An Improved Technique for Management of

Reprinted from OPHTHALMOLOGY Vol. 99, No.2 January 1992 © J. B. Lippincott Co. Printed in U.S.A.

An Improved Technique for Management of Dislocated Posterior Chamber Implants Clement K. Chan, MD

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any techniques for repositioning dislocated posterior chamber implants described in the recent literature involve intricate intraocular manipulation of a needle or other sharp instrument. The author describes an improved sulcus fixation technique, which combines the best features of external and internal approaches. Its main features involve temporary externalization of the haptics for easy and secured placement of suture knots, and subsequent reinternalization of the same haptics through horizontal sclerotomies directly external to the ciliary sulcus for precise fixation of the dislocated posterior chamber implant with consistency. Between May 1989 and December 1990, this technique was successfully used for posterior chamber intraocular lens repositioning in 12 cases. The main advantages of this technique include: (1) easy suture placement, (2) less chance of suture slippage with the secured knots, and (3) avoidance of difficult intraocular maneuvers and possible tissue injury. This improved technique expedites the process of posterior chamber implant repositioning. Ophthalmology 1992; 99:51-57

Because of the successful visual outcome and minimal associated complications, posterior chamber intraocular lens (PC IOL) implantation combined with extracapsular cataract extraction (ECCE) or phacoemulsification is currently the most widely accepted form of cataract surgery in the United States and the rest of the industrialized world.l" One of the few complications of PC IOL insertion is the dislocation of the pseudophakos into the vitreous cavity in the absence of adequate capsular or zonular support, or the lack of proper sulcus fixation.Y Leaving the dislocated implant undisturbed as advocated by some" is potentially sight-compromising and can lead to possible

Originally received: June 10, 1991. Revision accepted: September 3, 1991. From the Department of Ophthalmology, Lorna Linda University, Lorna Linda. Presented in part at the Western Retina Study Club, Seattle, February 1991, and at the 9th Biennial Paul Cibis Club Meeting, apa, California, May 1991. The author has no proprietary interest in the development or marketing of the sutures and forceps mentioned in this article. Reprint requests to Clement K. Chan, MD, 1276 Palm Canyon Dr, Suite 105, Palm Springs, CA 92262.

damage to the retina. Repositioning of the dislocated implant has many obvious visual advantages. Many surgical techniques of IOL repositioning have been reported in the literature.?"!? Some of the previous reports involve repositioning of iris-fixated types of implants.I+'? The more recent reports concern the repositioning of PC IOLs.9,11-16 They generally involve anchoring the PC IOL to the iris, 11,12ciliary SUlcUS,13-16the pars plana.!" or a combination of the above. The methods of fixating the dislocated PC IOL to these locations are modifications of the various suturing techniques for primary or secondary PC IOL insertion,18-22 sometimes in conjunction with aphakic penetrating keratoplasty+?" or with IOL exchange," in the absence of adequate capsular or zonular support. The pars plana techniques eliminate potential vitreoretinal traction and facilitate the adaptation of one of these IOL fixation techniques for IOL repositioning. Ciliary sulcus fixation restores the PC IOL to a position most similar to its original state before dislocation, with minimal disturbance to the surrounding tissues. But most reported techniques for sulcus fixation involve relatively complicated and sometimes cumbersome intraocular maneuvers. An improved sulcus fixation technique is herein presented, which combines the advantage of the

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high degree of control. of a "closed-eye," bimanual pars plana approach with the advantage of temporary externalization of the haptics for easy suture placement. This technique greatly expedites the process of PC IOL repositioning.

