IOL scaffold technique for posterior capsule rupture

[Optimization of phacoemulsification technique for Morgagnian cataract]

PURPOSE

This study was conducted to develop a new optimized phacoemulsification technique for Morgagnian cataract taking into account the anatomical and topographic parameters of the lens nucleus.

MATERIAL AND METHODS

A working classification of Morgagnian cataract was developed based on the size of the nucleus: if the edge of the nucleus is visualized at the upper edge of the pupil or between the upper edge and the middle of the pupil, it was classified as an initial stage of Morgagnian cataract with a large nucleus; if the upper edge of the nucleus is visualized in the middle of the pupil and below, it was classified as an advanced stage of Morgagnian cataract with a small nucleus. The first group included six patients who underwent surgery using the scaffold technique with removal of the whole small nucleus into the anterior chamber. The second group included 11 patients who underwent surgery using the scaffold technique with removal of the last fragment of the nucleus into the anterior chamber.

RESULTS

The use of the scaffold technique with removal of the nucleus into the anterior chamber helped reduce the number of intraoperative complications to 16.7% in the first group, compared to 27.3% in the second group, and the percentage of endothelial cell loss to 10.1% in the first group, compared to 10.7% in the second group.

CONCLUSIONS

The anatomical and topographic features of the lens and the anterior segment of the eye in Morgagnian cataract with a small nucleus allow for preliminary implantation of an intraocular lens into the capsular bag to protect the posterior capsule during phacoemulsification of the nucleus with minimal mechanical, hydrodynamic and acoustic damage to the surrounding structures of the eye.

Intraocular lens scaffolding technique in hypermature/Morgagnian cataract in manual small-incision cataract surgery

PURPOSE

To describe the surgical technique of intraocular lens (IOL) scaffolding in hypermature/Morgagnian cataract in manual small-incision cataract surgery (MSICS).

SETTING

Charitable section of the hospital through direct availed services at free/subsidized cost.

DESIGN

Interventional study.

METHODS

38 eyes of 38 patients operated at the charitable section of the hospital through direct availed services at free/subsidized cost were included in this study.

RESULTS

IOL scaffolding in MSICS was executed in 38 patients, of whom 25 patients were diagnosed as hypermature cataract, pseudoexfoliation syndrome with mature cataract in 5 patients, 5 patients had phacolytic glaucoma, and 3 patients had lens-induced uveitis. This technique was successful in 35 of 38 patients and was not successful in 3 patients in whom traditional SICS was performed in 2 patients and retrohaptic iris fixation in 1 patient.

CONCLUSIONS

A technique that uses the IOL as a scaffold in hypermature cataract in MSICS that provides a stable barrier by stretching the capsular bag to prevent the crumpling of the bag or whole bag removal after nucleus delivery is described.

Capsular tension ring assisted phacoemulsification of morgagnian cataract

Purpose:

To describe a novel technique of phacoemulsification in morgagnian cataract using capsular tension ring (CTR).

Methods:

This was a retrospective, non-comparative, clinical interventional study. Patients with hypermature morgagnian cataract who had undergone CTR-assisted phacoemulsification were included in the study. After capsulorhexis, CTR was inserted in a clockwise manner to stabilize the capsular bag in each case. Phacoemulsification was then performed using either horizontal chopping or vertical chopping. We have used the CTR in these cases without any obvious lens subluxation in order to perform safe emulsification of the nuclear pieces in the capsular bag. We have performed the procedure successfully in eleven eyes with hypermature morgagnian cataract.

Results:

The mean corrected distance visual acuity (CDVA) improved from 2.62 ± 0.25 Log MAR to 0.35 ± 0.28 Log MAR at 3 months postoperatively (P = 0.00008). Total nine out of 11 patients gained CDVA of 20/40 or better at 3 months postoperatively. No intraoperative complications such as posterior capsular rupture, zonular dialysis, iris trauma, vitreous loss were noted. The mean endothelial cell loss was 148.82 ± 41.52 cells/mm² after 3 months of surgery.

