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Clinical science

Sleeveless-extrusion cannula for levitation


of dislocated intraocular lens
Ashvin Agarwal,1 Priya Narang,2 Amar Agarwal,1 Dhivya A Kumar1

Additional material is ABSTRACT vitrectomy. A 23-gauge sleeveless-extrusion cannula


published online only. To view Background/aims To characterise a sleeveless- helps to create suction on the optic of the IOL as it
please visit the journal online
(http://dx.doi.org/10.1136/
extrusion cannula-based suction technique to levitate gives a larger surface area with respect to the soft-
bjophthalmol-2013-304700). dislocated intraocular lens (IOLs) and review the surgical silicone tip to hold on to the IOL, thus facilitating
1 outcome. the ability to lift and levitate the IOL into the
Dr. Agarwals Eye Hospital
and Eye Research Centre, Methods This retrospective, non-comparative, single pupillary plane.
Chennai, Tamil Nadu, India surgeon, interventional, consecutive case series examined
2
Narang Eye Care & Laser 10 patients (10 eyes) who underwent the surgical METHODS
Centre, Ahmedabad, Gujarat, procedure from October 2011 to December 2012.
India In this retrospective non-comparative series of con-
Reliability, reproducibility, and intraoperative and secutive cases in which the technique to levitate dis-
Correspondence to postoperative complications of the technique were located IOL was performed, the personal log of a
Professor Amar Agarwal, analysed. single surgeon (As A) from October 2011 to
Dr. Agarwals Eye Hospital and Results The technique involved suction levitation of a
Eye Research Centre, 19, December 2012 was reviewed. The study protocol
3-piece acrylic foldable IOL in six cases, 1-piece acrylic was approved by the Institutional Review Board
Cathedral Road, Chennai,
Tamil Nadu 600 086, India; foldable IOL in three cases and a plate haptic IOL in one and conrmed to the Declaration of Helsinki. A
dragarwal@vsnl.com case. The IOL was exchanged in four eyes whereas the well-informed consent was taken from all the
same IOL was repositioned in six eyes with sulcus patients undergoing the procedure and patients
Received 27 November 2013 repositioning in two eyes and glued intrascleral xation
Revised 16 January 2014 with at least 9 months postoperative follow-up data
Accepted 19 January 2014 in four eyes. Intraoperative suction loss and a were included from most end point analyses.
Published Online First subsequent IOL dislocation were reported in 1 (10%) Preoperatively, all the patients had a complete
7 February 2014 eye. Early preoperative complications included pigment ophthalmic examination, including best corrected
dispersion in 1 (10%) eye, grade 2 anterior chamber visual acuity (BCVA), slit-lamp examination, intrao-
cellular reaction in 2 (20%) eyes and intraoperative cular pressure (IOP) and indirect ophthalmoscopy.
corneal oedema in 1 (10%) eye which resolved with A pre-existing or any coexisting ocular pathology
medical line of management. Intermediate and late was considered as a confounding factor as it could
complications included macular oedema in one patient affect the nal outcome and were excluded from
(10%) which resolved considerably with medical line of the study. Three cases included in the study were
management. No incidence of postoperative vitreous or those who had an intraoperative IOL dislocation
retinal haemorrhage, retinal break or retinal detachment during cataract surgery at our centre and seven
was reported. cases reported an IOL dislocation at varied inter-
Conclusions The early results demonstrate this surgical vals within the rst postoperative week wherein the
intervention as a reliable, reproducible and an effective IOL was completely dislocated into the vitreous
alternative treatment option for levitation of dislocated cavity. Cases with intraoperative IOL dislocation
IOLs with a low complication rate. were levitated in the same sitting and the remaining
seven cases also underwent the levitation procedure
as soon as diagnosed. All the cases underwent IOL
INTRODUCTION levitation within the rst postoperative week of
Despite the advancement and improved technical- IOL dislocation. Various intraoperative features like
ities, reduced complication rate and hastened visual the type of IOL levitated, incidence of loss of
recovery period in phacoemulsication procedure, vacuum and a subsequent drop while levitating an
the risk for signicant complications, such as IOL and other intraoperative and postoperative
nucleus or lenticular fragment drop into the vitre- complications were recorded.
ous and posterior dislocation of the intraocular lens Sulcus placement of an IOL was done in cases
(IOL) into the vitreous, still remains.1 2 with adequate capsulorhexis support and glued
Various methods have been described for the intrascleral xation was done in cases with inad-
management of dislocated IOLs lying at on the equate capsulorhexis support. Patients undergoing
retina. Technical handling of a posteriorly dislo- IOL repositioning were exempted from IOL power
cated IOL requires lot of surgical expertise to avoid calculations whereas patients undergoing IOL
the risk of retinal traction and creating an iatro- exchange were categorically taken up for IOL
genic tear. The soft tipped-extrusion cannula rst power calculation. Intraoperative data included sur-
described by Flynn et al3 is commonly used during gical approach, management technique (reposition,
vitrectomy in complex retinal detachments for IOL exchange or removal) and additional proce-
To cite: Agarwal A, internal drainage of subretinal uid.4 We describe dures performed concomitantly.
Narang P, Agarwal A, et al. the use of extrusion cannula without sleeves for Examinations were performed 1, 3 and 7 days
Br J Ophthalmol facilitating levitation of dislocated IOL with suction postoperatively, then every week for the rst month
2014;98:910914. through 23-gauge transconjunctival sutureless and at monthly intervals for 9 months. Each

