Pars plana vitrectomy with endoscope-guided sutured posterior chamber intraocular lens implantation in children and adults

Longitudinal changes of refractive error in preschool children with congenital ectopia lentis

BACKGROUND

Congenital ectopia lentis (CEL) is a hereditary eye disease which severely impacts preschool children's visual function and development. This study aimed to evaluate the longitudinal changes in spherical equivalent (SE) refractive error in preschool children with CEL.

METHODS

A retrospective cohort study was conducted at Zhongshan Ophthalmic Center, Guangzhou, China. Medical records of CEL patients under 6-year-old who were diagnosed with Marfan syndrome at the initial visit from January 2014 to March 2022 were collected and were divided into surgery and non-surgery groups. Mean change rate of SE in the two groups was evaluated, and the potential associated factors of SE change rate were investigated by mixed-effect regression model.

RESULTS

A total of 94 preschool patients from 14 provinces of China were included. Among the 42 children of the surgery group, the mean age with standard deviation (SD) was 5.02 ± 0.81 years and patients experienced a myopic shift of -0.05 ± 0.09 D/month in average. The mean age with SD of the 52 children of the non-surgery group was 4.34 ± 1.02 years, and the mean myopic shift was -0.09 ± 0.14 D/month. The mixed-effect regression model identified that higher degree of myopia at baseline was associated with slower myopic shift both in surgery (β = 0.901, 95% CI: 0.822 ~ 0.980, P < 0.001) and in non-surgery group (β = 1.006, 95% CI: 0.977 ~ 1.034, P < 0.001) in CEL patients. Surgical treatment (β = 2.635, 95% CI: 1.376 ~ 3.894, P < 0.001) was associated with slower myopic shift in all participants CEL patients.

CONCLUSIONS

Myopic progression was slower in the surgery group than in the non-surgery group of CEL. Preschool CEL patients who met the surgical indication are suggested being performed with timely surgery to slow down the myopic progression.

Postoperative longitudinal refractive changes in children younger than 8 years with ectopia lentis and Marfan syndrome

PURPOSE

To evaluate the postoperative longitudinal refractive changes in children younger than 8 years with ectopia lentis and Marfan syndrome (MFS).

SETTING

Zhongshan ophthalmic center, Guangzhou, China.

DESIGN

Retrospective cohort study.

METHODS

Medical data of patients diagnosed with ectopia lentis and MFS that underwent surgery younger than 8 years were collected. Refractive errors and ocular biometric parameters were collected preoperatively and at each follow-up visit. Patients were stratified into groups according to age at surgery, and only the eye operated on first was selected. Multivariate analysis was performed to determine the association between refractive shift and potential risk factors.

RESULTS

In total, 54 eyes of 54 patients were enrolled. The median age at surgery was 6.21 years (interquartile range [IQR], 5.25 to 6.85), and the median follow-up was 2.0 years (IQR, 1.2 to 2.8 years). At age 8 years, patients demonstrated a median myopic shift ranged from -1.75 diopters (D) (IQR, -2.75 to -1.00 D) for the 4-year-old group to -0.13 D (IQR, -0.50 to -0.06 D) for the 7-year-old group. Multivariate analysis showed that greater myopic shift was associated with younger age at surgery ( P = .004), male sex ( P = .026), and shorter preoperative axis length ( P = .005).

CONCLUSIONS

A tendency toward increasing postoperative myopic was demonstrated in children with ectopia lentis and MFS, with the greatest myopic shift in the younger age groups. If the goal is to reach emmetropia by age 8 years, the immediate postoperative hypermetropic targets should be 1.75 D for age 4 years, 1 D for age 5 years, 0.5 D for age 6 years, and 0 to 0.25 D for age 7 years.

Endoscopic Visualization for Atypical Uveitis Glaucoma Hyphema Syndrome Management

We discuss how ophthalmic endoscopy was used in the management of 6 cases with atypical uveitis glaucoma hyphema syndrome. For case 1, the endoscope was used to remove a retained haptic foreign body after an intraocular lens (IOL) exchange with an iris-sutured IOL for a complete capsular bag-IOL complex dislocation. In case 2, the endoscope was key in identifying the presence and location of vascular lesions at the site of previous pars plana sclerotomies. In case 3, the endoscope enabled visualization of a large segmental Soemmering's Ring pushing a 3-piece IOL haptic into the posterior iris. For case 4, the endoscope allowed viewing of the sharp edge of the optic where the haptic of a one-piece lens had been amputated, and the sharp edge of the cut optic was anteriorly oriented and continuing to rub the posterior iris. In case 5, the endoscope confirmed the presence of 1 haptic of a 1-piece lens out of the capsular bag and in the sulcus space. Also, it showed that the capsular bag had inadequate zonular support to attempt repositioning the haptic into the bag. In case 6, the endoscope was helpful in identifying a 1-piece plate haptic IOL in the sulcus, with synechiae and anterior location causing iris bulging inferiorly.

Endoscope-Assisted Sutureless Intrascleral Haptic Fixation of a Posterior Chamber Intraocular Lens

Purpose:

In eyes with compromised capsule support, sutureless scleral fixation is a popular method of placing a posterior chamber intraocular lens (PCIOL). We describe an endoscope-assisted sutureless technique for intrascleral fixation of a 3-piece PCIOL.

Methods:

Eyes of patients who had endoscope-assisted scleral-fixated intraocular lens (SFIOL) implantation were examined retrospectively. The technique comprised direct capture of the IOL haptic with a forceps through a pars plana sclerotomy with subsequent haptic fixation into scleral tunnels created with a 26-gauge needle. The endoscope was used to visualize haptic positioning under the iris and ensure proper centration of the IOL.

