Glued endocapsular hemi-ring segment for fibrin glue-assisted sutureless transscleral fixation of the capsular bag in subluxated cataracts and intraocular lenses

Safety and efficacy of capsular tension ring and capsular hook implantation for managing ectopia lentis in Marfan syndrome: real-world study

PURPOSE

To evaluate the safety and efficacy of capsular tension ring and capsular hook (CTR-CH) implantation in Marfan syndrome (MFS) patients with ectopia lentis (EL).

SETTING

Eye and ENT Hospital of Fudan University, Shanghai, China.

DESIGN

Retrospective propensity score-matched cohort study.

METHODS

This study included patients with MFS who had in-the-bag intraocular lens (IOL) implantation assisted by CTR-CH or modified CTR (MCTR). The safety analysis focused on the resurgery rate. The efficacy analysis compared the corrected distance visual acuity (CDVA) and the incidence of laser capsulotomy after propensity score matching (PSM).

RESULTS

This study encompassed 148 eyes that had the CTR-CH procedure and 162 eyes that received MCTR implantation. In the CTR-CH group, the median age at the time of surgery was 5 years, with a mean follow-up duration of 1.81 ± 0.4 years. 5 eyes (3.38%) required a second surgery because of retinal detachment (2, 1.35%), IOL decentration (2, 1.35%), and CH dislocation (1, 0.68%). The resurgery rate was comparable with that of the MCTR group ( P = .486). After PSM, a total of 108 eyes were recruited in each group. Postoperative CDVA was significantly improved in both groups (both P < .001), but comparable between the groups ( P = .057). The posterior capsular opacification took place earlier ( P = .046) while the anterior capsular opacification required laser capsulotomy at a later stage ( P = .037) compared with the MCTR group.

CONCLUSIONS

The CTR-CH procedure was a feasible, safe, and efficient approach for managing EL in patients with MFS.

Novel trocar assisted intraocular lens and capsular bag complex fixation

PURPOSE

To describe the innovative technique of trocar-assisted intraocular lens (IOL) and capsular bag complex fixation.

METHODS

In this technique, initial pupil dilatation is achieved either with intracameral adrenaline or with the help of iris hooks. Automated anterior vitrectomy is performed in cases with vitreous prolapse. A 25 G trocar cannula is placed at the limbus through a paracentesis opposite the zonular dialysis area. The cannula lumen act as a guide to pass the double-arm polypropylene suture attached to the needle. This prevents any inadvertent corneal injury and acts as a perpendicular tract to pass the needle through IOL capsular bag complex.

RESULTS

We performed this technique in 9 cases with an excellent outcome with a minimum of 3 months of follow-up. All patients had well-centred IOL. There was no incidence of corneal injury, Descemet membrane detachment, iris trauma, IOL tilt, decentration, dislocation, vitreous prolapse or retinal detachment. All patients achieved excellent visual acuity ranging from 6/12-6/6 postoperatively.

CONCLUSION

The novel trocar-assisted IOL bag complex fixation technique is very effective and allows smooth IOL fixation in technically challenging cases with IOL subluxation. The trocar acts as a guide to prevent injury to the surrounding tissue, and IOL fixation is achieved with minimal manipulations in the anterior chamber. It also prevents the need for IOL explantation in these cases.

Flanged iris hook for capsular bag stabilization

A new surgical technique was demonstrated for fixating the capsular bag to the sclera using a capsular tension segment (CTS) and a flanged iris hook. In a patient with a 180-degree zonular dialysis, a capsular tension ring was implanted into the capsular bag, and a CTS was placed into the zonular dialysis area after cataract removal. Then, an iris hook was directed to the anterior chamber through a side port opposite the zonular dialysis area. After the hook tip was placed into the eyelet of the CTS, a 30-gauge injector was used to guide the hook tip out. Tension was adjusted to ensure the capsular centralization, and a flange was created using cautery. Finally, the procedure was completed by embedding the flange into the sclera. This method is simple, minimally invasive, and time-saving by eliminating the scleral suturing, scleral flaps, or large conjunctival dissections.

