 Hi, I'm Bob Sione from the I-Institute of Utah in Salt Lake City, and today we're going to talk about IOL exchanges and repositions. It's going to be impossible to cover the entire subject matter because there's so many variations of what can present to you and how you manage that. But we'll cover the general principles of what to do, what not to do, when to exchange, and then we'll hit some video cases so you can see some examples of these. What are some of the symptoms that lead to the need to exchange or reposition an IOL? Well, in 2016, it seems that refractive error is the most common cause for a patient being unhappy with with their vision with an IOL. Much more common than back in 2007 when it was a malpositioned implant. Second to that would be visual disturbances. So we're talking about positive or negative dysphotopsias and they're distinctly different, but they can be present in almost any kind of lens. Some lenses are more likely to give you such disturbances and even though a patient's vision may be 20-20 or better, they may be very unhappy with their vision due to glare or perhaps some negative scatomas that they see. Thirdly, ugg syndrome. There would be uveitis glaucoma hyphema syndrome. That can be caused by iris chafing of an IOL or its haptic. This can lead to inflammation, recurrent hemorrhage, and glaucoma. So when that condition presents, it's less of an option to exchange the implant or reposition and more a necessity to prevent chronic condition that can lead to blindness. So we've seen some of the symptoms. What's the etiology of an implant causing some of these problems? One can just be refractive error due to a miscalculation. That may be an error in the formula itself or the data that you entered or maybe it's just simply a variation in anatomy that doesn't fit well into any of the formulas. Improper positioning of the implant at primary surgery can be another reason for an implant being malpositioned. Most common would be asymmetric haptic placement where you have one haptic in the bag and the other haptic in the sulcus. That's not a good condition even with a three-piece lens, but it's a terrible condition when you're talking about a single-piece lens because that square edge of the haptic on a single-piece lens can cause a lot of damage to the iris. Xionnal dialysis or posterior capsule tear can cause an implant to be malpositioned and certainly vitreous prolapsing around the side of a lens can cause it to go out of position and require repositioning. In addition to problems during the primary surgery, trauma can induce a lens malposition. This can include surgical trauma such as vitrectomy. I've seen cases where the patient was fine until five years after the cataract surgery they had a vitrectomy and lo and behold the xionules were damaged or the vitrectomy in the lens goes out of position or the posterior capsule was damaged and it allowed the lens to become dislocated. Another condition is asymmetric capsule fibrosis. We see this more commonly in plate-style haptic lenses where the forces that hold the bag open are greater in one direction of the lens than the other and that asymmetry in the support for the implant allows the short axis of the implant to collapse and the xionules to break and for the lens to move out of position. We've also seen it more frequently in lenses such as the crystal lens which have flexible haptics. These lenses in time with caps or bag fibrosis can tilt an angle in such a way as to move the lens out of position or cause a lot of astigmatism. And finally there can be xionular compromise before, during, or after surgery that will lead the lens to moving out of position. So those are the basic etiologies of IOL malpositioning. The procedure that you're going to perform on the patient that has this pathology really depends on multiple factors. Is it just a refractive error in which case you're going to take out one implant and put in a different implant? It's in a NUG syndrome where you have to really look at the causes of, of the inflammation. Is it vitreous forward that's tugging on the iris? Is it an asymmetric haptic placement where one of the haptics is rubbing on the iris? It has to be looked at carefully and you have to understand why there's a problem before you attempt to solve it. Are there just visual disturbances such as negative dysphotopsias? A lot of time with negative dysphotopsias, we can simply place a piggyback lens in the sulcus given that there's room for that lens and that can alleviate the symptoms. The risks versus the benefits of each possible procedure need to be looked at. Is the capsule open? If the posterior capsule is already open and not contributing to the problem, then there it's a slightly higher risk because when you go to do anything with that implant you might have vitreous prolapse that you didn't have before. Are the zonials intact? If they're intact it's an easier surgery. If they're not intact we might have to look at stabilizing those zonials with a capsular tension ring. Is the iris normal or not? If it's a floppy iris this may be a more challenging patient. If there's been trauma and there's iris missing then we might also have to do something with the iris and it may make it impossible to suture a secondary implant to the iris. And what's the residual capsular anatomy like? Is it intact? Is it not intact? If there's a large summering's ring that's very hard and calcific it may be impossible to pass a suture through that. Or if you do pass a suture through that it may open up that residual and ticker debris to the rest of the eye which can cause