AC IOLs- how safe are they?

[RAMESH DORAIRAJAN]

Hello Friends,  

Given the possible challenges for  PXF cases, what is your preferred technique:

 

1.   capsule appears normal after nucleus  removal

2.   partial zonular dehiscence

3.   total zonular dehiscence

 

Thanks 

I think the best situation in your theoretical grandma is to leave her aphakic and refer her. If you were to re-consent her after the lens were out and your had no support, and the surgeon were to say 1) I could try a new secondary iol technique (pick your technique) that I am not familiar with in a compromised eye 2) I could put an ACIOL which has a 20-50% + plus risk of blinding complications or 3) I could leave the patient aphakic and refer to someone who is very comfortable placing pciol in this situtation. -- almost everybody would pick scenario 3. I think one of the issues for cataract surgeons that as you mention dont run into these situation often, they don't realize how horrible these lenses are.  The other reality is the assumption that a patient will die in the next few years is often wrong.  I just was referred a 97 year old patient this week that had cataract surgery 3 years ago and had an ACIOL in one eye.  He fell and had a bad corneal laceration in the other eye, and now in his ACIOL eye he will need an iol exchange, shunt and EK...... everybody that does these kinds of cases has many similar stories come into their office too often.  He's been a nursing home for 5 years and probably will keep going at least a few more years. 

I agree that these types of cases are not for many surgeons but I think placing an ACIOL is treating the surgeon and not the patient. If you dropped a nucleus, no one would fault a surgeon for referring to a retinal specialist for PPL.  IOLs should follow the same kind of logic.    

Thanks for sharing

I love this.  Don't feel like you are hijacking.  Personally, I rarely use aciols.  I don't typically take them out for my dsek cases and they typically do very well. 

 

I think there are two considerations.  How much surgical trauma do you want to introduce to the patient is the first.  For those dsek patients, they likely had a complicated cataract and may not want to go through another long surgery.  In fact, in my opinion, most of the decompensations are due to the prolonged cataract surgery and trauma to the endothelium than they are to the aciol that was placed.  These patients typically are hazy right of off the bat.  If it was just the aciol, then they would be clear for a while and decompensate later.  That is a discussion for another day.

 

The other consideration, which seems to continue to be swept under the rug, is surgeon experience and skill.  Again, we are talking to many superstars here.  That is not the rank and file ophthalmologist in the US and around the world.   Some of you are telling us to throw the fastball every time.  If you are Roger Clemens and can throw it 100 mph, you may be able to do that, even against Barry Bonds.  If you are an average pitcher, whos fastball is 88 mph,  Bonds hits it out of the park every time.  This is what we need to consider with this surgery.  It is easy for an expert to say everyone should do this.  In reality, in many surgeons hands, the outcome is not the same.  You need to assess those outcomes too when you claim that this procedure is better.  In a nonexperts hands, the complex procedure may not be better.  As I said before, it is not practical to refer all of these, since many come up as surprises during surgery.  To tell a doc not to do routine cataract surgery if they haven't mastered this technique, when it may only come up every few years, is not practical.

 

I think we can agree that there are options.  We all have opinions, some stronger than others.  If my 85 year old aunt with multiple medical problems was on the table, and the surgeon ran into this and asked my opinion...if he said he rarely does these and it might take him 45 minutes to do, or he can do an aciol in three minutes...I will tell him put in the aciol and get out of there. 

 

Enjoy your weekend, Keranetters.  I officially have nothing left to say.  That is a rarity for a big mouth like me.  I really enjoyed the exchange. 

 

 

I don’t want to hijack this thread and turn it into an AC-IOL hate-fest, but from my 25 years of IOL experience, ACIOL’s  have blinded more people than all the combined cases of endophthalmitis and open globe trauma that I have seen.  Selection bias? Of course.  Over the years some surgeons become magnets for this type of pathology, but it’s hard to ignore the collective misery the ACIOL  continues to cause. I could literally post a “nasty ACIOL story of the week” on keranet for the next 12 months.

 

Off the top of my head, I have 2 personal gripes about ACIOL’s

 

First, we need to stop calling them “modern ACIOL’s.”  Closed loop ACIOL’s are long gone and only deserve mention for historical purposes.  The clinical trials for the current Kelman multiflex ACIOL design started in 1982. The lens hasn’t been changed in 35 years and that makes it older than every ophthalmology resident and fellow in the country. There’s nothing modern about it. It’s a  terrible euphemism.

 

Secondly, we need to stop implanting ACIOL’s in younger people. If you have the opinion that ACIOL’s have an acceptable long term safety profile, you haven’t followed them long enough.

 

Here a 34 year guy who had congenital cataracts. At the age of 21 he was told he could have a quick and easy operation so he didn’t need contacts. Now he has hand motion vision and an IOP of 34. He’s going to need the ACIOL explanted, a Gore-Tex sutured CZ70BD, a trab and a DSEK procedure.

 



 

 

The biggest group of ACIOL complications that I am seeing now are patients who had ACIOL’s implanted during complicated cataract surgery in the distant past,  because of the belief that ACIOLs are “OK if you’re old.” Unfortunately many of these patients have the audacity to outlive their IOL. I’m explanting more ACIOL’s from 75+ year olds than ever.

 

2 years ago, our ASC removed the entire consignment of Alcon ACIOL’s. Surgeons can special order them as secondary IOL’s, but the use of primary ACIOL’s during complicated cataract surgeries has stopped. As a result the final outcomes of these cases have improved.

 

Finally, I would like to say that proper placement of a PCIOL without capsular support (either trans-scleral Gore-Tex or ISHF) is within the skill level of nearly every cataract surgeon. If you can do a manual rhexis and tie a 10-0 nylon suture, I promise you that I can teach you how to suture an IOL.

 

Just my 2 cents,

 

 

I am always impressed by some of the magnificent surgical treatments that our group does for these complex cases.  I must admit, though, that I am in some ways a minimalist.  I think that for many of these cases, an ACIOL works fine.  Many of these patients are elderly and have other comorbidities.  The current ACIOLs are much better than the ones we used many years ago.  It is often prudent to take 2 minutes and put in an ACIOL in an eye that can 

tolerate one rather than spending an hour sewing in a ring and or an IOL.  Particularly for surgeons that don't sew in lenses very often, it is not always as easy as it looks on a video.  Just my two cents.

 

I always try to preserve the capsular bag.

Situation 1….lens goes in the bag and if patient is younger or active I put a CTR in so that there can be a lasso of that if needed down the road.   No CTR if zonules are good and patient is older.

Situation 2.  CTR and lens in the bag OR can do 3 piece with optic capture which works extremely well here.   Also…if zonules are bad enough may need Malyugin modified CTR which can be sutured to sclera with Gore tex.  Works great n these cases.

Situation 3.  I will try to preserve the bag and put the lens in it.   CTR with 1 or 2 sutured CTS segments /goretex.     If bag cannot be preserved I would do PPV, remove everything and then do Double needle ISHF of EC3 Pal.