Results:

Thirteen eyes of 13 patients were examined. The mean age of the patients was 68.2 years (range, 38-87 years), and the mean follow-up was 13.6 months (range, 5-23 months). The indications for surgery were a subluxated IOL (6 eyes), postoperative aphakia (5 eyes), and a subluxated cataract (2 eyes). The mean best-corrected visual acuity ± SD improved significantly from 1.2 ± 0.6 logMAR preoperatively to 0.6 ± 0.7 logMAR at last the follow-up (paired Welch t test; t10 = 2.69; P = .023). IOL stability and centration were maintained in all patients.

Conclusions:

Endoscopic visualization during sutureless SFIOL implantation helped improve haptic localization, minimize intraoperative complications, and achieve excellent IOL centration.

Outcomes of Transscleral Two-Point Fixation Versus Closed Continuous-Loop Four-Point Fixation of Intraocular Lens in Subluxated Lens Secondary to Marfan Syndrome

Introduction

To compare the outcome of two different transscleral fixation approaches for posterior chamber intraocular lens (IOL) implantation, a two-point fixation of the Sensar (Allergan) or CZ70BD (Alcon) IOL and a four-point fixation of the Akreos Adapt (Bausch & Lomb) foldable IOL, for treatment of subluxated lenses in Marfan syndrome (MFS).

Methods

Fifty-three eyes of 33 consecutive patients with subluxated lenses secondary to MFS were studied. Eighteen patients with MFS (30 eyes) received two-point fixation of the Sensar (16 patients, 26 eyes) or CZ70BD (2 patients, 4 eyes) IOL, and 15 patients with MFS (23 eyes) received four-point fixation of the Akreos Adapt IOL. Preoperative and postoperative ophthalmologic examinations were performed. A primary outcome measure of postoperative complication was studied.

Results

The mean preoperative best corrected visual acuity (BCVA) in the two-point group was 0.68 ± 0.38 logarithm of the minimum angle of resolution (logMAR), and it improved to 0.30 ± 0.32 logMAR at the final follow-up (p < 0.05). The mean preoperative BCVA in the four-point group was 0.68 ± 0.45 logMAR, and it improved to 0.28 ± 0.28 logMAR at the final follow-up (p < 0.05). The BCVA results did not differ significantly between groups. The intraocular pressure was increased at the final follow-up in the two-point group (p < 0.05). Transscleral two-point fixation of IOL has relatively high incidences of pupillary capture of the IOL.

Conclusion

The closed continuous-loop transscleral four-point fixation of the Akreos Adapt foldable IOL is more suitable than two-point fixation of a two-haptic IOL in treating subluxated lenses due to MFS.

High-Resolution Ex-Vivo Imaging of Retina with a Laptop-Based Portable Endoscope

Purpose. Ophthalmic endoscopy is useful in vitreoretinal surgery with opaque anterior segments or anatomically challenging structures. However, standard ophthalmic endoscopy devices are usually large and costly. Thus, the development of a portable endoscope is necessary. Methods. The portable endoscope consisted of a probe, an illumination system, a high-resolution camera module, and a universal serial bus (USB). It was connected to a laptop and applied for intraocular imaging of porcine eyes in vitro. Basic parameters and pictures of the same tissue target were compared with those of the standard Endo Optiks E4 system. Results. The retinal images were displayed on the laptop screen, which clearly showed the overall appearance of the central and peripheral retina, and the details of the retinal vasculature and ciliary body. Compared with a standard endoscope, our portable endoscope is smaller and more affordable. It can be taken anywhere for intraocular imaging and vitreoretinal surgery. Conclusion. A laptop-based portable endoscope is a promising device in vitreoretinal surgery. It provides high-resolution images of intraocular tissues that should make a noticeable difference in intraocular surgery with disordered anterior segments. With its portability and high-resolution imaging, it may promote the application of endoscopes in ophthalmology.

Anterior chamber intraocular lens - An effective alternative in traumatic and surgical aphakia in the era of scleral-fixated intraocular lens

Purpose:

To evaluate outcomes of anterior chamber intraocular lens (ACIOL) implantation with vitrectomy in eyes with surgical or traumatic aphakia, and subluxated or dislocated lens.

Methods:

In this retrospective study, we evaluated patients who underwent pars plans vitrectomy with ACIOL implantation from April 2016 to March 2019. Patients with minimum follow-up period of 1 year and operated by single surgeon were included. Ophthalmic history, indication for surgery, BCVA, IOP, slit-lamp examination, and fundus assessment findings were noted. Postoperatively best-corrected visual acuity (BCVA), intraocular pressure (IOP) and complications if any were noted.

Results:

Ninety eyes of 88 patients were included in the study. The mean age of the patients was 60.2 ± 10.2 yrs. Majority (75.6%) were males and 24.4% were females. Indications for pars-plana vitrectomy (PPV) with ACIOL implantation were nucleus drop in 16.6%, IOL drop in 25.5%, large posterior capsular rupture (PCR) with vitreous disturbance or zonular dehiscence (ZD) during cataract surgery in 33.3%, more than 180° subluxation of lens in 10% and traumatic lens or intraocular lens (IOL) drop in 14.4% cases. Preoperative and postoperative mean Log MAR visual acuity was 1.59 ± 0.44 and 0.36 ± 0.33 respectively, with few complications like cystoid macular edema (CME) in 8.8%, persistently raised IOP in 4.4%, persistent uveitis in 2.2%, retinal detachment (RD) in 2.2%, and tilted IOL in 1.1% cases.

