Stephen Lash Eye Surgery

Intraocular lens complications INFORMATION LEAFLET CLICK HERE

It is becoming more common to find lenses that have slipped out of position within the eye years after surgery. It may be a factor with an aging population, it may be previously diagnosed Pseudoexfoliation Syndrome or previous vitrectomy surgery. Sometimes the original surgey was uncomplicated but often the surgery was complicated and the lens could not be placed inside the bag of the lens. Sometimes the lens is in the bag but the entire lens bag complex has dislocated and sometimes the lens is in the bag and central but has frosted and needs replacing. This surgery is relatively uncommon and the solutions vary according to each specific situation but on this page I hope to explain the various options commonly used to rectify these issues.

You will see the terms 'one piece lens' and 'three piece lens'. A one piece lens is literally made out of one piece of soft plasic with the lens section and the supporting Haptics (arms) of the same material. They are not suitable for sulcus fixation and can only be optic captured when the rhexis is an almost perfect size and shape. They can rub on the back of the iris and they are more difficult to suture given the shape of the haptics. A three piece lens has a lens section with two arms (Haptics) made of a hard plastic. They are larger and sit in the sulcus more securely, the haptics are round and easier to suture securely and they can be scleral fixated. Three piece lenses are very versatile and so I would recommend that if surgery becomes complicated these are good lenses to use to facilitate further surgery if required.

Simplest Solution- Lens in Sulcus recentred by Optic Capture

Capsular bag present but posterior capsule damaged Lens In Sulcus

This is a realtively common situation following complicated surgery where the back of the lens capsule has ruptured (Posterior Capsular Rupture). The lens cannot be placed in the bag but is placed on the bag and behind the coloured part of the eye, (The sulcus). It is not uncommon for these lenses to dislocate hence trying to capture the lens centrally in the bag.

In this situation the capsular bag is present and there has to be a good anterior rhexis (The hole in the front capsule that we peel open in the early stages of cataract surgery). The IOL is placed in the Sulcus (The space between the back of the iris and the capsular bag). The optic of the lens is then pushed through the rhexis and into the bag with 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 Scleral Haptic Fixate the lens.

3 Piece lens and bag dislocated < 50% Sutured centrally

This is another minimally invasive technique to recentre a lens and works well provided the lens has not dislocated more than 50%. Once over 50% there is significnant weakness and it is better to replace or refixate with Scleral Haptic Fixation (SHF)

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!

Removal and replacement- Optic capture not possible lens must be replaced- AC LENS (I no longer use this technique)

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

I have included this because the most common solution in current practice would be to use an AC lens. I no longer use these lenses as I prefer the technique of scleral haptic fixation, however, I include it in this section for completeness.

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 an Anterior Chamber Lens (AC Lens). This lens has been around a long time and is well tried and tested, surgery is reasonably predictable and does not take too long. 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. There are concerns over risks of glaucoma and corneal clouding and these lenses need to be ordered and so I do no longer use this technique but I hope it aids your consent process in terms of understanding options available.

Scleral haptic fixation

This is my standard technique when replacing a lens with no support. It can be applied in various scenarios as detailed below.

After three years of tweaking I have a technique I am now happy with! It is without edit and hopefully shows clearly how we do this technique.

A 3 Piece lens dislocated into the back of the eye repositioned with SHF

This chap had previous complicated cataract surgery with a 3 piece IOL placed in the sulcus. [Optomterists note- If you see a 3 piece IOL think of posterior capsular rupture and look for it- surgery was likley complicated!] The sulcus is this almost mythical gap between the Iris (The coloured part of the eye) and the capsular bag in whatever state it remains).

Unfortunately the lens did not stay there, he had sudden loss of vision and presented with the lens dangling from the sulcus. He had been happy with his outcome and was also found to have a low endothelial cell count (<1000) and so I elected to reuse his existing lens to reduce trauma on the cornea. Surgery was carried out under local anaesthetic and took less than 20 minutes to complete. I started with Vitrectomy (removing the jelly of the eye) and then identified which haptic of the lens to grasp first with my left hand in order to present this haptic nicely to my right hand holding the first 27G needle. Once grasped the lens system has to be flipped out with my right hand and then the needle placed and the haptic pushed up. The second haptic is 'found' and manoevered into the front part of the eye where the second- double bent- needle is placed and the haptic pushed up and withdrawn. Both haptics are burnt as per Yamane and the lens centres nicely at the end.

PMMA lens (Older lens) NOT suitable for SHF therefore removed and replaced with 3 Piece IOL by SHF

This is technically the most challenging surgery in this section requiring a stable tunnel without sutures, wide enough to remove the PMMA lens (These are solid plastic and cannot be cut in half). It starts with forming a long tunnel, then removing the lens in one piece and subsequently replacing it with a 3 piece lens by SHF with the approach adapted to the fact there is now a long tunnel.

Thanks to CF for allowing me to share his surgery. He had had cataract surgery many years ago and a retinal detachment. The lens had slipped into the gel. We needed to remove it but being made of PMMA it is brittle, hard and cannot be cut into smaller segments and so a large wound is required to remove it. This was achieved with a scleral tunnel based on the SICS technique. This is a great technique allowing a large wound to be formed that seals wihtout any stitches. This wound was used to remove and then replace the lens. The lens is held in place using needle haptic fixatipon adapted from the Yamane technique. Surgery went well and was carried out under a local anaesthetic.

 AC Lens causing chronic inflammation and swelling of the retina removed and replaced with SHF

Here is another example of a lens requiring removal and replacement. AC lenses are made of PMMA and are solid and cannot be cut. They require removal through a large tunnel in the white of the eye similar to the example given above.

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.

I hope to get some examples of frosted lenses in this next section.