Combined transconjunctival sutureless three-port vitrectomy and scleral fixation of intraocular lens

Purpose The aim of this article is to describe an innovative and minimally invasive surgical technique for posterior vitrectomy combined with secondary intraocular lens implantation, using a sutureless scleral fixation Carlevale intraocular lens (I71 FIL SSF Carlevale lens. Soleko IOL Division, Italy). Methods The technique was conducted with only three transconjunctival sclerotomies and a corneal tunnel to perform intraocular lens explantation, posterior vitrectomy and Carlevale intraocular lens implantation. It is easier, quicker, and less invasive than the traditional technique with conjunctival peritomy, two scleral flaps and five sclerotomies. Results Surgery was performed uneventfully on three eyes of three patients. Two of them presented a luxation of the intraocular lens into the vitreous chamber, while one patient presented an intraocular lens subluxation. No complications were observed after a 5 to 8 months of follow-up. The intraocular lenses were well positioned, no conjunctival erosion was noted, and the intraocular pressure remained normal at all stages. Conclusions This is the first report of a combined procedure of IOL explantation, posterior vitrectomy and secondary IOL implantation using only three transconjunctival sclerotomies. This appears to be less invasive and it causes less discomfort to the patient. We suggest considering this technique in all those cases requiring a combined procedure in absence of a proper capsular support.

Managing intraocular lens dislocation with one-port pars plana vitrectomy under direct vision with microscope illumination

AIM: To describe a technique of managing intraocular lens (IOL) with deep dislocation in the vitreous cavity by performing pars plana vitrectomy (PPV) with only one pars plana incision under the direct illumination of the surgical microscope. METHODS: Patients who had in-the-bag or out-of-the-bag (spontaneous) IOL dislocation after uneventful phacoemulsification cataract extractions, with the dislocated IOL or IOL-capsular bag complex dropping completely into the vitreous since 2013 were included in our studies. The postoperative patients were followed up for 6mo. Detailed description of technique and retrospective description of eight typical cases were demonstrated in this study. RESULTS: A total of 40 surgeries were conducted using this technique. The main possible predisposing conditions included: post-vitrectomy, posterior capsule rupture or broken zonules, a history of ocular trauma, long axial length, secondary IOL implantation, chronic uveitis, retinitis pigmentosa and post-glaucoma surgery. In all eyes, the IOLs were successfully removed. No intraoperative or postoperative complications related to the procedures occurred. The preoperative corrected distance visual acuity (CDVA) ranged from 20/133 to 20/25, and at 6mo postoperatively, the CDVA was similar or the same. The intraocular pressure was all within the normal range. CONCLUSION: One-port PPV under direct vision with microscope illumination is a simple and safe surgical technique to managing IOL dislocation, which shortens the surgical time, and largely avoids surgical complications.

Supporting IOL’S in a Deficient Capsular Environment: The Tale of No “Tails”

Purpose. To evaluate the efficacy and safety of the following three distinct surgical procedures for secondary IOL implantation without capsular support: Iris-claw lens, flanged transscleral fixated IOLs (Yamane technique), and sutureless transscleral hook IOL fixation (Carlevale IOL). Materials and Methods. In this retrospective comparative study, three different sutureless IOL implantation techniques were compared in patients without any capsular support. Visual acuity and outcomes were analyzed in 24 eyes of 23 patients (14 male and 9 female). Study included 13 iris-claw lenses (Artisan Ophtec), 6 flanged transscleral fixated IOLs (Yamane technique using a MA60MA Alcon Inc IOL), and 5 transscleral Carlevale IOLS (Carlevale IOL, Soleko, Italy). Results. logMAR mean best-corrected visual acuity (BCVA) improved from 0.49 ± 0.19 to 0.19 ± 0.10 at three months after surgery p < 0.05 . Postoperative BCVA was similar in all three groups, and no intergroup difference was noted. Three eyes (12.5%) had a raised IOP >25 mmHg, 2 eyes (8%) presented a subluxated/dislocated IOL, 4 eyes (16%) had corneal edema longer than 7 days, 3 eyes (12.5%) had irregular pupil profile, 2 eyes (8%) had vitreous hemorrhage, 7 eyes had (29%) corneal astigmatism over 3 diopters, and one patient (4%) developed cystoid macular edema (CME). Conclusions. All three surgical procedures can be considered adequate to correct aphakia in patients without capsular support with significant improvement in visual acuity and low complication.

Commentary review: challenges of intraocular lens implantation for congenital cataract infants

As an indispensable part of congenital cataract surgery, intraocular lens (IOL) implantation in infantile patients has long-term positive impacts on visual rehabilitation, as well as postoperative complications inevitably. Timing of IOL implantation in infantile congenital cataract patients is not simply a point-in-time but a personalized decision that comprehensively takes age at surgery, risks of postoperative complications, and economic condition of family in consideration, and combines with choosing suitable IOL type and power. For infants with well-developed eyeballs and good systemic conditions, IOL implantation at six months of age or older is safe and effective. Otherwise, secondary IOL implantation may be a safer choice.