Conclusion:

The main culprit for intraoperative complications during phacoemulsification in a morgagnian cataract is the vulnerable capsular bag. Following insertion of a CTR after capsulorhexis, the bag becomes stable and the subsequent steps of the surgery become uneventful, thereby, preventing any further complications.

[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.

Clinical outcomes of management of posterior capsule rupture with air bubble techniques

AIM

To introduce a new surgical technique, air-bubble technique for the management of posterior capsule rupture (PCR) and to evaluate the safety and efficacy of the technique.

METHODS

A retrospective case series analysis of 24 eyes of 24 patients, in which the air bubble technique was used for the management of PCR, was performed. Once PCR occurred, a dispersive ophthalmic viscosurgical device (OVD) was injected into the tear. And small volumes (0.2-0.3 mL) of air bubbles were injected beneath the OVD. The air bubble served as a physical barrier and supported the posterior capsule.

RESULTS

After surgery, none of the patients had serious complications during the follow-up period of 1y. Extension of the PCR size occurred in only 2 cases, and additional OVD injection was required only in 3 cases. Air bubbles imparted great stability to the nuclear pieces and the posterior capsule.

CONCLUSION

The air-bubble technique may be considered a safe and effective procedure for managing a PCR. It may be of value to the inexperienced cataract surgeon.

"Crack, Reduce, and Implant": A Safe Phaco Technique in a Case with Hard Brown Cataract

This report describes two maneuvers in different steps of phaco surgery in a case with hard cataract, which provide debulking of the central dense nucleus and prevents posterior capsule rupture (PCR). In the current case, clear corneal incisions were created, and anterior chamber was filled with ophthalmic viscosurgical device (OVD). Anterior capsule was punctured, and capsulorhexis was completed. Nucleus was cracked into two halves following vertical groove formation. Core nucleus was hollowed sideward bilaterally in the capsular bag. Nuclear halves were removed from capsular bag, and each one was pushed to one side on the iris plane. Capsular bag was inflated with OVD, and intraocular lens (IOL) was implanted. Nuclear halves were removed in confidence. The presented maneuvers initially reduce dense nucleus load in the safe zone and allow surgeon to use IOL as a barrier to protect floppy posterior capsule from early steps of the surgery.

Femtosecond Laser-Assisted Intraocular Lens Fragmentation: Low Energy Transection

PURPOSE

To describe a case of femtosecond laser-assisted hydrophobic intraocular lens transection.

METHODS

Case report.

RESULTS

Femtosecond laser-assisted transection of a one-piece acrylic hydrophobic intraocular lens for explantation via a small surgical incision was successfully performed with low energy parameters.

CONCLUSIONS

This case illustrates a novel and effective clinical application of the femtosecond laser. [J Refract Surg. 2017;33(9):646-648.].

Glued intrascleral haptic fixation of an intraocular lens

Glued intrascleral haptic fixation of an intraocular lens (glued IOL) has evolved as a technique with various modifications that are adopted and practiced by several surgeons. With adequate and appropriate haptic tuck, glued IOL imparts a stable IOL fixation and is a secured method of secondary IOL placement with no pseudophacodonesis.

Intraocular lens exchange-removing the optic intact

Current practice for intraocular lens (IOL) exchange is to cut the optic of the posterior chamber intraocular lens (PCIOL) prior to removing it. Great care must be taken during this maneuver to avoid a posterior capsular tear. Removing the haptics from the fibrosed capsule can also be hazardous, as it may result in zonular stress and dehiscence. A technique is described for performing foldable (one-piece acrylic) IOL removal without cutting the optic. Careful visco-dissection of the haptics with a low viscosity ophthalmic viscosurgical device (OVD) in the fibrosed peripheral capsular tunnel avoids zonular or capsular stress. Internal wound enlargement permits foldable IOL removal in one piece, whilst preserving a self-sealing sutureless corneal wound. This technique may enhance the safety and efficacy of foldable IOL exchange.

