This video was part of aroundtable discussion involving surgeons Christina Y. Weng, MD, MBA; Mrinali Gupta, MD, FASRS; Nimesh A. “Nemo” Patel, MD; and Frank Brodie, MD, MBA. An edited transcript of the case presentation and discussion follows below:

Nimesh A. “Nemo” Patel, MD: All right, before I start, I'll introduce this case. It was a case of a patient that came in with a dislocated Akreos AO60 lens (Bausch + Lomb) that was previously sutured with Prolene. I think this is an important case, because it's something that we may start seeing going forward with increased use of these secondary intraocular lenses (IOLs) and particularly the Akreos AO60 lens with the 4-point fixation.

One thing to note is that this was Prolene and not Gore-Tex, which we used most of the time and that may have led to some of the dislocation as it was about 10 years after the initial surgery.

The other thing I’d say about this is that it's good to ask your friends, because I had this case with the lens dislocated and I was trying to think through it and I called a few people and Ajay E. Kuriyan, MD, MS,was the one who had done this before and came up with this technique. So the credit goes to him for this, and this [surgery was performed] with our fellow Darius Bordbar, MD. Thank you, Christina, for sending this guy—he was the best.

Christina Y. Weng, MD, MBA: Thanks for teaching him.

Dr. Patel: So first we do the vitrectomy. We always want to check the vitrectomy, see if there's any residual capsule or any retained lens material. You can see that the lens is still stuck in some areas, so we use a retinal scissors to cut the remaining Prolene that one side was still fixated with. The lens is at the bottom of the eye, we pick it up with a soft-tip cannula. I like the MST set to grab any type of lenses through a corneal paracentesis. I use a 1.1 blade which fits the MST. I usually make one on each side, so I have two hands. And then what you do, and Dr. Kuriyan came up with this tip, is that surprisingly the lens is quite malleable and you can bring the eyelet out of a keratome wound and thread it. And you think it would break doing this, but surprisingly it doesn't. 

And maybe because it's nice and warm in the eye and the plastic can bend. So what you can do is take the eyelet out and thread each one as you normally would just outside the eye. 

So we do the nasal side first and then we bring the temporal side out that's superotemporal and then you can just push it back inside the eye, spin the lens around, grab the Inferotemporal, thread it in. And so now you have all your strings outside the eye and the lens you can put inside the eye. And then just like you normally do for a regular Akreos, you put it hand to hand with one hand in the sclerotomy and one through the keratome wound. And then you just thread all 4. And similarly, you tie down each side individually, taking care not to pull each one too tight, give it a little bit of a hang-back. We suture the corneal wounds and then the conjunctival wounds with gut suture. And so that's the case. 

Dr. Weng: That's a beautiful case, Nemo. Thanks for showing that. I wanted to ask first of all, when you're trying to make sure these are centered well, one of the great points about 4-point fixation is you avoid some of the tilting challenges that can be a little bit of an obstacle with 2-point fixation. I'll show you one on the next case here, but how do you ensure that it's properly centered? How far back from the limbus are you and how far apart did you put those 27-gauge and 25-gauge cannulas? 

Dr. Patel: So it's funny because we used to be very meticulous about this and I think the one thing you want to do is at least put it far enough back where you're going to avoid the iris chafing. So we usually go 3 mm or 3.5 mm back from the limbus. And that also probably helps the lens targeting because then you're close to doing in-the-bag calculation. So that's why I prefer to go a little bit further back. And I also do a little bit of hang-back where you don't tighten those sutures. Now in terms of the positions of the trocars, I actually don't think it matters a lot and that may be controversial, but we do measure them and put them about 4 mm apart on each side and we try to make it a nice square. But I have found that if you're in any sort of square fashion because it's 4-point fixated, it's very difficult for it to rotate or tilt. 

And in terms of centration, as long as it is kind of making sense with the eye and you're in a reasonably equatorial position with the curvature of the limbus, I think that goes fine. So it's good to measure and it's good to be exact about it, but it doesn't matter a lot. The other thing too is that I have seen some move in the kind of XY plane. So a little bit side to side, not tilted. And again, it doesn't surprisingly matter. 

Those patients still are 20/20 and I think we've seen that in other lenses and sulcus lenses and things like that where you don't always have to be looking through the very center of the optic as long as it's not tilted. They still see fine even maybe a third off. 

Dr. Weng: Mrinali, Frank, have you seen these dislocated? Have you ever had to explant one of these and replace it? Or do you want to talk about some of the preferred techniques that you've used?