Prognostic Factors for Low Visual Acuity after Cataract Surgery with Vitreous Loss

Purpose. The purpose of this study is to find prognostic factors associated with low visual acuity in patients experiencing vitreous loss during cataract surgery. Methods. A retrospective, noncomparative, interventional, case study of patients experiencing vitreous loss during cataract surgery. Data collected included demographics, best corrected visual acuity (BCVA), axial length (AL), presence of ocular comorbidity affecting central vision, timing of intraocular lens (IOL) implantation, position of the implanted lens, and the presence of corneal sutures. Low visual outcome was defined as BCVA < 20/40. Results. Overall, 179 patients (60.3% males) with a mean age of 73 ± 12 years and axial length of 23.5 ± 1.3 mm with a mean follow-up of 12 ± 13 months were included. In multivariable logistic regression analysis, low visual outcome was independently associated with persisting postoperative complications (OR 6.25, 95% CI 1.378–30.9), preexisting ocular comorbidities (OR 4.45, 95% CI 1.1–18.00), and secondary intraocular lens (IOL) implant (OR 10.36, 95% CI 1.8–60.00). Conversely, pars plana vitrectomy (PPV) for dislocated fragments of lens material, age > 70 years, gender, axial length, degree of surgeon, corneal suturing, and anterior chamber lens implantation were not found to have significant associations with low visual outcomes ( P > 0.05 ). Conclusions. Low visual outcome after vitreous loss during cataract surgery was associated with ocular comorbidities, secondary IOL implantation, development of cystoid macular edema, and additional surgical complications.

Microperipheral Iridectomy for Troublesome Posterior Synechiolysis in Secondary Intraocular Lens Implantation

Purpose. To introduce an effective method for separating extensive posterior synechiae and those located under or adjacent to surgical incisions. Methods. Pediatric patients who had been subjected to cataract surgery and developed troublesome posterior synechiae requiring secondary intraocular lens (IOL) implantation were recruited. All patients underwent microperipheral iridectomy at the 12 o’clock position. Then, an ophthalmic viscosurgical device was injected into the posterior chamber through the iris fistula to mechanically separate the posterior synechiae, using scissors to cut robust posterior synechiae if necessary. The results of posterior synechiolysis and the position of the implanted IOL were analyzed. Results. Sixteen patients (median age, 51.56 months; range, 28–80 months) were included. The scope of posterior synechia in clock was 4.42 (range, 1–10). All troublesome posterior synechiae were successfully separated using the microperipheral iridectomy method, and all patients underwent IOL implantation in the ciliary sulcus. There was one case of peripheral iridectomy-related early intraoperative bleeding; no bleeding was observed at the end of surgery. Conclusions. Microperipheral iridectomy is a useful method for the management of troublesome posterior synechiae during secondary IOL implantation in pediatric patients, which makes secondary IOL implantation an easier and safer method in some challenging cases.

Secondary Piggyback Intraocular Lens for Management of Residual Ametropia after Cataract Surgery

Purpose: To investigate the indications, clinical outcomes, and complications of secondary piggyback intraocular lens (IOL) implantation for correcting residual refractive error after cataract surgery. Methods: In this prospective interventional case series, patients who had residual refractive error after cataract surgery and were candidates for secondary piggyback IOL implantation between June 2015 and September 2018 were included. All eyes underwent secondary IOL implantation with the piggyback technique in the ciliary sulcus. The types of IOLs included Sulcoflex and three-piece foldable acrylic lenses. Patients were followed-up for at least one year. Results: Eleven patients were included. Seven patients had hyperopic ametropia, and four patients had residual myopia after cataract surgery. The preoperative mean of absolute residual refractive error was 7.20 ± 7.92, which reached 0.42 ± 1.26 postoperatively (P < 0.001). The postoperative spherical equivalent was within ±1 diopter of target refraction in all patients. The average preoperative uncorrected distance visual acuity was 1.13 ± 0.35 LogMAR, which significantly improved to 0.41 ± 0.24 LogMAR postoperatively (P = 0.008). There were no intraor postoperative complications during the 22.4 ± 9.5 months of follow-up. Conclusion: Secondary piggyback IOL implantation is an effective and safe technique for the correction of residual ametropia following cataract surgery. Three-piece IOLs can be safely placed as secondary piggyback IOLs in situations where specifically designed IOLs are not available.

