Surgical Technique Edited by George A. Williams No-Touch Removal of Anterior Segment-Migrated Dexamethasone Implant S ince the US Food and Drug Administration’s initial approval of an intravitreal sustained-release dexa- methasone implant (Ozurdex, Allergan Inc., Irvine, CA) in 2009, instances of implant migration into the anterior chamber have been reported in the literature. 1–8 Many of these reports describe either repositioning the implant back into the posterior chamber, or removing it from the eye altogether, which can be a challenging process. As the implant becomes friable over time, grasping with forceps often fractures it into multiple pieces. Alternatively, aspiration with a vitreous cutter or similar instrument, in addition to not being cost- effective, may lead to intraocular dispersion of the material. Meanwhile, replacing the implant into the vit- reous cavity still carries the risk of repeat migration back into the anterior chamber. A novel “no-touch” viscoelastic-based technique facilitates removal of the dexamethasone implant from the anterior chamber in its entirety without fragmenta- tion. The technique is economical, with no need to open vitrectomy or phacoemulsification packs. Furthermore, it ensures that no vehicle particles are left behind after the intervention. A description of the technique is as follows. Technique Supplemental Digital Content 1 (see Video; http:// links.lww.com/IAE/A369) demonstrates the key steps of this procedure. A 2.75-mm keratome blade is ini- tially used to create a clear corneal incision into the anterior chamber. This opening can be slightly enlarged to 3 mm if necessary. Positioning the wound 180° away from the rod-shaped implant lying in the angle oriented perpendicular to the keratome blade (Figure 1) gives the surgeon sufficient working space to reorient the device during subsequent maneuvers. Intracameral injection of acetylcholine chloride to con- strict the pupil may help reduce the risk of the implant falling back into the posterior chamber intraoperatively. A viscoelastic agent of the surgeon’s preference is then injected through the incision to maintain the ante- rior chamber. Either a dispersive or cohesive viscoelastic can be used, although the latter is easier to remove at the conclusion of the case. If the initial choice of material is ineffective, the surgeon might consider using a more viscous product such as Healon5 (Abbott Medical Optics Inc., Santa Ana, CA) instead. Once the anterior chamber is sufficiently inflated, the tip of the cannula is advanced distally beyond the implant (Figure 2A), and a steady viscoelastic wave is created to reorient the implant lengthwise and gently float it toward the inci- sion. A small bolus of viscoelastic can additionally be injected underneath the proximal tip of the device to elevate it toward the clear corneal incision. During these steps, the posterior lip of the incision is simultaneously depressed using the proximal end of the cannula (Figure 2B) to encourage ejection of the implant in a single piece (Figure 2C). Once removed, the anterior chamber is thoroughly irrigated with balanced salt solution to ensure that all viscoelastic has been evacuated to avoid postoperative intraocular pressure spikes. The corneal wound may then be sutured if any evidence of leakage is present. Results The no-touch viscoelastic-based technique for dexa- methasone implant removal was used in four consecu- tive cases in which the device had migrated into the anterior chamber. The average age of the 4 patients (2 males and 2 females) was 75 years (range: 55–85 years). The initial indication for the dexamethasone implant was macular edema secondary to branch retinal vein occlusion in two eyes, and chronic noninfectious poste- rior uveitis in the other two eyes. All four eyes were pseudophakic at the time of implant migration into the From the *Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania; and †Oakland University William Beaumont School of Medicine and Associated Retinal Con- sultants, Royal Oak, Michigan. None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). Reprint requests: Julia A. Haller, MD, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, Suite 1510, Philadelphia, PA 19107; e-mail: jhaller@willseye.org 2414