more inflammation after surgery than before. We also like to know what kind of an implant is already in the eye. If you know the design of the implant, the style and the power it'll help you better figure out what you're going to do, how you're going to replace that lens or reposition that lens. Is there vitreous prolapse? If there's no vitreous prolapse it's a much simpler procedure though you have to be careful not to cause vitreous prolapse during your procedure. And has the patient had a vitrectomy? If there's been a complete vitrectomy and let's say for instance you cut the haptics off of the optic, well if you're not careful if that poster capsules open the optic can fall down. Or if there's been a complete vitrectomy and you want a suture and implant to the iris and someone who has a floppy iris syndrome, then post-operatively there'll be a lot of irididinesis and perhaps that can incite a NUG syndrome. The patient's age plays a role as well. Anteur chamber lenses are a great option in someone who's older and perhaps may not need an implant for 20 or 30 years and surgeon experience is also important. With more experience you'll feel more comfortable at doing some of the more advanced techniques with less experience you might settle for something that's perhaps not more what should I say perfect but adequate for the patient in your hands. So with that let's talk about general principles for a single piece IOL that needs to be repositioned or replaced. In general the first step is going to be filling the anterior chamber with a viscoelastic material and my my choice would be a dispersive viscoelastic such as viscote. And then once we've done that we're going to open the capsule bag with the viscoelastic. It's easy in some cases it's really tough in other cases. If there's 360 degrees of fibrosis on top of the optic it may be difficult to get under that optic to allow the viscoelastic to fill the capsule bag. There are a couple of tricks that can help you. One would be using a 27 or 30 gauge needle to tease that fibrotic capsule edge up and off of the optic. Once that's teased up you can then place viscoelastic into the capsule bag. Another trick is to go to the edge that has the least amount of coverage by the anterior capsular edge. If you push that edge of the IOL posteriorly quite often you can snake your viscoelastic cannula underneath it and behind the optic and then when you inflate the capsule bag with the viscoelastic it frees up the remaining adhesions and that's generally my preferred method for opening the capsule bag. Once you begin opening the capsule bag you really need to go all the way out to the periphery and take your viscoelastic cannula right along the haptics and inject as you're moving forward all the way to the end of the haptic to free up any fibrosis at the end of the haptics. With the single piece lenses especially the type of lens that has a bulb at the end you're really going to do a lot of viscoelastic ejection right at the end to break that that fibrotic syneco adhesion. Another general principle would would be how to get the lens out of the bag if you're going to exchange. In general with a single piece lens you're going to do more anterior movement of that lens in the haptics than a rotation as opposed to a three piece lens which is going to be more of a rotation of the lens. You want to bring both haptics and the optic into the anterior chamber if you're planning on exchanging the lens. Once in the anterior chamber you can grasp it with forceps or with the second doll instrument and bisect that lens with eye well cutting forceps. With the single piece acrylic lenses they're not real slippery so it's they're fairly easy to hold on to and the MST style of intraocular scissors work really well to cut those forceps and they're now available as a disposable design. Once the lens is out of the eye and and each half that lens should fit through an incision about 2.4 or 2.5 millimeters. Once the lens is out of the eye you'll re-inflate the bag with visco elastic and place the secondary implant into the capser bag if possible. If it's a single piece lens you're replacing it with it has to be completely within the capser bag. If the bag's not intact or if you're going to be using a three piece style lens then that lens goes in the sulcus and if possible you'll want to capture the optic through the anterior capsuleotomy or through both the anterior and posterior capsuleotomy if the posterior capsule is open. If we're unable to open the capser bag completely and free the peripheral syneco adhesions of the haptic then there are other options. You'll want to bring the optic into the anterior chamber and using eye well cutting forceps cut the haptic as far peripheral as possible. You don't have to be all the way out at the bulbous end you can cut it as close as the haptic optic junction but in general you want to move as far peripheral as possible. Once you've cut the haptics free from the optic you then bisect the optic and bring it out just as I mentioned before. Then you can replace this with a three piece eye well placing both haptics in the sulcus and once again if possible you're going to capture the optic through the anterior capsuleotomy or through the anterior and posterior capsuleotomy. Single piece eye wells are a little more difficult to optic capture because of the broad haptic optic junction. It can be done and it's not uncommon in a patient who has a torque eye well that is rotating and not remaining in position that will simply leave the haptics in the bag and lift the optic in front of the anterior capsuleotomy