Conclusion:

Out of different options available for secondary IOL implantation in patients with poor capsular support ACIOL has the advantages of cost-effectiveness, small learning curve, faster surgical time with a lesser rate of complications like IOL tilt, vitreous hemorrhage, and suture erosion as compared to scleral-fixated IOL (SF-IOL). Comparable visual outcome can be obtained by proper patient selection in these cases.

Intraocular endoscopy: A review

Optimal visualization is one of the most challenging aspects of performing vitreoretinal surgery. In situations where conventional microscopic techniques provide poor posterior visualization, the adjunctive skill set of endoscopic visualization may be needed. This allows for by-passing the opaque anterior segment media and getting access to the posterior segment pathology. Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical set-up of endoscopy allows for clinical approaches that are impossible with regular microscope viewing systems. These include the ability to observe across optically significant anterior segment opacities and directly visualize the posterior segment of the eye. It also allows for visualizing the difficult-to-access retroirideal, retrolental, and anterior retinal structures. Surgical access to anatomic spaces like the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens is tedious. This is made simpler by endoscopy. In this review, we summarize and review the usage of the intraocular endoscope as a diagnostic and therapeutic armamentarium across a wide spectrum of ocular pathologies.

A Review of Robotic and OCT-Aided Systems for Vitreoretinal Surgery

The introduction of the intraocular vitrectomy instrument by Machemer et al. has led to remarkable advancements in vitreoretinal surgery enabling the limitations of human physiologic capabilities to be reached. To overcome the barriers of perception, tremor, and dexterity, robotic technologies have been investigated with current advancements nearing the feasibility for clinical use. There are four categories of robotic systems that have emerged through the research: (1) handheld instruments with intrinsic robotic assistance, (2) hand-on-hand robotic systems, (3) teleoperated robotic systems, and (4) magnetic guidance robots. This review covers the improvements and the remaining needs for safe, cost-effective clinical deployment of robotic systems in vitreoretinal surgery.

Analysis of the etiologies, treatments and prognoses in children and adolescent vitreous hemorrhage

AIM

To determine the etiologies, treatment modalities and visual outcomes of vitreous hemorrhage (VH; range from birth to 18y).

METHODS

A total of 262 eyes from 210 patients between January 2010 and September 2016 were included. All children underwent an appropriate ocular and systemic examination. Data collected included demographics, clinical manifestations, details of the ocular and systemic examination, management details, final fundus anatomy and visual acuity (VA).

RESULTS

The most common etiologies were non-traumatic VH (64.89%), most of which were due to retinopathy of prematurity (ROP; 37.10%); while traffic accidents, including 16 (21.00%) eyes, was the most common ocular traumas. Surgery, performed in 143 (54.58%) eyes, was the most common management modality. The initial mean baseline visual acuity was 2.77±0.21 logarithm of the minimal angle of resolution (logMAR) in children and adolescent with traumatic VH, which was significantly improved to 2.15±1.31 logMAR (P<0.05).

CONCLUSION

VH in children and adolescent has a complicated and diverse etiology. ROP is the primary cause of non-traumatic VH, which is the most common etiology. Appropriate treatment of traumatic VH is associated with obvious improvement in visual acuity. The initial VA is one of most important predictors of outcome.

Endoscopic vitreoretinal surgery: Review of current applications and future trends

Endoscopy provides unique optical properties to circumvent anterior segment opacities and visualize difficult-to-access anatomical regions, including retroirideal, retrolental, ciliary body, and anterior retinal structures. We summarize the basic principles and utilization of endoscopic vitreoretinal surgery, along with recent technological advances in the field base on a structured literature search in Pubmed, Embase, and Google Scholar database up to February, 2020. Endoscopy has been used in the management of retinal detachment, ischemic retinopathies with neovascular glaucoma, severe ocular trauma, endophthalmitis, lens-related disorders in the posterior segment, pediatric vitreoretinal diseases, and implantation of retinal prostheses. Ongoing development of endoscopic technology aims to provide higher resolution images with endoscopes of smaller diameter. New surgical techniques supported by the adoption of endoscopy are available to manage challenging surgical scenarios. Endoscopy can be a useful adjunct to microscope wide-angle viewing systems in the management of complex vitreoretinal diseases.

Endoscope-assisted scleral buckle procedure

BACKGROUND

Retinal reattachment surgery requires clear visualization of the posterior segment for optimal outcomes. Select patients may benefit most from primary scleral buckling without vitrectomy, but lack adequate posterior segment ophthalmoscopic visualization to use standard techniques.

CASE PRESENTATION

The authors describe a retinal reattachment technique utilizing endoscope-assisted visualization to perform a primary scleral buckle procedure for a 34yo female with Peters' Anomaly and a macula-sparing retinal detachment. Retinal reattachment was achieved with a single procedure and she remained stable with preservation of baseline visual acuity at 30 months follow-up.

CONCLUSION

In cases where a primary scleral buckle procedure is the preferred retinal detachment repair technique but posterior segment visualization is limited, intraoperative fundus examination, cryotherapy administration, and scleral buckle positioning can be facilitated with intraocular endoscopy.

Secondary intraocular lens implantation using the flanged intrascleral fixation technique in pediatric aphakia: case series and review of literature

PURPOSE

To present a pediatric case series in which the flanged intrascleral intraocular lens (IOL) fixation technique (Yamane technique) was used to correct aphakia.

METHODS

The surgical database of a single tertiary children's hospital was reviewed to identify all patients who underwent secondary IOL implantation by a single surgeon from May 2018 to January 2020. The medical records and operative reports of all patients operated on using the Yamane technique were reviewed retrospectively. Intra- and postoperative complications and pre- and postoperative vision and refraction were documented to assess outcomes.

