Lahore Dec 2010-Sec Iol-Overview

Secondary posterior
chamber IOL (PC IOL)

Implantation-made
simple
Dr. Zia.ul.Mazhry
FRCS(Edin), FRCS(Glasgow),
FCPS(Pak), CICOphth- (UK)
Assistant Professor
Central Park Medical College Life Member OSP Pakistan
Lahore Pakistan
Member Executive council OSP LHR (Pak)
Consultant Eye Surgeon
Member American Academy of Ophthalmology
& Head of Department
WAPDA Teaching Hospital
Lahore Pakistan
We do not have any financial interest in this presentation

APAO
2010
Beijing
China
Introduction
• The Speaker
– Dr. Zia.ul.Mazhry • The Course
• FRCS(Edin), FRCS(Glasgow),
FCPS(Pak), CICOphth- (UK) – Secondary posterior
• Life Member OSP Pakistan chamber IOL (PC IOL)
• Member Executive council OSP
LHR (Pak) Implantation-made
• Member American Academy of
Ophthalmology
simple
• Assistant Professor • Part 1 Background and
– Central Park Medical College classification
Lahore Pakistan
• Part 2 Clinical and
• Consultant Eye surgical skills
Surgeon & Head of • Part 3 To review and
Department interact
– WAPDA Teaching Hospital
Lahore Pakistan
General Issues in
Learning and Teaching
• “Learning without thought is labor lost. Thought

without learning is intellectual death”
• Confucius
Objective:
• To demonstrate the safe and effective use of
techniques for Secondary posterior chamber
IOL implantation while avoiding the pitfalls, and
to explore the alternative of scleral fixation of
PC IOL in eyes with partial or total absence of
posterior Capsule.
• To classify Indications and to discuss surgical
planning for secondary PC IOL implantation
• To elaborate variations of surgical procedure
required to manage different situations
encountered in secondary PC IOL implantation.
Upon completion of this
course,
• the ophthalmologist should be able to:

– Plan a surgical intervention when faced with
uniocular or binocular aphakia needing a secondary
PC IOL Implant.
– Classify and describe the different clinical
presentations and appropriate surgical technique for
secondary PC IOL Implantation
– Identify and manage the most frequent
intraoperative and post operative complications
encountered in secondary PC IOL Implantation .
Synopsis:
• Secondary PC IOL implantation in aphakics is

an established procedure. Variation of surgical
procedure are required to manage different
situations. The status of posterior capsule may
vary from intact to partially deficient or totally
absent. Similarly the technique has to be varied
from simple implantation to synechiolysis to
anterior vitrectomy combined with single or
double haptic trans-scleral fixation of PC IOL.
This course will present simplified approach to
manage secondary IOL implantation.
Course overview
• Objectives Considerations
• Synopsis • Surgical Techniques
• Historical Review • Post Operative
Management
• Background
• Video Review
• Classification Criteria
• FAQs
• Classification
• Secondary IOL Pearls
• Preoperative
Considerations • Summary
• Intraoperative • Conclusion
Secondary posterior
Implantation-made
simple
Part 1 Background & Classification

Sir Harold Ridley, Kt, MD,
FRCS, FRS the inventor of IOL
– Sir Harold Ridley

performed first
IOL implantation
on November 29,
1949.
– long-standing
dogma that one
"should never put a
foreign body into the
delicate tissues of
the eye“
First IOL: A Secondary
Procedure
• The first operation, done at St Thomas' Hospital,
London, England, was a 2-step procedure. The
extracapsular removal of the cataract occurred
on November 29, 1949. The insertion of the
pseudophakos manufactured by Rayner Ltd,
London, was a secondary procedure performed
on February 8, 1950, after Ridley had verified
that the eye was quiet and suitable for
implantation (David Spalton, MD, written
communication, December 1998).
Relevence
• 270,000 cataract procedures were performed in
UK National health service in 2008.1
• The reported incidence of PC rupture and
zonular dehiscence is 1.92% and 0.46%
respectively. 2
• Both of these complications have the potential to
prevent primary lens insertion and aphakia
• Secondary lens implant is now the standard for
managing aphakia.3 However there is a wide
variation in the choice of lenses for secondary
lens implant.
Aphakia
• Aphakia with Full Capsular Support