Materials and Methods A standard pars plana vitrectomy is first performed (Fig IA). A 4-mm infusion cannula is anchored 3.5 mm posterior to the limbus at the inferior temporal pars plana. The vitrector and the fiberoptic light pipe are inserted through the superior sclerotomies 3.5 mm posterior to the limbus (posterior sclerotomies). The anterior and central vitreous are removed. The formed vitreous around the dislocated IOL is also eliminated to prevent vitreous traction on the retina during the process of IOL manipulation. Two diametrically opposed 3-mm partial-thickness triangular scleral flaps as described by Hu et al'? are

prepared at the horizontal meridians, close to the 3- and 9-0'clock positions. The base of the flaps are less than 1 mm from the limbus. Sclerotomies are made within the bed of the scleral flaps between I to 1.5 mm from the limbus (anterior sclerotomies), (Fig l B), The fiberoptic light pipe is inserted through one of the posterior sclerotomies, while a pair of fine non-angled intraocular forceps (e.g., Grieshaber 612.95) is inserted through the anterior sclerotomy at the opposing quadrant. One of the haptics of the dislocated PC IOL is grasped by the forceps and then externalized through the anterior sclerotomy (Fig 1C). After the light pipe and the forceps are withdrawn, they are switched to the surgeon's opposite hands. The light pipe is then inserted through the posterior sclerotomy and the forceps through the anterior sclerotomy at the opposite quadrants. The other haptic is similarly engaged and externalized through the corresponding anterior sclerotomy (Fig IC). As both haptics are externalized to a position close to the external surface of the ciliary sulcus,

Figure 1. A, a standard pars plana vitrectomy is performed to remove the anterior and central vitreous around the PC IOL B, anterior horizontal sclerotomies are made through the ciliary sulcus at 1 to 1.5 mm from limbus, under partial thickness scleral flaps. 14.19.29 C, haptics of IOL . are externalized by intraocular forceps through the horizontal sclerotomies.

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Chan . Dislocated Posterior Chamber Implants the optic is automatically centered behind the pupil in the posterior chamber (Fig 2A). Separate double-armed 9-0 polypropylene sutures (Ethicon TG 140-8 plus, Somerville, NJ) are tied around the distal one third to one half of each of the externalized haptics to make a secured knot (Fig 2A). To prevent slippage of the polypropylene suture from the polypropylene haptic of an open-loop PC IOL, a clubbed deformity as described by Hu et al'" is made near the distal end of the haptic with a disposable cautery, if a control tip eyelet or a loop is not already present at the end of each haptic (Fig 2B). If necessary, the sclerotomies can be widened to allow passage of the haptics with the surrounding polypropylene knots and the enlarged haptic tips (Fig 2C). The externalized haptics are then reinternalized through the same anterior sclerotomies by grasping the ends of the haptics distal to the polypropylene knots with the intraocular forceps (Fig 3A). When the distal ends of the suture associated with the needles external to the eye are gently pulled to remove any slack, the optic of the IOL is automatically centered at the posterior chamber behind the pupil, and the haptics are immediately anchored at the ciliary sulcus (Fig 3B). Scleral bites are taken around the lips of each anterior sclerotomy by the needles. Making a knot with both ends of the suture automatically results in closure of each anterior sclerotomy. The overlying scleral flap is then closed with a 9-0 or 10-0 nylon suture.14,19,29 Alternate Closure To further simplify the procedure, the scleral flaps can be eliminated altogether. Instead, anterior sclerotomies

through full-thickness sclera can be made external to the ciliary sulcus (1 to 1.5 mm from limbus) in the horizontal meridians. Once the externalized haptics with suture knots are reinternalized, inverted bites are taken on the edges of the anterior sclerotomies with the haptic sutures for closure (Fig 3C). The resultant knots are buried inside the anterior sclerotomies. 3D Closed-loop PC IOLS For a dislocated PC IOL with closed loops, creation of a clubbed deformity by the disposable cautery is not necessary. It may be difficult to externalize the haptics of certain closed-loop PC IOLs. Much wider horizontal sclerotomies may be required for externalization of their haptics. However, only a small portion of their haptics needs to be externalized for suture placement. If difficulty is encountered in having both haptics externalized at the same time due to their lesser degree of flexibility, their haptics can be externalized one at a time for suture placement. Selected Case Reports Case 1. An 82-year-old man underwent ECCE with PC IOL for his right eye in August 1990. During the procedure, the nasal portion of the posterior capsule was ruptured. However, enough of the temporal capsule was left intact that a PC IOL was inserted. Postoperatively, the PC IOL was in the bag, and the visual acuity of the right eye improved to 20/30. On November 12, 1990, the patient discovered marked blurring of the vision of the right eye after waking from a nap. There was no pain. He sought an eye examination 2 weeks later. Results of

