Surgical pearls for IOL explantation

Microsurgical instruments have revolutionized how ophthalmologists perform procedures. One procedure that has gained particular benefit from the evolution of ophthalmic tools is IOL explantation. I work at a high-volume center and perform more than 1,000 procedures a year-about 5% of which are IOL explantations for several reasons.

Initially, lenses explantation were primarily anterior chamber IOLs, needing removal secondary to pseudophakic bullous keratopathy, uveitis-glaucoma-hyphema syndrome, or cystoid macular edema.¹

Since posterior chamber IOLs have become more common, indications for explantation or exchange has shifted to IOL decentration, incorrect power calculation, intolerable visual symptoms such as glare or halos, and opacification.²

Technique for IOL explantation

The technique for IOL removal is partially dependent on the IOL type and location, as well as perioperative complications.

Two limbar corneal incisions are made in the cornea with the main incision on the temporal side. An ophthalmic viscoelastic device is introduced into the anterior chamber. A 23-gauge needle with a bent tip and viscoelastic device can be used for separation of potential adhesions between the IOL and adjacent tissue. Injection of OVD is used to distend the anterior capsule, with continued injection at each haptic site to isolate and dislocate the lens within the capsule bag. Once separated, the IOL should be rotated 180 degrees to confirm it is free of adhesions in the periphery.

The video shown here demonstrates lens explantation 12 months after implantation of a wrong-powered hydrophobic IOL. Microsurgical instruments allow for efficiency and versatility in performing IOL explantation. (Video courtesy of Andrea Cantagalli, MD, FEBOphth)

To dissect the lens, I have used the MST 19g Coaxial Packer/Chang IOL cutters for a few years now.

In the past, standard size scissors caused distortion of the IOL corners and their larger size increased risk for damage to the cornea anteriorly and iris posteriorly.  In contrast, the MST 19g Coaxial Packer/Chang IOL cutters have a strong grasp and are usable in a very small paracentesis.

Precision within such small incision allows for maximal visibility in the anterior chamber with a very low distorsional corneal effect and a beneficial factor in preventing accidental contact with the adjacent structures. If a closed-loop IOL is being removed, I cut the superior haptic first then the optic, while leaving the inferior haptic in place. MST 23g Coaxial Micro Holders can then be used to grasp the superior half for removal. With the other hand, MST Capsule Retractors can be used to stabilize the capsular bag to avoid damage from accidental shifts. The remaining lens can then be removed.  

Pearls

• Always verify the issue. There are many reasons for explantation, but a thorough work-up including OCT and corneal topography should be performed. Making sure the visual problems are secondary to the IOL and will likely be resolved with explantation or exchange is essential.
• If it becomes apparent a patient is going to require IOL explantation, it is better to go ahead and do it, rather than wait. Explantation should be performed as early as possible following the initial surgery to avoid severe anterior capsule fibrosis. Rushing into a YAG capsulotomy can further complicate a corrective surgery when performed.
• Stabilization of the capsular bag is essential for avoiding damage to anterior capsule structures. The less trauma caused during intraocular manipulation, the fewer complications the patient will experience. With MST Capsular Retractors, you can use the hook to sustain the capsular bag.
• When performed for the correct reasons and with the right tools, IOL explant can be a beneficial procedure for patients displeased with a prior IOL implant.

Disclosures:

Dr. Andrea Cantagalli, MD, FEBOphth is an ophthalmologic surgeon from GSD Villa Erbosa in Bologna, Italy. He did not indicate a proprietary interest in the subject matter.

References:

1. Mamalis N, Crandall AS, Pulsipher MW, et al. Intraocular lens explantation and exchange. A review of lens styles, clinical indications, clinical results, and visual outcome. J Cataract Refract Surg. 1991;17:811-818.
2. Jones JJ, Jones YJ, Jin GJ. Indications and outcomes of intraocular lens exchange during a recent 5-year period. Am J Ophthalmol. 2014;157:154-162 e151.