Clinical outcomes of glued transscleral fixated intraocular lens in functionally one-eyed patients.

PURPOSE: To analyze the indications, visual outcome, mental status, and quality of life after glued transscleral fixated intraocular lens (IOL) in functionally one-eyed individuals. SETTING: Dr Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. DESIGN: Prospective observational comparative case series. METHODS: Patients with one functioning eye with surgical indications (aphakia, luxated IOL, or dislocated lens) and the fellow eye with no perception of light were included. Indications, uncorrected distant visual acuity (UDVA), corrected distant visual acuity (CDVA), mental status (Amsterdam Preoperative Anxiety and Information Scale) and quality of life (visual function scoring VF-14) were assessed. Outcomes of nonsurgical and surgical management were evaluated and compared. RESULTS: Of 22 patients, 10 (45.4%) patients underwent glued IOL (group A) and 12 (54.5%) wore spectacles (group B). There was a strong association between the initial clinical presentation and management (χ, P=0.000). Subluxated cataract and dislocated lens (or IOL) required surgical treatment. Postoperative aphakia with adequate spectacle correction were conservatively treated. There was change (P=0.005) in UDVA and CDVA after glued IOL surgery. There was no loss of CDVA. There was difference between the 2 groups in reading small prints (P=0.021), sporting activities (P=0.000), and night driving (P=0.000). Surgical anxiety was higher in group B (P=0.014). Females were more anxious than the males (P=0.014). There was an association of increasing age and the decision for nonsurgical management (χ, P=0.005). CONCLUSION: Glued transscleral fixated IOL can be safely performed in one-eyed patients for specific indications to provide good functional results.

Outcomes of Pre-Descemet Endothelial Keratoplasty for Failed Therapeutic Penetrating Keratoplasty.

PURPOSE: The aim of this study was to analyze the outcomes of pre-Descemet endothelial keratoplasty (PDEK) for failed therapeutic penetrating keratoplasty. METHODS: This was a retrospective, interventional study that involved 12 eyes of 12 patients with failed therapeutic penetrating keratoplasty that underwent PDEK. All cases had a minimum follow-up of 12 months. The main outcome measures were best-corrected visual acuity, graft clarity, endothelial cell density loss, and graft survival. Corneal clarity was graded on a scale from 0 to 4, where grade 4 denoted an absolutely clear cornea and grade 0 denoted a totally opaque cornea. Three cases underwent PDEK, 6 cases PDEK with phacoemulsification, and 3 cases underwent PDEK with pupilloplasty. RESULTS: The mean follow-up period for all cases was 18.5 ± 4.9 months. The mean preoperative and postoperative best-corrected visual acuity (in Snellen decimal equivalent) was 0.02 ± 0.01 and 0.54 ± 0.17, respectively, at the last follow-up. Postoperatively, corneal clarity grade 4 was present in 9 eyes, grade 3 in 2 eyes, and grade 2 in 1 eye. Mild subepithelial haze was noted in 2 eyes. The percentage of endothelial cell density loss was 28.2% ± 10.6%. No correlation was observed between the postoperative graft clarity and preoperative specular count (r = -0.021, P = 0.512). Rebubbling was performed for 1 eye that developed partial graft detachment in the first postoperative week. One patient had an episode of rejection that was managed with systemic and topical steroids. CONCLUSIONS: In patients with failed therapeutic penetrating keratoplasty, PDEK can be a useful alternative for visual rehabilitation as it demonstrates favorable visual outcomes with a good graft survival rate.

Posterior Corneal Curvature Changes After Pre-Descemet's Endothelial Keratoplasty: A Prospective Analysis.

