hand this off. And I’ll take the super-grip forceps there, yup, and I’ll wipe right here by the sclerotomy site. Just wipe that blood away a little bit more.
And I think it’s right there, right? Helps to have a good assistant. The pupil is a little bit small but that shouldn’t bother us too much in this case. That’s from the trauma of pulling out the other lens. Here’s a little hand-shake and this one comes through. We’re all set. That’s one side.
On occasion when you get to the nasal side like this, he’s going to show us that one. Go ahead.
On occasion it’s a little tough to get the forcep in the right angle. You can bend these forceps. They’re disposable. But I can see this one pretty well, I think. Make sure we’re not crisscrossed anywhere and we’re not.
And there we go.
That doesn’t have to be too exact. Make sure it’s not distorted because it blows the optics. Make sure the — the visco came out when the lens came out. I like to always be considerate of the cornea and not have — as much protection there as we can.
Gotcha, so this is a lens folder. Picks it up like so. We’re going to make it fold the other direction, tackle this lens like so, and we’re going to make sure we pull up on these inferior sites as we go.
Can you get the McPherson again there for me?
What we’re doing is keeping those sutures a little tight compared to the video.
And there we go in the eye. you’re pulling up on the sutures, I’m releasing, and that saves the tangling. So now if I have the — you can see the one haptic still in the anterior chamber, I’m just going to push that back with the super-grip there, just to get the lens in the posterior segment.
So I’m going to grab the suture here, make sure I have slack, and I’m going to dunk the lens behind the iris, and let go of that suture, too. I’m going to make sure there’s no tension there, push the lens back, there we go.
OK, the McPherson — oh, you got MSTs? I’m sorry. So we’re going to grab the other end of that suture and thread it where it belongs. And again, we want to try and keep everything just like it’s supposed to go. There we go. I’m good. If the lens implants a little further back, a little easier, so it gives you room to stay on top. One of the reasons I like the sutures being on top when I place them is I can work above the lens to make sure nothing is getting tangled.
One of the problems we ran into with this procedure when I was first learning it — right, I didn’t create this. Many others before me did all that.
Over a little bit. You can see my forceps are above the lens implant.
Oh, no, they’re not. They’re behind. That’s no good.
I am I’m going to bend that forcep right now, which I was talking about earlier. So I’m just going to take this forcep, get a little bend here on the shaft. I mean, there’s some risk you could break it, of course, but for the most part, very well tolerated. It makes a huge help working on the nasal side.
These are the types of things you don’t get to see in an edited video.
Just trying to get my forcep up above, now I’m above the lens implant.
So again, you don’t want to be twisting, you’ve got to keep your orientation correct.
Look how much easier that is now, with a bent forcep, to work in that plane. OK, now we’re going to take the forceps, we’re going to pull the cannulas, because we don’t need those. I’m just going to pull this out, and here is a finger there, we’re going to pull this out and everything that’s gone wrong or could go wrong, has gone wrong, including one time we didn’t have our finger down tight enough and pulled the suture right out of the eye. And Mike’s laughing, because that was him. Heh-heh. So can you put these down to get rid of the excess? We’re going to cut that right there. There you go.
The same on the other side.
Hm. Just cut it right there. It’s fine, yeah.
And so what we’re looking at. Again we want to make sure everything is lined up. You can see how well that lens implant lines up and these look pretty darn symmetrical. So we’re in good shape. We pull it over nasally, or pull it temporally. You can see the nasal ones are like that, too. No twist, no wrapping around the haptics. Took me a while to figure out that if we took out some of the slack as we were putting the lens in the eye, it will save a lot of wrapping around the lens. So things like that make a big difference. I’m trying to figure out the center of the lens, because the pupil is smaller, you can’t see the edge of the optics, but right there, we’re pretty good. I’m going to take another look at that there we go.