Clinical Profile and Visual Outcome of Pediatric Cataract Surgeries in West Malaysia

Purpose: We aim to describe the clinical profile and visual outcome of paediatric patients who underwent cataract surgery in a tertiary ophthalmology referral centre in West Malaysia from 2013 to 2018. Methods: This is a retrospective review of all paediatric patients who underwent cataract surgery in our centre from 2013-2018. Results: A total of 35 eyes from 23 patients were included. There were 10 (43.5%) female and 13 (56.5%) male patients. Twelve patients (24 eyes) had bilateral cataract while 11 patients had unilateral cataract. Sixteen (45.7%) eyes had congenital cataract, followed by ectopia lentis (n=10, 28.6%), traumatic cataract (n=8, 22.9%) and steroid induced cataract (n=1, 2.8%). Three types of intraocular lens (IOL) were implanted: which were posterior chamber IOL (n=22, 62.9%), iris claw IOL (n=12, 34.3%) and scleral-fixated IOL (n=1, 2.8%). Majority of eyes (n=28, 80%) had primary IOL implantation. Twenty-five (71.4%) eyes achieved best corrected visual acuity (BCVA) of 6/12 and better at 6 months post-IOL implantation. There was no statistically significant difference in the BCVA at 6 months post-IOL implantation among the different cataract aetiology, primary or secondary IOL implantation and types of IOL implant. Eight (22.9%) eyes developed post-operative complications, which included posterior capsular opacification (PCO) (n=6, 17.1%), IOL decentration (n=4, 11.4%) and glaucoma (n=1, 2.8%). Nineteen (82.6%) patients required glasses for visual rehabilitation. Conclusion: Majority of the paediatric cataract patients achieved BCVA of 6/12 or better at 6 months post-IOL implantation. The visual outcome among the different cataract aetiology, primary or secondary IOL implantation and types of IOL implanted were similar. PCO was the most common post-operative complication.

Nucleus Drop or Intraocular Lens Drop Underwent Pars Plana Vitrectomy due to Complication of Cataract Surgery

Background: The incidence of nucleus drop or intraocular lens (IOL) drop as the complication of phacoemulsification increases due to the increased frequency of phacoemulsification. Pars plana vitrectomy (PPV) followed by endofragmentation and secondary IOL implantation is the choice of procedure for management. This study aims to determine the frequency, outcomes, and complication of PPV in the case of nucleus drop or IOL drop in the Department of Ophthalmology, Fakultas Kedokteran Universitas Indonesia – Rumah Sakit Cipto Mangunkusumo (FKUI-RSCM) Methods: This study is a retrospective descriptive study conducted in the Vitreoretinal Division of the Department of Ophthalmology, FKUI - RSCM. Research data was taken from the medical records of all nucleus drop or IOL drop patients underwent PPV in January 2017-December 2017. Results: There were 19 cases studied. The incidence of nucleus drop occurred in phacoemulsification surgery techniques (94.7%) and ECCE techniques (5.3%). Vitrectomy surgery was performed ≤2 weeks in 31.6% and >2 weeks in 68.4% after the patient first arrived at the vitreoretinal clinic. Most pre-PPV visual acuity was 1/60-6/60 (47.1%). In the final follow-up, visual acuity improved from 6/45 to 6/6 occurred in 42.2% of cases. Complication after PPV and secondary IOL implantation include elevated IOP (10.5%), IOL decentration (5.3%), corneal decompensation (5.3%), macular edema (5.3%), and retinal detachment (5.3%). Conclusion: Nucleus drop or IOL drop generally occurs in phacoemulsification cataract surgery techniques. Improved visual acuity was achieved after PPV and secondary IOL implantation at the end of the follow-up period. Most common post-PPV complication is elevated IOP.

Comparison of the Techniques of Secondary Intraocular Lens Implantation after Penetrating Keratoplasty

Aim. To conduct a retrospective analysis of secondary IOL implantation in patients who underwent PK with no simultaneous IOL implantation. Materials and Methods. The retrospective study of the secondary implantation of IOLs was conducted in 46 eyes that underwent a primary operation with PK and cataract/lens extraction with no IOL implantation due to capsule rupture or combining corneal or intraocular complications. The minimum period from PK was 12 months. All secondary IOL implantations were performed from January 2011 to August 2017. Aphakic postkeratoplasty patients were treated using one of the surgical techniques for secondary IOL implantation. In-the-bag IOL implantation was possible if the posterior capsule was complete. If the lens capsule remnants were sufficient to provide secure IOL support, an in-the-sulcus IOL implantation was performed. Scleral fixation was offered in eyes with extensive capsular deficiency or the presence of the vitreous body in anterior chamber. BCVA and expected and achieved refraction were evaluated; we included using two biometry devices, and results were compared. Results. The corrected distance visual acuity (CDVA) before surgery ranged from 0.1 to 0.8 (mean 0.54 ± 0.17). After secondary IOL implantation, CDVA ranged from 0.2 to 0.8 (mean 0.43 ± 0.14) at postoperative 1 month and from 0.3 to 0.9 (mean 0.55 ± 0.15) at postoperative 6 months (p<0.05). Comparison of the final refraction using two methods of biometry showed no statistically significant difference in the group that underwent scleral fixation of the IOL, similar to the findings for the in-the-bag and in-the-sulcus IOL implantation groups. In the scleral-fixation group, p=0.55 for the USG biometry technique and p=0.22 for the OB technique. p values for the IOL-implantation group were p=0.49 and p=0.44, respectively. Conclusion. Both implantation methods are safe for the patients. Final refraction is depending on the technique and indication to keratoplasty. Both biometry techniques deliver precise data for IOL choice.