Single suture iris-to-capsulorhexis fixation for in-the-bag intraocular lens subluxation.

UNLABELLED: We present a simplified modification to a technique for early or mild in-the-bag subluxation that avoids conjunctival and scleral incisions and minimizes intraocular manipulation. While the capsulorhexis edge is grasped with an intraocular forceps to stabilize the IOL-capsular bag complex, a 10-0 polypropylene suture on a long curved needle is used to secure the fibrotic superior capsulorhexis edge to the midperipheral iris at 12 o'clock using a combination of a modified McCannel suture and a Siepser sliding knot. FINANCIAL DISCLOSURE: Dr. Condon receives speaker and consultant fees from Alcon Surgical, Inc., Allergan, Inc., and Microsurgical Technology. Although the Microsurgical Technology Condon snare instrument is named after him, Dr. Condon reports no patents, fees, or payments related to it. Dr. Siegel has no financial or proprietary interest in any material or method mentioned.

Complication from combined use of capsule retractors and capsular tension rings in zonular dehiscence.

UNLABELLED: We describe a new complication associated with capsular tension ring (CTR) implantation after placement of capsule retractors. We report 3 cases from 3 different surgeons of inadvertent threading of a CTR through a capsule retractor loop. In each case, the distal loop was opened or amputated to facilitate hook removal. We report this case series to alert cataract surgeons to a potential complication of using CTRs and capsule retractors together and to offer potential strategies for preventing and managing an intracapsular entanglement. FINANCIAL DISCLOSURE: Dr. Kim is a consultant to Alcon Surgical, Inc. Dr. Chang receives personal fees from Abbott Medical Optics, Inc. Dr. Condon receives personal fees from Alcon Surgical, Inc. and Microsurgical Technology. No other author has a financial or proprietary interest in any material or method mentioned.

Minimizing the invasiveness of traditional trabeculectomy surgery.

UNLABELLED: Microinvasive invasive glaucoma surgery has become increasingly popular as a surgical alternative for glaucoma. Although the time-honored trabeculectomy remains the unrivaled contender for lowering intraocular pressure (IOP) into the single digits, newer devices are available that attempt to reach similar IOP levels with fewer complications and quicker visual recovery. The Express mini-shunt and the Innfocus microshunt are 2 devices that bring us closer to the goal of repeatable, lower risk surgery; improved patient satisfaction; stabilization of the visual field; and long-term IOP control. The mini-shunt has been approved by the U.S. Food and Drug Administration, while the microshunt is still under review. FINANCIAL DISCLOSURES: Dr. Condon is a consultant to and speaker for Alcon Laboratories. Dr. Moster has served on the advisory board of, been a consultant to, received honoraria for lectures from, and performed contracted research for Alcon, Inc.

Modified Wise closure of the conjunctival fornix-based trabeculectomy flap.

We present modifications to the Wise fornix-based conjunctival trabeculectomy flap technique that have minimized early wound leakage in our experience. A retrospective chart review of 509 consecutive eyes revealed a 2.9% leak rate in the first postoperative month and 1.6% returned to the operating room to resuture a persistent leak. If meticulously performed, this modified closure technique may provide watertight closure as commonly as limbal-based techniques.

Randomized, prospective, comparative trial of EX-PRESS glaucoma filtration device versus trabeculectomy (XVT study).

PURPOSE: To compare the clinical outcomes of the EX-PRESS glaucoma filtration device placed under a partial-thickness scleral flap with trabeculectomy. DESIGN: Randomized, prospective, multicenter trial. METHODS: A total of 120 eyes in 120 subjects were analyzed, including 59 eyes treated with EX-PRESS and 61 eyes treated with trabeculectomy. Both the EX-PRESS and the trabeculectomy groups were treated intraoperatively with mitomycin C and followed postoperatively for 2 years. Surgical success was defined as 5 mm Hg ≤ intraocular pressure ≤ 18 mm Hg, with or without medications, without further glaucoma surgery. RESULTS: Mean intraocular pressure was significantly reduced compared with baseline in both groups (P < 0.001). Average intraocular pressure and number of medications were similar in both groups during follow-up, with mean intraocular pressure at 2 years after surgery of 14.7 ± 4.6 mm Hg and 14.6 ± 7.1 mm Hg in the EX-PRESS and trabeculectomy groups, respectively (P = 0.927). At 2 years after surgery, the success rate was 83% and 79% in the EX-PRESS and trabeculectomy groups, respectively (P = 0.563). Although visual acuity (logMAR) was significantly decreased on day 1 in both groups, the vision was not significantly different compared with baseline at 1 month after EX-PRESS implant (P = 0.285) and 3 months after trabeculectomy (P = 0.255). The variance of early postoperative intraocular pressure values was similar between groups on the first postoperative day but higher after trabeculectomy compared with EX-PRESS implant on day 7 (P = 0.003). The total number of postoperative complications was higher after trabeculectomy than after EX-PRESS implantation (P = 0.013). CONCLUSIONS: Mean intraocular pressures, medication use, and surgical success were similar at 2 years after treatment with the EX-PRESS device and trabeculectomy. Vision recovery between groups was also similar throughout the study, although return to baseline vision was more rapid in the EX-PRESS group. Intraocular pressure variation was lower during the early postoperative period, and postoperative complications were less common after EX-PRESS implantation compared with trabeculectomy.

Simplified ab externo scleral fixation for late in-the-bag intraocular lens dislocation.

Many surgical techniques to repair late in-the-bag intraocular lens (IOL) dislocation have been described. We present a modification to ab externo scleral fixation of in-the-bag IOL dislocation that minimizes cumbersome intraocular manipulations. Using an iris hook for intraocular suture retrieval under direct visualization eliminates the need to mate the suture needle with a hypodermic needle, and the site through which the hook is used provides an ideal place for suture knot burial, potentially minimizing late suture erosion or exposure.