[Optimization of phacoemulsification in complicated cataract with lens subluxation]

Purpose - to optimize the process of phacoemulsification in patients with cataract complicated by degree I-II lens subluxation by using the scaffold technique, and to determine the indications for its application.

MATERIAL AND METHODS

The patients were divided into two groups: group 1 - the main group - included 29 patients (29 eyes; 47.54%) who underwent cataract phacoemulsification with implantation of iris retractors and capsular ring using the scaffold technique. Group 2 - the comparison group - included 32 patients (32 eyes; 54.46%) who underwent cataract phacoemulsification with implantation of iris retractors and capsular ring using standard technique.

RESULTS

Patients' visual acuity improved up to 0.53 (0.35; 0.80) in group 1, and up to 0.50 (0.45; 0.80) in group 2 by the time of hospital discharge. At 6 months and 1 year follow-ups, visual functions were equal, in group 1 - 0.70 (0.65; 0.80), in group 2 - 0.70 (0.60; 0.90). The number of intraoperative complications decreased from 8.20% in standard phacoemulsification to 1.64% in scaffold technique. The latter reduces endothelial cell loss by 1.95% in comparison with traditional phacoemulsification over 1 year follow-up. With the scaffold technique, the number of intraoperative complications decreased from 15.63% in group 2 to 3.45% in group 1, the number of postoperative complications - from 43.75% to 31.04%, respectively.

CONCLUSION

The scaffold technique is indicated in pseudoexfoliation syndrome with weakness of zonular apparatus, degree I-II lens subluxation, in hard nucleus with absence of posterior cortical layer, in intumescent cataract, Morgagnian cataract to stabilize the posterior capsule and protect it from rupture.

Evaluation of the Utility of Capsular Stabilization Devices in a Zonular Fiber Defect Model with the Slit Side View System

Capsular stabilization devices were evaluated in a zonular fiber defect model using the slit side view (SSV) system to confirm their utility for capsular stabilization during phacoemulsification. A zonular fiber defect model was made by cutting Zinn’s zonule under observation with a slit lamp microscope in a porcine eye. Phacoemulsification was performed, and the movement of the lens capsule and the depth of the anterior chamber were observed using the SSV in three groups: control group: no surgical instruments used, CE group: a capsule expander was inserted, and CTR group: a capsular tension ring was inserted. In the control group, the equator of the lens was unstable and was easily suctioned to the port of the ultrasound handpiece. The lens capsule was stable in both in the CE and CTR groups. In the CTR group, the equator responsible for the zonular rupture also returned and closed true to its original position. The utility of the capsular stabilization devices in this zonular fiber defect model was confirmed with the SSV system.

Scleral fixation of intraocular lenses

PURPOSE OF REVIEW

To review current, effective and more popular techniques for scleral fixation of intraocular lens (IOLs) and IOL-capsular bag complex.

RECENT FINDINGS

Scleral fixation of IOLs became popular, originally with sutured scleral fixated IOLs and later the Scharioth technique of intrascleral haptic fixation. This was further developed as the Glued IOL technique which enjoys widespread adoption all over the world. Recently the Yamane technique has also become popular and is being widely adopted as well.

SUMMARY

Scleral fixated IOLs have evolved in the last 2 decades with technical modifications, extended indications and improvised instrumentation. Though sutured and sutureless techniques have been growing equally, the sutureless scleral fixation techniques have attracted special interest. Reduced suture-related complications, technical ease and high-quality functional outcomes may be possible reasons. Sutureless capsular bag fixation also has distinct advantages.