but that broad haptic optic junction makes it a little more difficult and a little less predictable in terms of stability. Now what are the general principles for a three piece eye well that needs to be exchanged or reposition? Well the principles really are not that much different from a single piece eye well with the exception that you can put the haptics of a three piece implant in the sulcus that is completely acceptable whereas with a single piece lens as I mentioned before the square edge of those haptics will cause iris chafing and they're generally not a good idea in the sulcus so please don't put a single piece lens in the sulcus. Whenever possible with a three piece implant when the haptics are in the sulcus if you have the ability to posterior optic capture the optic then you should do that it provides much more stability long term. It also creates a separation between the anterior and the posterior segments so once you have that eye well optic captured in the posterior capsule or opening or through the anterior capsule or opening there's a seal between the anterior and posterior segments and so you're less likely going to get vitreous prolapse. Now occasionally we'll get a three piece or single piece implant that has really strong fibrosis and you can't really get it out of the capsule bag or there may just be one half of the capsule bag that's loose and you really only need fixation on one side. In that instance it's easiest and quite acceptable to simply lasso the free haptic with some 9-0 proline or some off-label Gore-Tex suture and suture that haptic to the sclera wall. You can place the needle in a mattress fashion right through the periphery of the capsule bag and around the haptic and exit through the sclera wall a couple millimeters posterior to the limbus and tighten and tie that suture and then rotate and bury the knot. It's a very simple solution for somebody that perhaps has had trauma and only has weakness on one side of the capsule bag. Alternatively you can remove the entire capsule bag with the implant in place from the eye and then replace it with a sutured secondary implant or an anterior chamber lens. If you're going to suture a three-piece lens to the iris I tend to use 9-0 proline suture and there's some wonderful techniques that will show in the videos on how to do that. You can suture the three-piece IOL to the sclera wall using 9-0 proline suture or off-label Gore-Tex suture and Gore-Tex is my preference. It's very strong it'll last forever and it's quite inert. The knot is compressible so it's easy to bury and when you place this through a sclerotomy it you can bury the knot and the sclerotomy sites tend to be watertight without any suturing. Some of the newer techniques are glued haptics to the sclera which work quite well and are popularized by Amar Agawal out of India and now there's a new technique that's a non-glued IOL fixation to the sclera wall that was actually a video award winner at the ASCRS this year out of I believe Japan and we'll show you a video that demonstrates my first attempt at this and we'll talk about the nuances of that procedure. Another technique that that I think is a wonderful technique is using a B&L A060 lens in Gore-Tex suture. This is a plate style lens which are not my favorite lenses but for sclera fixation they work quite well because there is a hole in each of the haptics so you can place the Gore-Tex suture mattress style and suture it. It creates a nice non-tilted lens a beautifully centering lens and it works quite well. It's a pretty simple technique. The only negative to that it is is that it is a hydrophobic lens so if you're going to put an air bubble in the eye for let's say a desec or a retinal procedure then there's a high probability that lens will pacify so when someone who's going to subsequently need a desec procedure you might not want to use that technique or that particular lens. The newer style anterior chamber lenses are quite acceptable especially in the older patient so a fallback position would be to make a slightly larger incision about a six millimeter incision remove the capsular bag and the implant complex and replace it with an ACI well. So let's look at a video this is a patient who is 56 year old he has dysphotopsias poor vision after a multifocal lens. During the original surgery the surgeon felt the inferior zonals were weak but that the implant centered well. Postoperatively the best vision was 2060 and you can see the patient has a lot of astigmatism but even if you give the patient that prescription the vision's hazy to the patient and he doesn't want anything done with his other eye until this eye is fixed. This is the implant you can see it's off-centered. I thought there one haptic was in the sulcus and the other in the bag but indeed both haptics were in the capsular bag and the lenses is descentered as you can see superiorly. So what we're going to do is we're going to make a stab incision with a 0.9 millimeter millimeter blade and as I mentioned the first step is putting viscoelastic in and expanding that capsular bag with the viscoelastic. We're going to fill the chamber with viscoelastic agent then we're going to make an opening in the origin where the original incision was. We just make a small little perpendicular incision over top of it find the primary incision that was made previously and go into that incision and this particular lens design it's a technus multifocal has no bulbous ends on it so it actually frees up quite nicely and the primary surgeon did a great job cleaning up the caps or bag there there's no residual debris