PURPOSE: To assess the changes in the posterior corneal curvature after pre-Descemet's endothelial keratoplasty (PDEK) and correlate with the visual outcomes. METHODS: Eyes with pseudophakic bullous keratopathy, aphakic bullous keratopathy, and Fuchs dystrophy undergoing PDEK were included. The main outcome measures were the topography (OrbscanIIz, Bausch and Lomb) indices-total corneal power (TCP) in diopters (D), radius of the posterior curvature (mm), and best-fit sphere of the posterior corneal surface (BFS in D) at preoperative and postoperative 1 month, 3 months, and 6 months. RESULTS: Overall, 43 eyes of 43 patients with a mean age of 68 ± 9.6 years were studied. The mean preoperative TCP 43.1 D ± 2.3 reduced to 42.4 D ± 2.6 at 3 months (P < 0.010). There was a statistically significant decrease in the mean posterior corneal curvature at 1 month and 3 months postoperatively (P = 0.002). There was no significant change in the TCP and posterior corneal curvature at 6 months (P > 0.05). The mean BFS showed an increase at 1 month (53.45 ± 5.2 D) and 3 months (52.95 ± 5.1 D) and decrease at 6 months (51.90 ± 5.3 D). The overall change in BFS (P > 0.05) was not significant. There was significant improvement in visual acuity (P < 0.05). The best-corrected visual acuity was ≥20/40 in 79.07% and ≥20/60 in 100% at 6 months. There was no statistically significant correlation between the change in the best-corrected visual acuity and TCP, posterior corneal curvature, or BFS. CONCLUSIONS: Although there was immediate postoperative change in the posterior curvature, no significant change was induced by PDEK.

Anterior segment transplantation with a novel biosynthetic graft.

PURPOSE: Staphylectomy with sclerokeratoplasty has been performed in cases with large anterior staphyloma. This report describes a technique using a new biosynthetic graft to simulate the anterior segment in the eye of a 4-month-old child with diffuse anterior staphyloma and cataractous lens with compromised zonules. METHODS: The graft had a biologic part (corneoscleral button) and a synthetic part (aniridia intraocular lens). Two partial thickness flaps and sclerotomies were made in the graft through which the lens haptics were externalized. After staphylectomy and lensectomy of the host, the graft was sutured. After intrascleral tuck of the lens haptics before fibrin glue-assisted flap closure was then done. RESULTS: On the first postoperative day, the child was following light with the operated eye, and closure of the lids and cosmesis were markedly improved. Between the first and fourth month follow-up, and with the normal eye occluded, the child was following light and reaching out for objects. The cornea was clear with no evidence of rejection or failure. At 5 months, a persistent epithelial defect developed, leading by 6 months into a nebulomacular opacity partially obscuring the pupil. At 6 months, the results of the technique are anatomically and cosmetically satisfactory; however, a longer follow-up term will establish the visual benefits. CONCLUSIONS: This technique may provide a suitable cosmetic and anatomic alternative to conventional procedures like staphylectomy with sclerokeratoplasty. It also retains the potential for more effective visual rehabilitation as an intraocular lens has been implanted.

Pinhole pupilloplasty: Small-aperture optics for higher-order corneal aberrations.

This technique of performing pinhole pupilloplasty helps filter the straylight from the periphery of the cornea in cases with higher-order corneal aberrations. The pinhole effect blocks distorted and unfocused light rays and isolates more focused central and paracentral rays through the central aperture, thereby reducing aberrations of the optical system as a whole and enhancing visual acuity and its image quality.

Single-pass four-throw pupilloplasty for Urrets-Zavalia syndrome.

PURPOSE: To demonstrate the efficacy and initial results of single-pass four-throw pupilloplasty in cases of Urrets-Zavalia syndrome. METHODS: In this prospective interventional study, single-pass four-throw was performed to reconstruct the pupil in all symptomatic cases with Urrets-Zavalia syndrome. Applanation tonometry, indentation gonioscopy, and anterior segment optical coherence tomography for anterior chamber angle assessment were performed in all the cases. RESULTS: Out of 10 cases that were identified with Urrets-Zavalia syndrome, the procedure was performed in 7 cases, whereas 3 cases were left untreated, as they did not have any visual complaints. Five out of seven eyes had preoperative raised intraocular pressure with appositional closure of the angle. Postoperatively, intraocular pressure was controlled in all the eyes, whereas one eye required antiglaucoma medications to control the intraocular pressure. The mean preoperative and postoperative best-corrected visual acuity was 1.1 ± 1.2 and 0.4 ± 0.4 LogMar, respectively. There was a significant improvement in the best-corrected visual acuity (p = 0.0169) in the postoperative period. The mean preoperative and postoperative intraocular pressure was 26.6 ± 11.23 and 16.3 ± 2.98 mm Hg, respectively (p = 0.0168). All the patients had a minimum of 6-month follow-up period (range = 6-8 months). CONCLUSION: Single-pass four-throw can be employed for cases with Urrets-Zavalia syndrome, and single-pass four-throw helps to prevent the postoperative glare and narrows down the pupil size effectively. Single-pass four-throw helps to alleviate the anterior chamber angle apposition in patients with Urrets-Zavalia syndrome by mechanically pulling the peripheral iris centrally as demonstrated on anterior segment optical coherence tomography. The study also reports the occurrence of Urrets-Zavalia syndrome after glued intraocular lens surgery.