Management of subluxated capsular bag-fixated intraocular lenses using a capsular anchor

We describe the use of the capsular anchor (AssiAnchor) to manage a subluxated intraocular lens (IOL) in the capsular bag. The anchor comprises 2 prongs that hold the anterior lens capsule and a central rod that is sutured to the scleral wall, enabling centration of the IOL-capsular bag complex. Six pseudophakic patients presenting with subluxated posterior chamber IOLs in the capsular bag were operated on using the device. The anchor was used successfully in all cases, although in 2 cases only 1 prong was placed under the capsulorhexis edge. In 1 eye, 2 anchors were used 1 month apart following repeated traumatic zonular injury. The capsular bag holding the IOL remained centered and stable throughout the follow-up period. The anchoring device, which was originally designed to preserve the lens capsule and stabilize subluxated crystalline lenses, can also be used to treat subluxation of a capsular bag-fixated IOL.

FINANCIAL DISCLOSURE

Dr. Assia is the inventor of the AssiAnchor, has a licensed patent of the anchor, and is consultant to Hanita Lenses. Dr. Lapid-Gortzak is a consultant to and speaker for Alcon Surgical, Inc., Hanita Lenses, Orca Surgical, and Sanoculis Ltd.; a speaker for Santen; and a consultant to Icon. Drs. Ton and Naftali have no financial or proprietary interest in any material or method mentioned.

Modified sewing machine technique for iridodialysis repair, intraocular lens relocation, iris coloboma repair, Cionni ring fixation, and scleral-fixated intraocular lens

The purpose of this study is to report the modification of sewing machine technique for iris dialysis repair (MSMT) and its usefulness in managing other conditions such as intraocular lens (IOL) subluxation, iris coloboma, Cionni ring for zonular dialysis, and for scleral-fixated IOL. MSMT was based on sewing machine principle using a prethreaded 26G/30G needle with prolene suture for minimally invasive iris dialysis repair in a closed chamber manner. So far, eight patients (trauma - 3, surgical complication - 5) underwent this procedure. This technique is further modified to extend its use for IOL relocation - 2, iris coloboma repair - 3, and Cionni ring fixation for zonular dialysis - 2, SFIOL - 5 patients. All 20 patients had good visual recovery and cosmetic outcome with minimal morbidity. To conclude, MSMT offers cost -effective, minimally invasive, easy to learn procedure with a potential to tackle several problems related with cataract surgery and iris defects, which even an average cataract surgeon can learn to perform when required. Further comparative studies with conventional techniques with large sample size are required to standardize this procedure.

[Study of the results scleral-fixated intraocular lenses in the absence of capsular support]

INTRODUCTION

In the absence of sufficient capsular support, scleral fixation of the intraocular lens is an interesting alternative. The goal is to evaluate this implantation technique when traditional implantation is impossible.

PATIENTS AND METHODS

This is an observational, retrospective, monocentric study at the Amiens university medical center between August 2013 and March 2016. Patients all underwent scleral fixation of a three-piece implant without suturing of the haptics, after posterior vitrectomy. All patients requiring implantation in the absence of stable capsular support were included. Patients with adequate iris or capsular support were excluded from our study.

RESULTS

Eighteen patients were included, with an average age of 69.3±16.9 years. The surgical indications were: complicated surgery, trauma and endothelial decompensation. The preoperative mean corrected visual acuity was 1.2±0.4 LogMAR while the postoperative acuity was 0.7±0.5 LogMAR. The mean postoperative corneal astigmatism was 1.9±1.9 diopters. The main complications observed were ocular hypertension, macular edema, retinal detachment, iris incarceration and exteriorization of the haptic.

DISCUSSION

There are two alternatives when faced with lack of a sufficient capsular support: scleral fixation or iris fixation. Our technique is the only one achievable in the presence of iris atrophy. Furthermore, it induces less astigmatism and enables the repositioning of a three-piece implant dislocated into the vitreous.

CONCLUSION

Scleral fixation is a technique allowing both a satisfactory and a lasting functional result and is to be considered when faced with a lack of sufficient capsular support.

Intrascleral IOL Fixation

Intrascleral sutureless intraocular lens (IOL) fixation utilizes direct haptic fixation within the sclera in eyes with deficient capsular support. This has advantages of long-term stability, good control of tilt and decentration, and lesser pseudophakodonesis. This review summarizes various techniques for intrascleral haptic fixation, results, complications, adaptations in special situations, modifications of the technique, combination surgeries, and intrascleral capsular bag fixation techniques (glued capsular hook).

