CASE PRESENTATION
A 65-year-old white male desired surgical correction and was referred to our clinic by his ophthalmologist. The patient had previously undergone a penetrating keratoplasty procedure and suturing of a posterior chamber IOL (PCIOL) 10 years earlier for pseudophakic bullous keratopathy in his right eye. Fairly recently, he had begun to note monocular diplopia OD, and his visual acuity in that eye had declined. His refraction revealed a significant change in his prescription from -1.25 + 5.25 X 10 to -4.00 + 2.25 X 25. The patient's BCVA was only 20/30, whereas it had previously been 20/20. His slit lamp examination showed a thin, clear corneal graft and the posterior chamber sutured IOL subluxed inferiorly. All corneal graft sutures had been removed well before this time, and only a small part of the superior rim of the optic could be seen in the pupil. The patient's IOP and dilated retinal examination were otherwise normal.
HOW WOULD YOU PROCEED?
1. What are the patient's options for visual rehabilitation?
2. Would you plan to exchange the IOL? If so, would you replace it with another sutured PCIOL or an anterior chamber IOL?
3. Would you attempt to resuture the free haptic? If so, how would you do this?
4. Where would you place the incision?
5. What method of anesthesia would you use? Topical? Retrobulbar/peribulbar block? General anesthesia?
SURGICAL COURSE
I explained to the patient that I would determine the course of action by my findings in the operating room.
I would first determine whether I could elevate the subluxed lens and suture the superior haptic (the latter's suture had eroded) to the iris using a McCannel suture. This procedure could be accomplished through clear corneal incisions. If, however, this was not possible, I planned to create a corneoscleral incision. Through this incision, I would attempt to either resuture the existing PCIOL or, if necessary, remove it and replace it with either another sutured PCIOL or an anterior chamber IOL. This would clearly be a more challenging procedure. Additionally, the increased complexity of this approach could potentially jeopardize the status of the corneal graft.
Prior to surgery, I repeated the IOL calculations using the current keratometry readings. Preoperatively, I dilated the patient's pupil with three sets of Cyclogyl (Alcon Laboratories, Fort Worth, TX) and phenylephrine. Next, I administered one drop each of Ocuflox (ofloxacin; Allergan, Inc., Irvine, CA) and Acular (ketorolac tromethamine; Allergan, Inc., Irvine, CA) three times. I achieved anesthesia and akinesia using a retrobulbar block with Marcaine (bupivacaine HCL injection; USP, Abbott Laboratories, Abbott Park, IL), lidocaine, and hyaluronidase.
To decompress the eye and orbit, I placed a super-pinky over the operative eye for 5 minutes. I then prepped and draped the right eye in the usual sterile fashion. Next, I placed a Lieberman speculum (Katena Products, Inc., Denville, NJ) between the lids, providing excellent exposure. My examination through the operating microscope revealed the PCIOL to be inferiorly and posteriorly subluxed. I created a counterpuncture site with a diamond stab superonasally at the 2 o'clock position. Then, I exchanged the anterior chamber fluid for Amvisc Plus (sodium hyaluronate; Bausch & Lomb, Inc., San Dimas, CA). Finally, I inserted a Lindstrom Trident Nucleus Rotator (Rhein Medical, Inc., Tampa, FL) through the paracentesis and elevated the PCIOL.
It was now apparent that the suture for the inferior haptic was still intact and stable; the inferior haptic was sutured to the sclera at the 7 o'clock position. By elevating the optic with the nucleus rotator, I was able to reposition it in the center of the pupil. With continued elevation of the lens, I could visualize the superior haptic tenting up the superior iris from beneath it, and I made the decision to perform a McCannel iris suture. While still supporting the optic with the nucleus rotator in my left hand, I took a 10–0 polypropylene suture (Ethicon, Somerville, NJ) on a long needle (JA-2559 N) in my right hand. I passed the needle through the clear cornea at the 11 o'clock position, approximately 2 mm from the limbus. I continued to pass the needle through the superior iris, beneath the haptic, back up through the iris on the other side of the haptic, and then out through the clear cornea at the 1 o'clock position (Figure 1A). In order to leave a length of suture emanating from the corneal entrance and exit sites, I carefully cut off the needle.
At the 12 o'clock position, I made a second counterpuncture superiorly. Using a Kuglen hook, (Storz, St. Louis, MO) I drew out each end of the prolene suture through the 12 o'clock paracentesis (Figure 1B), tying the suture ends while using the hook to cinch the knot down onto the iris (Figure 1C). Using a Vannas scissors (Katena Products, Inc.), I cut the suture ends. When I inspected the IOL, I found it to be nicely centered, and, when I tapped on the optic with the nucleus rotator, I found the IOL to be stable (Figure 1D). No vitreous was present in the pupil or anterior chamber. The pupil was perfectly round. I then irrigated residual viscoelastic from the eye using BSS (Alcon Laboratories, Fort Worth, TX). In order to constrict the pupil, I injected Miostat (carbachol; Alcon Laboratories) into the patient's eye. I stromally hydrated the paracenteses, which were watertight upon inspection. I applied a drop of Ocuflox, Pred Forte 1% (prednisolone acetate; Allergan, Inc., Irvine, CA), and Betagan 0.5% (levobunolol HCL; Allergan, Inc.) to the patient's eye. Finally, I removed the lid speculum and taped a patch and a Fox Eye Shield (Katena Products, Inc.) into position. The patient tolerated the 10-minute procedure well, and there were no complications.
OUTCOME
On the first postoperative day, the patient reported having a comfortable night. His BCVA was 20/60 with a refraction of -1.75 + 2.50 X 25, and he did not complain of diplopia. The slit lamp examination revealed a clear corneal transplant without any visible edema. There were a few dispersed red blood cells in the anterior chamber from the iris suture; no active bleeding was present. The PCIOL was well centered and a dilated retinal examination was normal.
I instructed the patient to take Ocuflox, Acular, and Pred Forte four times per day. His ophthalmologist in another state continued his follow-up care, and correspondence with his ophthalmologist has indicated that the patient is doing so well (BCVA is 20/20) that, in fact, he is currently interested in having LASIK surgery performed on that eye.
Elizabeth A. Davis, MD, is a Partner at Minnesota Eye Consultants, P.A., and a Clinical Assistant Professor at the University of Minnesota. She does not hold a financial interest in any of the products mentioned herein. Dr. Davis may be reached at (952) 885-2467; eadavis@pol.net
