Look carefully at the title picture and you will see that the posterior capsule is ruptured and it appears to be wide open. In this situation, my preference is to place a three-piece IOL with the haptics in the sulcus and the optic captured behind the intact capsulorhexis like this. However, the anonymous surgeon in this video opts to place a single-piece acrylic IOL in the capsular bag with the haptics oriented 90 degrees away from the linear capsule rupture. It seems to work, but there is additional risk in this situation.
Let’s also touch on the topic of the IOL power calculations:
- The originally chosen IOL is a single-piece acrylic IOL designed for in-the-bag placement and it has an A-constant of 119.2 which calculates to +20.0 D for a plano outcome.
- If we switch to a three-piece IOL and place it fully in-the-bag, we must simply adjust for the difference in A-constant, which for this 3-piece design is 118.7 and that makes the new power +19.5 D for a plano outcome.
- If we place haptics of the three-piece IOL into the sulcus and then capture the optic behind the capsulorhexis, then technically the optic is still in-the-bag, so the IOL power is still the same +19.5 D for a plano outcome.
- If we place both the haptics and the optic of the three-piece IOL into the sulcus, now we have to change our calculations because the effective lens position (ELP) of the optic is more anterior and thus we need to lower the power. Using the rule of nines, we know to drop the IOL power by 0.5 D and so we would implant a +19.0 D IOL for a plano outcome.