RESULTS

A total of 12 eyes of 10 consecutive patients were included. Mean age at surgery was 10 ± 6 years. Indications for scleral fixation were ectopia lentis (secondary to Marfan syndrome [n = 3] or idiopathic [n = 1]), lens subluxation with intermittent pupillary block secondary to Weill- Marchesani syndrome (n = 2), early childhood lensectomy with insufficient residual capsular support (n = 5), and traumatic aphakia after an open globe (n = 1). Mean follow-up was 8 ± 5 months. No major intraoperative complications occurred. Postoperatively 1 patient required IOL repositioning 1 week after surgery. The location of one haptic was noted to be intrascleral but superficial in another patient, who did not require surgical intervention. The mean postoperative astigmatism was 2 ± 2 D. Good visual results were achieved in all eyes.

CONCLUSIONS

With slight modifications, the Yamane technique can be adapted to the pediatric eye. This technique has significant surgical and anatomic advantages and provides stable IOL fixation. Visual outcomes and adverse events compare favorably with older techniques.

Characteristics and Risk Factors for Pupillary Capture of Intraocular Lens in Congenital Ectopia Lentis

Importance: To analyze the characteristics and risk factors for pupillary capture (PC) of the intraocular lens (IOL) in congenital ectopia lentis (CEL) patients.Methods: Data of CEL patients who underwent lens extraction and intraocular implantation from 2013 to 2016 at Zhongshan Ophthalmic Center in China were collected. Best-corrected visual acuity (BCVA), axial length (AL), refractive status, corneal curvature, intraocular pressure (IOP), degree of lens dislocation, presence of strabismus, and methods of IOL fixation were recorded. Postoperative data were collected from the routine one-month postoperative follow-up. Patients with PC of IOL were characterized and risk factors for PC of IOL were analyzed using age-sex adjusted multiple logistic regression analysis.Results: Of the 89 included CEL subjects, 43.8% (39/89) of them suffered from PC after IOL implantation. There was no statistically significant difference in BCVA, AL, refractive status and IOP between the eyes which developed PC versus those which did not. Age-sex multiple logistic regression analysis shows that PC of IOL was associated with a more severe degree of lens dislocation and eyes with strabismus before surgery.Conclusions: Eyes with strabismus and more severe degrees of lens dislocation before surgery are risk factors for PC of IOL. When treating patients that present these risk factors, preoperative communication, and postoperative follow-up should be strengthened. Considering that PC of IOL has little effect on visual acuity, patients with slight PC of IOL can be exempt from surgical intervention.

Endoscopic vitreoretinal surgery: principles, applications and new directions

Purpose

To analyze endoscopic vitreoretinal surgery principles, applications, challenges and potential technological advances.

Background

Microendoscopic imaging permits vitreoretinal surgery for tissues that are not visible using operating microscopy ophthalmoscopy. Evolving instrumentation may overcome some limitations of current endoscopic technology.

Analysis

Transfer of the fine detail in endoscopic vitreoretinal images to extraocular video cameras is constrained currently by the caliber limitations of intraocular probes in ophthalmic surgery. Gradient index and Hopkins rod lenses provide high resolution ophthalmoscopy but restrict surgical manipulation. Fiberoptic coherent image guides offer surgical maneuverability but reduce imaging resolution. Coaxial endoscopic illumination can highlight delicate vitreoretinal structures difficult to image in chandelier or endoilluminator diffuse, side-scattered lighting. Microendoscopy’s ultra-high magnification video monitor images can reveal microscopic tissue details blurred partly by ocular media aberrations in contemporary surgical microscope ophthalmoscopy, thereby providing a lower resolution, invasive alternative to confocal fundus imaging. Endoscopic surgery is particularly useful when ocular media opacities or small pupils restrict or prevent transpupillary ophthalmoscopy. It has a growing spectrum of surgical uses that include the management of proliferative vitreoretinopathy and epiretinal membranes as well as the implantation of posterior chamber intraocular lenses and electrode arrays for intraretinal stimulation in retinitis pigmentosa. Microendoscopy’s range of applications will continue to grow with technological developments that include video microchip sensors, stereoscopic visualization, chromovitrectomy, digital image enhancement and operating room heads-up displays.

Conclusion

Microendoscopy is a robust platform for vitreoretinal surgery. Continuing clinical and technological innovation will help integrate it into the modern ophthalmic operating room of interconnected surgical microscopy, microendoscopy, vitrectomy machine and heads-up display instrumentation.

An experimental and clinical study on the initial experiences of Brazilian vitreoretinal surgeons with heads-up surgery

PURPOSE

To evaluate the initial experiences of several vitreoretinal surgeons in Brazil, both experienced and beginners, with a three-dimensional (3D) system, and to report the advantages and disadvantages of this technology. We also report surgical manipulations performed using the heads-up method in porcine eyes. For full-thickness idiopathic macular holes (MHs), we analyzed the times required for pars plana vitrectomy (PPV) and internal limiting membrane (ILM) rhexis by using traditional microscopy and 3D system, and to evaluate anatomical surgical results.