I’m going to start over here a little bit. Because this is not always, when you kin much this knot down, you’re always going to pull a little out to the side. I’m going to use another instrument besides my Bonakulta here, what you got? Yeah, it should work. So you don’t want to just tie the knot down and … and kind of play with this knot a little bit, but you know you’re not too tight. Like to leave these loose, bus you don’t want to put stress on the optic. If you put stress on the optic, then you get all kind of optical aberrations and nobody’s happy. So you want the lens to kind of be suspended, not tied.
And again, these are all things we learn as we — not going to put it down quite yet because you saw the lens implant jumps so we want to make sure it’s in a good spot. Just cut these pieces down here. Yup. There we go. We’re just cut the other side because it was getting wrapped around other stuff, including my finger.
There we go. Just making sure we’re well centered. And if we’re not, like I said, you can always actually untie these knots. The Gore-Tex is so forgiving and I’ve done this quite a few times where things weren’t centered up like I thought they would be. And so we put this knot down, and now before we cut that, we’ll tie this one.
Just a 3-1-1 knot and you can see that come across there very nicely and before I tie I don’t want anything tight. I just want it suspended. The lens won’t move. It won’t shake in the eye or optical problems like that.
Looks pretty well centered, I’m just going to put that one down. He’s going to cut that.
You can leave little tails on these. There you go.
Now we’re going to cut the other side. Again, the tails are fine. And we’re going to bury the knot in the wound. These knots, the Gore-Tex is very well tolerated in the eye. We just got to … — there you go. We just rotate it in the eye. Like so.
The Gore-Tex is very well tolerated. You can see how it’s going to look when we cover it up with the conjunctiva. Now we check our wounds and see how they’re leaking, and put some sutures over there. And you can see that suture is a little bit loose like that and that’s perfect. We did not need it tight. But you can see this one’s leaking, the working sclerotomies are always leaking, so a 7.0 and a .12, and I did orientate this in a way that we can, you know, again, it’s possible, it is possible to cut the Gore-Tex with a Vicryl needle. But try to avoid passing in that location if I can, just do a little compression suture here. That one is above the Gore-Tex, and this one above the Gore-Tex
And we get that little knot out of there.
And we just tie this down. Typically the other sclerotomy sites usually are closed on their own, where we don’t have a cannula. I tried this with 27-gauge just for this reason, to avoid these sutures, but it still had a leak at. So show them with whether we got a water-tight closure or not? I think we do. Can you — we’ll come back to it, it may be leaking a touch, but it may close up on its own.
This wound, oriented this way, I’m going to sew it up this way, and again, I think it’s very unlikely to hit the Gore-Tex, kind of went deep to it.
You can come off there again, so it rotates a little less. There you go. I should be able to rotate the eye, yup, I just grabbed the wound myself. Get this lined up the right way. There we go.
There we go. Good.
Pinch that down. I’ve even seen these wounds leak some after surgery, a little bit of hypotony, the only case that ever came back. And the leading is stopped nicely so we’re going to wipe this field out so it’s a little cleaner. Got another Q-Tip there? There we go, we’re going to check the wounds here. That one is dried down there, a little bit of blood coming up, but that’s just from the wound, but no fluid.
Over here … also dry. Very good.
You got some BSS for the cornea. We’ll put the conjunctiva up, we’re going to put the corneal wound suture in, and we’re all set. So you got the t tunnel. I do tend to — I’ll check the wound here a little bit so this wound is actually water-tight, but again, I don’t trust my wounds like I would some of the cataract surgeons, and I tend to always throw the stitch feeling that I’m a little safer in terms of lowering my infection chances.
One 10-0 suture, right in there somewhere. That’s fine. And typically to cut the suture out and remove it, about week 3 after surgery or so, sometimes this suture is a little tithe or whatever, my refractive errors, but whatever works for you. If you’re confident in your wound, you maybe you wouldn’t even bother putting the suture. A little compression, lock it, probably my least favorite part of the case.
We’re going to cut this. Let me see what I got here.
Yup, we broke it. That’s fine. We’ll put another one in. That was a little choose anyhow. So we’re taking the 10-0 back, making this wound again, just close this again. I think this time what we’re going to do, by the way, is we’re going to also — nice bite there, kind of in two steps, we’re going to clamp the infusion, so I’m not tying against the pressure of the vitrectomy system.