• Aphakia with Partial/Absent Capsular Support
– Complicated by:
– Dislocated/subluxated
» Nuclear fragments
» Pseudophacos
Options for correcting
Aphakia:
• Epikeratophakia
• Angle supported IOLs
• Iris supported IOLs
• Scleral supported IOLs
• Capsule supported IOLs
Aphakia with Full Capsular
Support
– Pupil
• Mobile/Fixed
• Regular/Irregular
• Constricted /Dilated
– Iris Tissue
• Intact/Missing
– Synechiae
• Anterior
• Posterior
– Visual Axis
• Clear/Opaque
Aphakia with Partial/
Absent Capsular Support
• Posterior Capsule
– Deficient
• Central round rent
• Central linear rent
• Peripheral Rent
– Absent
• Anterior Vitreous
– Prolapsed
– Vitrectomized
• Further Complicated
– Sublux/Dis-Pseudophacos
– Dislocated Nuclear Fragmant
– Dispersed Cortical Matter
Classification .
SIMPLE 2 IMPLANTATION OF IOL
• Simple Secondary PC IOL

(Sec- PC IOL):
SYNECHIOLYSIS AND IMPLANTATION
• Sulcus
Dissection/Synechiolysis
and PC IOL implantation
(SD &PC IOL)
INTRASHELF IMPLANTATION
• Intra shelf PC IOL WITH ANTERIOR VITRECTOMY
implantation (IS PC IOL)

with anterior vitrectomy
Classification
SINGLE HAPTIC FIXATION
• Single Haptic Sclera

Fixation (SHSF PC
IOL)
• Double haptic scleral
fixation (DHSF PC DOUBLE HAPTIC FIXATION
IOL).
• Retrieval & Fixation of
dislocated IOL (R&SF
PC IOL)
Secondary posterior
chamber IOL (PC
IOL) Implantation-
made simple
Assistant Professor Part- 2 Clinical & Surgical Skills
Central Park Medical College
Lahore
Consultant Eye Surgeon Dr. Zia.ul.Mazhry
& Head of Department
WAPDA Teaching Hospital FRCS(Edin), FRCS(Glasgow),
Lahore
Life Member OSP
Executive Member OSP Lahore Branch
Over twenty-four hundred
years ago, Confucius
declared:
•What I hear, I forget.

•What I see, I remember.
•What I do, I understand.
Preoperative
Considerations
• Status of zonula-capsule • Anterior Vitreous
complex – Prolapsed in AC
• Intact clear – Vitrectomized
• Intact opaque
• Central rent • Visual Potential
• Peripheral rent – BCVA
• Pupil – Corneal status
– Mobile reactive – Retinal status
– Fixed constricted • Investigate
– Fixed dilated – FFA
– irregular OCT
Bscan
• Iridocapsular Adhisions
Preoperative
Considerations
Instruction Course
Secondary PC IOL Implantation - made simple
Preoperative
Considerations
Instruction Course
Preoperative
Considerations
Instruction Course
Preop Planning
Instruction Course
Preop Planning
Instruction Course
Preop Planning
Instruction Course
Preop Planning
Instruction Course
The Materials
• The Instruments – Foldable Acrylic
Single piece
– Routine Cataract Set
• Min 13.00 mm overall
• Kuglon’s Hook
• Optic 6.00 -6.5 mm
– 27-30G hypodermic
needles • The Sutures
• The IOL – Polypropylene
(Prolene) 10/0
– PMMA Single Piece • Double arm straight
• Preferably Eyelets on needle
the haptics
– Nylon 9/0, 10/0
• 13.5-14.0 mm overall
• If Prolene not available
• 6.00-7.00 mm optic
Aphakia with Full Capsular Support
Clinical Situation:1
• Sec- PC IOL
– eyes with intact
posterior capsule
and no anterior or
posterior synechiae
along with clear
visual axis
.
SIMPLE 2 IMPLANTATION OF IOL
Aphakia with Full Capsular Support
SD &PC IOL
in eyes with intact posterior capsule but with
anterior or posterior synechiae and
clear/opaque visual axis
SYNECHIOLYSIS AND IMPLANTATION
Aphakia with Partial/ Absent
Capsular Support
IS PC IOL
in eyes with central rent in posterior capsule or
densely opaque visual axis
INTRASHELF IMPLANTATION
WITH ANTERIOR VITRECTOMY
Aphakia with Partial/
Absent Capsular Support
IS PC IOL
in eyes with Periph- rent in posterior capsule extending less than 90 degrees
Instruction Course
Capsular Support
SHSF PC IOL
in eyes with partially deficient
posterior capsule with
peripheral rent extending for
less than 180
SINGLE HAPTIC FIXATION
Case Report-SHF PC IOL
• Pre-OP 6/18 ec,