METHODS

During experimental vitreoretinal surgery on porcine eyes, two retinal surgeons applied the heads-up method. In clinical surgery, 14 retinal surgeons performed almost all types of vitreoretinal surgeries in association with facectomy, Ahmed glaucoma valve implant, or minimally invasive glaucoma surgery using an iStent®. The Ngenuity® 3D Visualization System was digitally integrated with intraoperative optical coherence tomography, the Verion™ Image-Guided System, and an endoscope (with a modified GoPro® camera). To compare the 3D system with traditional microscopy, ergonomics, educational value, image sharpness, depth perception, field of view, advantages and disadvantages, and technical feasibility were assessed using a questionnaire. One year later, the 14 surgeons answered the same questionnaire again, in order to assess whether they became more comfortable or not with 3D. For treating MHs, four surgeons (surgeon 1, fellows 1, 2, 3) performed the total of 40 surgeries. Each one performed 10 surgeries (5 with traditional microscopy and 5 with 3D visualization). The completion time for PPV and ILM rhexis were determined by using both methods.

RESULTS

In porcine eyes, disabling the color channels allowed better visualization of the ILM, either with Brilliant Blue G (BBG), indocyanine green chorioangiography (ICG), or açai dye; transillumination through the sclera was also better without a color channel, but visualization of the peripheral vitreous was better with a blue channel. Regarding clinical experience, the questionnaire responses showed that the respondents generally favored the heads-up method compared with traditional microscopy (p < 0.05); however, despite a slightly higher average score, the 3D system was not statistically significantly preferred in terms of technical feasibility (p = 0.1814). Answering again the same questionnaire 1 year later, the 14 surgeons felt more comfortable with 3D (p < 0.05). The type of surgery benefitting most from the 3D system was peeling of the ILM or epiretinal membrane (p < 0.001), and that receiving the least benefit was anterior segment surgery (p < 0.001). In addition, surgeons did not report benefits of color channels, preferring to disable it (p < 0.001). Comparisons between the average time for full PPV and ILM rhexis by using the two methods were non-significant, neither in each individual case of 3D surgery for each surgeon. Surgeon 1 had always been faster than his fellows. Thirty-six (90%) full-thickness MHs were successfully closed with one surgery.

CONCLUSIONS

The 3D system was preferred to traditional microscopy. The 3D system was especially helpful for certain specific types of surgeries and served as an educational tool, having reduced illumination and allowing precise focusing. Concerning MH surgery, heads-up method was similar to traditional microscopy regarding length of time and anatomical surgical results. As a digital platform, it will be amenable to constant upgrades and may ultimately become the new standard for ophthalmic surgery.

Secondary Sulcus-Fixed Foldable IOL Implantation with 25-G Infusion in Patients with Previous PPV after Open-Globe Injury

PURPOSE

To evaluate the safety and efficacy of secondary sulcus-fixed foldable intraocular lens (IOL) implantation through a clear corneal incision with 25-G infusion in patients with previous pars plana vitrectomy (PPV) after open-globe injury, and to analyze postoperative outcomes and prognostic factors of treatment.

METHODS

Clinical data of 89 eyes of 89 patients with open-globe injury who underwent secondary sulcus-fixed foldable IOL implantation through a clear corneal incision with 25-G infusion after vitrectomy in our hospital between January 2008 and June 2015 were retrospectively analyzed. The examinations before IOL implantation mainly included visual acuity, slit-lamp examination, direct and indirect ophthalmoscope, visual electrophysiology, corneal endothelium, B scan, ultrasound biomicroscope, and intraocular pressure. Five eyes underwent suturing of peripheral iris and 7 eyes underwent suturing of iris laceration simultaneously. The mean follow-up was 18 months with a range from 6 months to 8 years.

RESULTS

The mean interval between secondary sulcus-fixed foldable IOL implantation and vitrectomy was 2.8 months with a range from 2 to 6 months. The uncorrected visual acuity improved in all patients with a well-centered IOL ranging from 0.1 to 0.8 with the best-corrected visual acuity from 0.1 to 1.0 after secondary IOL implantation. The postoperative complications mainly included mild anterior chamber exudates in 10 eyes (11%), temporary IOP elevation in 12 eyes (13%), and recurrent retinal detachment in 5 eyes (6%), which were subsequently managed by surgery.

CONCLUSIONS

The interval of 2.8 months between vitrectomy and secondary IOL implantation is an appropriate and safe option to correct aphakia in patients receiving vitrectomy for open-globe injury.

Comparison of Three Intraocular Lens Implantation Procedures for Aphakic Eyes With Insufficient Capsular Support: A Network Meta-analysis

PURPOSE

To compare the clinical outcomes and main complications of transscleral-fixated (TSF), intrascleral-fixated (ISF), and iris-fixated (IF) intraocular lenses (IOLs).

DESIGN

Systematic review and network meta-analysis.

METHODS

The authors searched PubMed, EMBASE, and the Cochrane Library for relevant articles up to April 2017 with no language restrictions, and related studies meeting the eligibility criteria were included. A Bayesian framework was applied to compare the visual outcomes and complications of these 3 approaches.

RESULTS

A total of 14 studies with 845 eyes were included in the present report. There was no significant difference between any pair of surgical approaches in best-corrected visual acuity (BCVA) and in final BCVA achieving 20/40 or better (Snellen). ISF presented a lower risk of cystoid macular edema (CME) compared with TSF (risk ratio [RR], 0.45; 95% confidence interval [CI], [0.18, 1.0]). IF showed superiorities in less intraocular hemorrhage (IOH) than ISF (RR, 0.078; 95% CI [0.0095, 0.38]), as well as TSF (RR, 0.26; 95% CI, [0.09, 0.72]). IF had a lower risk of glaucoma escalation; the difference was slightly higher than the conventional level of significance (RR, 0.41; 95% CI, [0.16, 1.04]). Moreover, the surgical time in IF was shorter than TSF (standard mean difference [SMD], -2.98; 95% CI, [-4.32, -1.64]) and ISF (SMD, -2.60; 95% CI, [-3.71, -1.49]). However, IF was associated with a significantly higher risk of endothelial cell density (ECD) impairment (SMD, -0.54; 95% CI, [-1.02, -0.05]) and significantly greater postoperative corneal endothelial cell loss rate (ECLR, %) (SMD, 0.35; 95% CI, [0.08, 0.63]) compared with TSF.