There you go, I’m going to cut this down here again, so sometimes if you’re having trouble suturing, especially 10-0 sutures, in a retinal surgery, you have to remember that the big difference is we’re pressuring the eye and you’re — while where we’re trying to put that suture? , so you can turn it down a little bit or just be better at suturing. This is where it helps with to have the fellow come in and do it. They’re a little more familiar with corneal wounds than I am. All right, I did that again. I kind of snapped it off.
But I think we’re OK.
Yeah. No, it’s loose again. Put the infusion. I want to see if it tightens up.
That’s too loose.
So sometimes the smallest parts of the case can give you a little bit of trouble, but you just got to get it right. This is obviously not the critical part of the case. Now clamp it up.
What I did in both times of my tying of the knot, I had it locked — you can put the infusion on for just a moment. Now turn it off again.
So our third try here, can you cut this for me?
And then the tiers … don’t have to lock the… I think that’s half my problem.
There we go. And we’ll cut this again, try and rotate the knot into the eye.
This doesn’t have to be rotated, either. It can be — we’re getting held up. We’re just going to let that go. You have the 7-0?
Take this clot out.
Let me show you the — these are the sutures I care more about, actually. You want to make sure that conjunctiva is well up over your Gore-Tex being exposed while it heals or healing up on top of the conjunctiva. That’s where you get your infection risk.
And so we want to make sure that we got the conjunctiva up to the point where it’s not going to recede and create a problem in terms of exposing the suture. Long-term infection risk here. I’ve not had a patient come back yet with late infection ophthalmitis, I would not expect this to be a problem.
So see that gap? We don’t want that, so we’re always going to put the extra suture in the conjunctiva in these cases, and go around there, yeah.
So that gets us where we need to be.
On the nasal side, which is always a little more difficult.
And again, you can see where this is at, you can see the GoreTex under the conjunctiva there.
So a couple things, when you do these cases you have to have the lens implant that’s already in the eye or you can have the patient remeasured, you know, with biometry
This one we put a cannula there. You got a Q-Tip, Mike?
And so we’re just going to take a look over here real quick, so the conjunctiva is up to a limbus, a little subconjunctival hematoma, not a problem. And then we’re going to pull out this one, the next to the last suture, and this one, we can press on the wound right there again on the top of the wound, to make sure that leak is closed, not looking to close that up if I don’t have to, the eye is well pressurized, and again, I’m always going to place the extra suture to keep the Gore-Tex case, whereas in a normal case you might not bother, meaning, you might cut the conj down or whatever, but here you’re always better off, even if it holds for just a few days.
And there you go. OK, squirt us all down. You got a little BSS for the reconstitute the eye. And so there’s that one suture clearly visible, well covered, the eye is just a little soft, how about a needle, 30-gauge?
And very little, one of the broken 10-0s, a little BSS to put in the eye there. Holding pressure very well. So that’s it. That’s our case, and the suture is a little oblique here, but it’s coming out. It’s not going to affect us. We’ll get that out in a couple weeks. So that’s the conclusion of lens removal and suturing of a Akreos 4-point fixation with Gore-Tex. I’m sure there’s a few questions, what we’re going to do is answer some questions. There is a second case that we can roll right into, of a similar nature, and we can discuss some of your questions and jump back to the lecture, even. So in fact, why don’t I jump back to the lecture real quick and we’ll finish that up first. You know, and kind of see where we’re at, yeah.
There we go. Let me finish this up, because there’s the 4-point fixation, you know excellent cosmetic results. There we go, so Gore-Tex can be 2mm, I use 4, because I’m bumping into the back of the iris.
In our practice, we looked at this number recently, Harrison’s pulled together a report with some other people, we had about 250 cases over the last four years and the number that the Akreos/Gore-Tex are, the other … and as a percentage, you know, without suturing, that’s what I was just talking about, …
So it’s becoming a more common referral practice for our group doing quite a few of these, the treatment options can be tailored to the individual patients. Obviously, no suture or sterile fixation is ideal in places where there’s sulcus support. Long-term follow-up of this technique is always needed to see how things play out over, you know, even 10 or 20 years, to even see what’s going on.
