How to deal with IOLs in large eyes

The knot of the suture between the capsular tension ring and the IOL is made near the main incision avoiding the introduction of instruments in the anterior chamber The 50-year-old male patient presented with cataracts, high myopia and high astigmatism in both eyes. He wanted a multifocal intraocular lens. But with his high astigmatism the only viable choice was a bi-toric plate haptic IOL from Zeiss that is available in cylinder powers up to 12 dioptres, Claudio Orlich MD told the American Society of Cataract and Refractive Surgery 2018 Annual Symposium in Washington DC, USA. The patient’s high myopia also meant large eyes, with axial lengths of 25.8mm right and 26.86mm left. “That is a big bag for a small lens,” raising the risk of post-surgery IOL rotation degrading visual acuity, said Dr Orlich, of San José, Costa Rica. One day after surgery the IOL had rotated so much that visual acuity was 20/100. So Dr Orlich waited a week for the capsular bag to contract and rotated the lens back into position. The next day visual acuity was 20/25 and the patient satisfied – but four days later the lens rotated again. “Already we had two surgeries and the patient was not very happy,” Dr Orlich recalled. After waiting two more weeks, a third rotation resulted in 20/20 vision, which held for a month. The patient was ecstatic and asked “When can you do the other eye?” Rather than waiting weeks after implant for the capsular bag to shrink, Dr Orlich focused instead on bulking up the lens complex inserted into the capsular bag. His solution was suturing the lens to a capsular tension ring. Dr Orlich placed a nylon 10-0 suture through one haptic of the lens, and then inserted the lens into an injector. Using forceps designed for placing implantable collamer lenses, he pulled the suture into the anterior chamber before injecting the lens to avoid cutting it during injection. The haptic without the suture went into the bag, leaving the haptic with the suture outside. Dr Orlich then injected a capsular tension ring into the bag behind the lens and sutured it to the lens. Inserting the sutured haptic into the bag and rotating the lens into place completed the manoeuvre. The outcome was 20/20 and a very happy patient. “After this case I have been using this technique in all cases that have more than 24.0mm diameter,” Dr Orlich said. Other surgeons have since adopted the technique for stabilising toric IOLs in larger eyes, he reported. Claudio Orlich: orlichclaudio@hotmail.com