CONCLUSIONS

Postoperative visual outcomes were comparable among TSF, ISF, and IF for eyes with insufficient capsular support. However, the risk of some complications differed among approaches. IF showed its superiorities in lower risk of IOH and glaucoma escalation as well as shorter surgical time, while IF was at a disadvantage in greater endothelial cell impairment. Since some patients might have a clear contraindication to one of the surgical approaches, the decision of surgical approach eventually depends on surgeon experience and the presenting pathology.

Endoscopy for Pediatric Retinal Disease

Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical properties of endoscopy allow for some clinically advantageous approaches that are not possible with regular microscope viewing systems, namely, the ability to both bypass optically signficant anterior segment opacities and directly visualize dificult-to-access retroirideal, retrolental, and anterior retinal structures in their natural anatomical configuration. The surgical benefits include improved surgical access to the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens, along with unique access to anterior traction in complex pediatric anterior detachments, particularly in retinopathy of prematurity. This review will focus on the development and surgical utility of intraocular endoscopy, provide an update on its current uses in the era of microincision vitreoretinal surgery, and highligh its role in pediatric vitreoretinal diseases.

Endoscopy-assisted vitrectomy in the anterior vitreous

Endoscopy-assisted ocular surgery is a relatively old technique that is increasingly being recognized for its application in cases of vitreoretinal disease. This technique is especially useful when both the vitreous and retina are difficult to access because of media opacity, a small pupil, or a microcornea. In this context, the anterior vitreous is often difficult to dissect because of its complex pathological changes. This article reviews the common anatomical features and pathologies that are observed in the anterior vitreous, as well as the applications and indications of endoscopy-assisted vitrectomy in the anterior vitreous.

Scleral-Fixated Intraocular Lenses: Past and Present

Intraocular lenses (IOLs) can have inadequate support for placement in the capsular bag as a result of ocular trauma, metabolic or inherited conditions such as Marfan's syndrome or pseudoexfoliation, or complicated cataract surgery. Surgical options for patients with inadequate capsular support include alternative placement in the anterior chamber (ACIOLs), fixation to the iris, or fixation to the sclera. The surgical techniques for each of these approaches have improved considerably over the last several decades resulting in improved visual and ocular outcomes. If no capsular or iris support exists, the surgeon can fixate an IOL to the sclera or the patient can remain aphakic. IOLs can be fixated to the sclera using sutures or by tunneling the IOL haptics into the sclera without sutures. This review summarizes the pre-operative considerations, surgical techniques, outcomes, and unique complications associated with implantation of scleral-fixated IOLs.

Toric markers-assisted implantation of the scleral-fixated intraocular lens

AIM

To evaluate the efficacy of toric intraocular lens markers-assisted implantation of the scleral-fixated intraocular lens (SFIOL).

METHODS

From October 2010 to December 2013, all patients who had undergone secondary SFIOL implantation were assigned to group 1 and 2, in group 1 SFIOL was performed with the assist of radial keratotomy (RK)-marker, and in group 2 SFIOL was performed with the assisted of toric intraocular lens markers (T-and axis markers). Patients' demographic data and information on baseline preoperative visual acuity, indication for surgery and latest postoperative visual acuity were collected and analyzed. The haptic and optic positions were determined by ultrasound biomicroscopy. The optic tilt angle and decentration distance were measured.

RESULTS

The study evaluated 43 eyes of 43 patients ranging in age from 3 to 66y. Group 1 comprised 24 eyes (24 patients) and group 2, 19 eyes (19 patients). Uncorrected reoperative acuity was improved on all the eyes postoperatively. The improved postoperative acuity was significantly more in group 2 than that in group 1 (1.11±0.38 vs 0.82±0.45 logMAR; F=4.85, P=0.03). Ultrasonic biomicrograph examination showed that the rate of haptic asymmetry was significantly higher in group 1 (42%, 10/24) than that in group 2 (11%; 2/19) (Chi square=3.68, P=0.04). The mean tilted degree in group 1 was significantly higher than that in group 2 (P=0.04). Mean decentration distance in group 1 was greater than that in group 2 (P=0.03).

CONCLUSION

During SFIOL the toric markers help the surgeon identify the placement of fixation more precisely than that with the use of RK marker.

Pars Plana Vitrectomy Combined With Either Secondary Scleral-Fixated or Anterior Chamber Intraocular Lens Implantation

PURPOSE

To compare visual outcomes among eyes that underwent pars plana vitrectomy (PPV) in combination with either anterior chamber intraocular lens implantation (ACIOL) or scleral suturing of posterior chamber lens (PCIOL).

DESIGN

Retrospective comparative case series.

METHODS

All eyes presented with aphakia or luxated or subluxated posterior chamber intraocular lens (IOL) following complicated cataract surgery, trauma, or spontaneous dislocation. Eyes involving visually significant macular pathology, past retinal detachment, follow-up of less than 6 months, and surgeries requiring the removal of an ACIOL were excluded. The main outcomes measured were final best-corrected visual acuity (BCVA) and surgical complication rates.