Optic surface changes in Intraocular lens scaffold: An ex vivo study

PURPOSE

We aimed to assess the micro injuries on the intraocular lens (IOL) optic in the IOL scaffold technique by ex vivo study.

SETTING

This study was conducted at the Tahira Research Laboratory, Dr Agarwal's Eye Hospital and Eye Research Centre, Chennai.

DESIGN

This was an experimental study.

METHODS

IOL scaffold technique was simulated in 12 caprine eyes with moderate lens changes using 12 IOLs (six acrylic hydrophilic and six polymethyl methacrylate IOL) in experimental set up. IOLs (6 mm optic diameter) were explanted from the caprine eyes immediately after the surgery and examined under light microscopy and phase contrast microscopy for anterior and posterior optic changes, and again after 24 hours. Scanning electron microscopy (SEM) was performed in IOLs with abnormalities. Two IOLs placed in caprine eyes that did not undergo scaffold procedure acted as controls. A trocar anterior chamber maintainer was used in four eyes.

RESULTS

Four out of 12 IOLs showed mark defects on the surface in mid periphery. Linear mark defects measured IOL 1 (190 μm), IOL 6 (18 μm), IOL 2 (2.33 μm, 2.3 μm, 14 μm, 14 μm) and IOL 5 (12 μm). The marks do not change after 24 hours. There were no mark defects (micro abrasions or scratches) seen on any of the IOL's in the central 4 mm of the optic anterior surface. The control IOLs showed no surface changes. The pre-experiment mark defects (n = 0) in study IOLs changed to post-experiment (n = 7), with no statistical significance obtained (p = 0.059).

CONCLUSION

IOL scaffold technique can cause microscopic optic surface changes seen as linear marks defects in the mid periphery and intraoperative fluid maintenance can reduce its incidence.

INTRAOCULAR LENS SCAFFOLD TO PREVENT INTRAOCULAR FOREIGN BODY SLIPPAGE

PURPOSE

To report the application of intraocular lens (IOL) scaffold technique in intraocular foreign body (IOFB) removal.

METHODS

Patient with IOFB in posterior segment is included. The IOFB is retrieved from the posterior segment (pars plana vitrectomy and exteriorization of the IOFB from the retinal surface using an intravitreal forceps via the posterior capsulotomy) and placed on the iris. A three-piece posterior chamber IOL is placed in the sulcus via the clear corneal incision. IOFB is then removed from the anterior chamber over the IOL by forceps.

RESULTS

Metallic IOFB of 4 mm × 3 mm has been retrieved by IOL scaffold technique after rescuing it from the posterior segment. There has been no drop or slip of IOFB in the vitreous during removal. Posterior chamber IOL served as scaffold during IOFB removal from anterior chamber.

CONCLUSION

The IOL scaffold maneuver has shown to prevent slippage by acting as a barrier between the IOFB and the vitreous.

Clinical outcomes of pars plicata anterior vitrectomy: 2-year results

Purpose:

To demonstrate the safety and outcome of a surgical approach that uses pars plicata site for anterior vitrectomy during phacoemulsification procedure complicated by posterior capsule rupture and residual cortical matter.

Design:

Single center, retrospective, interventional, noncomparative study.

Materials and Methods:

Medical records of a consecutive series of 35 eyes of 35 patients who underwent pars plicata anterior vitrectomy (PPAV) were reviewed. The main outcome measures were corrected and uncorrected distance visual acuity (CDVA, UDVA), early and late postoperative complications and intraocular pressure (IOP). Ultrasound biomicroscopic (UBM) evaluation of sclerotomy site and spectral domain optical coherence tomography analysis for central macular thickness (CMT) was performed. The final visual outcome at 2 years was evaluated.

Results:

At 2 years follow-up, the mean postoperative UDVA (logarithm of the minimum angle of resolution [logMAR]) and CDVA (logMAR) was 0.49 ± 0.26 and 0.19 ± 0.14, respectively. There was no significant change in the IOP (P = 0.061) and the mean CMT at 2 years was 192.5 ± 5.54 μm. The postoperative UBM image of the sclerotomy site at 8 weeks demonstrated a clear wound without any vitreous adhesion or incarceration. Intraoperative hyphema was seen in 1 (2.8%) case and postoperative uveitis was seen in 2 (5.7%) cases, which resolved with medications. No case of an iatrogenic retinal break or retinal detachment was reported.