you don't see a lot of fibrosis. We're going to rotate this lens and make certain that both haptics are in the sulcus. We're going to go underneath the lens and what I'm trying to do now is capture the optic anteriorly in the anterior capsule on me. This in this case is not successful because the anterior capsule on me is slightly too big so every time we bring that optic forward it falls right back into the capture bag so now a decision has to be made notice that I rotated the lens 90 degrees and it's really centered well so is it possible that there is just for some reason some asymmetric capture bag fibrosis and that that lens moved out of position for that reason and now that we've rotated it it will stay in position. Well I think that's the case that's the most likely you can push the lens back and forth and it keeps bouncing into central position so we really don't need to take this lens out. Remember the patient still had some astigmatism but now that we move the lens into a different position the amount of astigmatism may not be the same so we perform intraoperative aberrometry confirm there's still some cylinder there and we'll make some arcuate incisions on the cornea and repeat the aberrometry to see if the astigmatism is reduced and indeed it has been patient did well 2020 very on very happy with their vision after this and so for the second eye we're going to use the same style implant so as I said in some cases you'll get some asymmetric bag fibrosis usually it's because the lens has one haptic in the sulcus and one in in the bag but in this case both haptics were properly positioned and maybe there was some inferior weakness but simply rotating that lens 90 degrees was all that was needed. Now here's a distinctly different case this patient from day one was very unhappy with the vision and she simply cannot tolerate multifocal vision so this lens has to come out once again the principles are the same we're going to put a lot of viscoelastic into the capsular bag in this case the poster capsule is open there had already been a yag capsulotomy so the viscoelastic will serve to tamponade vitreous from coming forward and it's secondarily will help to free up the implant because the capsule is open we don't want to spend a lot of time trying to free up the haptics that's just going to invite more vitreous prolapse so we're going to instead cut the haptics from the optic and then bisect the optic and remove each half half of that optic leaving the haptics in place they will cause no problem if I roast into the periphery of the bag we'll then place a secondary implant first into the ciliary sulcus and this is a three piece implant because remember single piece haptics do not belong in the sulcus but the three piece haptics can go into the sulcus and we're going to dial that second haptic in and then perform optic capture just pushing the optic through the opening and that secures the anterior segment from the posterior segment prevents vitreous prolapse so we can go in and remove viscoelastic safely without vitreous prolapse hydrate the incision with now a single focus interocular lens and the patient is much happier with the vision she's now 2020 although she needs reading glasses she's not complaining of overall poor vision third case is a 60-year-old gentleman cataract surgery in in 2013 dislocated lens which was repositioned twice did well for a couple years and then noticed a sudden change in his vision and it turns out that one of the sutured haptics the suture broke and this is what the lens looks like so when i first look at this patient i thought well why is that lens sutured we we can just optic capture and center that lens through an optic capture so that was the plan here the remaining suture that is still intact we're going to cut that free yet through after a congenital pyritomy place viscoelastic over top of the vitreous and then try to rotate this lens within the sulcus and optic capture and as you can see as we're trying to push the optic through the anterior capsular and posterior capsular opening it's not going through it's staying in the sulcus it keeps coming forward why might that be well the probable reason is that there's vitreous prolapse that we're just not recognizing and the vitreous is holding that optic forward so through a side port incision not through the main incision we never want to do a vitreous me through the main incision through an appropriately sized side port incision where you won't get a lot of fluid or vitreous egress we're going to do the track to me and remove that the vitreous is preventing that optic from going posteriorly and then we're going to optic capture it but once again it's still not staying behind that open capsule and it just turns out that the the capsular opening is a little too big and once again we're not going to get a secure hold of that optic through that large capsular opening so now we have a fallback position and that is put in a little by-call and bring the optic into the anterior chamber and do an iris fixation of this implant we can do this all through small stab incisions so this is a 9-0 proline suture that we will put through the iris around the haptic that's just behind the iris and out through a secondary stab incision and we're going to tie this not with a mechanical style suture but with a modified seeps or not the problem with a mechanical style suturing is that um when you try to tighten down the knot over the haptic you have the width of the cornea that prevents the knot from going down tightly so during the surgery or at the end of the surgery it may look