This valuable teaching video was submitted by an anonymous resident who is still in training. In this surgery, a smaller phaco incision was used and then the wound-assist technique was attempted for IOL delivery. This did not work as planned and the IOL was only partially delivered into the anterior chamber. The IOL then started to expand and became stuck in the incision. What would you do next?
My advice is to first try to push the IOL into the anterior chamber. Tying forceps can be used to grasp and roll the IOL in an attempt to keep it compact and therefore slide in. If this does not work then the incision can be enlarged by using a slim blade like a side-port blade to make an entry into the anterior chamber immediately adjacent to the main incision. This can then be slightly sawed until the two incisions connect, thereby creating one larger incision.
In this case, the resident pulled the IOL out of the eye completely which took multiple tries and required sturdier instrumentation. Then the incision was enlarged and a new IOL was placed. The outcome was good and the patient achieved excellent vision.
We thank this doctor for submitting the video so that we all can learn. I encourage all of our readers to submit a video for review — and anonymous is acceptable too.
click below to learn from this unusual case of a stuck IOL:
Dr. Devgan, what was the keratome blade size? In my experience, a keratome blade of 2.5mm or greater provides an incision size that is relatively easy to get the front of the cartridge through the incision. Some counter traction with a second instrument through the para-incision helps facilitate this process. I think a interesting discussion could be had about the value of reducing incision size below 2.5mm and effects on astigmatism, especially if the surgeon is making the incision at the limbus. I feel that reducing the incision size to 2.4mm or 2.2mm provides more difficulty inserting the IOL and an insignificant reduction in astigmatism correction compared to a 2.5mm or 2.75mm incision size.
A firm pull with the needle driver or a toothed forceps with traction on the optic would have probably removed the lens on the first try. I prefer reloading with a new back-up lens when I remove a lens. The last thing I want is a scratched lens in the capsular bag when initial insertion of the IOL doesn’t go as planned.
I appreciate that the surgeon shared the video. I would recommend that the iris is placed back into the anterior chamber before enlarging the incision size. This may require stopping the irrigation through the anterior chamber maintainer. Last thing you need is strands of iris prolapse through the incision or blood obstructing the view when the case isn’t going as planned and the incision is sub-optimal and most likely requiring sutures.
Great input. Thanks for the insight. I agree with you about incision size.
See here
https://cataractcoach.com/2018/09/21/phaco-incision-size-is-smaller-better/
Dear Dr Devgan, I quite agree with Dr Fisher that increasing the incision to 2.5 & more facilitates easier lens incision ; I’m not a great fan of wound assisted implantation. The reason being I too have often faced this situation and then its a struggle. However when I see your routine cases what incision size do you employ, 2.2 ? But I don’t see you enlarging it for IOL insertion. Could you clarify.
Depends on the case. Most cataract patients have ATR astigmatism and benefit from an incision at 180 (temporal). For these I use 2.75 mm, otherwise I do 2.2 or 2.4 mm depending on the case.