Conclusions:

PPAV enables a closed chamber approach, allows thorough cleanup of vitreous in the pupillary plane and anterior chamber and affords better access to the subincisional and retropupillary cortical remnant with a significant visual outcome and an acceptable complication rate.

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.

Clinical outcomes of sleeveless phacotip assisted levitation of dropped nucleus

BACKGROUND/AIM

To demonstrate the feasibility of a sleeveless phacotip-assisted approach to levitate dropped nucleus.

METHODS

This single-centre, retrospective, interventional, non-comparative case series reviewed the medical records of 34 eyes of 34 patients. Corrected and uncorrected distance visual acuity (CDVA, UDVA), early and late postoperative complications and ultrasound biomicroscopic (UBM) evaluation of the sclerotomy site was analysed.

RESULTS

At 18 months follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.42 ± 0.16 and 0.91 ± 0.2, respectively. There was a significant improvement in the UDVA (p=0.001) and CDVA (p=0.002). Nucleus drop occurred following intraoperative posterior capsular rupture in 25 eyes (73.5%), zonular weakness in 5 eyes (14.8%) and post-trauma in 4 eyes (11.7%). In the early postoperative period, corneal oedema was seen in 2 eyes, pigment dispersion in 3 eyes and vitritis in 2 eyes. There was loss of CDVA in 1 (2.9%) eye due to persistent cystoid macular oedema. UBM did not reveal any vitreous incarceration into the sclerotomy site.

CONCLUSION

Dropped nucleus was successfully levitated into anterior chamber with this technique, resulting in a significant visual outcome with a favourable complication rate.

Clinical outcomes of intraocular lens scaffold surgery: a one-year study

PURPOSE

To evaluate the safety and 1-year outcome of the intraocular lens (IOL) scaffold technique in eyes with soft to moderate nuclear remnants after intraoperative posterior capsule rupture (PCR).

DESIGN

Single-center, retrospective, interventional, noncomparative, consecutive case series.

PARTICIPANTS

A total of 20 eyes of 20 patients who had intraoperative PCR underwent IOL scaffold surgery in a tertiary clinic.

METHODS

A retrospective analysis of medical records of a consecutive series of patients who underwent IOL scaffold surgery from August 2011 to February 2013 was reviewed. All surgeries were performed by a single surgeon, and a 3-piece, 6.0-mm optic, acrylic, foldable IOL with a modified C-loop haptic configuration was implanted in all eyes.

MAIN OUTCOME MEASURES

The preoperative and postoperative parameters evaluated were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), specular microscopy, gonioscopy, ultrasound biomicroscopy, central macular thickness, intraocular pressure (IOP), and anterior and posterior segment inflammation. The final visual outcome at 1 year was evaluated.

RESULTS

At 1-year follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.58 ± 0.15 and 0.90 ± 0.17, respectively. The IOL was placed in the sulcus for 14 eyes and in the capsular bag for 3 eyes, and glued intrascleral fixation of IOL was performed in 3 eyes. The mean postoperative refractive error at the final examination was -0.4 ± 0.05 diopter (standard error of mean). Postoperative CDVA of 20/20 and 20/30 was achieved in 75% (15 eyes) and 25% (5 eyes), respectively. There was no correlation between preoperative specular count and percentage loss of cells (P = 0.602; r(2)=0.015). The mean central macular thickness at 1 year was 182.5 ± 11.79 μm. Clinical macular edema was observed in 1 of 20 eyes (5%).

CONCLUSIONS

The IOL scaffold provided an effective, relatively noninvasive means of emulsifying moderate to soft nuclear remnants in eyes with intraoperative PCR, with a good visual outcome and a favorable complication rate.