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Clinical science

examination included the BCVA, central macular thickness on anteriorly, just behind the iris. The IOL was grasped by the end
optical coherence tomography, IOP, and anterior and posterior opening forceps introduced from the corneal incision under
segment inammation, fundus biomicroscopy, lens positioning direct visualisation through the microscope; the suction was
and complications. turned off and the extrusion cannula was then removed as the
forceps grasped the IOL (gure 1D). The surgeon then proceeds
to remove, reposition or exchange the IOL, depending on the
SURGICAL TECHNIQUE status of the capsulorhexis rim and the type of IOL in each indi-
All the surgeries were performed with constellation machine vidual case (web only video le). The retinal periphery was
from Alcon and local anaesthesia was used comprising a peribul- checked 360 with scleral indentation to rule out any retinal
bar injection of a mixture of lidocaine 1%, bupivacaine 0.5% breaks.
and hyaluronidase. Standard 23-gauge 3-port pars plana vitrec-
tomy incisions were framed and the initial step was complete
removal of the vitreous to prevent traction on the retina from RESULTS
subsequent manoeuvres. All the vitreo-lenticular adhesions were Data were entered in a Microsoft Excel sheet (Microsoft Corp,
gently released from the retinal surface using the vitrectomy Redmond, Washington, USA) and analysed using SPSS V.16.1
probe. A complete vitrectomy with careful separation and (SPSS Inc, Chicago, Illinois, USA). The change in the mean pre-
removal of the posterior hyaloid face was performed prior to operative and postoperative visual acuity was analysed using the
lifting the IOL. Once the lens implant was freed from such Wilcoxon signed-rank test. Differences were considered statistic-
attachments (gure 1A), it gently oated to the posterior pole ally signicant at p value <0.05.
of the eye. Care was taken to shave the vitreous as close to the Of 15 identied cases, complete case notes were available for
surface of the peripheral retina and pars plana. 10 eyes whose database was evaluated. The study included 10
The sleeveless-extrusion cannula was connected to the vitreo- eyes of 10 patients (seven men, three women; mean age of 57.1
tome aspiration and the vacuum was set to 300 mm Hg, with 4.58 years; range 5163 years) with a mean follow-up of
the cutting function turned off. Occluding the IOL before com- 36 weeks. The dislocation involved a 3-piece foldable IOL in six
pleting the vitrectomy was avoided to minimise the risk of per- cases, 1-piece foldable IOL in three cases and a plate haptic IOL
ipheral retinal breaks due to trapping of the vitreous in the in one case. Intraoperatively, suction loss and a subsequent IOL
lumen of the cannula. dislocation while levitating the IOL from the surface of retina
As the IOL rested at on the retina, the sleeveless-extrusion were seen in 1 (10%) eye and a second attempt was made to
cannula was placed in contact with the centre of the optic and create an effective suction. No intraoperative or any post-
suction was initiated to allow a rm grasp (gure 1B). operative complication was observed in this case in the entire
Addressing the IOL with extrusion cannula without sleeves gives follow-up. Intraoperative corneal oedema was seen in 1 (10%)
a larger surface area to be adhered to the IOL. The suction can eye which resolved in the immediate postoperative period. On
be dynamically controlled with the foot pedal. The IOL was the rst postoperative day, pigment dispersion was observed in 1
lifted from the surface of the retina (gure 1C) and was brought (10%) eye and grade 2 anterior chamber cellular reaction was

Figure 1 Levitation of dislocated posterior chamber intraocular lens (IOL). (A) Vitrectomy is done to clear all vitreo-lenticular adhesions. (B)
Sleeveless-extrusion cannula is placed close to the anterior surface of the optic of the IOL; vacuum is initiated and occlusion is achieved. (C) IOL is
lifted from the surface of retina. (D) The IOL is lifted, brought in to the mid-pupillary plane and is grasped by an end opening forceps.