So I’ll go back to the questions, Rachel, and we’ll see what else we got. The other cases — similar: A lens implant that I think is more displaced or subluxed more than totally dislocated and we have to look at whether that’s going to be a sutured IOL also. So we always kind of have to prepare for both, so we have the measurements for the Akreos, but also get the measurements for like a 3-piece —
So a few questions: How do you remove lenses that are calcified or unable to cut in half. Well, this one’s from Alex Miller, my son, is a resident over at Missouri, so on the retina service, so a very good question. So the ones that can’t be cut, which are the older ones, we just open the wound up to 6mm, I don’t like doing that as much, because now you got a big corneal wound and it’s good to know ahead of because you can break the scissors trying to cut these hard plastic lenses. So it basically comes to the plastic lenses. If they’re calcified. I’ve never had a lens that I couldn’t cut. You end up trying to bring those to the anterior chamber and pulling them out that way, flushing them out. Another question was: Why was the suture buried in the wound?
The reason we do that is because we’re afraid that the knot is above the sclera, that it will rub through the conjunctiva, that type of irritation, I’m not sure that’s likely. Gore-Tex is so pliable and not stiff that you can compress it with the needle holders and it would almost flatten out like a pancake, so if you can’t rotate it in, which can be a trick sometimes, I’ve seen people struggle with that, if you have to leave it on the surface, just compress it flat with the needle driver and you’ll probably be fine.
If you don’t have Gore-Tex available, another suture that you can probably use is 9-0 or 8-0 proline. That was what we used to use. The prolines are very thin and they can cheese wire, so a thin suture can cut through tissue. But longs you leave it loose enough — but I do think 8 or 9-0 proline would suffice, or nylon for that matter.
I’d say 95% of the time I’m stuck throwing the — how often do you find CME? How do you manage that? So CME, we found that to be a problem in the early going with this procedure. It seemed like oh, my gosh, up to a third or even half of the patients were getting recalcitrant CM. He would treat it with steroids and it would go away. But it would always come back.
I was seeing a lot of translocation defects and so you’re right behind the iris and I thinl the chafing up there was contributing to the CME. It has been much less of a problem from 4mm back from 3 and that’s what’s working for me over the last couple of years.
Next question: Am I using a 27-gauge card? No, I’m using a 25. I have a tri- — I still had the sutures, so I quickly went back to 25. But I do think the 27 is instinctive. Just your instinct is the wounds are going to be tighter, they’ll close and I do want to go back and try that some more with 27-gauge? Do I think it would work with 23? I think it would work, you just got to sew the wound.
So the issue with Akreos is that type of material can opacify, especially with intraocular gas. I’ve seen exactly one case of that, and it was my own patient where I sutured in a lens years ago and they came back and detached several years later in the same eye and the lens that opacified, had to go back and cut it out and replace it, so it made for extra steps. It’s not that big a concern, I guess. Like, it’s such a rare event. I have plenty of other patients that we’ve done retinal surgery for with Akreos and these types of lenses and they don’t opacify. So I think the risk of it is small enough that I’m not at all frightened off and want to use other lenses or other material. I think this goes in so well with four-point fixation. If you get intraocular gas, it’s like you know you’re starting to treat complications that are very unlikely to happen, as opposed to doing what can work best for you in a case.
The next question there is: What sides of the suture do you use for corneal stitches? Makes it break easy, can you use a figure of 8? You can do anything to close those corneal wounds. That’s definitely not my forte. I would tell you that you saw me break two and the third one was still a little bit oblong or you know, not radial. It’s a temporary suture, whatever works for you is fine. You don’t have to bury the knot, it’s just a typical teaching to bury the knot for comfort, but the conjunctiva, being — the knot on the surface for a couple of weeks won’t matter.