RESULTS

Fifty-seven eyes met inclusion criteria; median follow-up was 13.2 months. Initial median BCVA for ACIOL patients was logMAR 1.301 (Snellen equivalent 20/400, range 20/20 to light perception); final median BCVA was logMAR 0.477 (Snellen equivalent 20/60, range 20/20 to light perception, P < .001). Initial median BCVA for PCIOL patients was logMAR 1.239 (Snellen equivalent 20/347, range 20/60 to light perception); final median BCVA was logMAR 0.301 (Snellen equivalent 20/40, range 20/20 to hand motions, P < .001). The change in BCVA between the 2 groups over the course of the study was similar (P > .05). More epiretinal membrane (ERM) formations occurred postoperatively in the ACIOL group (P = .011). Other complication rates were similar between both groups.

CONCLUSIONS

PPV with secondary IOL placement is safe and effective, resulting in improved visual outcomes regardless of the technique used. Patients undergoing ACIOL placement have a higher incidence of ERM formation.

Ultrasound Biomicroscopy Comparison of Ab Interno and Ab Externo Intraocular Lens Scleral Fixation

Purpose. To compare ab interno and ab externo scleral fixation of posterior chamber intraocular lenses (PCIOL) using ultrasound biomicroscopy (UBM). Methods. Randomized patients underwent ab externo or ab interno scleral fixation of a PCIOL. Ultrasound biomicroscopy was performed 3 to 6 months postoperatively, to determine PCIOL centration, IOL distance to the iris at 12, 3, 6, and 9 hours, and haptics placement in relation to the ciliary sulcus. Results. Fifteen patients were enrolled in the study. The ab externo technique was used in 7 eyes (46.6%) and the ab interno in 8 eyes (53.3%). In the ab externo technique, 14 haptics were located: 4 (28.57%) in the ciliary sulcus; 2 (14.28%) anterior to the sulcus; and 8 (57.14%) posterior to the sulcus, 6 in the ciliary body and 2 posterior to the ciliary body. In the ab interno group, 4 haptics (25.0%) were in the ciliary sulcus, 2 (12.50%) anterior to the sulcus, and 10 (75.0%) posterior to the sulcus, 4 in the ciliary body and 6 posterior to the ciliary body. Conclusions. Ab externo and ab interno scleral fixation techniques presented similar results in haptic placement. Ab externo technique presented higher vertical tilt when compared to the ab interno.

Iris Fixation of Unstable Anterior Chamber Intraocular Lenses

PURPOSE

To present a surgical approach for the treatment of unstable anterior chamber intraocular lenses (ACIOLs).

METHODS

We present a series of 8 patients who underwent iris fixation of an unstable open-looped ACIOL associated with progressive corneal damage. The loops of the intraocular lens were firmly fixated to the iris using 9-0 or 10-0 polypropylene sutures. In 2 cases, iris fixation was associated with penetrating keratoplasty. The other cases were performed using a relatively closed-system technique.

RESULTS

All procedures were uneventful, with no intraoperative or postoperative complications. Suture fixation effectively prevented anterior-posterior or propelling movement. The ACIOLs in all cases were stable and well centered at the end of follow-up.

CONCLUSIONS

Fixation of an existing unstable angle-supported ACIOL to the iris is an effective and simple alternative to intraocular lens exchange and posterior chamber fixation.

New Management Strategies for Ectopia Lentis

Ectopia lentis refers to displacement of the crystalline lens in the setting of various systemic and metabolic disorders. A literature review was conducted to investigate the management of non-traumatic ectopia lentis in the pediatric population, particularly focusing on surgical intervention. Both limbal and pars plana approaches for lensectomy are well established in the literature. Surgical options for intraocular lens implantation in pediatric eyes with ectopia lentis include anterior chamber intraocular lenses and iris-fixated or scleral-fixated posterior chamber intraocular lenses. Recently, the use of capsular tension rings has also been described with promising results. Visual rehabilitation and treatment of amblyopia are essential for patients within the amblyogenic age group following surgical intervention.

Multiple methods of surgical treatment combined with primary IOL implantation on traumatic lens subluxation/dislocation in patients with secondary glaucoma

AIM

To describe clinical findings and complications from cases of traumatic lens subluxation/dislocation in patients with secondary glaucoma, and discuss the multiple treating methods of operation combined with primary intraocular lens (IOL) implantation.

METHODS

Non-comparative retrospective observational case series.

PARTICIPANTS

30 cases (30 eyes) of lens subluxation/dislocation in patients with secondary glaucoma were investigated which accepted the surgical treatment by author in the Ophthalmology of Xi'an No.4 Hospital from 2007 to 2011. According to the different situations of lens subluxation/dislocation, various surgical procedures were performed such as crystalline lens phacoemulsification, crystalline lens phacoemulsification combined anterior vitrectomy, intracapsular cataract extraction combined anterior vitrectomy, lensectomy combined anterior vitrectomy though peripheral transparent cornea incision, pars plana lensectomy combined pars plana vitrectomy, and intravitreal cavity crystalline lens phacofragmentation combined pars plana vitrectomy. And whether to implement trabeculectomy depended on the different situations of secondary glaucoma. The posterior chamber intraocular lenses (PC-IOLs) were implanted in the capsular-bag or trassclerally sutured in the sulus decided by whether the capsular were present.

MAIN OUTCOME MEASURES

visual acuity, intraocular pressure, the situation of intraocular lens and complications after the operations.

RESULTS

The follow-up time was 11-36mo (21.4±7.13). Postoperative visual acuity of all eyes were improved; 28 cases maintained IOP below 21 mm Hg; 2 cases had slightly IOL subluxation, 4 cases had slightly tilted lens optical area; 1 case had postoperative choroidal detachment; 4 cases had postoperative corneal edema more than 1wk, but eventually recovered transparent; 2 cases had mild postoperative vitreous hemorrhage, and absorbed 4wk later. There was no postoperative retinal detachment, IOL dislocation, and endophthalmitis.