Subluxated cataract lens surgery using sutured segments or rings and implantation of toric intraocular lenses

PURPOSE

To evaluate the intraoperative performance and postoperative outcomes of toric intraocular lens (IOL) with suture ring implantation in adult patients with subluxated lenses.

SETTING

Department of Ophthalmology, Kaiser Permanente, Santa Clara, California, and the Eye Institute of Utah, Salt Lake City, Utah, USA.

DESIGN

Retrospective case review.

METHODS

Eyes with subluxated cataractous lenses and preoperative corneal astigmatism having toric IOL implantation with a sutured ring or segment were studied. Preoperative and postoperative analyses included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and cylindrical power postoperatively and 3, 6, and 12 months postoperatively.

RESULTS

Twenty-one eyes of 15 patients were studied. The median follow-up was 14.6 months. The mean CDVA at the final follow-up (0.10 logMAR ± 0.15 [SD]) was significantly improved from the mean preoperative CDVA (0.73 ± 0.40 logMAR). Postoperative cylindrical power was significantly improved in all patients (mean reduction in astigmatism 2.37 ± 1.46 diopters). Patients who required postoperative enhancement had anterior laser capsulotomy for bilateral capsule phimosis (2 eyes), photorefractive keratectomy (1 eye), pupilloplasty (1 eye), and posterior laser capsulotomy (2 eyes).

CONCLUSION

Cataract removal and implantation of a toric IOL combined with a sutured ring or segment capsule stabilizing device was a safe and efficacious long-term solution for patients with subluxated cataract lenses and corneal astigmatism.

Ophthalmic use of blood-derived products

There is a wide spectrum of blood-derived products that have been used in many different medical and surgical specialties with success. Blood-derived products for clinical use can be extracted from autologous or allogeneic specimens of blood, but recombinant products are also commonly used. A number of blood derivatives have been used for a wide range of ocular conditions, from the ocular surface to the retina. With stringent preparation guidelines, the potential risk of transmission of blood-borne diseases is minimized. We review blood-derived products and how they are improving the management of ocular disease.

Modified capsule expander implantation to reposition and fixate the capsular bag in eyes with subluxated cataractous lenses and phacodonesis: intermediate-term results

PURPOSE

To report the intermediate-term results of capsule stabilization for scleral fixation with implantation of the Yaguchi hook, a modified capsule expander stabilization hook.

SETTING

Department of Ophthalmology, School of Medicine, University of Showa, Fujigaoka Rehabilitation Hospital, Yokohama, Japan.

DESIGN

Retrospective case series.

METHODS

Patients with zonular dialysis and phacodonesis were followed postoperatively for at least 2 years. All eyes had phacoemulsification and aspiration using an ordinary capsule expander and in-the-bag implantation of an intraocular lens (IOL). Capsule expanders were removed after the residual cortex was removed, and the capsular bag was fixated to the scleral wall via the ciliary sulcus using the modified capsule expander stabilization hook. Preoperative findings, intraoperative complications, and postoperative courses were examined.

RESULTS

The mean age of the 11 patients (11 eyes) was 72.2 years ± 10.5 (SD); 5 patients were men. The mean postoperative follow-up was 48.6 ± 13.6 months. The zonular dialysis range was 90 to 180 degrees in 1 eye, 180 degrees in 4 eyes, and 180 to 270 degrees in 1 eye. In 5 eyes, severe phacodonesis was observed without obvious zonular dialysis. In all eyes, the capsular bag and IOL were well centered without severe intraoperative or postoperative complications.

CONCLUSION

The modified capsule expander stabilization hook provided good centration and stabilization of the capsule-IOL complex in eyes with severely weak zonular fibers.

FINANCIAL DISCLOSURE

Dr. Yaguchi, who is the inventor of the modified capsule expander, has received financial support from Handaya, Tokyo, Japan. No other author has a financial or proprietary interest in any material or method mentioned.

Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive-a Laboratory and Clinical Perspective

Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care.