B Figure 2. A, secured knots are tied around the externalized haptics by double-armed 9o polypropylene sutures. Externalization of both haptics centers the IOL in the PC and provides temporary but stable IOL support by the surrounding scleral wall, without the need of transfixation with a sharp instrument. B, to prevent suture slippage, the tips of the haptics are enlarged with a disposable cautery, before haptic reinremalization." C, enlargement of the sclerotomies may be necessary to allow internalization of the haptics with the surrounding suture knots and thickened haptic tips.

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B

~\ \

A

~ 1

/

Figure 3. A, the haptics are reinternalized. B, the distal ends of the sutures are gently pulled to remove any slack, automatically centering the PC behind the pupil, and immediately anchoring the haptics at the' ciliary sulcus. Bites around the sclerotomy lips by the haptic sutures are taken for closure. Scleral flaps are closed by 9-0 or 10-0 nylon sutures. C, alternate closure: to expedite the procedure, full thickness sclerotomies without the scleral flaps are made initially. Inverted suture bites are taken to bury the knots at closure."

c examination showed that the PC IOL had been dislocated into the inferior and posterior vitreous cavity. A retinal consultation revealed no associated retinal breaks or detachment. The implant was found to rotate when the patient changed his position. On December 6, 1990, the patient underwent pars plana vitrectomy and repositioning of the PC 10L to the ciliary sulcus by the method described above. The haptics of the dislocated PC IOL were grasped by the intraocular forceps and temporarily externalized through horizontal sclerotomies at J mm posterior to the limbus. A double-armed 9-0 polypropylene suture was used to tie a secured knot around each haptic. The haptics were then reinternalized, leaving the distal ends of the suture external to the eye. Inverted bites of the needles were taken on the sclerotomy lips to bury the knots. Two months after surgery, a choroidal neovascular membrane superior temporal to the macula was successfully treated with focal dye laser. Three months after surgery, the best-corrected visual acuity of the surgical eye was 20/ 25. The PC IOL remained well positioned with the haptics anchored in the ciliary sulcus (Figs 4A and B). Case 2. A 70-year-old man underwent phacoemulsification with PC IOL placement for his right eye on February 8, J 990. The patient had severe chronic obstructive pulmonary disease and experienced deep coughing frequently. On the first postoperative day, the visual acuity of the right eye was counting fingers. the PC IOL in the right eye was noted to be dislocated into the vitreous cavity. Diffuse superficial and stromal corneal edema was present. There was minimal macular degeneration. Mild inferior vitreous hemorrhage was present. The patient was immediately referred for retinal consultation and management. On February 10, J 990, the patient underwent pars plana vitrectomy and repositioning of the PC IOL into the ciliary sulcus with the method described above. Triangular partial-thickness scleral flaps were made over the horizontal sclerotomies to cover the suture knots. One month after surgery, the visual acuity of the right eye improved to 20/50 with the PC IOL positioned at

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the ciliary sulcus. The vitreous cavity was clear and the retina was attached. Six months later, the right eye maintained a visual acuity of20/25 without correction, and the PC IOL was in place (Figs 5A and B).