CONCLUSION

To take early treatment of traumatic lens subluxation/dislocation in patients with secondary glaucoma by individual surgical plan based on the different eye conditions would be safe and effective, which can effectively control the intraocular pressure and restore some vision.

Endoscopic ophthalmic surgery of the anterior segment

We summarize the uses of anterior segment endoscopic techniques and the basic science and technology of endoscopic cyclophotocoagulation (ECP) as compared with transscleral cyclophotocoagulation. This is followed by an analysis of patient selection for ECP, a description of surgical techniques, and clinical results. In addition, the ophthalmic endoscope has other uses in anterior segment surgeries. We discuss the techniques for these endoscope-assisted surgeries.

Scleral fixation of a one-piece toric intraocular lens

PURPOSE

To describe a novel technique for toric intraocular lens (IOL) repositioning and fixation in the absence of adequate capsular support.

METHODS

Case report and literature review.

RESULTS

Two cases are presented with scleral fixation of a one-piece toric IOL (SN6AT series; Alcon Laboratories, Inc., Fort Worth, TX). In both cases, toric IOLs initially placed within the capsular bag became decentered due to poor capsular support. To avoid the potential complications of lens explantation and maintain the astigmatic benefits of the toric IOL, scleral fixation of the lenses was performed. The Hoffman technique was used to create reverse scleral pockets without conjunctival dissection. A 10-0 non-dissolvable suture was used to capture and then secure the lens haptics in a lasso-type fashion. Sutures were then buried within the previously created scleral pockets. Both patients had well-centered lenses postoperatively that remained stable at last follow-up, 30 months postoperatively.

CONCLUSION

In the absence of adequate capsular support, scleral fixation is a viable option for one-piece toric IOL fixation to avoid IOL explantation.

Management of subluxated lens in young patients

OBJECTIVES

To evaluate visual outcomes in patients treated for lens subluxation. Secondary objectives are to report best corrected visual acuity (BCVA) in LogMAR and compare the outcomes of patients managed conservatively with those treated surgically.

METHODS

Retrospective comparison of BCVA in patients under 50 years-old with lens subluxation, managed conservatively or surgically.

RESULTS

A total of 49 eyes of 28 patients were included. Demographic characteristics were similar in both groups. Twenty eyes were treated surgically (40.8%) compared to 29 with medical treatment (59.2%). Marfan syndrome (79.6%) was diagnosed in 39 eyes. LogMAR BCVA post intervention was 0.35±0.31 for medical treatment and 0.39±0.32 for the surgical group, with no significant differences (P=.63). Improvements in LogMAR lines were 2.7±4.2 and 4.11±4.2 (P=.35), respectively. Two eyes in the surgery group developed ocular hypertension (0.04%), none with retinal detachment.

CONCLUSIONS

The final BCVA showed no significant differences in this group of patients. BCVA depends on the visual potential of the rehabilitated eye rather than a specific type of intervention.

Vitreous hemorrhage in children and adolescents in India

PURPOSE

To report the clinical profile, etiologies, treatment modalities, and outcomes for vitreous hemorrhage in patients <18 years of age in India.

METHODS

The medical records of patients presenting with vitreous hemorrhage between January 2000 and January 2010 were retrospectively reviewed.

RESULTS

A total of 261 eyes of 246 patients (201 males) were included. Of these patients, 231 (94%) were unilateral. Trauma was the leading cause of injury in 179 eyes (68.5%); blunt trauma was more common than penetrating trauma in both males (64.7%) and females (57.7%). Wooden sticks were the most common cause of trauma (20.7%). Spontaneous causes accounted for 82 (31.5%) eyes, including 33 eyes (40%) with Eales disease, and 16 eyes (19.7%) with sequelae of retinopathy of prematurity. Trauma was most common cause of vitreous hemorrhage in all age groups, except in children <4 years of age, in whom spontaneous hemorrhage predominated. Overall, the most common management was surgery, performed in 173 (66.2%) eyes; 63 (24.1%) eyes were observed. Male sex, age >8 years, unilateral presentation, surgical treatment (P < 0.001), and blunt trauma (P = 0.047) were associated with severe visual loss. Mean follow-up was 636.5 ± 802.0 days overall, 597.0 ± 749.0 days for eyes observed and 638.8 ± 802.6 days for eyes that underwent surgery.

CONCLUSIONS

Posttraumatic vitreous hemorrhage comprises almost two-thirds of children and adolescents presenting with vitreous hemorrhage. Blunt trauma is more common than penetrating trauma. Male sex, age >8 years, unilateral presentation, and surgical treatment were all significantly associated with severe visual loss.

Anterior chamber intraocular lens, sutured posterior chamber intraocular lens, or glued intraocular lens: where do we stand?

PURPOSE OF REVIEW

To review the recent literature addressing the surgical approaches to intraocular lens (IOL) fixation in the setting of inadequate capsular support.

RECENT FINDINGS

Lack of capsular support is a commonly encountered problem facing the anterior segment surgeon. Recent reports suggest that visual outcomes are generally good with modern IOLs and surgical approaches. More recently described techniques include sutureless scleral fixation and intraocular endoscopy-guided suture placement.

SUMMARY

Many clinical circumstances require extracapsular IOL fixation and multiple options exist in the setting of inadequate capsular support. Ultimately, there are many factors that must be considered in selecting an appropriate surgical approach. These include ocular history as well as the skill, experience, and comfort level of the individual surgeon. The myriad of options that now exist for IOL fixation increases the likelihood that patients with a wide variety of pathologic states will attain their best possible visual outcome.