Stephen Lash Eye Surgery

Here I will show you the variety of issues that arise with Intraocular lenses likedisplacement, disclocation, dropping back, loss of etc. Eventually this will include all the various options and manipulations (that I am capable of that is!)  for intraocluar lenses where normal anatomy is or is not present.

Solutions for Aphakia (Loss of lens)


Aphakia causes very long sight in most cases. The spectacles to correct this are very thick and very magnifying and optically not a great solution. Contact lenses work very well in this situation but there are times when patients cannot tolerate them. It is at this point we can discuss options for getting a lens into the eye.In an ideal world the plastic lens is placed into the empty capsule of the lens as in standard cataract surgery. If this was complicated there may be no intact capsular bag and we may need to place the lens in front of the capsule in the sulcus. If there is no capsule present we are left with either placing the lens behind the iris as in Scleral Haptic Fixation, Sutured lenses, on the iris and behind it as in a posterior vaulted Artisan, on the iris and infront of it as in an Artisan lens or and Anterior Chamber lens. I will slowly add examples of each over time so bear with me!

No Capsule present. Lens clipped onto Iris with an anterior Vaulted Artisan lens


This young patient could not tolerate contact lenses and was keen for surgery. They had an artisan lens placed through a sutureless scleral tunnel, a technique I have copied from Small Incision Cataract Surgery or SICS. Surgery is under local anaesthetic and it took around 15 minutes to complete. Clipping the lens has a variety of techniques and in this example a small needle is used behind the iris to push a fold of iris through the clip. It works well. The patient did well achieving one line below 20/20 vision at 0.12 LogMAR and is happy.

Scleral Haptic fixation is a relatively new technique for fixing standard lenses behind the iris but without any capsular support. Its incredibly fiddly but very useful when there may be trauma in the front of the eye and my 'go to' simple solution of an AC lens is not appropriate. This is one of my first attempts and the patient did well, the lens is still there! I will talk to you in depth if I am considering this option for you. I like to keep things simple so an AC lens is my first choice, surgery is simple and predictable. This solution is not as simple or predictable! Surgery is again under local anaesthetic with or without some chemical courage in your veins.


 

This is a very recent technique where the haptics (the blue supporting bits not the clear bit in the centre!) are secured in the sclera (white of eye)by passing them into  30G Needle and bringing them out onto the surface and then burning the tip to form a bell which then secures the haptic in the sclera. It is less fiddly than the tunnel technique and shows great promise when we have acquired the correct needle! This video shows my first ever attempt and using a standard 30G needle proved very difficult although surgery was uncomplicated.


THIS IS NOW MY STANDARD TECHNIQUE FOR A SECONDARY LENS WHERE NO CAPSULE IS PRESENT.


Having completed many cases I am now very happy that this is an excellent technique to deliver safe and effective correction of vision where the capsular bag is absent or weak. It uses standard lenses widely available and results are excellent. Surgery now takes around 10 minutes and is minimally invasive.

Thanks to VH for allowing me to share this video of her surgery. She had previously had complicated cataract surgery with rupture of the posterior capsule. The lens had been placed upside down in the sulcus and was now dislocated giving her very disturbed vision. I proceeded to do vitrectomy to remove most of the vitreous gel and then removed the remnants of the capsular bag allowing the lens to drop to the back of the eye. The video starts at this point.

The lens is grapsed from the retina on the left sided haptic with my right hand. The magnifying lens system is then removed with my left hand and then the 27G needle is introduced through the sclera 2mm back in a very shallow plane. Once in the eye the Haptic is docked into the needle so it sticks and then this is removed from the eye and grasped so that the end can be burnt into a button to wedge it in the sclera. The lens system is replaced and the second haptic is grasped with my Right Hand and then the lens system is removed and a needle introduced with my left hand and docked as before. This is withdrawn pulling the second haptic out of the eye and this is also burnt to form a button end. The haptics are wedged into the tunnels and the lens is well centred. Having phoned the patient this morning she is very happy! Surgery was under a local anaesthetic and took around 20 minutes.

Solutions for Intraocular Lenses that have dislocated at the front of the Eye

Sometimes,( even after uncomplicated surgery, lenses move! In this situation there are several options from redialling lenses, to capturing them in the capsular bag and suturing them. Sometimes there is just not enough support for the lens hence it has moved and in this situation it is often best to remove and replace. Here are a few examples of my surgery in these situations.