Results Between May 1989 and December 1990, 12 patients underwent repositioning of a dislocated PC IOL into the vitreous cavity by the modified ciliary sulcus fixation technique, as described above. The author performed all of these procedures. There were 8 men and 4 women. Their ages ranged from 35 to 88 years. Seven cases involved the right eye, and 5 cases involved the left eye. Partial-thickness scleral flaps over the anterior horizontal sclerotomies were made in 8 cases, while full thickness anterior horizontal sclerotomies with inverted needle bites for closure were used in 4 cases. The operated eyes underwent complete ocular examination on a periodic basis. The duration of follow-up ranged from 6 months to 20 months. At the latest follow-up examination, the bestcorrected visual acuity of the operated eyes ranged from 20/20 to 20/60, and the PC IOLs remained fixated by the ciliary sulcus in all eyes. Of the 12 eyes, 5 had a visual acuity of 20/20, 6 had a visual acuity of 20/25 to 20/40, and 1 had a visual acuity of 20/60. Minimal pre-existing macular changes associated with mild macular degeneration or histoplasmosis accounted for the mild visual deficit in the 6 eyes. The visual acuity of 20/60 in 1 eye was associated with previous history of amblyopia. Three eyes experienced cystoid macular edema, which eventually resolved during the course of the study. One eye developed

Chan . Dislocated

Posterior

Chamber

Implants

Figure 4. Case 1. Inverted closure without scleral flaps. Top left, A, the dislocated PC IOL of this 82-year-old man was repositioned described. The superior haptic anchored to the ciliary sulcus can be seen through the superior iridectomy. Top right, B, inverted the polypropylene sutures to close the anterior sclerotomy allows minimal suture exposure under the conjunctiva.

with the method suture bites with

Figure 5. Case 2. Closure with scleral flaps. Bottom left, A, the PC IOL in the right eye of this 70-year-old man dislocated into the posterior vitreous on the day after phacoemulsi1i.cation and PC IOL placement. The IOL was repositioned by ciliary sulcus fixation at sclerotomies covered by partial thickness scleral flaps. Bottom right, B, the sclerotomy was well covered by the triangular partial-thickness scleral flap held down by a single nylon suture 1 month after surgery.

choroidal neovascular membrane, which was successfully treated with laser (case I). No other posterior segment complications, including retinal breaks or detachment, developed in any eyes during the follow-up period. Very minimal IOL decentration were present in 2 eyes. Iridodialysis, iris erosion or hemorrhage, suture erosion or migration, IOL tilting or rotation, haptic breakage, and endophthalmitis did not develop in any eyes during the course of the study.

Discussion The method presented in this report combines the best features of the "closed-eye" or internal approach via pars plana vitrectomy techniques, and the "opened" or external approach by temporary haptic externalization. Since the placement of PC IOLs has been demonstrated to be superior to other types of IOLs,1,2 many techniques have been developed to fixate the PC IOL to the iris or the

ciliary sulcus through an anterior segment incision for primary or secondary IOL placement when no capsular or zonular support exists.18-28 Such techniques share a common advantage: the ability to easily secure suture materials around the haptics in an "open" environment. Theoretically, the dislocated PC IOL can be retrieved through such an anterior segment incision, and then secondarily reinserted after the suture is secured around each haptic. However, this approach introduces the disadvantage of a relatively large limbal incision which may lead to various complications such as iris prolapse and injury, endothelial damage, postoperative astigmatism, or intraoperative pressure fluctuation. The internal approach with pars plana techniques allows repositioning of the dislocated IOL with the integrity and intraocular pressure of the globe maintained in a controlled fashion during the entire process of delicate intraocular maneuvering, while avoiding the need of a large Iimbal incision. However, placement of suture materials around the haptics of the dislocated IOL by such an internal approach as described