Aphakia with intact
PC shelf IT
• Post-OP 6/18 ec,

Capsular Support
DHSF PC IOL
In eyes missing posterior
capsule completely
DOUBLE HAPTIC FIXATION

Ab Externo Surgical Tech-
27G Needle &10/0 Nylon
Suture
Ab Externo Surgical Technique
10/0 Prolene Straight Needle
and PMMA SP IOL
PMMA SP IOL with eye lets and two
10/0 Prolene Double armed suture
Surgical Technique
Pre-Tied IOL Fixation
PMMA SP IOL with eye lets and
10/0 Prolene Double armed suture
Capsular Support
•R&SF PC IOL
•In eyes with
rented posterior
capsule and
subluxated
/dislocated
pseudophacos
(IOL)
In-situ Haptic Fixation of
Decentred IOL
Using 10/0 Prolene Double armed suture
“The mediocre teacher tells. The
good teacher explains. The
superior teacher demonstrates.
The great teacher inspires.”
Intra Operative
Considerations
• Proper IOL Positioning
– Abexterno Suture Passage
• 1.00 mm behind the limbus
– Thorough Anterior Vitrectomy
– Choose a proper IOL
• 13-14.00 mm overall, 6-6.5mm Optic
• Minimize Intraoperative Bleeding

– Measured enteries
– Use smaller gauge thin needles
– Screen for dispirin use and bleeding disorders
Instruction Course
Intra Operative
Considerations
• Hypotony
– Closed Chamber Technique
– Keep Globe Tense
– Minimize surgical time
• Suture Exposure
– Use self sealing tunnel
– Burry the knots properly
Instruction Course
Postoperative Care
• Remove the sutures in

time but warn the
patient if fixation
suture knot is exposed
• Monitor
– Glaucoma
– uveitis
Instruction Course
Secondary PC IOL Implantation - made
Secondary posterior
Implantation-made
simple
Part 3 Course Review & Interactive
Dr. Zia.ul.Mazhry
Assistant Professor
Central Park Medical College FRCS(Edin), FRCS(Glasgow),
Lahore
Consultant Eye Surgeon &
Head of Department Life Member OSP
WAPDA Teaching Hospital
Lahore Member Executive council OSP LHR
Instruction course
Dr Mazhry FRCS, FCPS Secondary PC IOL Implantation-made simple
Memory Levels
(Dale)
• 10% of what is read
• 20% of what is heard
• 30% of what is seen
• 50% of what is heard and seen
• 70% of what is said and written
• 90% of what is said as it is done
Dr Mazhry FRCS, FCPS

Video Review
Instruction course
Video Review
Instruction course
• "Who dares to teach must never cease
to learn."
- John Cotton Dana
Instruction course
Surgical
Plan?
Decent red IOL
Prolapsed Vitreous
Instruction Course
Dr Mazhry FRCS, FCPS Secondary PC IOL Implantation - made simple
What I did
• PC IOL was arranged for exchange

• Anterior Vitrectomy through the rent
• A little dialing of IOL got it well centered
and remained so postoperatively
Instruction Course
Post traumatic surgical
Aphakia referred for 2nd IOL
Capsular remnants
Vitreous Instruction Course
Deficient Iris Secondary PC IOL Implantation - made simple
DHSF PC IOL with anterior core vitrectomy
2 months postop
Instruction Course
MCQ-1
1. Following are the indication for secondary
IOL Implantation except:
A. Subluxated Crystalline lens
B. Aphakia with Intact Capsule
C. Aphakia with No Capsular support
D. Dislocated or subluxated PC IOL
E. Aphakia with Central Rent in Posterior
Capsule
F. Aphakia with partial capsular support
Instruction course
MCQ-1
1. Following are the indication for secondary
IOL Implantation except:
A. Subluxated Crystalline lens
B. Aphakia with Intact Capsule
C. Aphakia with No Capsular support
D. Dislocated or subluxated PC IOL
E. Aphakia with Central Rent in Posterior
Capsule
F. Aphakia with partial capsular support
Instruction course
MCQ-2
2- Anterior Core Vitrectomy is mandatory for
following surgical Procedure:
A. Trabeculectomy
B. Phacoemulsification
C. ECCE with PC IOL
D. Scleral Fixation of PC IOL
E. Secondary IOL Implantation on Intact
Posterior Capsule
F. Refractive Surgery
Instruction course
MCQ-2
• Anterior Core Vitrectomy is mandatory for
following surgical Procedure:
A. Trabeculectomy
B. Phacoemulsification
C. ECCE with PC IOL
D. Scleral Fixation of PC IOL
E. Secondary IOL Implantation on Intact
Posterior Capsule
F. Refractive Surgery
Instruction course
MCQ-3
• Ideal site for IOL implantation in order of