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Clinical science

seen in two eyes which resolved with topical medication. Late have been described.614 Retinal forceps have been described to
postoperative complication included macular oedema in 1 lift the IOL, although they run a risk of damaging the retina dir-
(10%) eye which resolved considerably with medical line of ectly or indirectly;14 the IOL is often sneaky, slippery, difcult to
management but eventually led to a compromised vision of 0.6 grasp and manipulate. By lifting the IOL from the retinal surface
Snellens decimal equivalent in that eye. The mean central with an illuminated pick or hook, the IOL optic can be grasped
macular thickness at 9 months was 181.99.39 mm. None of with serrated or diamond-dusted forceps.14 Olson et al13 devised
the eyes had postoperative vitreous or retinal haemorrhage, a suction-based grasping tool that has a suction cup at its terminal
retinal break or retinal detachment (table 1). end for lifting the dislocated IOLs. But it necessitates the use of
The mean BCVA was 0.960.1 (table 1). The mean post- specially designed suction tips to allow grasping and stabilisation
operative IOP as measured with non-contact tonometer was of the IOL. The fragmatome tip has been described to manipu-
13.21.8 mm Hg and there was no statistically signicant late the posteriorly dislocated IOLs by applying adequate suction
change in the IOP at 9 months follow-up ( p=0.32). to the centre of the anterior surface of the IOL optics.15
In all, out of 10 eyes, eight eyes with inadequate sulcus support However, the device requires a conjunctival peritomy, which
underwent glued intrascleral xation of an IOL and two eyes can cause conjunctival oedema, and also necessitates a 20-gauge
underwent sulcus implantation of an IOL. Out of three eyes sclerotomy wound. Moreover, its availability and accessibility may
which had intraoperative dislocation, repositioning in the sulcus be an issue to many surgeons and it is also comparatively bulky to
was done in one eye and the remaining two eyes underwent hold as compared with a 23-gauge extrusion cannula.
glued intrascleral xation of an IOL. The IOL remained well Perurocarbon liquids (PFCL) have also been used to prevent the
positioned throughout the follow-up interval and no recurrence adjacent retina from damage16 and to facilitate the anterior dis-
of IOL dislocation was reported. The nal vision and symptoms location of luxated IOL. They have high density and low viscosity
were stable in nine eyes and improved considerably in one eye and it is these characteristics that allow easy aspiration and injec-
which developed macular oedema out of the total 10 patients. tion of PFCL in a 23-gauge vitrectomy system where it can be
Repeat surgery was not required in any of the eyes. injected to levitate the IOL in the pupillary plane. However,
ocular toxicity due to retained PFCL, including uncontrolled
DISCUSSION IOP,17 corneal epithelial toxicity18 and decreased focal sensitivity
Since the inception of the rst intraocular implant in 1949 by of the retina,19 has been reported. An in vitro study showed that
Dr Harold Ridley, IOL dislocation has been recognised as an PFCL is directly toxic to human retinal pigment epithelial cells
important complication of cataract surgery. Perspex lens had to when exposed to the cells for 7 days.20 Retinal forceps are often
be abandoned as a 13% rate of IOL dislocation5 was reported. used to manipulate dropped IOLs and are usually the standard
Improvements in IOL design have decreased the reported inci- mainstay of treatment in vitreo-retinal surgery. Accidental pinching
dence of dislocation of rigid posterior chamber IOLs from 0.2% and creation of an iatrogenic retinal tear while lifting an IOL from
to 2%.6 7 Phacoemulsication with implantation of various fold- the surface of the retina is always a possibility with its use. Often
able IOL designs has become the established cataract surgery the IOLs are sneaky, slippery and difcult to grasp14 especially in
technique8 and, consequently, the incidence of dislocation of cases of plate haptic IOLs.
foldable IOLs has increased.9 Extrusion cannula is used primarily for internal drainage of
Inadequate capsular support is the most common cause of IOL subretinal uid in eyes with rhegmatogenous retinal detach-
dislocation and most commonly manifests in the early post- ments. It is also used to remove haemorrhage, gas or silicone oil
operative period,4 but late, in-the-bag dislocation of IOLs in the subretinal space along with removal of surface retinal
owing to progressive zonular dehiscence has been increasingly haemorrhage. The exible silicon sleeve ts snugly within the
reported. Dislocation of a posterior chamber IOL into the vitre- rigid outer shaft of the instrument to prevent an air or uid
ous cavity is an uncommon but serious complication. Numerous leakage around the outside of the cannula and provides better
techniques for the management of posteriorly dislocated IOLs access due to its exibility into the subretinal space.21 Santos

Table 1 Demographics of eyes with sleeveless-extrusion cannula-based suction levitation of dislocated posterior chamber IOL (vision in
Snellens decimal equivalent)
Age/ Type of IOL BCVA BCVA IOP mm Hg Intraoperative/postoperative IOL repositioning/IOL
Case sex levitated (preoperative) (9 months) (9 months) dislocation (1 week) exchange

