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Today's Practice | Mar 2010

Repositioning a Luxated Lens

The glued IOL technique maintains a closed system and minimizes incision size, trauma, surgical time, and intraocular pressure fluctuation.

Postoperative luxation of an IOL remains an infrequent but significant sight-threatening complication after cataract surgery (Figure 1). The limited management options include observation and IOL exchange or repositioning. In these situations, we frequently choose to reposition and glue the implanted IOL into the posterior chamber with no lens exchange. This method minimizes astigmatism induced by the corneal wound1-4 and can be performed with the following types of IOLs: rigid PMMA, three-piece posterior chamber foldable IOLs, and those with modified PMMA haptics.

SURGICAL TECHNIQUE
After localized scleral peritomy and wet cautery, two partial-thickness scleral flaps (2.5 X 3 mm) are created approximately 1 mm from the limbus. The flaps are located 180° diagonally apart, and an infusion cannula is fixed in another quadrant (Figure 2). After vitrectomy— using triamcinolone for better visualization if preferred— two straight sclerotomies are made under the scleral flaps, approximately 1 mm from the limbus, with a 20-gauge needle. The tip of the haptic of the dislocated IOL is externalized through one of the sclerotomies (Figure 3) using microrhexis forceps to hold the haptic tip.

While another assistant holds the tip of the externalized haptic, the surgeon is free to pull the other haptic through the second sclerotomy and tuck the tips of the haptics into scleral tunnels created at the point of externalization with a 26-gauge needle (Figure 4). The scleral flaps and peritomies are closed with fibrin glue (Tisseel; Baxter Healthcare, Deerfield, Illinois; Figures 5 and 6).

HAPTIC STABILITY AND IOL CENTRATION
Fibrin glue allows the rough apposing surfaces of the manually created flaps and stromal beds to heal firmly around the haptics, helps in forming good surgical adhesion, and prevents haptic movement along the long axis. Tucking the haptic tip into the scleral wall provides additional stability and prevents haptic movement along the transverse axis. The IOL loops maintain their original symmetrical configuration; loop rigidity and loop memory allow the haptics to be stretched and compressed in vivo. Adequate loop memory enables the IOL to remain stable in the posterior chamber.

In our study, no IOL tilt was observed. Additionally, postoperative anterior segment optical coherence tomography (OCT) showed perfect scleral flap adhesion as early as day 1 and again at 1 week and 1 month. Commonly reported complications during management of subluxated and posteriorly dislocated IOLs (ie, intraoperative retinal dialysis, postoperative extension of an existing subclinical retinal detachment, recurrent subluxation of an anterior chamber IOL, breakdown of chronic cystoid macular edema to form a macular hole, and pseudophakic pupillary block requiring laser iridotomy) were not encountered.

CONCLUSION
After this IOL-rescue procedure, complete wound healing may take up to 3 months, but the IOL continues to remain stable. During lengthy procedures to suture IOLs to the sclera, retinal photic injury can occur; however, the short surgical time associated with the glued IOL technique reduces this risk. Because the IOL haptic is tucked into the scleral tunnel, further movement of the haptic is prevented and late redislocation is minimized. Because no sutures are used, there is no threat of suture-related complications such as suture erosion, suture knot exposure, dislocation of the IOL after suture disintegration, or broken suture.

Repositioning and gluing the original IOL in the posterior chamber avoids the use of large surgical incisions and minimizes surgically induced trauma from sclerotomy sites, prolonged surgical time, and intraocular pressure fluctuation. Interim results are promising; however, long-term follow-up is required to assess the safety of this technique.

Amar Agarwal, MS, FRCS, FRCOphth, is in private practice at Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. Dr. Agarwal states that he is a consultant to Abbott Medical Optics Inc., Bausch + Lomb, and STAAR Surgical. He may be reached at tel: +91 44 2811 6233; fax: +91 44 2811 5871; e-mail: dragarwal@vsnl.com.

Dhivya Ashok Kumar, MD, practices at Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. Dr. Kumar states that she has no financial interest in the products or companies mentioned. She may be reached at tel: +91 44 2811 6233; fax: +91 44 2811 5871; e-mail: susruta2002@gmail.com.

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