1030hrs: Retained Lens/Surgical Management of Aphakia (Andrew Merkur)

Dr Merkur is on faculty at UBC. His residency training was at University of Ottawa, and fellowship at UBC.



This talk is on surgical management of aphakia. We’ve come along way since the early days of couching lenses.

Starts reviewing option for lens implantation when no capsular support including aphakic glasses, AC/iris fixated IOLs, next generation foldable AC IOLs, iris-sutured PC IOL, sulcus-fixated lenses and new techniques. These were all discussed.

AC IOLs seem to be showing a trend to better vision and fewer complications than even posterior fixated IOLs. People often concerned of potential chaffing issues but not outweighing its benefits.

If have complicated case, do not put something like an SA60 into the sulcus; leave aphakic if don’t have appropriate sulcus 3-piece lens.

AC IOL (non-folding ones) less technically demanding but no sutures to erode or break. They do require large incisions and could effect the angle which is of concern with glaucoma patients. Risk pupillary block and UGH. Newer open-loop designs are quite good. Still glaucoma docs shy away from this out of glaucoma concerns. 

Iris-fixated claw lenses discussed. Some potential concerns with inability to dilate patient afterwards as pinch onto iris with claws.

Iris-sutured IOL. Still better than a one-piece lens in the sulcus in terms of rubbing. These patients do end up with a cat-eye pupil (which patients not always happy with) and mydriasis is restricted. Fairly stable surgery. 

Sutured sulcus IOL is commonly done here in Vancouver. Rather large incision and shows off your surgical prowess. Prolene does breakdown eventually, and those are the sutures used to fixate these lenses. When these start to break down, extra trauma to the eye to re-suture them. Also risk of chaffing with iris if too anterior and of tilting the IOL. However, can get great dilation of the pupil afterwards. Surgery is long and there can be significant light toxicity with this surgery. As this is the standard technique here, he goes into greater detail showing drawings. Scleral flaps at each end where the suture will be fixated. Tie sutures to the haptics then internalize the lens. Newer lenses now that can allow 4-point fixation instead of just 2 which can help minimize decentration or tilt.

Foldable IOLs when sutured are like gummy bears in that the suture tightening can distort the lens.

New sutureless small incision sutureless scleral IOL. Technically a bit challenging but over time will be easier. Pass the haptic through avascular tissue. Broad fixation of the haptic with this technique. Shows video starting with 24-G scleretomies 180 degrees apart after a complete vitrectomy done. With bent needle, create needle tracks. Corneal incision inject IOL and leave trailing haptic out corneal wound.With end-grasping forceps, pull each prolene haptic of the IOL into the sclerotomy then bury into the needle tracks sclerotomy incision. (The video shown during the talk was presumed to be that performed by the speaker but was in fact copied from EyeTube.net without appropriate credit. He has performed the procedure and will provide me with this to post.) Minimal incision, foldable small incision, no exposed sutures.

Updating video clip first week of May so that actually surgery the speaker has performed then will re-post.