1 55/M 3-piece foldable 0.1 1 12 Intraoperative Repositioning with glued


intrascleral fixation
2 60/M 1-piece foldable 0.08 1 14 Postoperative IOL exchange+glued fixation
3 57/M 1-piece foldable 0.25 1 16 Postoperative IOL exchange+glued fixation
4 51/M Plate haptic 0.1 1 12.2 Postoperative IOL exchange+glued fixation
5 63/F 3-piece foldable 0.25 1 11 Postoperative Repositioning with glued
intrascleral fixation
6 56/F 3-piece foldable 0.33 1 11 Postoperative Repositioning with glued
intrascleral fixation
7 62/M 1-piece foldable 0.2 0.6 14 Intraoperative IOL exchange+glued fixation
8 58/M 3-piece foldable 0.33 1 12 Postoperative Repositioning with glued
intrascleral fixation
9 61/M 3-piece foldable 0.33 1 16 Intraoperative Repositioning in sulcus
10 53/F 3-piece foldable 0.1 1 14 Postoperative Repositioning in sulcus
BCVA, best corrected visual acuity; F, female; IOL, intraocular lens; IOP, intraocular pressure; M, male.

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Clinical science

and Roig-Melo22 proposed lifting the IOL by the optic with a grasp with a retinal forceps, and no difculty was encountered
silicone-tip aspiration cannula connected to the vacuum of the in the levitation process. Another advantage is that no additional
vitrectome. Removal of the silicon sleeve gives a wider access of device is required and inaccessibility or unavailability of the
the bore of the cannula to create an effective suction around the device will not be an issue.
IOL. The authors conceptualise that the vacuum created by the In conclusion, in this retrospective analysis, it seems that
sleeveless-extrusion cannula is strong enough to hold the optic short-term outcomes of suction-based levitation of posterior
of an IOL in the vitreous cavity. Since a complete pars plana chamber dislocated IOLs in eyes are encouraging. The results
vitrectomy seems mandatory to avoid retinal traction with a presented here must be interpreted with caution for a number
high risk of retinal breaks, triamcinolone can be used to increase of reasons. First, this is a retrospective study with a relatively
the visibility of the vitreous adhesions in the posterior chamber small number of subjects. Therefore, only large differences in
before any anterior IOL dislocation. Care is taken that the visual acuity or in the number of complications might be recog-
lumen of the cannula faces the at surface of the optic of IOL nised as signicant by the statistical tests used, thereby making
and that it completely apposes and occludes the IOL optic, more subtle differences difcult to ascertain. Moreover, ethical
thereby, creating an effective active suction to grasp and lift the implications would preclude a prospective study and also it is
IOL. Meanwhile, no pressure is exerted on the IOL while trying difcult to ascertain as to which patients will need this surgical
to occlude and create suction and no passive suction ow to procedure. Second, the mean follow-up period of 9 months is
move the IOL is attempted either. This prevents any uncon- relatively short as compared with many of the previous reports
trolled movement of the IOL that could be detrimental for the on the management of dislocated IOLs. Despite the limitations
retina. The linear control of the foot pedal helps to increase the of this study, it does provide information regarding the tech-
vacuum as and when needed during the levitation of IOL. Loss nique and postoperative outcome of levitation and subsequent
of vacuum while holding and lifting the IOL was reported in IOL implantation in these eyes and indicates the need for
one case and a second attempt had to be made to lift the IOL. further prospective trials with longer follow-up. Adequate
The loss of vacuum control was probably due to ineffective follow-up and study sample size remain critical issues with any
apposition of the lumen of the cannula to the surface of the new approach in technique or technology.
IOL optic.
A dislocated IOL can cause complications such as decreased Contributors All authors included on this paper full the criteria of authorship. In
addition, there is no one else who fulls the criteria but has not been included as
vision, monocular diplopia, glare, hyphaema, iritis, secondary an author. Study plan, conception and design: PN, AmA and AsA. Data acquisition:
glaucoma, corneal decompensation, cystoid macular oedema, DAK and AsA. Drafting article: PN and AmA. Final approval: AmA and PN.
and peripheral retinal traction and subsequent retinal detach- Competing interests None.
ment.23 The complications associated with dislocated IOLs like
Patient consent Obtained.
cystoid macular oedema, corneal oedema, glaucoma and intrao-
cular inammation are often difcult to differentiate from con- Ethics approval Local institutional review board.
sequences of the initial complicated cataract surgery. In our Provenance and peer review Not commissioned; externally peer reviewed.
limited series of cases, we did not come across any major com-
plication, probably because the effective time interval between REFERENCES
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Sleeveless-extrusion cannula for levitation of


dislocated intraocular lens
Ashvin Agarwal, Priya Narang, Amar Agarwal and Dhivya A Kumar

Br J Ophthalmol 2014 98: 910-914 originally published online February 7,


2014
doi: 10.1136/bjophthalmol-2013-304700

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