like that lens is nice and stable and centered but in time that lens can that the haptics can rotate in that loose knot and come free again so we use a modified seeps or style knot and this is a technique where the part of the haptic I'm sorry part of the suture is brought out through the incision we tie the suture outside the incision and when we pull both ends it tightens down on the haptic and I don't have a great video to demonstrate that there are some intricacies to the seeps or not but we'll try to get you some uh in a subsequent presentation um Mike Snyder and Gary Condon have some great videos and publications that detail this quite nicely in the journal of cataract and refractive surgery so we do this to both haptics once both haptics are sutured we can cut the needles free from from the knot and then all we need to do is prolapse that optic behind the iris and if you went peripheral enough with your needle passes you get a just a very slight ovalization of the pupil and a nicely centered implant with long-term stability at the end I always like to go behind the optic or remove any visco elastic or as much visco elastic as I can and any any vitreous that may have found its way a little bit forward again we're doing that through a side port incision we then close the conjunctival pyrimine and that patient should enjoy good vision long-term vision stable vision so this is a patient who had uh traumatic cataract loss of virus tissue 30 years previously macro hole repair so he's had a vitrectomy recently diagnosed with the dislocated IOL and the implant is very dislocated you'll see the capsular bag, somerings ring and IOL completely in the anterior chamber and there's very little iris remaining so in this case we're going to plan on an artificial iris with a sutured implant to the artificial iris and then suture the artificial iris to the sclera it's a challenging procedure I'm not showing this video to show you an artificial iris but I'm going to show you a mistake that I made in doing this procedure so we've made a large opening this is a single piece it's not a foldable IOL it's about a set six and a half millimeter optic and as I'm bringing the IOL out of the eye the capsular bag pulls free from it and remember the patient's head have attracted me so where is all this capsular bag and somerings ring material going to go even though I'm trying to get under it to get it out the incision it's going to drop right back into the back of the eye so this was not very well managed and what can we say to the patient is well I think you're going to notice a new floater so that patient's going to have to have a retinal surgeon come in and remove that debris and then we'll plan for an artificial iris and secondary IOL down the road a better way to manage this we'll show in this next video here's a very similar case I believe this is a plate style haptic lens you can't even see it it's so far out of position but as we retract the iris you can see that it's it's just dangling by one or two zonials we'll very carefully bring this up into the interior chamber and you can see in this case as well not only do we have the implant in the capsular bag but you have that somerings ring not as dense a ring but definitely a somerings ring there and this case occurred just a week after the case I just showed in the previous video so I learned my lesson we're going to bring this into the interior chamber and before we try to bring this out of the eye we're going to place a protective barrier behind this implant to capsular bag complex we're going to remove the iris retractors as well so that we can get the pupil to contract in this case the patient had iris tissue so it's nice that the the iris itself can act as a barrier to that lens material falling back and here you see me putting some myacol into constrict the pupil but in addition we'll put a sheet's glide a little piece of plastic underneath the implant in the capsular bag to further protect from any material falling into the back of the eye we can then rotate the implant bring it out of the eye now fortunately most of the capsular bag came with it partially because it has that sheet's glide to allow it to slide but not all of it did and here you see some residual debris that did not fall into the back of the eye because we had that protective barrier there and we can usher that debris out of the eye safely with the sheet's guide in place and not worry about falling to the back and there's the last little bit of it will burp out with a little bit of viscoelastic and then we can place the secondary implant and then we can place the secondary implant the secondary implant is going to be a three-piece iol and it's placed into the anterior chamber first grasped with mst forceps put behind the iris completely holding on to it you don't want to let it go here and then the optic only is brought back in front of the iris this is a technique that gary connan showed me at one of our park city meetings and it really is very simple it's an easy manipulation of the intracural lens and then like in the case before we're going to suture each haptic to the posterior surface of the iris with modified seeps or not once the haptics are sutured securely we can then prolapse that optic back behind the iris and we'll have a nicely centered stable intracural lens let's move on to another case this is a case where a crystal lens an accommodating lens and a patient who had a four-incision rk developed a lot of astigmatism and lo and behold she had what's known as a z syndrome so one of the haptics is angled anteriorly and the others