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by many reports usually involve intricate and sometimes cumbersome maneuvers.12,13,15,22 Suture placement by internal means is at best comparatively difficult in contrast to the external approach. There is also the possibility of suture slippage, when suture loops instead of knots are made internally around the haptics. Such suture loops often slip from the haptics when the IOL is moved or rotated during the repositioning process, requiring repeated suture placement, which can be time-consuming. Extensive intraocular manipulation of large needles and other sharp instruments can be hazardous. Temporary transfixation of the PC IOL at the posterior chamber by passing a straight needle through the pars plana has been described. 15 All such intraocular manipulation with sharp instruments can cause inadvertent injury to intraocular tissue, such as the iris, ciliary processes, the retina, or the choroid. The method described herein combines the advantages of controlled IOL manipulation by the internal approach with easy external suture placement by temporary haptic externalization, while avoiding any difficult intraocular maneuvers. Externalization of both haptics through the horizontal sclerotomies external to the ciliary sulcus not only automatically centers the IOL in the PC, but also provides temporary but stable IOL support by the surrounding scleral wall itself (Fig 2A) without the need of transfixation by a sharp instrument, before final IOL fixation at the focus. A technique of externalizing the haptics through the pars plana sclerotomies and suturing the haptics to the external scleral wall has been previously described. 16 Another technique of imbricating the haptic loops into the sclerotomies with sutures for fixation was also described." However, leaving the haptics within or external to the sclerotomies on a permanent basis may lead to haptic erosion through the conjunctiva and the associated risk of endophthalmitis. Heilskov et al30 reported a case oflate endophthalmitis after transcleral fixation of a PC IOL at the pars plana associated with an exposed suture knot protruding through the conjunctiva. The presence of a permanent open track created by exposed suture knots or haptics may allow organisms to gain access to the vitreous cavity, resulting in endophthaI mitis. 30 Reinternalization of the haptics after suture placement not only avoids such a complication but also restores the dislocated PC IOL to a position closest to its original state. Additional anti-infectious measures can be taken. This may include the use of partial-thickness scleral flaps to cover the polypropylene knots at the anterior sclerotomies'Yv" or the placement of inverted needle bites through the edges of the full-thickness sclerotomies, in order to bury the knots within the anterior sclerotomies." The horizontal meridians are the preferred locations of the two anterior sclerotomies, since their position enhances the ease of manipulating the forceps and haptic sutures during the repositioning process, as well as closing the sclerotomies and flaps at the end. It is important to create the anterior sclerotomies for temporary haptic externalization close to the external surface of the ciliary sulcus, since their locations determine the final position of the implant. Recent studies have demonstrated the av-

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erage locations of the ciliary sulcus to be at 0.46 mm posterior to the limbus horizontally, and 0.8 mm posterior to the lim bus vertically. 3 I However, creation of a sclerotomy with such precision is impossible in a clinical setting. Making a sclerotomy lessthan 1 mm from the limbus with a sharp blade also increases the risk of impaling the iris or causing iridodialysis or hemorrhage. On a practical basis, the distance of 1 to 1.5 mm from the limbus is sufficient to place the sclerotomies by the ciliary sulcus. Location of the anterior sclerotomies posterior to this distance may result in injury to the ciliary processes or inadvertent fixation of the IOL to the pars plana. Furthermore, the two opposing anterior sclerotomies should be made at precisely the same distance from the limbus, in order to minimize the chance of IOL decentration and tilting in relation to the pupillary plane. Two other measures are taken to minimize IOL decentration and tilting after fixation: (1) the opposing anterior sclerotomies are made precisely 180 from each other; (2) the 9-0 polypropylene sutures are tied at equal distance from the ends of each haptic, close to the distal one third to one half of the haptic loops. An optional maneuver can be considered for enhancing the stability of the final IOL position. This involves the placement of two separate sutures on each haptic, resulting in a fourpoint fixation on the scleral wall (Matthew Thomas, MD, personal communication). However, because of the inherent stability of the sulcus fixation, two-point fixation did not result in any postoperative IOL tilting or rotation in this series. To prevent suture slippage from the externalized haptic of an open-loop PC IOL, a clubbed deformity as described by Hu et al'? is made at the end of the haptic by a disposable cautery if a distal loop or widened tip is not already present. Even if suture slippage occurs after haptic reinternalization, the haptics can simply be externalized again, and suture placement can be easily repeated. The risk of haptic breakage is minimized and the ease of haptic externalization is increased when fine non-angled intraocular forceps are used and excessive pinching of the haptics is avoided. The horizontal anterior sclerotomies should have adequate sizes to allow easy passage of the haptics. They may have to be enlarged before haptic reinternalization, since the thickness of the haptics is somewhat increased by the suture knots and the clubbed endings (Fig 2C). Finally, the technique presented in this report selects haptic fixation at the ciliary sulcus instead of the iris or the pars plana. Fixation of the haptic to the iris by a McCannel-type technique requires suture placement through a relatively fragile tissue, which may lead to various complications: iris erosion, hemorrhage, iridodialysis, iris chafing, and suture migration. 13,20 None ofthese complications were encountered in this series. Scleral fixation of the IOL at the sulcus allows anchoring of the haptics to secured and stable structures. It also results in an IOL repositioning closer to the original location than the pars plana fixation. In conclusion, this technique expedites the repositioning of a dislocated PC IOL with secured and precise fix0

