Dislocated IOL Levitation With a Sleeveless Extrusion Cannula

Dislocation of an IOL into the posterior chamber is a dreaded complication. It leads to a continuous tussle to optimize visual outcomes and meet the expectations of a highly demanding patient. Below we explain how to use a sleeveless extrusion cannula to reposition a dislocated IOL atraumatically.

Flynn et al^1,2 described the technique of using a soft-tipped extrusion cannula to drain posterior subretinal fluid. In this commonly used procedure, flexible silicone tubing is attached to the end of a tapered extrusion needle and advanced into the subretinal space, through a preexisting open peripheral break or a retinotomy performed during vitreoretinal microsurgery, in order to allow atraumatic drainage of posterior subretinal fluid.

In complicated cataract surgery, using a sleeveless extrusion cannula to address a dislocated IOL provides a large contact area with the IOL. With application of adequate suction, the IOL can be lifted and brought into the pupillary plane, from whence it can be grasped by forceps and removed.

SURGICAL TECHNIQUE

Under local anesthesia, standard 23-gauge threeport pars plana vitrectomy incisions are created. After releasing all vitreolenticular adhesions, complete vitrectomy with careful separation and removal of the posterior hyaloid face is performed prior to lifting the IOL. This prevents traction on the retina in subsequent maneuvers. The IOL gently floats to the posterior pole of the eye once it is freed from all attachments (Figure 1A).

The sleeveless extrusion cannula is then connected to the vitreotome, and the vacuum is set to 300 mm Hg with the cutting function turned off. As the IOL rests flat on the retina, the sleeveless extrusion cannula is positioned carefully to face the center of the optic; ineffective contact of the cannula’s lumen with the surface of the IOL optic can lead to vacuum loss. Suction is then initiated and controlled with the footpedal. Linear footpedal control allows vacuum to be increased when needed during levitation of the IOL (Figure 1B).

The IOL is lifted from the surface of the retina and brought into the anterior vitreous cavity in the midpupillary area (Figure 1C). Next, end-opening forceps, introduced from the corneal incision under direct visualization through the microscope, are used to grasp the IOL, and the extrusion cannula is removed. The IOL can then be managed depending on the surgical scenario; it can be either repositioned in the sulcus or explanted (Figure 1D).

BETTER ACCESS, EFFECTIVE SUCTION

Various methods of IOL levitation have been described in the literature.^3-7 Retinal forceps are a mainstay of treatment in vitreoretinal surgery; however, an accidental iatrogenic retinal tear while lifting an IOL from the surface of the retina is possible with use of these instruments. Often IOLs are sneaky, slippery, and difficult to grasp,³ especially those with plate haptics

The flexible silicone sleeve fits snugly within the rigid outer shaft of the vitrector cannula, preventing leakage of air or fluid and providing good access into the subretinal space.⁸ Removal of the silicone sleeve exposes a wider access of the bore of the cannula, which helps to create effective suction around the IOL.

CONCLUSION

eyetube.net/?v=uheni.

The technique described above and in a video at eyetube.net/?v=uheri is safe, reliable, and reproducible. Moreover, it is an effective solution for a dislocated IOL of any type, including platehaptic IOLs, which are often difficult to grasp with retinal forceps. Other advantages are that no additional device is required and availability of an extrusion cannula is not an issue, as these instruments are included in virtually all vitreoretinal set-ups.

Amar Agarwal, MS, FRCS, FRCOphth, is Professor and Head of Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Professor Agarwal states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +91 44 2811 6233; fax: +91 44 2811 5871; e-mail: dragarwal@ vsnl.com.

Ashvin Agarwal, MS, is a Senior Consultant at Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Mr. Agarwal states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: agarwal.ashvin@gmail.com.

Priya Narang, MS, is a Director at Narang Eye Care & Laser Centre, Ahmedabad, India. Ms. Narang states that she has no financial interest in the products or companies mentioned. She may be reached at tel: +91 79 2642 0034; fax: +91 79 2268 4556; e-mail: narangpriya19@gmail.com.

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