ROBERT J. ARLEO, MD, FACS

This woman's visual disability stems from two sources: the PCO and the IOL's decentration. Prior to examining them, quite a few of my patients with similar amounts of IOL dislocation secondary to malpositioned lenses during extracapsular cataract extraction have undergone Nd:YAG laser capsulotomies to the optical axis. They have done surprisingly well, with visual acuities ranging from 20/20 to 20/30. If these patients were happy, I did nothing, and their vision has remained stable over the last 10 years.

The difference in this case is the probability of the IOL's further dislocation, based on the history, the possibility of microspherophakia, and the phacodonesis. Any attempt to perform an Nd:YAG laser capsulotomy, even if it temporarily relieved her symptoms, might complicate further surgical intervention. My preference would be first to secure the IOL in the proper position for the long term and then to perform the capsulotomy at a later date.

The options for visual rehabilitation include (1) removing the IOL and capsule and leaving the patient aphakic in this eye like its fellow, (2) removing the IOL and capsule and replacing them with an ACIOL, (3) removing the IOL from within the capsule and fixating a new PCIOL transsclerally, (4) trying to insert a CTR with transscleral support, or (5) fixating the existing IOL to the iris without removing it from the capsular bag. I think the last option is the best.

Suturing the IOL to the iris is a straightforward procedure. First, I would make paracentesis incisions at the 3-, 6-, 9-, and 12-o'clock positions. Then, I would fill the anterior chamber with a dispersive viscoelastic such as Viscoat (Alcon Laboratories, Inc.), and I would place some viscoelastic behind the IOL/capsular bag complex to push back the vitreous face. After making relaxing incisions in the anterior capsule, I would try to prolapse the IOL optic out of the capsular bag with more Viscoat. It would then be possible to prolapse the optic further with the help of a cyclodialysis spatula in the anterior chamber. A pupil constricted with Miochol-E (Novartis Ophthalmics, Inc., Duluth, GA) would trap the optic in the anterior chamber.

At this point, I would again elevate the IOL's optic with the cyclodialysis spatula and thus tent the iris over the IOL's haptics, which would still be in the capsular bag. Next, I would pass a 10–0 Prolene suture (Ethicon Inc., Somerville, NJ) in a McCannel fashion through the limbus, across the anterior chamber, through the iris, under the haptic, out the iris into the anterior chamber, and back out the opposite limbus. I would use a lens hook to retrieve the suture ends through one of the paracentesis incisions and tie them down, thus securing the IOL's haptic in a good position relative to the iris. After repeating the procedure for the other haptic, I would prolapse the optic back into the posterior chamber and remove the Viscoat. I would perform an Nd:YAG capsulotomy at a later date. The patient should receive NSAIDs prior to surgery and topical NSAIDs and steroids postoperatively.

This technique has the advantages of not disrupting the IOL/capsular bag complex and of restoring it to its normal position without having to rely on transscleral fixation, which could in time be complicated by eroding sutures. In addition, this procedure is technically easier than the other options mentioned earlier. The only negative is that this patient would have a 0.50 to 2.00D myopic shift in her refraction, depending on the original IOL power. Because her fellow eye is aphakic, this refractive change should not be a problem.

DOUGLAS D. KOCH, MD

There are at least four possible approaches to this case. First, one could try to reopen the bag, insert a Cionni modified CTR (Morcher GmbH, Stuttgart, Germany; not FDA approved), and suture it into the ciliary sulcus. Second, one could suture the IOL/bag complex to the iris using a McCannel suture approach. A third option would be the scleral fixation of the IOL/bag complex. Fourth, after removing the entire bag/IOL complex, one could insert a PCIOL and suture it to the iris or place an ACIOL.

Reopening the capsular bag can be extraordinarily difficult when there is marked phacodonesis and capsular fibrosis, as seen in this case. My preference would be the second or fourth options I described, but I have seen excellent results with the third alternative as well. I would make a pars plana incision and use a spatula to elevate the bag/IOL complex sufficiently to permit a McCannel suture-type approach. If for some reason this were not feasible, I would prolapse the entire complex into the anterior chamber in order to capture it and then perform an anterior pars plana vitrectomy prior to removing the complex. This approach minimizes the risk of inducing excessive vitreous traction. My final step would be to implant an ACIOL.

GARRY P. CONDON, MD

In the short term, a somewhat decentered Nd:YAG laser capsulotomy might dramatically improve the visual acuity of this relatively young patient. The progressive IOL/bag decentration and obvious exposure of the optic's edge through the pupil, however, strongly suggest the likelihood of increased visual difficulty in the long term as the dislocation worsens. The current position of the IOL/bag complex appears amenable to either iris or scleral suture fixation and recentration using a minimally invasive approach. I would offer her that option before performing a capsulotomy and before more marked subluxation or dislocation occurred. I could easily and more centrally perform a capsulotomy after IOL/bag suture fixation.

I have managed eyes with early but progressive decentration by means of modified, McCannel, peripheral iris suturing in combination with Siepser sliding knots.1-3 I pass a 10–0 polypropylene suture on a long curved needle (a PC-7 [Alcon Laboratories, Inc.] or a CIF-4 or CTC-6 [both Ethicon Inc.]) through a corneal paracentesis so as to incorporate a bite of peripheral iris as well as lens capsule and one of the IOL's haptics. The needle travels easily through the fibrotic capsule. Once passed under the haptic, the needle returns through the capsule and peripheral iris and exits through the clear cornea. By improving the visibility of the haptic's position and stabilizing the IOL/bag complex, a Kuglen or Sinskey hook placed through the limbus promotes the accurate passage of the needle (Figure 2). Although it is possible to retrieve the two suture ends through a common paracentesis created over the haptic to tie the knot, I find that the Siepser sliding knot allows more precise tightening of the suture. I irrigate out preplaced cohesive viscoelastic through a paracentesis.

Slight ovalization of the pupil is common and well tolerated by patients (Figure 3). This microincisional approach has the advantage of avoiding the large incision associated with IOL exchange as well as the use of any scleral sutures.
Section Editors Robert J. Cionni, MD; Michael E. Snyder, MD; and Robert H. Osher, MD, are cataract specialists at the Cincinnati Eye Institute in Ohio. They may be reached at (513) 984-5133; rcionni@cincinnatieye.com.
Robert J. Arleo, MD, FACS, is Medical Director of the Arleo Eye Institute in Ithaca, New York. He is a compensated speaker and participates in clinical trials for Alcon Laboratories, Inc. Dr. Arleo may be reached at (607) 257-5599; rarleo@aol.com.
Garry P. Condon, MD, is Clinical Associate Professor for the Department of Ophthalmology at Allegheny General Hospital in Pittsburgh. He is on the speaker's bureau for Alcon Laboratories, Inc. Dr. Condon may be reached at (412) 359-6298; garlinda@usaor.net.
Douglas D. Koch, MD, is Professor and the Allen, Mosbacher, and Law Chair in Ophthalmology at the Cullen Eye Institute, Baylor College of Medicine, Houston. He states that he holds no financial interest in the products or companies mentioned herein. Dr. Koch may be reached at (713) 798-6443; dkoch@bcm.tmc.edu.
1. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg. 1976;7:98-103.
2. Siepser SB. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol. 1994;26:71-72.
3. Condon GP. Peripheral iris fixation of a foldable acrylic intraocular lens in the absence of capsule support. Techniques in Ophthalmology. 2004;2:3:104-109.
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