HAPTIC TUCK FOR REVERSE OPTIC CAPTURE
Howard V. Gimbel, MD, MPH and Hala Marzouk, MD
Posterior capsule tears may occur at many different stages of cataract removal. With a small posterior capsule tear, a posterior continuous curvilinear capsulorrhexis (PCCC) may be initiated by grasping one edge of the advancing tear with forceps and applying the CCC principles.1 The tear is extended and completed into a continuous edge that encompasses the extent of the original tear and is blended from the periphery toward the center as the circle or oval is completed. The PCCC diameter is kept as small as possible to preserve the maximum integrity of the posterior capsule and, if possible, the vitreous face. PCCC helps to avoid a possible extension of the inadvertent linear or triangular tear during such maneuvers as vitrectomy or lens placement.2 With a successful PCCC, an intraocular lens (IOL) may be implanted in the bag, and if the PCCC is of proper size and of reasonable centration, the optic may be captured posteriorly if desired.
Sometimes the IOL is implanted into the bag and a large posterior capsule tear develops that cannot be converted to a PCCC for in-the-bag IOL placement. In this situation, the IOL optic may be lifted anteriorly and captured through the anterior continuous curvilinear capsulorrhexis (ACCC) to achieve a reverse ACCC optic capture fixation, where the IOL haptics remain posterior to the CCC.
Cases where large posterior capsule tears are discovered before IOL implantation may be best managed with sulcus placement of a 3-piece posterior chamber IOL (PCIOL). Conventional ACCC optic capture of a sulcus 3-piece PCIOL can be done if the posterior capsule tears have not extended anteriorly around the equator of the capsule to the ACCC, resulting in insufficient capsular bag-IOL support.
Single-piece acrylic lenses should not be placed in the sulcus even with conventional ACCC optic capture because of the thickness of the haptics. Iris pigment epithelial damage and haptic-induced pigmentary glaucoma has been reported when a single-piece acrylic lens haptic had become displaced into the ciliary sulcus.3–5 Various postoperative complications necessitating IOL explantation have been documented when single-piece AcrySof IOLs (Alcon Laboratories, Inc) were placed in the ciliary sulcus. Areas of iris atrophy, iris chafing, and haptic displacement causing recurrent hyphema, vitreous hemorrhage, or pigment dispersion have been diagnosed and confirmed with ultrasound biomicroscopy, light microscopy, and electron microscopy.4 These are in addition to the common complication of IOL decentration and subluxation.
Interestingly, several reports support the use of single-piece acrylic IOLs in the sulcus in eyes developing posterior capsule tears in order to maintain the benefit of the small incision and attain early visual rehabilitation.6,7
Members of the American Society of Cataract and Refractive Surgery Cataract Clinical Committee conducted a retrospective survey of patients referred for complications associated with single-piece acrylic IOLs implanted in the ciliary sulcus.8 For back-up IOL design and placement, they recommended that any IOL placed in the sulcus should have adequate posterior iris clearance and secure fixation. The loop-to-loop dimension is less than 13 mm for most single-piece IOLs, and the loops may not fully extend because of their low compressibility force. For these reasons, the lens will be inclined to decenter in the ciliary sulcus of larger eyes. Chronic uveal inflammation would also result in uveitis-glaucoma-hyphema syndrome with recurrent microhyphemas that can abruptly raise the intraocular pressure. Using ACCC optic capture would avoid some of these concerns, but even then the haptics are too thick to avoid most of these complications.
Figure 23-1. First haptic tucked. A Sinskey hook is used to grasp one haptic and tuck it into the ACCC.
Figure 23-2. Second haptic is also tucked with the help of a Sinskey hook and a spatula or a second Sinskey hook.
Alcon has recommended implanting single-piece AcrySof lenses only if the haptics are in the capsular bag and to change to a 3-piece IOL in cases that require sulcus haptic placement for ACCC optic capture fixation of the IOL.
Recently, we described a new technique for single-piece acrylic IOL capsule fixation in the presence of a larger posterior capsule tear resulting in an open capsule, but where the ACCC is intact. To keep the single-piece IOL haptics out of the sulcus, we described a variation of reverse anterior capsule optic capture in which the haptics are placed beneath the anterior capsule while the edges of the optic remain above the anterior capsule. This is done by first placing the IOL in the sulcus and then sequentially tucking the 2 haptics through the ACCC. This is a different maneuver than that described for conventional reverse optic capture, in which the IOL is first implanted into the capsular bag and then the optic is elevated through the ACCC so that its edges sit above the capsule. The reverse optic capture technique allows for the use of single-piece acrylic IOLs such as toric and other specialty IOLs in cases complicated by large posterior capsule tears.
Surgical Technique
- Surgery may be planned for cataract extraction with an acrylic toric or multifocal IOL implantation. For toric IOLs, the horizontal axis is marked by the surgeon using a fine-tip sterile marking pen (surgeon’s marking pen 115; Medical Action Industries). Marking is done at the 3 and 9 o’clock positions with the patient seated at the slit lamp with the eyes level. This is a back-up for reference marks guided by the Callisto (Carl Zeiss Meditec) or similar markerless system integrated into the operating microscope. The assigned axis is then marked with an inked spatula. During phacoemulsification or irrigation/aspiration, a posterior capsule tear may occur. If the tear cannot be rounded to a PCCC for in-the-bag placement of the IOL, or if the posterior capsule tear has extended across the posterior capsule and the vitreous is herniating through the opening requiring vitrectomy, there is no anatomic bag in which to place an IOL. This happened during irrigation/aspiration in our case.
- An additional paracentesis is made and a 2-port vitrectomy is performed. The same intended IOL (toric or multifocal single-piece acrylic IOL) is implanted in the sulcus. A few drops of triamcinolone acetonide (Triesence) 40 mg/mL are instilled to help visualize any anterior chamber vitreous during the vitrectomy.
- For haptic tuck, a cohesive ophthalmic viscosurgical device (OVD) is instilled into the sulcus. Rather than placing a nontoric 3-piece IOL in the sulcus for standard ACCC optic capture and forgo astigmatism correction (or multifocal correction), the selected foldable posterior chamber ultraviolet-absorbing biconvex single-piece acrylic IOL is placed in the sulcus. If it is a toric IOL, it is aligned at the proper axis orientation.
- Using a Sinskey hook, and a spatula or a second Sinskey hook if necessary, one haptic (Figure 23-1) followed thereafter by the second haptic (Figure 23-2) is tucked through the ACCC to capture the optic using this modification of the reverse ACCC optic capture technique (Figure 23-3). Following successful reverse optic capture, the IOL should be stable, well centered, and with the axis of toric IOLs aligned as planned. The proper orientation for the toric IOL is confirmed by the previously placed ink marks or the target axis may be displayed as an overlay on the live image seen through the eyepiece when using the Callisto system.
- The OVD is removed and the wounds are hydrated and confirmed to be watertight.
Figure 23-3. The IOL is well centered, stable, and properly aligned with the axis markings.
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