There are times when we need to explant an IOL from the eye. This can be at the time of the original cataract surgery if we note a defect in the IOL that was just implanted. Or it can be months (or even years) later for a variety of reasons such as undesired IOL power, dislocated IOL, or even opacity of the IOL optic. In this case, the IOL power was good but this single-piece acrylic IOL was in the sulcus where it caused a host of issues such as pigment loss from the posterior surface of the iris, tilt of the optic, and irritation to the patient.
The first step is to get the IOL out of the capsular bag or sulcus and into the anterior chamber. Visco-dissection with a dispersive viscoelastic is helpful in this regard and it is also important to protect the corneal endothelium. Once the IOL is in the anterior chamber, we inject more dispersive viscoelastic in front of it and behind it.
In this case, the original phaco incision was used to avoid having extra incisions, so it is easily opened with a spatula since the surgery was just a month prior. For this twist technique to explant the IOL, no special instruments are required. All we need is a straight tying forceps and a spatula or similar long, thin instrument.
One haptic is brought out through the incision and this also brings the optic closer to the incision. The optic is then grabbed with the straight tying forceps at one edge, not in the middle. The spatula is then inserted via a paracentesis and place above the optic.
While the spatula protects the corneal endothelium, it also helps roll the optic into tube-form as the tying forceps are twisted 360 degrees. Now the IOL is compact enough that it can simply be pulled out of the incision.
When the IOL is explanted, a good practice is to place it on the corneal epithelium to examine it to ensure that it is completely intact and that no pieces are broken or left inside the eye. You are now ready to implant the new IOL.
Cohesive viscoelastic is used to expand the ciliary sulcus space and deepen the anterior chamber and then a three-piece IOL is inserted. When the pupil is small, like in this patient, I favor temporarily implanting the IOL on top of the iris and then gently dialing it down, under the iris, into the sulcus. This IOL exchange procedure was performed by one of my senior residents and he certainly has the talent to achieve big things in ophthalmology.
Click below to learn the Twist Technique to easily explant an IOL:
We must give a special thanks to Jack Chapman MD who first showed me something similar to this at the Caribbean Eye Meeting many years ago. We have since evolved and modified it as shown above.
Elegant technique, but does a suture tying give sufficient grip on the optic or a toothed forceps is better?
Either will work fine.
Very cool technique. Does this also work with the stiffer Abbott/J&J ZCB00?
Yes. Any acrylic IOL. May have to slightly enlarge incision if Optic cannot be rolled tightly.
Wow. What an amazing technique. Definitely I will try in my next case.
Great technique. Can you use the twist technique for multifocal IOL exchanges?
Thanks
Excellent technique. I was trying to do similar technique but abandoned . I will try again. Thanks for sharing
very interesting. I will try it . Thank you!
Without leaving the forceps grip rotating 360’ may not be possible. If the spatula is in your other isn’t hand one handed rotation difficult.
Start with the hand supinated and then grab the optic with the forceps. Now pronate the hand and roll the fingers to twirl the forceps. That’s an easy 360 degrees.