Results in comparison between 30 gauge ultrathin wall and 27 gauge needle in sutureless intraocular lens flanged technique in diabetic patients: 24-month follow-up study

Potential role of the light-adjustable lens in flanged intrascleral haptic fixation

PURPOSE

To compare maximum tensile strength between commonly used 3-piece intraocular lens (IOL) for flanged intrascleral haptic fixation (FISHF).

SETTING

Willis-Knight Eye Institute, Shreveport, Louisiana.

DESIGN

Laboratory investigation.

METHODS

Haptic tensile strength was compared with MA60AC, CT Lucia 602, AR40E, and the light-adjustable lens (LAL). Haptic strength with a 24-diopter (D) IOL was compared across all lenses, as well as across a range of 10 to 30 D with the MA60AC. A custom device was created to hold the IOL in correct haptic orientation. The maximum tension (mean ± SD) was recorded in Newtons (N) when the haptic lost tension or broke.

RESULTS

CT Lucia was the strongest at 1.53 ± 0.11 N vs 1.00 ± 0.15 (MA60AC), 0.87 ± 0.19 (AR40E), and 0.83 ± 0.14 N (LAL) ( P < .001). The LAL and AR40E were similar to a 9-0 polypropylene suture while being significantly stronger than 10-0 polypropylene suture ( P < .001). No difference in haptic tension for the MA60AC from 10 to 30 D ( P > .05). High magnification revealed the highest haptic fractures for MA60AC at 40% compared with LAL, AR40E, and CT Lucia at 0%. CT Lucia and AR40E had 100% of haptics disinserted from the IOL without any damage compared with 60% LAL and 60% MA60AC. CT Lucia, AR40E, and LAL have a flatter haptic angulation at 5 degrees.

CONCLUSIONS

Haptic strength, durability, and angulation of the LAL may support the possibility of FISHF in the hands of experienced surgeons. However, further testing is strongly recommended to verify whether physiologic conditions or light treatments may compromise long-term haptic stability.

Severe Spontaneous Tilt of Scleral-Fixated Intraocular Lenses

PURPOSE

To report and evaluate a multicenter series of 18 cases of severe, spontaneous IOL tilt involving the flanged intrascleral haptic fixation technique (FISHF).

DESIGN

Clinical study with historical controls.

METHODS

We report a cross-sectional study of 46 FISHF cases using the CT Lucia 602 IOL at a single academic center over a period of 24 weeks to determine the incidence of severe rotisserie-style rotational tilt. These rates were then compared with the same time-frame the prior year to help determine if this is a new phenomenon. Additional cases of severe tilt were solicited from another 4 academic centers.

RESULTS

Among 46 FISHF cases at a single center, 5 developed severe tilt. No clear pattern in surgical technique, ocular history, or ocular anatomy was evident in these cases compared with controls, although the involved IOLs clustered within a narrow diopter range, indicative of a batch effect. In the same 24-week interval the year before, 33 FISHF cases were performed, none of which exhibited severe rotational tilt. In our multicenter dataset, 18 cases of tilt were identified. Surgeons included fellow and early-career physicians as well as surgeons with multiple years of experience with the Yamane technique. A variety of surgical approaches for FISHF were represented. In at least 8 of the cases, haptic rotation and/or dehiscence at the optic-haptic junction were documented.

CONCLUSIONS

The identification of haptic rotation and dehiscence intraoperatively in several cases may reflect a new stability issue involving the optic-haptic junction.

Accuracy of biomicroscopy, ultrasonography and spectral-domain OCT in detection of complete posterior vitreous detachment

BACKGROUND

To evaluate the accuracy of preoperative biomicroscopy (BM), ultrasonography (US), and spectral domain optical coherence tomography (SD-OCT) to determine complete posterior vitreous detachment (PVD) confirmed by intraoperative findings of triamcinolone acetonide-assisted pars plana vitrectomy (PPV).

METHODS

This prospective study included all consecutive patients admitted for surgical treatment of the epiretinal membrane (ERM) and macular hole (MH). The presence of complete PVD was determined one day before PPV using BM, US, SD-OCT. The preoperative findings were compared to the PVD status determined during PPV.