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.

Stab Incision Glaucoma Surgery: A Modified Guarded Filtration Procedure for Primary Open Angle Glaucoma.

Purpose. To describe a modified guarded filtration surgery, stab incision glaucoma surgery (SIGS), for primary open angle glaucoma (POAG). Methods. This prospective, interventional case series included patients with POAG (IOP ≥21 mmHg with glaucomatous visual field defects). After sliding superior conjunctiva down over limbus, 2.8 mm bevel-up keratome was used to create conjunctival entry and superficial corneoscleral tunnel in a single step starting 1.5 mm behind limbus. Lamellar corneoscleral tunnel was carefully dissected 0.5-1 mm into cornea and anterior chamber (AC) was entered. Kelly Descemet's punch (1 mm) was slid along the tunnel into AC to punch internal lip of the tunnel, thereby compromising it. Patency of ostium was assessed by injecting fluid in AC and visualizing leakage from tunnel. Conjunctival incision alone was sutured. Results. Mean preoperative IOP was 27.41 ± 5.54 mmHg and mean postoperative IOP was 16.47 ± 4.81 mmHg (n = 17). Mean reduction in IOP was 38.81 ± 16.55%. There was significant reduction of IOP (p < 0.000). 64.7% had IOP at final follow-up of <18 mmHg without medication and 82.35% had IOP <18 mmHg with ≤2 medications. No sight threatening complications were encountered. Conclusion. Satisfactory IOP control was noted after SIGS in interim follow-up (14.18 ± 1.88 months).

Implantation of glued intraocular lenses in eyes with microcornea.

PURPOSE: To evaluate the intraoperative modifications for and vision outcomes after implantation of glued intraocular lenses (IOLs) in eyes with microcornea. SETTING: Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. DESIGN: Prospective case series. METHODS: Eyes with a horizontal cornea of 10.0 mm or less were evaluated for intraoperative modifications and postoperative vision after implantation of a glued IOL. The type of surgery, type of IOL, incision and optic sizes, haptic length modifications, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and postoperative complications were analyzed. RESULTS: A glued IOL was implanted in 15 eyes to treat subluxated cataract (9 eyes), aphakia (5), and intraoperative capsule loss (1). In cases involving a subluxated cataract, implantation of the glued IOL was followed by lensectomy (7 eyes) or intracapsular cataract extraction (2 eyes). The mean follow-up was 22.4 months ± 17.2 (SD). The mean horizontal corneal diameter and axial length were 8.0 ± 0.6 mm and 21.0 ± 2.4 mm, respectively. The mean amount of IOL haptic trimmed intraoperatively was 1.54 ± 0.33 mm. There was significant correlation between the horizontal corneal diameter and the amount of haptic trimmed (P = .000). The mean size of the main incision was 3.70 ± 0.98 mm. Three-piece foldable IOLs with a 6.0 mm optic were used. There were no cases of haptic extrusion or subconjunctival haptic placement. There was statistically significant improvement in CDVA (P = .032) and UDVA (P = .012) after surgery. CONCLUSION: Glued IOLs were safely implanted in eyes with microcornea using modifications such as custom haptic trimming and 6.0 mm optic foldable IOLs. FINANCIAL DISCLOSURE: Dr. Amar Agarwal is a paid consultant to Staar Surgical Co. No other author has a financial or proprietary interest in any material or method mentioned.

Glued capsular hook: technique for fibrin glue-assisted sutureless transscleral fixation of the capsular bag in subluxated cataracts and intraocular lenses.

We describe a technique that uses a capsular hook to obtain sutureless fibrin glue-assisted transscleral fixation of the capsular bag. The hook passes through a sclerotomy created under a scleral flap and engages the capsulorhexis rim, providing scleral fixation intraoperatively and postoperatively. A standard capsular tension ring expands the capsular fornix. The haptic of the hook is tucked into a scleral tunnel for postoperative fixation. The scleral flap is closed with fibrin glue. The glued capsular hook is used for subluxated cataracts and IOLs. It anchors the capsular bag to the sclera, providing vertical and horizontal stability, and stabilizes the bag intraoperatively and postoperatively. The technique was used in 7 patients, who were followed for more than 4 months.