posteriorly the haptics are fibrous quite strongly into the capsule bag principles however are quite the same we're going to open the capsule bag with visco elastic agent and we're going to try to open that all the way into the periphery of the bag and this is the dispersive agent viscote that we're using swinging the cannular around to break break the fibrotic adhesions for 360 degrees and we're going to go right along that haptic and put as much visco elastic as we can to get that adhesion to break and then much like a single piece lens we're going to bring this anteriorly we're not going to rotate this lens we're just going to pull it anteriorly with the visco elastic cannula and you'll see the haptics free up now they don't always free up that nicely sometimes you have to cut the haptics and just like with a single piece lens you can leave these haptics in the bag and they're quite stable there they don't cause any inflammation in the bag once you get them freed from the optic once you have this lens forward we're going to cut the haptics free again using mst scissors and an mst forceps and then we can bring each of the haptics out through the incision the incisions 2.4 millimeters and you can bisect the optic or bring it out in in one piece through that small incision we'll then clean up any debris with some with a automated irrigation aspiration tip this is the polymer tip that alkan has and in this particular patient who wants a refractive outcome or once again you use intraoperative abirometry to confirm lens power and astigmatism and now since the capture bag is intact and fully inflated we can put a single piece lens because remember it's going completely in the bag it's not going in the sulcus the haptics and the optic are in the bag and then we always in these lens cases like to put a little myocall in the end just to confirm that the pupil rounds and that there are no there's no vitreous forward and I do have one final case this is my first case of a patient who's going to have a glue non-glue sclerophyxated lens she had had several lens repositionings before the lens that's in now was iris fixated causing an ugg syndrome she's had a complete vitrectomy so obviously an iris sutured lens in this patient is not going to work well for her she has quite a floppy iris and I think just the the mobility of the iris hitting on the implant was causing some intermittent hemorrhages the haptics can be rotated to free them from their from their suture fixation to the iris and once the lens is free from that we're going to place a 30 gauge thin walled or large board needle at an angle through the scleral wall about two millimeters behind the the limbus the distal haptic is then fed into the needle as you see here and you only really need to feed it in two or three millimeters I go in a little bit further here but again this was my first case so chalk that up to inexperience if you feed it in too deeply it's hard to manipulate that implant for placement of the second haptic the the syringe is taken off the needle so that that needle hub is free holding the haptic and then 180 degrees away from that the second needle is placed and the proximal haptic is fed into the lumen of that needle this is harder to do in a small pupil you see I have iris retractors in place so I can visualize that and because of the difficulty with the angle that I had in this particular case we do get some kinking of that second haptic the needles are then withdrawn from the scleral wall you try to do it in unison so they both exit about the same time here you see that the proximal haptic came out first and I'm going to grab onto that so it doesn't go back into the eye and then I can remove the second needle and as I do so the haptic is exposed now we have both haptics externalized and in order to keep these haptics in place without glue we need to deform the haptic we do that with cotteries so we'll create uh use a disposable cotterie to create a bulbous end of the haptic and do the same thing on the other side you don't need to touch the haptic just get close to the haptic and you'll see it melt and a nice bulb is created and then each of these bulbs is tucked into this scleral wall just barely underneath the top of this scleral wall because you don't want it under the conging taba where it can cause some irritation and perhaps erosion you want it in that needle track within this scleral wall but not so deep that it ends up back completely inside the eye in this case I was a little bit frightened of of of its stability so I put a little bit of reassure sealant and really is not necessary though you can see how nicely the lens centers remove the iris retractors and this patient is now about three months out and well not quite three months but several months out and she's uh got a beautifully stable implant it looks like a routine fecocase now so that's the non-glue scleral fixated IOL technique I don't have a video to show you of the agarwal glued technique but it also is a nice technique so in conclusion IOL reposition or exchange I believe is becoming more common part of the reason is the refractive desire that the patients have with cataract surgery today and part is it is just that patients are living to be older so we have a lot more lenses out there and older patients and in time we're seeing some of the zonials come loose from pseudo exfoliation type of conditions the management decision depends on the patient's complaints and the pathology that's present a well thought out plan is imperative to success I'm Dr. Sione from the Institute of Utah in Salt Lake City thank you