RESULTS

A total of 123 eyes from 123 patients were included in the study. Indications for PPV included ERM in 57 (46.3%), full thickness macular hole in 57 (46.3%) and lamellar macular hole in 9 (7.3%) patients. Complete PVD during PPV was observed in 18 (31.6%; 95%CI:18.7-49.9) patients with ERM and 13 (19.7%; 95%CI:10.4-33.7) patients with MH. The sensitivity of preoperative BM, US, SD-OCT was 48.4% (95%CI:30.2-66.9), 61.3% (95%CI:42.2-78.2) and 54.8% (95%CI:36.0-72.7) respectively. The specificity of preoperative BM, US, SD-OCT was 81.5% (95%CI:72.1-88.9), 90.2% (95%CI:82.2-95.4) and 85.9% (95%CI:77.0-92.3) respectively. With a prevalence of 25.2% of PVD in our sample the positive predictive value of preoperative BM, US, SD-OCT was 46.9% (95%CI:29.1-65.3), 67.9% (95%CI:47.6-84.1) and 56.7% (95%CI:37.4-74.5) respectively.

CONCLUSION

Preoperative BM, US, and SD-OCT showed relatively low sensitivity but also good specificity in assessing complete PVD. A combination of all three diagnostic methods can provide a good assessment of the vitreoretinal interface state.

Convolutional neural network-based sea lion optimization algorithm for the detection and classification of diabetic retinopathy

AIMS

Diabetic retinopathy (DR) becomes a complicated type of diabetic that causes damage to the blood vessels of the retina's light-sensitive tissue. DR may initially cause mild symptoms or no symptoms. But prolonged DR results in permanent vision loss, and hence, it is necessary to detect the DR at an early stage.

METHODS

Manual diagnosing of DR retina fundus image is a time-consuming process and sometimes leads to misdiagnosis. The existing DR detection model faces few shortcomings in case of improper detection accuracy, higher loss or error values, high feature dimensionality, not suitable for large datasets, high computational complexity, poor performances, unbalanced and limited number of data points, and so on. As a result, the DR is diagnosed in this paper through four critical phases to tackle the shortcomings. The retinal images are cropped during preprocessing to reduce unwanted noises and redundant data. The images are then segmented using a modified level set algorithm based on pixel characteristics.

RESULTS

Here, an Aquila optimizer is employed in extracting the segmented image. Finally, for optimal classification of DR images, the study proposes a convolutional neural network-oriented sea lion optimization (CNN-SLO) algorithm. Here, the CNN-SLO algorithm classifies the retinal images into five classes (healthy, moderate, mild, proliferative and severe).

CONCLUSION

The experimental investigation is performed for Kaggle datasets with respect to diverse evaluation measures to deliberate the performances of the proposed system.

Intralenticular Ozurdex injection in an eye with thicker lens and the therapeutic effect maintained for 15 months

Introduction

To report a case of accidental intralenticular Ozurdex injection in an eye with thicker lens. During the follow-up period of 15 months, the therapeutic effect of intralenticular Ozurdex was maintained.

Case description

Ozurdex was accidently injected into the lens of an eye with uveitis, and the lens thickness was measured to be 5.70 mm. The uveitis was under good control, and no significant development of cataract was observed until 7 months after the intralenticular Ozurdex injection. Then due to the outbreak of COVID-19, follow-up was suspended. Fifteen months after the injection, the patient returned to the doctor. At this time, significant cataract development was observed, whereas uveitis was still under good control. Accordingly, cataract surgery and Ozurdex extraction were performed. Two months after surgery, a mild recurrence of uveitis occurred.

Conclusions

A thicker lens might be an important risk factor for accidental intralenticular Ozurdex injections. However, after intralenticular Ozurdex injection, the development of cataract was slow, and Ozurdex could still have a therapeutic effect on uveitis in this case. Thus, immediate surgery might be unnecessary for certain accidental intralenticular Ozurdex injection cases, and a follow-up strategy could be chosen to maintain the effect of Ozurdex.