Effect of unilateral congenital ptosis on ocular higher order aberrations in children.

To analyse the effect of congenital unilateral ptosis on the ocular higher order aberrations (HOA) and to compare these eyes with normal fellow eyes this study has been performed. In this observational comparative case series, 16 eyes of 16 patients less than 15 years old with congenital unilateral upper eyelid ptosis were included. Corrected distance visual acuity (CDVA), corneal topography, ocular HOA's with Zywave workstation was recorded. The amount of ptosis was measured from marginal reflex distance (MRD1). The ocular HOA's were compared between the ptosis and the normal fellow eyes after making necessary corrections to avoid errors due to enantiomeric midline symmetry. The mean age was 12.5±2.7years (range7-15years). The mean MRD1 was -0.9±1.8mm in the ptosis eyes. There was significant difference noted in the mean 6mm Zernicke coefficients Z3 (-3) (p=0.002), Z4 (-2) (p=0.034), Z4 (2) (p=0.008), Z5 (-5) (p=0.044), Z5 (1) (p=0.039), Z5 (3) (p=0.036), Z5 (5) (p=0.044) between the ptosis and the fellow eyes. The mean Z3-3 was -0.17±0.15 and 0.07±0.12 in the ptosis and the normal eyes respectively. There was a significant difference (p=0.023) in total RMS (root mean square) between the ptosis and the normal eyes. Total coma aberration correlated with CDVA (p=0.004) and MRD (p=0.030) in the ptosis eyes. There was no correlation (p=0.815) between the age (duration of ptosis) and total RMS. In conclusion, Eyes with congenital ptosis differed from their normal fellow eyes in the higher order aberrations. None of the HOA's which differed between the two groups affected the visual acuity in the ptosis eyes.

Comparison of laser in situ keratomileusis for myopic astigmatism without iris registration, with iris registration, and with iris registration-assisted dynamic rotational eye tracking.

PURPOSE: To compare the visual and refractive outcomes of laser in situ keratomileusis (LASIK) without iris registration, with static preablation iris registration, and with preablation iris registration-assisted intra-ablation with dynamic rotational eye tracking. SETTING: Refractive Surgery Services, Dr. Agarwal's Eye Hospital, Chennai, India. DESIGN: Randomized clinical trial. METHODS: Eyes with myopic astigmatism (cylinder >1.00 diopter [D]) had LASIK using the Technolas 217z100 platform. Preoperative and postoperative assessment included uncorrected and corrected distance visual acuities, refraction, topographic analysis, and a routine LASIK workup. All cases were followed for 6 months. RESULTS: The mean spherical equivalent (SE) was -6.1 D ± 2.4 (SD) with no iris registration, -6.2 D ± 2.3 D with static iris registration, and -6.5 ± 2.2 D with dynamic iris registration (P=.4) preoperatively and -0.27 ± 0.4 D, -0.12 ± 0.4 D, and -0.02 ± 0.35 D, respectively, 6 months postoperatively (P < .001). The mean cylindrical error was -2.05 ± 0.7 D, -2.08 ± 0.5 D, and -2.13 ± 0.7 D, respectively, preoperatively (P=.6) and -0.37 ± 0.2 D, -0.29 ± 0.2 D, and -0.20 ± 0.3 D, respectively, at 6 months (P < .001). Alpins analysis showed comparable target and surgically induced astigmatism between the 3 groups; however, the difference vector, error angle, correction index, success index, and flattening index were best after dynamic iris registration (P < .001). CONCLUSIONS: In myopic astigmatism, iris registration with dynamic rotational eye tracking gave better results than iris registration alone or no iris registration. The worst outcomes were in cases without iris registration.

Spectral domain optical coherence tomographic characteristics of unilateral peripapillary myelinated retinal nerve fibers involving the macula.

Unilateral, peripapillary, retinal nerve fiber myelination involving the macula, with optic disk hypoplasia, myopia, and amblyopia, is rare. We performed spectral domain optical coherence tomographic findings in 2 patients with this condition. Both patients had normal foveal morphology, reduced retinal thickness in the same distribution as the myelination, and optic nerve hypoplasia.

Turnaround technique for intrastromal corneal ring implantation in eyes with false channel dissection.