Frank Brodie, MD, MBA: Kudos to you, Nemo, that is a really challenging case. And overall, I think these secondary lens cases, the way we do them is very challenging. A lot of problems with them and I think we are seeing a lot more dislocation than probably any of us would care to admit. There was a really interesting IRIS Registry study that looked at secondary lens techniques with pars plana vitrectomy. It was like a 14% redislocation rate. So I think all of us would look at our practice and say, “Oh no, there’s no way this is happening to me.” But it was a big study, 10,000 eyes or so in that IRIS study.

I think that was beautifully done. I think just piggybacking on your comment about how far back to go, I think in these techniques where you are a little bit more anterior, 2 mm back or something like that, you're really in the pars plicata, which I think is just going to lead to much more cystoid macular edema (CME) as you're in a more vascular structure. So I think it's a really smart thing you're doing getting further back, not just for the lens calcification issue, but I think it's going to reduce the pain and suffering long term as you're not battling quite as much CME.

Dr. Weng: Mrinali, have you ever taken out a dislocated Akreos lens?

Mrinali Gupta, MD, FASRS: I have never had to take one out. I had one sent to me once where one side of the lens the Gore-Tex had unraveled or something was not right with the knot and it was hanging back. And the other great thing about Gore-Tex is it's so forgiving and it's so flexible. You can twist it and have a thicker end and work inside of the eye really well too. So in that case, I just put a chandelier in and threaded it bimanually inside of the eye. But I love the Akreos lens. I also love anterior-chamber intraocular lenses (ACIOLs) now for the reasons that Frank mentioned. The ACIOLs today, especially in older patients, those patients do great. It's a straightforward surgery, especially if you're taking out a 3-piece and you might as well just make a bigger wound. I do a tunnel and take it out and put another lens in right away. 

But for fixated lenses, I also like the Akreos for the tilt purposes. It's very reliable, good refraction. I've never had to reoperate one of my Akreos patients due to lens issues or tilt or exposure or things like that. I do a similar thing to what Nimo does in terms of placement of the trocars. I make them parallel to the limbus because I do find—especially if I had another lens I was taking out and manipulating in that sclerotomy—that sometimes they leak, and I like to be able to suture it without worrying that I'm going to suture through my Gore-Tex.

Dr. Patel: It's actually funny that you mentioned that about the lack of reoperations on the Akreos. I don't think I've had to go back on any for any major reason. I've had to cover a suture once, but nothing touching the lens. But I think because of that, I've actually started moving away from ACIOLs even on older patients, because I think we've gotten so good with this Akreos that I'm starting to think it's actually even better for the older patients as well.

I have had some issues as I've gone along with ACIOLs. It's rare, but I think the problem is once they fail and you get corneal edema, you're really stuck because if you get a little bit of corneal edema, you have to decide now, am I taking the lens out and putting in a new one? Am I taking it out and doing a Descemet stripping automated endothelial keratoplasty (DSAEK)? You're really stuck. I find that what ends up happening is, you end up taking the lens out, then trying to find someone to do an aphakic DSAEK and it gets very messy from there.

So I've actually gone almost exclusively to Akreos scleral fixated lenses, even in older patients. And I think the other reason is now some of my patients are living a long time. I've been surprised. Some of the patients I've done secondary IOLs on, you're like, okay, you're low visual potential and we're going to be around, we don't have to worry about corneal edema in the long term. And then here they are still years and years later.

Dr. Brodie: Yeah. I guess and to your point, Nemo, I think one of the things I worry about with ACIOLs is, why did that lens drop in the first place? A lot of time it's pseudoexfoliation or trauma or things like that, things that really put them at risk for glaucoma. And so many of our glaucoma treatments are in the anterior chamber now, whether it's laser or MIGS or any of this other stuff [like the] Xen stent. I don't like crowding out that anterior chamber and potentially also risking the angle. So I’ve stayed away from them.

Dr. Weng: Frank, do you ever use the Akreos lens?

Dr. Brodie: No. I trained with Yamanetechnique, so when I have to do a secondary lens, I do Yamane, although more and more I've enjoyed partnering with my cornea surgeons. I'll do the fishing expedition and let them figure out refraction.

