As glaucoma specialists, challenging cataract extractions often fall into our hands for several reasons. First, exfoliation syndrome is the most common identifiable cause of glaucoma, and it causes cataracts and loose zonules.1 Second, because primary open-angle glaucoma is associated with myopia and chronic angle-closure glaucoma occurs in hyperopes, many patients at the extremes of axial length enter our ORs. Third, a large proportion of our patients are in the cataract age group, and both glaucoma surgery and hypotensive eye drops have been associated with an increased need for cataract extraction.2,3 Finally, glaucoma tends to occur in eyes with a history of uveitis or trauma, and those eyes often require complex lens extraction surgery. This month's “Inside Eyetube.net” therefore showcases enlightening videos on the subject of cataract surgery.
A COURAGEOUS OFFERING
While browsing Eyetube.net, I came across something
that immediately caught my attention—the weak
zonules tab on the cataract surgery channel. Out of
morbid curiosity, I clicked on a video titled “Iatrogenic
Zonular Disaster.” I praise Khiun Tjia, MD, for having the
courage to share this case. While I will not spoil the surprise
by sharing details, I will say that the moral of the
video is that, in some cases, aphakia is not such a bad
thing (Figure 1) (http://eyetube.net/v.asp?kozade).
ELEGANT TECHNIQUES
On Eyetube.net, there are no videos on how to place
an ACIOL. In all likelihood, most of us have seen enough
of these cases to last a lifetime. Rather, there is a collection
of videos on graceful, avant-garde techniques for
ensuring optimal placement of the IOL in the absence
of adequate capsular support.
Consider the submission by Som Prasad, MS, FRCSEd, and Gabor B. Scharioth, MD, titled “Sulcus Fixation of an IOL Using Scleral Tunnels” (Figure 2) (http:// eyetube.net/v.asp?surijo). The surgeons demonstrate a graceful method for fixating a three-piece IOL in the sulcus through a scleral tunnel. Instead of creating a scleral flap, the surgeons temporarily externalize the lens' haptics from the sulcus through an incision made with a 25-gauge needle and located 1.5 mm posterior to the limbus. After they use intra- and extraocular forceps to grasp and externalize the haptic, it is placed into a 3- to 4-mm scleral tunnel that runs parallel to the limbus. No fixation sutures or scleral flaps are required for this elegant treatment of aphakia. As a member of the “conjunctival preservationist society,” I found the minimal conjunctival dissection appealing.,/p>
Using another technique for sutureless, scleral-fixated, secondary IOL placement, Amar Agarwal, FRCS, and Dhivya Ashok Kumar, MD, place an IOL in the sulcus through a scleral flap (Figure 3) (http://eyetube.net/ v.asp?gasiha). The scleral flap is ultimately glued closed. The surgeons also describe the placement of a threepiece multifocal IOL with this approach. In addition, they present data from their case series as well as several arguments on the rationale for and safety of their technique.
A CLASSIC
If the sutureless placement of a secondary IOL is not
for you, a video presented by Maria H. Berrocal, MD,
showcases a fairly classic McCannel iris-sutured IOL
placement (Figure 4) (http://eyetube.net/v.asp?beseko).
Using 25-gauge instrumentation during a pars plana vitrectomy,
she attaches the haptic to the iris through the
cornea using a 9–0 Prolene suture (Ethicon, Inc.,
Somerville, NJ), which is then brought outside the eye through a corneal paracentesis for repeated placement
of the knots.
Eyetube.net has a large library of videos on secondary
IOLs' placement and other topics that the glaucomacataract
surgeon will likely find useful. Even if you
already have an optimal technique, you may enjoy
watching another surgeon struggle with the fallout of
weak zonules for a change.
Section editor Nathan M. Radcliffe, MD, is an assistant professor of ophthalmology at Weill Cornell Medical College, New York-Presbyterian Hospital, New York. He acknowledged no financial interest in the product or company mentioned herein. Dr. Radcliffe may be reached at (646) 962- 2020; drradcliffe@gmail.com.
