3 Keys to doing 4-point Sceral-sutured IOLs

From CataractCoach.com: With video footage provided by Dr. Michael Patterson, we review the anterior segment approach to 4-point fixation of an IOL to the sclera. You will note that this approach, performed by an anterior segment surgeon, is very similar to the approach shown previously here by vitreo-retinal surgeons. (scroll down for full video)

(1) Use a pars plana approach to remove prolapsed vitreous.

Both surgeons use a pars plana approach to do an anterior vitrectomy. Both surgeons use an infusion port, the anterior segment surgeon inserts it via the limbus, while the retinal surgeon does it via the pars plana. Both are careful to ensure that there is no vitreous prolapsed into the anterior segment.

In this case, the issue was long-standing pseudo-exfoliation, which is a progressive disease. The patient had successful cataract surgery done many years ago with the single piece acrylic IOL placed securely within the capsular bag, behind a great capsulorhexis. But a decade later, the pseudo-exfoliation progressed and the zonular attachments became very loose. The high degree of pseudo-phacodonesis negatively affected the vision and the patient was determined to need an IOL exchange for visual rehabilitation.

dislocated IOL PXF
Figure: The blue arrow shows the pseudo-exfoliative deposits on the iris. This is also the maximum pupil dilation achieved using pharmacologic agents. The entire lens+bag complex is freely mobile with the eye and will need to be explanted.

(2) Calculate the IOL power appropriately

The power of the IOL should be the same as the “in-the-bag” placement of the IOL being used. In the videos shown here, the lens is the Bausch & Lomb Akreos AO60 which has an A-constant of 118.5 and we calculate the power as if there was a capsular bag for placement because the suture positions will give the gore-tex fixated IOL the same effective lens position.

(3) Place the sclerotomies carefully and make sure they seal completely

These sclerotomies for the gore-tex suture must be placed evenly on either side of the central pupil in order for the IOL to be centered in the visual axis. If the sclerotomies are off-set by even a millimeter, the IOL will not be properly centered in the visual axis.

The sclerotomies may also leak in the post-op period. Using tissue glue to close them and seal the conjunctiva over the sclerotomies can help as well. Watch the patients carefully in the post-op period to ensure that there is no leak.

Watch the video below to see expert anterior segment surgeon Dr. Michael Patterson do an IOL exchange with 4-point scleral fixation of an IOL using Gore-Tex suture material.



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