Part VII

Micro Instruments That Facilitate Fibrorhexis Technique and Late IOL Explantation

In this seventh part of the Complex Cases, Simplified series, Dr. Amzallag shares his experience with the fibrorhexis technique and how to simplify it by using micro instrumentation.

Thierry Amzallag, MD. Institut Ophtalmique Somain (France), president-elect of the French Society of Cataract and Refractive Surgery (SAFIR), co-opted member of the Board of the European Society of Cataract and Refractive Surgery (ESCRS).

The Role of Micro Instruments

In my private practice in Northern France, patient outcomes are excellent, and I attribute, in part, these results to my choice of micro instruments. I have been using the MicroSurgical Technology (MST) micro instruments for many years and find that they allow me to work within a micro environment with control and ease, mainly owing to quality purposeful design elements and sizing of the instruments.

Cases where I find the 23g Hoffman/Ahmed Scissors and 23g Micro-Holding Forceps very useful are:

1. Abnormal anterior capsule, with sub-capsular fibrosis. In these cases, it is very difficult to perform a continuous curvilinear capsulorhexis and it is useful to have the Hoffman/Ahmed scissors in order to cut the capsular bag to achieve a capsulotomy.
2. Late onset explantation of an intraocular lens (IOL) where zonules are fragile. In these cases, it is difficult to cut the capsulorhexis. You must engage under the capsulorhexis and then cut it with the Hoffman/Ahmed scissors and grasp it with the micro-holding forceps.

Capsular fibrosis or late explantation of an IOL can present a problematic surgery; however, with the right micro instruments these difficult cases can be standardized.

Fibrorhexis Technique — The steps to a successful surgery

In cases with significant fibrosis of the capsular bag requiring late explantation of a lens, the adherence between the capsule and the lens can lead to an explantation of the lens and removal of the capsular bag. However, if the adherence is not too strong, my preference is to always try to retain the posterior capsule. To do so, I use the fibrorhexis technique as follows:

• First, I make two 1.3 mm incisions.
• I introduce a blunt manipulator between the anterior capsule and the lens to carefully create space for dispersive ophthalmic viscoelastic device (OVD).
• I inject the OVD into the different zones of the capsular bag, especially between the capsulorhexis and the lens to loosen up the lens for easier removal.

Figure 1 Fibrorhexis case (courtesy of Thierry Amzallag, MD)

• Then, I partially cut the fibrosis using the 23g Hoffman/Ahmed micro-scissors and the Micro-Holding Forceps which will allow me to perform a second large capsulorhexis to free the IOL in the following steps. The 23g Hoffman/Ahmed curved scissors provide great control during the cutting thanks to their small size, curved shape, and hinge-less design.
• I follow with the fibrorhexis with a capsulorhexis forceps, such as the 23g Seibel Capsulorhexis Forceps (MST), and the manipulator, trying to avoid luxation of the IOL and the capsular bag.
• While using the capsulorhexis forceps, the blunt manipulator is positioned at the equator to avoid displacement of the capsular bag or the lens.
• Slowly, I will then remove the fibrosis.

It can be a little more difficult to remove the fibrosis around the haptics of an IOL and one should proceed with patience and caution. However, if the fibrosis gets stuck, it can be cut and removed with the use of the micro-scissors and micro-forceps.

• Once the fibrorhexis is completed, the IOL becomes free.
• I use the 19g MST Packer/ Chang explantation system to cut the lens in two halves and explant it out through the main incision. Cutting the lens in half ensures no stretching on the main incision, the IOL comes out easily, and doesn’t damage the cornea or other structures on explantation.

Figure 2 Fibrorhexis case continued (courtesy of Thierry Amzallag, MD)

The MST Packer/Chang IOL Cutting Kit combines the Single-Use 19g Packer/ Chang IOL Cutters and the Single-Use 23g MST Micro Holding Forceps. This single-use pack is designed for insertion through a paracentesis incision while the surgeon holds the optic with forceps through the phacoemulsification incision. The fine tips, controlled opening, sharpness, and precision of the scissors allows the IOL to be cut with little pressure, thereby reducing the risk of lens twisting. They cut very cleanly to divide the lens in a controlled manner, making lens exchanges a lot easier.

• Finally, I implant the second hydrophilic three-piece IOL in the sulcus.

In terms of refraction and visual acuity, the post-operative results are excellent with this technique.

Pearls of Surgical Wisdom — I advise the novice to this technique to be patient and slowly explore the surgical technique.

Potential pitfalls to avoid with the Fibrorhexis Technique

Precise design of the micro instruments certainly helps control the manoeuvres involved in complex cataract cases, but the surgeon who will rush this technique may well fail. Caution and patience are required components for successful outcomes.

Conclusion

The surgical exchange of a multifocal IOL or the removal of an abnormal anterior capsule with fibrosis present, are very difficult cases requiring both skills and patience along with micro sized instruments designed specifically for the task at hand.

MST Micro instruments enable the surgeon to move within a small space with greater ease, therefore transforming an otherwise difficult case into a simplified surgery. With the help of the right instrumentation, surgeons can accurately and safely perform complex cases, such as late onset IOL explantation.

Key learnings

Find a way for the viscoelastic to go between the capsulorhexis, the lens and the posterior capsule — this works best and will loosen up the lens for easier removal.

It might be a little more difficult to remove the fibrosis around the IOL haptics but with caution and patience this can be completed. If you see that you cannot move fibrosis further, you can use the Hoffman/Ahmed scissors to cut it.

Creating a precise capsulorhexis is one of the most challenging surgical steps. It requires a great degree of precision, control, visibility, and manoeuvrability which needs to be attainable through a microincision. This is best achieved with micro sized instruments.

The MST Seibel Capsulorhexis Forceps has a coaxial design and includes a unique capsulorhexis ruler, which helps me to visualize the desired capsulorhexis size. The coaxial design allows a greater control at the distal end of the instruments.

Sometimes, I need to perform a capsulotomy for phacoemulsification with an abnormal anterior capsule on a white matter cataract. To carry out the capsulotomy in the anterior chamber, the Hoffman/Ahmed Scissors and the MST Micro Holding Forceps could be useful to achieve a well-centred capsulorhexis.