preference is:
A. A C Angle, Ciliary Sulcus, Pupil.
B. Ciliary Sulcus, A C Angle, Iris.
C. Ciliary Sulcus, Capsular Bag, A C Angle.
D. Capsular Bag, Ciliary Sulcus, A C Angle.
E. A C Angle, Capsular Bag, Ciliary Sulcus.
F. Iris, Ciliary Sulcus, A C Angle.
Instruction course
MCQ-3
• Ideal site for IOL implantation in order of

preference is:
A. A C Angle, Ciliary Sulcus, Pupil.
B. Ciliary Sulcus, A C Angle, Iris.
C. Ciliary Sulcus, Capsular Bag, A C Angle.
D. Capsular Bag, Ciliary Sulcus, A C Angle.
E. A C Angle, Capsular Bag, Ciliary Sulcus.
F. Iris, Ciliary Sulcus, A C Angle.
Instruction course
MCQ-4
• Recommended site for scleral fixation

sutue placement lies:
A. 2.00mm behind the limbus
B. At pars plana
C. 1.00mm behind limbus
D. 0.5 mm behind limbus
E. 3.00 mm behind limbus
Instruction course
MCQ-4
• Recommended site for scleral fixation

sutue placement lies:
A. 2.00mm behind the limbus
B. At pars plana
C. 1.00mm behind limbus
D. 0.5 mm behind limbus
E. 3.00 mm behind limbus
Instruction course
Secondary PC IOL Pearls
• Pre Op- assessment is crucial

• Dilated ant seg and VR exam
• Chalk out a clear Plan
• Be ready for intraoperative modification of the
plan
• Remnants of the Posterior Capsular support
need to be utilized to the maximum
Instruction course
Secondar PC IOL Pearls
Capsular Support
• Scleral Fixation Pearls
• Where to fix
− 1.00 mm behind the limbus
− Avoid 3 and 9 o’clock positions for scleral sutures due
to the presence of ciliary artery and nerve.
• How to choose an IOL
− having eyelets on haptics
− large optic 6.0mm or 7mm and
− 13.0 to 14mm haptic span
• What is the ideal suture
− 10/0 Prolene
Instruction course
Secondar PC IOL Pearls
Capsular Support
• Scleral Fixation Pearls
• Fixation suture be always be burried
underneath partial thickness scleral flaps
• Deep Anterior vitrectomy is mandatory.
• Recommended suture pssage is from
outside in Ab Externo Method
Instruction course
To Summarize
Preoperative Intended surgical
characteristics Plan
1 Intact clear PC with Simple Secondary Sec-
mobile dilated pupil PC IOL Implantation PC
IOL
2 Poorly dilating pupil Sulcus dissection PC SD
secondary to Polishing and PC IOL &PC
Synechiae Implantation IOL
3 Scenario2+ central Sulcus dissection, PC IS
rent in Posterior Polishing, anterior PC
capsule vitrectomy and IOL
Intrashelf PC IOL
Implantation
Instruction course
To Summarize
Preoperative Intended surgical
characteristics Plan
4 Partially deficient Sulcus dissection, SHS
posterior capsule with Anterior Vitrectomy F PC
peripheral rent and Single Haptic IOL
extending for less Sclera Fixation of PC
than 180 IOL
5 Absent Posterior Double haptic scleral DHS
capsule fixation with Anterior F PC
Vitrectomy IOL
6 Subluxated Retrieval & Scleral R&S
/dislocated PC IOL Fixation/ Exchange of F/X
with rented posterior IOL with Anterior PC
capsule Vitrectomy/ PPV IOL
Instruction course
The Message
• The status of posterior capsule may vary from :
• intact to
• partially deficient or
• totally absent.
• Thus the technique has to be varied from :
• simple implantation to
• synechiolysis to
• anterior vitrectomy combined with
• single or
• double haptic trans-scleral fixation of PC IOL.
Instruction course
Conclusion
• Secondary PC IOL implantation is an

effective and safe technique for visual
rehabilitation of aphakic patients. One
should be ready and well versed with
the variations of surgical technique
required while carrying out such
procedures.
Instruction course
Literature Review
• 2003 AAO Report: IOL Implantation

in the Absence of Capsular Support
• Open-loop AC IOLs
• Scleral-sutured PC IOLs
• Iris-sutured PC IOLs
• all are safe and effective in correcting aphakia
in eyes without capsular support