Dr. Weng: Exactly. So let me ask a question of Nemo and Mrinali, since both of you like the Akreos. The Akreos is a hydrophilic IOL, so theoretically—I guess that's a word I choose carefully—it can opacify, especially if you're dealing with patients who oftentimes have a lot of comorbidities, they might need a tamponade down the road. Have you had any issues or challenges with that? I know it's a little bit debatable of how much that really does happen, but have you seen that? Does that worry you? 

Dr. Gupta: That's one of the reasons why I'm a little hesitant and I'll put an ACIOL in an older healthy eye. That being said, I haven't had that many patients, hardly had any patients who needed gas in the eye after a secondary IOL, but it's a known entity and then it creates a big problem in terms of dealing with the posterior pathology. 

Dr. Patel: Jay Sridhar, MD, was one of my mentors as a resident and fellow and we put together a case series of 12 patients, I believe, who had a retinal detachment (RD) with an Akreos in the eye, and I think 6 of them were so opacified.¹ So if you have an RD, and if you have to use gas, it's about 50% and I think that's similar to the DSAEK literature as well. Then the other problem is that you don't know who's going to get it. And then once the lens opacifies, again, you're in this kind of sticky situation of, how do I get this fairly large lens out of the eye? I thankfully also have not had to come up to that yet.

To Dr. Brodie's point about some of the complications associated, I don't think we realized how high the RD rate is after secondary IOLs. I think a Wills Eye study² published about 5% and at first that seemed high, but I think if you really think about it in some of these cases, it is about a 5% RD rate even when you're doing this because of all the other complex pathology.

Dr. Weng: I agree. And I think part of it is because of the complex pathology, but I have always wondered because a lot of our anterior-segment surgeon colleagues, they actually will do secondary IOLs without a full vitrectomy. And that's always made me nervous because a lot of times you're swinging things seemingly pretty anteriorly, but of course that's right by the vitreous space. And I've always wondered if that had anything to do with it because I've seen several myself as well after seemingly a very uneventful and beautifully placed secondary IOL. So I think there's a lot to be learned and you're right, because some of these have become so popular over the past 10 years, I think we are going to see a lot more of these dislocations. So, I love that you showed that case.

We'll finish with one more question, which I think is the obvious one people think about: How do you avoid that spaghetti string mass, Nimo, and how do you keep that in order with this technique? 

Dr. Patel: The benefit of sticking to one main technique—I do all of them, but this has really become preferred—is you find some optimizations along the way that you just kind of play around with. I think one that was told to me that has been a big help was when we first did this, we used to thread all 4 sutures, then insert the lens, and that was a whole mess. Then it went to 3, and then someone said, “You can just do two.” And that’s changed everything for me because when you can only thread 2 and you insert the lens, you have so many degrees of freedom where the strings can unfurl. So I'll either inject the lens very deep and then you just pull on the 2 strings and it just really unflips itself because it can flip completely over when it’s not tethered in 3 spots.

Something I found that was actually quite helpful is sometimes, when you’re working with fellows, they do things that you don’t expect. For example you'd say, “Hey, can you inject it really deep in the eye so we can flip it over?" And then they put it in the anterior chamber. 

And actually that's happened to me a few times and I found that that's actually not a bad way because once you put in the anterior chamber, you get one quick look before you shove it to the back of the eye to see if everything is in the correct position. So sometimes I've actually started doing that now, just putting it in the anterior chamber, getting a look at the strings and then put it in. I also mark the 2 inferior strings just to make sure that those are the inferior ones and you haven't messed it up that badly. Usually that doesn't happen, but that's always a thing.

The other thing I've started doing is to mark the lens. I put a little dot on the superotemporal eyelet junction and that way once you put it in the eye, you kind of know which way the lens has to spin or if it's off by 90° and it really helps you unfurl it and you're not trying to guess, where's my superotemporal one again? So that's been a big help. But yeah, the spaghetti strings is an issue, but I think if you do just threading to marking the inferiors, putting it in the anterior chamber first and marking the lens that I haven’t had too many issues recently. 

Dr. Weng: Fantastic. Love it. Thanks for sharing that case. RP

References

1. Patel NA, Fan KC, Yannuzzi NA, et al. Akreos AO60 Intraocular Lens Opacification after Retinal Detachment Repair. Ophthalmol Retina. 2020;4(8):854-856. doi:10.1016/j.oret.2020.03.030

2. Kaufmann GT, Gupta O, Yu J, et al. Vitreoretinal outcomes following secondary implantation with pars plana vitrectomy. Retina. 2024;44(8):1337-1343. doi:10.1097/IAE.0000000000004139