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A Dislocated Bifid Lens

  Channels: Cataract Surgery | Posted 5/13/2019

A 95-year-old male presents with full angle-closure glaucoma with a dislocated lens sitting in the anterior chamber causing corneal decompensation. Michael Patterson, DO, notes the complete absence of zonular support and opts for an extracapsular extraction. After the large, bifid lens is burped from the main incision, Dr. Patterson walks through his glued IOL technique.

Cataract • Cataract Surgery • Dense Cataract • Extracapsular Cataract Extraction (ECCE) • Glued IOL • Hypermature Cataract • TISSEEL Fibrin Sealant, glue

4 / 4 Series: Noteworthy Cases - San Diego 2019

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I'm Michael Patterson from Crossfield, Tennessee. And this is an interesting case of a 95-year-old that came into my clinic in full angle closure glaucoma with a lens sitting in the anterior chamber causing corneal decompensation. And of course when we laid him back on the table as you can see, the lens is falling back in the mid-vitreous. So I went in and did a small vitrectomy first with a 3-port vitrectomy, just to clear up the lens, make sure that the vitreous wasn't going to drag on the retina any further and just kind of elevate the lens of the anterior chamber.

Obviously there's no question that there's no capsular support, there's no zonular integrity, it's completely dislocated and so the decision here is to make kind of a wide angle incision right at the limbus here. This will allow you to use less sutures and I'll take a viscoelastic cannula and place that into the posterior chamber and you'll see here, I'm going to inject viscoelastic and this lens is quite remarkable.

You'll see here the vitrector was behind it to make sure that it was safe and you see how quickly this lens, even in slow motion here. This is a very slowed down video, that this lens basically gets birthed out of the eye and the impact was is that lens actually shot onto my surgical gown. You'll see that this is a bifid lens if you would and it was quite remarkable. No way that you could have phacoed it. Certainly extra cap was the only option here.

But the question is, is what should you do next? So I decided that at the time of surgery, that a glued IOL would be the option to place in the eye, to give this guy some vision and I do after every one of these cases, I always try to go back in with the vitrector out of two ports just to make certain that we've cleared all vitreous posteriorly and it's coming anterior. You see, I put a few sutures in just to kind of stabilize the eye. I've got an infusion cannula running and this is just a classic glued IOL technique in which you make scleral flaps and with a bent scleral crescent blade here, and I'll insert the haptics into some pockets.

This allows you to have very good stability of the lens. The lens won't rotate at all and won't move and as long as you're deep enough into the sclera, you won't have any problems with erosion from the haptics or the lens tilting down the line. And so you'll see here, just making some pockets, and I use an inserter here just to inject the lens slowly and using that MST Micro-Grasper, this will allow you to grab it. What you want to do here is I've got a 25 gauge, Micro-Grasper here with smooth paddles. I think smooth paddle forceps are important when you're doing any sort of haptic grab and you can use a serrated forceps but I have had instances where the PMMA haptic is altered a little bit.

So I typically use a smooth paddle forceps and just pull the haptic through the ostomy, and then you can have an assistant hold it but it typically stay externalized on its own. You can see here the trailing haptic coming into the eye and again, you'll just externalize that. Once both haptics are externalized, the most difficult portion of the procedure is over. You see here very good centration, certainly with the Purkinje images they look very good. You'll be able to place the haptics inside the pockets that you've made and then I'll use tisseel glue to close both the scleral pockets and the conjunctiva. I do that kind of all at the same time.

That leaves a very good closure without any concern of any leaks through your ostomies. An option here is to place some air in the eye at the end also just to help you with any sort of leak from aqueous coming out. Again, the vitrector always goes back in just to make certain there's no vitreous coming forward. In here I've placed in some sutures in the sclerostomies just to make sure we don't have any leaks and glue at the end of the case here, just to sure up the rest of the eye and you see a perfectly centered eye well. And this 95-year-old did quite well considering the extreme circumstances at the beginning of the case.

You see there just the last bit here, you'll just remove the remaining glue. To seal, I usually cut that off and then go in and I typically hydrate even though I've already placed sutures, I'll hydrate the wounds just to give a little bit more security. Thank you very much.

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