So if you get the IOL calculations, I know the patient’s refraction with the old lens, then you can figure out what the old A constant was and do the math medical conversion. For the most part they’re coming out what we want. When we’re doing IOL calculations or biometry, we kind of just go for in the bag replacement.
I do always warn the patient you’re going to have a refractive correction, glasses will be changed. Other questions is sometimes come out what about tauric lenses and multifocal lens? And my answer is we don’t get that fancy here. We’re not trying to reposition tauric lenses or multifocal lenses. The tauric lenses I did try once or twice and it’s a matter to get that lens to fixate in a way by punching a hole in it. Not that straightforward. There are some surgeons punching holes in the — where the haptic joins the IOL and then stringing the suture and getting the lens in the right axis. I’ve not found that to be very reproducible or easy to learn, I’ll say, and so for the most part I don’t chase after the.
What was the — this was a Bausch and Lomb Akreos AO60. It’s one of these, so there you go, is what it looks like in the box. And the numbers are like so, you know. Whoops, upside down.
So you know, if we just — we don’t — we actually do enough of these that we keep a whole consignment of all the powers here. You can always order these one-off. I actually work at Children’s Hospital, too, in Akron, doing retinal surgery and we’ve actually replaced this exact same lens in pediatric patients, ages 10, 8, and maybe as low as a 6-year-old now for whatever reason could not tolerate aphakic contact lens and needed a lens implant and this works very well for them, too.
Does this procedure have advantage over the other types of cataract surgery? I think the best accurate surgery is always one without complications. Phacoemulsification or however you do the procedure or in the bag placement is ideal. I think both of those are better than suturing or fixating anything. Always prefer to not have to do this type of procedure and go for one that is the standard cataract procedure of your region.
The comparison of visual outcomes — that’s a very good question. So this lens you can definitely play with the centration and also don’t have any tilt. The Emamis can tilt — I do not know of any literature or studies that compare those outcomes. We are going to be looking at that this year and next year together with other groups.
Have you tried explaining the IOL via a well construct sterile tunnel? Yes, I have done that prior and the problem with the scleral tunnels is oftentimes these surgeries are old enough that the sclera was already incised and sutured together 20 years ago, and it’s very, very thin, and so they make a second scleral tunnel in the same location. It’s difficult and they end up being too shallow or too deep. Too deep, you enter up entering the anterior chamber, if too shallow, you end up with scleral — I prefer at this point just to go up to the cornea and if it’s small, it’s fine. And even at 6mm we can —
If a vitrectomy machine is not available, can you do — you certainly can. You if you don’t have access to a vitrectomy and the lens implant somewhere in the iris plane area, I think you can very cautiously, you know, manipulate it where you could grab that lens implant and do a scissor vitrectomy to try and keep the vitreous from trailing you out of the eye.
Does this type of IOL have any — intraocular lens — implant have any side effect? The one that everybody knows about is opacification with intraocular gas which we covered earlier, which I think is so rare in my own personal experience — I don’t recall what the numbers are, percentages, but so rare, I just don’t see it as much of an issue.
And what is your point of view about multi-focals and trifocals in formal cases? Multi-focals, interestingly, I have family members with multifocal IOLs, and they love it, so these are people who are healthy, in their mid-60s, and they love the multifocal ability.
A lot of my patients are elderly with macular degeneration or macular puckers or prior macular holes and in that case I think it’s not healthy. If you’re maybe towards the younger side of cataract surgery, my bias is the multi-focals are probably very, very nice. If you’re an older patient with any retinal compromise or just older in general and you may be frustrated by the lack of contrast, you may want to stay away from the multi-focals:
And the last question here is what would be the preferred — what will be the preferred to this procedure to Lasar, please? I’m not exactly sure what you mean. But you just try to be careful for retinal tears and making sure….
Well, that’s the last question. And we’re prepping the next patient now, it’s actually already been an hour and a half so we’re probably going to cut it here for the program. You saw the bigger case, for sure. But thank you for joining us here in Cybersight. Appreciate everybody participating and asking questions, and I look forward to doing more presentations in the future. Have a great day. OK.