 

Capsular bag present but posterior capsule damaged

In this situation the capsular bag is present and there is a good anterior rhexis (The hole in the front capsule that we peel open in the early stages of cataract surgery). In this situation I prefer to put a lens behind the Iris (the coloured bit of the eye)  but on top of the bag and then push the lens part of the lens through the hole and trap it leaving the haptics (The supporting legs of the lens) in the sulcus. If the anterior rhexis is not intact the lens cannot be trapped and I would place the lens entirely in the sulcus but there is a risk it will slip and move out of the way in this position.


Lens disclocated following complicated cataract surgery which had failed to centre following simple redialling. Optic capture not possible due to complicated first surgery.


This patient had poor vision as a result of the lens dislocating over to the side such that he was no longer looking through it to see. In the video the lens can be seen dislocated over to the right. We discussed the options of removing and replacing or using the current lens and securing it in the sclera. We elected to secure the lens in the sclera. This is a very fiddly technique as you will see although the power of editing makes it look much more straightforward! Surgery was carried out under a local anaesthetic and took about half an hour to complete. I have seen the patient since and he is happy with his vision although one of his haptics had broken and the lens is not as centred as I would have liked. He is happy and that is the main thing! Thanks to him for letting me share this video.

Lens dislocated following complicated cataract surgery-Solution Exchange with Anterior Chamber Lens (AC Lens)


This patient underwent cataract surgery which became complicated by a wobbly lens. They have used a Capsular Tension ring and places a one piece lens into the bag. Although all seemed to go well on review they found this situation with the lens dislocated. You can see the Haptic of the lens at the bottom left of the eye and the tension ring at the top.

In this situation the capsular bag is faulty and the lens cannot be repositioned and so I used my 'get out of Jail' technique which is to replace the lens with an Anterior Chamber Lens (AC Lens). This lens has been around a long time and is well tried and tested, surgery is predictable and quick with good outcomes. I use the technique of Small Incision Cataract surgery (SICS) to form a sutureless tunnel into the eye large enough to remove the existing lens and then replacing it with an AC Lens. Surgery is under a local anaesthetic and takes around 15 minutes to complete so not too arduous for the patient with rapid recovery.

 

Lens and capsular Bag dislocated- Solution Suture of lens and bag to the wall of the eye using a Hoffman Pouch.

This patient presented with a lens displaced off to one side and was constantly looking through the edge of the lens getting blurred and double vision. They had had uncomplicated cataract surgery but clearly the supporting zonules of the lens are weak and the lens and bag have slipped. This technique avoids sutures on the surface which makes recovery more rapid and more comfortable for the patient. You will see a pocket is first created and then a 'needle and thread' is passed over and under the lens Haptic to pull it all across. The Sutures are removed from the pocket and tied with the lens coming centrally in the end. This is my first ever attempt at this technique. I do get frustrated when the best surgeons put their best cases nicely edited on show because real life surgery is real life and we have to learn to work with the eye and deal with the issues that arise. If we are to learn a variety of techniques to deal with as many problems as we can we must learn to push the boat out and that means sometimes struggling through a new technique! It went well and the patient was happy and I am more slick now!

Thanks to G for allowing me to share her surgery. G had surgery as a child and subsequently had an AC IOL implanted. As you can see from the video the AC Lens has caused significant distortion of her iris with parts of the lens caught up in her iris. Behind the iris the remnant of her cataract can be seen as a whitish brown later with a hole in the centre and out of view was a significant Soemmerings ring. This is seen after surgery for congenital cataract and these rings of remant lens tissue have to be delivered from the eye, they cannot be cut or emulsified.I was not aware of this until half way through surgery but the large sceral wound facilitated removal of this ring (Thankfully!). The AC lens cannot be cut and so this was removed through a large sutureless scleral tunnel (SICS approach). Having removed the lens and the Soemmerings ring I was tempted to stop and did briefly discuss this with G. However I felt the sceral tunnel was secure and it was safe to proceed to put the lens in behind the iris with needle haptic fixation. It was technically more challenging given the large wound which was kept open by the trailing haptic when I put the sdecondarylens into the eye. This made getting the second needle into the eye more difficult as the eye was tending to become soft with the pressure of trying to push the needle through the sclera. With time and different grabs the needle was in the correct position. The lens centred well.