Literature Review
• 2005 ASCRS-ESCRS Report:

• AC-IOL and Sutured PC-IOL in eyes with
poor capsular support
• Findings suggest no significant differences in
outcome exist between AC-IOL and sutured
PC-IOL in the absence of capsular support
− KE Donaldson, JJ Gorscak, DL Budenz,WJ
Feuer, MS Benz, RK Forster. JCRS 2005,
31:5,904-909.

References
1. Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL American Academy of
Ophthalmology. Intraocular lens implantation in the absence of capsular support: a report by
the American Academy of Ophthalmology. Ophthalmology. 2003 Apr; 110(40:840-59
2. Zheng G, Chen Y, Wang L, Chen G, Zhang X. The choice of methods of intraocular lens
implantation in traumatic cataract in the absence of capsular and zonular support. Zhonghua
Yan Ke Za Zhi. 1998 Sep; 34(5): 327-9
3. Dick HB, Augustin AJ. Lens implant selection with absence of capsular support. Curr Opin
Ophthalmol. 2001 Feb; 12(1): 47-57
4. Hannush SB. Sutured posterior chamber intraocular lenses: indications and procedure. Curr
Opin Ophthalmol. 2000 Aug; 11(4): 233-40
5. Bellamy JP, Queguiner F, Salame N, Montard M. Secondary intraocular lens implantation:
methods and complications. J Fr Ophthalmol. 2000 Jan:23(1):73-80
6. Krause L, Bechrakis NE, Heimann H, Salditt S, Foerster MH. Implantation of scleral fixated
sutured posterior chamber lenses: a retrospective analysis of 119 cases. Int Ophthalmol.
2008 Apr 10.
7. Everklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of
flexible open loop anterior chamber and scleral fixated posterior chamber intraocular lenses.
J Cataract Refract Surg. 2003 Feb; 29(2): 301-8
8. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic surg. 1976
summer; 7(2): 98-103
Instruction course
Acknowledgements
• My teachers
− Prof- Wasif M Kadri, Dr Tariq Saeed,
Prof Mohammad Tayyib, Prof Samina Jahangir, Prof
Nadeem Riaz, Prof Hamid Mehmood, Dr Z A Qazi
• My Colleagues
− Dr Saqib Siddiq, Dr Mohammad Aamir for graphics
• My Superiors
− Mr Afzaal Sheikh DGMS WAPDA Medical Services
for providing digital video capturing system to eye
opd and Operation room at WAPDA Hospital Lahore
Instruction course
Q&A
Instruction course
Instruction course
Thank you
for your attention
Dr Mazhry FRCS, FCPS One and a half decade with scleral fixated IOLs

Lahore Dec 2010-Sec Iol-Overview

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Secondary posterior

chamber IOL (PC IOL)

We do not have any financial interest in this presentation

• “Learning without thought is labor lost. Thought

• the ophthalmologist should be able to:

• Secondary PC IOL implantation in aphakics is

Part 1 Background & Classification

– Sir Harold Ridley

• Aphakia with Full Capsular Support

• Simple Secondary PC IOL

implantation (IS PC IOL)

• Single Haptic Sclera

•What I hear, I forget.

• Pre-OP 6/18 ec,

• Post-OP 6/18 ec,

DOUBLE HAPTIC FIXATION

• Minimize Intraoperative Bleeding

• Remove the sutures in

Dr Mazhry FRCS, FCPS

- John Cotton Dana

Decent red IOL

• PC IOL was arranged for exchange

• Ideal site for IOL implantation in order of

• Ideal site for IOL implantation in order of

• Recommended site for scleral fixation

• Recommended site for scleral fixation

• Pre Op- assessment is crucial

• Secondary PC IOL implantation is an

• 2003 AAO Report: IOL Implantation

Dr Mazhry FRCS, FCPS

• 2005 ASCRS-ESCRS Report:

Dr Mazhry FRCS, FCPS

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