UNLABELLED: We describe a turnaround technique for implantation of intrastromal corneal ring segments in eyes with femtosecond laser-assisted channel creation in which inappropriate surgeon maneuvering creates a false channel. The false channel causes difficulty in implantation as further forward maneuvering leads to enlargement of the false channel, finally precluding forward movement of the segment. This may result in suboptimal placement of the segment or abandoning the procedure. The situation can be overcome by removing the segment and turning it around so it is inserted in the opposite direction through the entry incision. It is then advanced using the second segment as an intrachannel instrument. The double-pass turnaround is used if asymmetric segments are planned and obstruction is encountered with the second segment. This technique was used successfully in 4 eyes with a false channel. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Evaluation of bilateral minimum thickness of normal corneas based on Fourier-domain optical coherence tomography.

PURPOSE: To determine the normative ranges and various aspects of the relationship between the minimum corneal thicknesses (MCT) in fellow eyes and the location of the MCT in relation to the central cornea using Fourier-domain optical coherence tomography (OCT). SETTING: Tertiary care ophthalmic hospital, Chennai, India. METHODS: In this cross-sectional observational trial, both eyes of consecutive healthy young subjects with a low refractive error and no clinical or topographic evidence of corneal disorders had bilateral pachymetric assessment with a Fourier-domain OCT platform (RTVue). The MCT, central corneal thickness (CCT), and x-y coordinates of the MCT location were noted. RESULTS: The CCT and MCT followed a normal distribution with a good correlation. The difference between CCT and MCT was approximately 5 microm in right eyes and left eyes (P<.05 for both). The difference in CCT was the best predictor of the difference in MCT. The mean distance from the center (0.63 mm +/- 0.13 [SD], right eyes; 0.66 +/- 0.17 mm, left eyes) was well correlated. The MCT points in fellow eyes tended to be symmetrical along the vertical midline. The mean angular distance between mirror-superimposed MCT points was 20.54 +/- 17.6 degrees and the mean linear distance, 0.25 +/- 0.17 mm. CONCLUSIONS: The findings establish normative MCT pachymetry data and location using Fourier-domain OCT. The MCT and CCT points, although symmetrical, differed significantly in location and magnitude and should be evaluated separately in normal eyes and eyes with disease. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional financial disclosures are found in the footnotes.

Predictive factor analysis for successful performance of iris recognition-assisted dynamic rotational eye tracking during laser in situ keratomileusis.

PURPOSE: To analyze the predictive factors associated with success of iris recognition and dynamic rotational eye tracking on a laser in situ keratomileusis (LASIK) platform with active assessment and correction of intraoperative cyclotorsion. DESIGN: Interventional case series. METHODS: Two hundred seventy-five eyes of 142 consecutive candidates underwent LASIK with attempted iris recognition and dynamic rotational tracking on the Technolas 217z100 platform (Techolas Perfect Vision, St Louis, Missouri, USA) at a tertiary care ophthalmic hospital. The main outcome measures were age, gender, flap creation method (femtosecond, microkeratome, epi-LASIK), success of static rotational tracking, ablation algorithm, pulses, and depth; preablation and intraablation rotational activity were analyzed and evaluated using regression models. RESULTS: Preablation static iris recognition was successful in 247 eyes, without difference in flap creation methods (P = .6). Age (partial correlation, -0.16; P = .014), amount of pulses (partial correlation, 0.39; P = 1.6 x 10(-8)), and gender (P = .02) were significant predictive factors for the amount of intraoperative cyclodeviation. Tracking difficulties leading to linking the ablation with a new intraoperatively acquired iris image were more with femtosecond-assisted flaps (P = 2.8 x 10(-7)) and the amount of intraoperative cyclotorsion (P = .02). However, the number of cases having nonresolvable failure of intraoperative rotational tracking was similar in the 3 flap creation methods (P = .22). CONCLUSIONS: Intraoperative cyclotorsional activity depends on the age, gender, and duration of ablation (pulses delivered). Femtosecond flaps do not seem to have a disadvantage over microkeratome flaps as far as iris recognition and success of intraoperative dynamic rotational tracking is concerned.

Quantitative assessment of post-LASIK corneal infiltration with frequency domain anterior segment OCT: a case report.

We present the use of frequency domain (FD) optical coherence tomography (OCT) for quantitative assessment of the infiltration in the eye with post-laser in situ keratomileusis (LASIK) corneal inflammation. Serial OCT images are taken in a patient with post-LASIK inflammation and are used to see the response to treatment over a time period. Clinical value of FD-OCT as a diagnostic tool in objective assessment of corneal inflammation and response to treatment is shown.