Attaining optimal flange size with 5-0 and 6-0 polypropylene sutures for scleral fixation

A technique for achieving an optimal flange size with 5-0 polypropylene and 6-0 polypropylene used for flanged intrascleral intraocular lens fixation is described. Flange size in polypropylene sutures is dependent on heating length and independent of forceps grip during heating. It was identified that heating of 1 mm created the optimal flange size for a 5-0 polypropylene suture when used for a 27-gauge needle scleral tunnel and for a 6-0 polypropylene suture when used for a 30-gauge needle scleral tunnel. Alternatively, 2 mm heating of a 6-0 polypropylene suture fits well for a 27-gauge needle tunnel. Even gentle forceps grip caused flattening of the polypropylene sutures but did not influence shaping and sizing of the flange.

Characterization of Dysfunctional Lens Index and Opacity Grade in a Healthy Population

This study enrolled 61 volunteers (102 eyes) classified into subjects < 50 years (group 1) and subjects ≥ 50 years (group 2). Dysfunctional Lens Index (DLI); opacity grade; pupil diameter; and corneal, internal, and ocular higher order aberrations (HOAs) were measured with the i-Trace system (Tracey Technologies). Mean DLI was 8.89 ± 2.00 and 6.71 ± 2.97 in groups 1 and 2, respectively, being significantly higher in group 1 in all and right eyes (both p < 0.001). DLI correlated significantly with age (Rho = −0.41, p < 0.001) and pupil diameter (Rho = 0.20, p = 0.043) for all eyes, and numerous internal and ocular root-mean square HOAs for right, left, and all eyes (Rho ≤ −0.25, p ≤ 0.001). Mean opacity grade was 1.21 ± 0.63 and 1.48 ± 1.15 in groups 1 and 2, respectively, with no significant differences between groups (p ≥ 0.29). Opacity grade significantly correlated with pupil diameter for right and all eyes (Rho ≤ 0.33, p ≤ 0.013), and with some ocular root-mean square HOAs for right and all eyes (Rho ≥ 0.23, p ≤ 0.020). DLI correlates with age and might be used complementary to other diagnostic measurements for assessing the dysfunctional lens syndrome. Both DLI and opacity grade maintain a relationship with pupil diameter and internal and ocular HOAs, supporting that the algorithms used by the device may be based, in part, on these parameters.

Biomechanical Testing of Flanged Polypropylene Sutures in Scleral Fixation

OBJECTIVE

To optimize the flanged belt-loop technique of scleral fixation through biomechanical testing and report clinical outcomes of resultant modifications.

DESIGN

Experimental study.

METHODS

The force to disinsert flanged polypropylene suture from human cadaveric sclera was assessed using a tensile testing machine and compared to the breaking strengths of 9-0 and 10-0 polypropylene. The effects of modifying suture gauge (5-0, 6-0, 7-0, or 8-0), amount of suture cauterized (0.5 or 1.0 mm), and sclerotomy size (27, 30, 32, 33 gauge) were investigated. Belt-loop intrascleral fixation using 6-0 and 7-0 polypropylene with 30 and 32 gauge needles, respectively, was performed in 4 patients. Main outcome measures were flanged suture disinsertion forces in cadaveric sclera.

RESULTS

The average force to disinsert a flange created by melting 1.0 mm of 5-0, 6-0, 7-0, and 8-0 polypropylene suture from human cadaveric sclera via 27, 30, 32, and 33 gauge needle sclerotomies was 3.0 ± 0.5 N, 2.1 ± 0.3 N, 0.9 ± 0.2 N, and 0.4 ± 0.1 N, respectively. The disinsertion forces for flanges formed by melting 0.5 mm of the same gauges were 72%-79% lower (P < .001). In comparison, the breaking strengths of 9-0 and 10-0 polypropylene were 0.91 ± 0.4 N and 0.52 ± 0.03 N. Belt-loop fixation using 6-0 and 7-0 polypropylene with 30 and 32 gauge sclerotomies demonstrated good outcomes at 6 months.

CONCLUSIONS

The flanged belt-loop technique is a biomechanically sound method of scleral fixation using 1.0 mm flanges of 5-0 to 7-0 polypropylene paired with 27, 30, and 32 gauge sclerotomies. In contrast, 8-0 polypropylene and 0.5 mm flanges of any suture gauge will likely be unstable with this technique.

A Biomechanical Study of Flanged Intrascleral Haptic Fixation of Three-Piece Intraocular Lenses

PURPOSE

Flanged intrascleral haptic fixation (FISHF) is a useful method for securing intraocular lenses (IOLs) in eyes without capsular support. Biomechanical studies were conducted to support the use of this technique.

