The following exchange refers to an article for the Cataract Surgery Complications Management column titled “Incorrect Lens Implant” that appeared in our January 2006 issue. The section editors for this column are Robert J. Cionni, MD; Michael E. Snyder, MD; and Robert H. Osher, MD.
As always, I enjoyed the Cataract Surgery Complications Management column that appeared in January's edition. The esteemed panelists' responses, which addressed in-the-bag IOL exchange, were both informative and useful. I think that the technique of folding an acrylic lens in the eye prior to its removal is an exceptionally elegant way to tackle the problem. I would like to share two pearls that I learned during a video presentation at the AAO annual meeting several years ago involving the removal of a foldable acrylic IOL from the bag. Although several of the panelists described a similar technique of folding the IOL within the eye, I would like to add two small modifications that might help a beginning surgeon. I believe that this approach results in easier and safer explantation of the lens.
Once the IOL has been carefully extricated from the bag and is in the anterior chamber, I refill the bag and the anterior chamber with viscoelastic and implant the new IOL in the bag using the inserter, while the “old” IOL is still in the anterior chamber. Care must be taken to protect the endothelium, but the insertion of the new IOL stabilizes the capsule and allows the folding of the old IOL in a safer fashion. Prior to folding the IOL as described in the article, the other modification I make is to bring one haptic of the old IOL out of the eye through the clear corneal incision, and then I complete the fold. This allows for smoother removal of the folded optic without the leading haptic's becoming ensnared in the incision.
Fortunately, these maneuvers are not required often, but, in a pinch, this is a great technique for explanting an IOL without the risks of using intraocular scissors to cut the lens.
Parag A. Majmudar, MD
I agree with Dr. Majmudar that leaving one of the haptics out of the incision during folding simplifies explantation. However, I fail to understand how leaving the original IOL in the anterior chamber while implanting the secondary IOL stabilizes the capsule. Additionally, there would be a risk of the primary IOL's touching the corneal endothelium during the implantation of the secondary IOL. For these reasons, I would recommend removing the primary IOL first, followed by the injection of the secondary implant.
Robert J. Cionni, MD