Anterior Vitrectomy & Sulcus IOL with Optic Capture

With vitreous prolapsed into the anterior chamber, we must perform a vitrectomy before placing the IOL in the eye. In this case we will use a three-piece IOL which will be placed with the haptics in the sulcus and the optic captured behind the capsulorhexis. This placement allows for great long-term stability and it re-establishes the barrier between the anterior segment and vitreous cavity. This surgery is performed by a young surgeon in residency training and the final results are very good.

This is the step-by-step guide for performing this anterior vitrectomy and IOL placement:

  • Step 1: Abandon the main incision. This incision is not suitable for bimanual small gauge (23 gauge) vitrectomy because it is too wide and it will leak during the procedure.
  • Step 2: Make a second paracentesis incision to provide access for the bimanual instrumentation. You may need to make these slightly wider depending on your set-up.
  • Step 3: Set-up and prime your phaco machine to get the vitrectomy cutter ready to be used. Also at this time, ask for triamcinolone to be opened on the field.
  • Step 4: Put the machine into Anterior Vitrectomy Mode (not I/A Cut Mode). We want the foot pedal positions to be: 1 irrigation, 2 vitrectomy cutting action, and 3 aspiration.
  • Step 5: Choose a high cutting rate of at least 1000 cuts per minute and a moderate flow rate (20 to 30 cc/min depending on your instrument flow). Try a vacuum level of 200-400 mmHg
  • Step 6: Place a small amount of triamcinolone into the anterior chamber and swirl it around using the infusion hand-piece or injection of balanced salt solution.
  • Step 7: Enter the anterior chamber with the vitrectomy cutter and look for the prolapsed vitreous that is stained with triamcinolone. Stay centrally in the eye at the lens plane.
  • Step 8: Take your time removing the prolapsed vitreous. This takes time, usually 5 to 10 minutes. Avoid putting traction on the vitreous or pulling it.
  • Step 9: Re-inject another small aliquot of triamcinolone to re-stain the vitreous. Since the triamcinolone particles only stain the outside of the prolapsed vitreous, more must be used
  • Step 10: Sweep any prolapsed vitreous from the incisions back into the eye and completely remove with the vitrectomy cutter.
  • Step 11: Once the anterior vitrectomy is complete and you have confirmed that the anterior segment is clear, inspect and determine the degree of capsular support available.
  • Step 12: Viscoleastic is lightly placed in the anterior chamber and a small amount under the iris in order to open the ciliary sulcus area.
  • Step 13: The three-piece IOL is inserted in to the eye and the haptics are placed in the sulcus with care taken to avoid entrapment of iris tissue.
  • Step 14: The optic is then pushed through the capsulorhexis, much like putting a button through a buttonhole in a shirt.
  • Step 15: The main incision is sutured closed and then the bimanual instrumentation is used to remove the viscoelastic from the eye.

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6 Comments

  1. After cleaning vitreus in the anterior chamber, can vitreus come back to anterior chamber why and how ? Can you explain ? Thanks

    1. in this case, the optic capture creates a barrier to stop vitreous from coming into the anterior segment. without the optic capture, there can be more vitreous prolapse.

    1. You could but it may not be stable and it could induce a tilt of the optic. I do not recommend it.

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