Chan . Dislocated Posterior Chamber Implants ation at the ciliary sulcus on a consistent basis. To successfully use this method, proper training and familiarity in vitreoretinal surgical techniques are necessary.

Acknowledgment. The diagrams were prepared by Aileen Arakaki Chan, DDS. The author thanks Aileen Arakaki Chan, DDS, Gerald Schultz, MD, and Robert Olinck, CRA, for assistance.

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15. Campo RV, Chung KD, Oyakawa RT. Pars plana vitrectomy in the management of dislocated posterior chamber lenses. Am J Ophthalmol 1989; 108:529-34. 16. Insler MS, Mani H, Peyman GA. A new surgical technique for dislocated posterior chamber intraocular lenses. Ophthalmic Surg 1988; 19:480- I. 17. Girard LJ. Pars plana phacoprosthesis (aphakic intraocular implant): a preliminary report. Ophthalmic Surg 1981; 12: 19-22. 18. Stark WJ, Goodman G, Goodman D, Gottsch J. Posterior chamber intraocular lens implantation in the absence of posterior capsular support. Ophthalmic Surg 1988; 19:240-3. 19. Hu BV, Shin DH, Gibbs KA, Hong YJ. Implantation of posterior chamber lens in the absence of capsular and zonular support. Arch Ophthalmol 1988; 106:416-20. 20. Shin DH, Hu BV, Hong YJ, Gibbs KA. Posterior chamber lens implantation in the absence of posterior capsular support [letter). Ophthalmic Surg 1988; 19:606-7. 21. Dahan E. Implantation in the posterior chamber without capsular support. J Cataract Refract Surg 1989; 15:339-42. 22. Pannu JS. A new suturing technique for ciliary sulcus fixation in the absence of posterior capsule. Ophthalmic Surg 1988; 19:751-4. 23. Spigelman AV, Lindstrom RL, Nichols BD, et al. Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant. Ophthalmic Surg 1988; 19:396-8. 24. Drews RC. Posterior chamber lens implantation during keratoplasty without posterior lens capsule support. Cornea 1987; 6:38-40. 25. Wong SK, Stark WJ, Gottsch SD, et al. Use of posterior chamber lenses in pseudophakic bullous keratopathy. Arch Ophthalmol. 1987; 105:856-8. 26. Waring GO III, Stulting RD, Street D. Penetrating Keratoplasty for pseudophakic corneal edema with exchange of intraocular lenses. Arch Ophthalmol 1987; 105:58-62. 27. Shin DH. Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens [letter]. Ophthalmic Surg 1988; 19:755-6. 28. Lindstrom RL, Harris WS, Lyle WA. Secondary and exchange posterior chamber lens implantation. J Am Intraocul Implant Soc 1982; 8:353-6. 29. Girard LJ, Nino N, Wesson M, Maghraby A. Scleral fixation of a subluxated posterior chamber intraocular lens. J Cataract Refract Surg 1988; 14:326-7. 30. Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transscleral fixation of a posterior chamber intraocular lens [letter]. Arch Ophthalmol 1989; 107:1427. 31. Ohmi S, Apple DJ, Dawn ME, Tetz M, et al. Dimensions of the crystalline lens and the ciliary sulcus in the human eyes obtained postmortem. J Cataract and Refract Surg [In press].

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