DESIGN

Laboratory investigation.

METHODS

Haptics of 3-piece IOLs were passed through cadaveric human sclera using 30- and 27-gauge needles. Flanges were created by melting 1.0 mm from the haptic ends using cautery. The forces required to remove the flanged haptic from the sclera and disinsert the haptic from the optic were measured using a mechanical tester and a custom-fabricated mount.

RESULTS

The mean FISHF dislocation force using 30-gauge needles was greatest with the CT Lucia 602 (2.04 ± 0.24 newtons [N]) compared to the LI61AO (0.93 ± 0.41 N; P = .001), ZA9003 (0.70 ± 0.34 N; P = <.001), and MA60AC (0.27 ± 0.19 N; P <.001). Using 27-gauge needles with the CT Lucia resulted in a lower dislocation force (0.56 ± 0.36 N; P <.001). The FISHF dislocation force was correlated with the flange-to-needle diameter ratio (r = 0.975). The FISHF dislocation forces of the CT Lucia and LI61AO using 30-gauge needles were not significantly different from their haptic-optic disinsertion forces (P = .79 and .27, respectively). There were no differences in flange diameters between 1.0 mm and 2.0 mm haptic melt lengths across the IOLs (P = .15-.85).

CONCLUSIONS

These data strongly support the biomechanical stability of FISHF with the polyvinylidene fluoride haptics of the CT Lucia using small diameter instruments for the creation of an intrascleral tunnel. 1.0 mm of haptic may be the optimal melt length.

COMPARISON OF 25- AND 27-GAUGE SUTURELESS CANNULA-BASED INTRAOCULAR LENS SCLERAL FIXATION VISUAL ACUITY OUTCOMES AND COMPLICATION RATES

PURPOSE

To compare the visual outcomes and complication rates of sutureless cannula-based intraocular lens scleral (SCILS) fixation performed with 25-gauge (25 G) versus 27-gauge (27 G) instrumentation.

METHODS

A retrospective chart review of consecutive cases of eyes without capsular support that underwent SCILS fixation of a three-piece intraocular lens. Sutureless cannula-based intraocular lens scleral fixation was performed by transconjunctival use of either 25-G or 27-G trocar cannulas. During postoperative follow-up evaluations, visual acuity and intraocular pressure were measured, and slit-lamp and indirect ophthalmoscopy examinations were performed to assess for development of known complications.

RESULTS

A total of 69 eyes underwent 25 G (27 eyes) or 27 G (42 eyes) SCILS fixation. The mean preoperative logarithm of the minimum angle of resolution visual acuity trended toward improvement from 0.95 ± 0.68 (20/178 Snellen equivalent) to 0.67 ± 0.64 (20/94 Snellen equivalent) for 25 G group at 1 year. Similar trend toward visual acuity improvement was seen in 27 G group with a mean preoperative logarithm of the minimum angle of resolution visual acuity of 1.43 ± 0.94 (20/538 Snellen equivalent) improving to 0.86 ± 1.00 (20/145 Snellen equivalent) at 1 year. Statistically significant improvement was seen as early as postoperative week one for 27 G group (P < 0.01), whereas statistically significant worsening was noted at the same time in 25 G group (P = 0.01). There was a statistically significant reduction in intraocular lens displacement (P = 0.01) and need for reoperation (P = 0.01) in 27 G group.

CONCLUSION

Compared with 25 G SCILS fixation, eyes managed with 27 G SCILS fixation experienced more rapid visual acuity improvement. In addition, there was a lower rate of complications including intraocular lens displacement and need for reoperation.

Visual outcomes and complications following one-way air-fluid exchange technique for vitreous hemorrhage post vitrectomy in proliferative diabetic retinopathy patients

BACKGROUND

To evaluate the efficacy and outcomes of one-way surgical technique for the treatment of vitreous hemorrhage post vitrectomy on proliferative diabetic retinopathy (PDR) patients.

METHODS

This retrospective case series include 47 PDR patients who had vitrectomy with balanced saline solution tamponade and have developed vitreous hemorrhage without significant absorption. The one-way air-fluid exchange procedure which involves the application of a 0.22-μm pore size filter to exchange about 4.5-5.5 ml of fluid with a 10 ml syringe was performed on 47 patients (47 eyes). Post procedure, additional treatments were administered when needed. Best corrected visual acuity (BCVA), occurrence of intra-procedural and post-procedural complications were recorded and analyzed.

RESULTS

A total of 47 eyes of 47 PDR patients with a mean age of 50.8 ± 12.0 years were reviewed. Because of vitreous hemorrhage or tractional retinal detachment of PDR, all 47 eyes underwent vitrectomy with balanced saline solution tamponade prior to the exchange procedure. Four patients (8.51%) and 43 patients (91.5%) were diagnosed with type 1 diabetes mellitus (T1DM), or type 2 diabetes mellitus (T2DM), respectively. All 47 eyes were given the one-way air-fluid exchange procedure in the treatment room. Forty-two cases (89.4%) needed the air-fluid exchange procedure only once, 4 cases (8.51%) underwent the procedure twice, and 1 case (2.13%) was given the procedure three times, followed by additional retinal photocoagulation and one intravitreal injection of Conbercept. In addition to the procedure, no further treatment was needed for 5 eyes (10.6%) while additional retinal laser treatment was provided for 41 eyes (87.2%). The BCVA at the final follow-up was significantly improved from the initial acuity baseline in all cases. No complications were observed during the follow-ups.

CONCLUSION

This one-way air-fluid exchange procedure can effectively exchange the vitreous hemorrhage and improve visual acuity of PDR patients who develop vitreous rehemorrhage post vitrectomy without obvious complications.

Flanged fixation: Yamane technique and its application

PURPOSE OF REVIEW

To review variations of flanged intraocular lens fixation (Yamane technique) and their outcomes.

RECENT FINDINGS

Sutureless intrascleral IOL fixation has become popular, and many techniques have been reported. Among them, the Yamane technique has been widely used in recent years, and there are many variations. However, there are no reports that systematically compare them.

SUMMARY

There are variations of the Yamane technique, such as those used to create a scleral tunnel or to dock needles and haptics. Although few reports have directly compared each technique, small scleral wounds appear to be beneficial for long-term stability of the IOL. A method of fixing a capsule tension segment or iris using a flange has also been reported, demonstrating the diverse range of uses of the flange.

Interdigitation and Ellipsoid Zones Disruption Correlate with Visual Outcomes among Treatment-Naive Patients with Diabetic Macular Edema

INTRODUCTION

We have recently shown that defects in interdigitation and ellipsoid zones (IZ and EZ) can predict response to anti-VEGF therapy in a small group of treatment-naive diabetic macular edema (DME) patients. The aim of the current study is to further evaluate this association in a larger study group of patients over a longer follow-up time.

METHODS

Thirty eyes of 30 treatment-naive DME patients were analyzed in this retrospective study. The integrity of foveal IZ and EZ was evaluated using optical coherence tomography at the diagnosis of DME and following anti-VEGF injections. The defect size was correlated with best-corrected visual acuity (BCVA) and central macular thickness (CMT).

RESULTS

The mean patients' age at baseline was 63.0 ± 10.0 years. Patients underwent 3.9 ± 2.9 anti-VEGF injections for a mean of 9.1 ± 4.8 months. Following treatment, the mean Snellen visual acuity (VA) improved from 20/52 to 20/44 (p = 0.05), CMT decreased from 432.5 ± 141.4 μm to 375.2 ± 121.4 µm (p = 0.05) and IZ/EZ defect size decreased from 259.83 ± 375.94 µm to 65.34 ± 143.97 µm (p = 0.001). In patients with no IZ/EZ defects at baseline, the mean Snellen VA was better when compared to those with IZ/EZ defects (20/36 vs. 20/70, p = 0.031). The number of eyes with IZ/EZ defects decreased from 17 (57%) at baseline to 6 (20%) at end of follow-up (p < 0.01). BCVA gain correlated with IZ/EZ defect size reduction (r = 0.41, p = 0.02) but not with improvement in CMT (r = 0.28, p = 0.121).

CONCLUSIONS

IZ/EZ defect size correlated not only with baseline BCVA but also predicted the change in BCVA after anti-VEGF treatment. Possible future automatic measurement of IZ/EZ defect size might prove helpful for the evaluation of treatment response.