Ultrasound biomicroscopic analysis of iris-sutured foldable posterior chamber intraocular lenses.

PURPOSE: To report ultrasound biomicroscopic (UBM) findings of iris-sutured foldable posterior chamber intraocular lenses (PCIOLs). DESIGN: Prospective, noninterventional consecutive case series. METHODS: Fifteen eyes with foldable acrylic IOL implantation using peripheral iris suture fixation in the absence of capsular support were included. UBM was used to determinate the haptic position in relation to the ciliary sulcus and ciliary body in these eyes. Additionally, anterior chamber depth, lens tilt, site of suture fixation, focal iris or angle abnormalities, and relationship of iris to lens were determined. Main outcome measures were haptic position, anterior chamber depth, and iris anatomic changes. RESULTS: Of the 30 haptics imaged, 16 (53.3%) were positioned in the ciliary sulcus. Nine (30%) haptics were found over the ciliary processes, and 5 (16.7%) were over pars plana. No patients were found to have peripheral anterior synechiae present at the haptic position. The mean (+/- standard deviation) depth of the anterior chamber was 3.84 +/- 0.36 mm. The iris profile was altered in all patients at the iris-haptic suture fixation site. No angle abnormalities or tilted lenses were found. CONCLUSIONS: Iris-sutured PCIOL haptics were found to be in the ciliary sulcus or over the ciliary body with no significant tilt on UBM analysis. The procedure respects the angle anatomy, and no evidence of angle closure was found. The anterior chamber was deeper than has been reported previously for scleral sutured PCIOLs and was similar to that of pseudophakic eyes. This may have implications for surgical technique, IOL power calculations, and postoperative complications.

Small-incision iris fixation of foldable intraocular lenses in the absence of capsule support.

PURPOSE: To report visual outcomes and complications of modified McCannel iris suture fixation of small-incision foldable acrylic intraocular lenses (IOLs) for aphakia in the absence of capsule support. DESIGN: Retrospective interventional case series. PARTICIPANTS: Forty-six patients who underwent foldable acrylic IOL implantation using peripheral iris suture fixation for aphakia in the absence of capsule support. METHODS: Data from 46 patients who underwent iris fixation of a foldable acrylic IOL were retrospectively evaluated for underlying diagnoses, surgical history, clinical results, and complications. MAIN OUTCOME MEASURES: Postoperative best-corrected visual acuity (BCVA), spherical equivalent, and surgical complications. RESULTS: Best-corrected visual acuity improved from 20/100 to 20/50 (P = 0.01), with 97% of eyes maintaining or improving BCVA after a mean (+/- standard deviation) follow-up of 24.1+/-12.4 months. Complications included transient low-grade uveitis (3 [6.5%]), transient pigment dispersion (3 [6.5%]), IOL dislocation (2 [4.3%]), elevated intraocular pressure (1 [2.2%]), and retinal detachment (1 [2.2%]). No new cases of cystoid macular edema or worsening of glaucoma occurred. CONCLUSION: Small-incision peripheral iris fixation of 3-piece acrylic foldable IOLs in the absence of capsule support appears to be an effective technique with few severe adverse events.

Late in-the-bag intraocular lens dislocation: incidence, prevention, and management.

Dislocation of an intraocular lens (IOL) with the capsular bag is a late complication of cataract surgery, reported with increasing frequency in recent years. Pseudoexfoliation, uveitis, myopia, and other diseases associated with progressive zonular weakening and capsular contraction are the predisposing conditions. Capsular tension rings probably help but do not prevent this complication. Management includes IOL exchange, replacement with an anterior or a sutured posterior chamber IOL, or suturing the IOL through the bag to the iris or the sclera.

Simplified small-incision peripheral iris fixation of an AcrySof intraocular lens in the absence of capsule support.

In the absence of capsule and zonule support, a modified insertion technique allows simple peripheral iris fixation of a posterior chamber 3-piece acrylic intraocular lens (IOL) via a small incision for secondary implantation. A bimanual unfolding maneuver creates pupillary capture of the optic to temporarily stabilize the IOL. Peripheral modified McCannel sutures fixate the flexible monofilament poly(methyl methacrylate) haptics to the posterior peripheral iris surface, after which the optic is safely prolapsed into the posterior chamber.

Efficacy and safety of mitomycin-C in primary trabeculectomy: five-year follow-up.

PURPOSE: To examine the 5-year complications and results of primary trabeculectomy with mitomycin-C (MMC). DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: One hundred twenty-three eyes that underwent primary trabeculectomy with MMC between December 1991 and March 1995. METHODS: All patients received standard trabeculectomy performed by one of two surgeons, using a Weck cell-soaked pledget of MMC, 0.25, 0.33, or 0.5 mg/ml, for 0.5 to 5 minutes. Laser suture lysis was performed postoperatively for intraocular pressure control. MAIN OUTCOME MEASURES: The incidence of complications, including hypotony with or without maculopathy, bleb leak or blebitis, pressure control, and medication reduction at yearly intervals. RESULTS: Mean preoperative and year 5 postoperative intraocular pressures (IOP) were 25.79 and 9.91 mmHg (P < 0.05, paired t test). Hypotony (IOP < 6) occurred in 42.2% of eyes after a mean follow-up of 26.1 months. Hypotony maculopathy occurred in 8.9% of eyes at mean follow-up of 33.7 months. Bleb leak occurred in 14.6% of eyes at a mean follow-up of 27.9 months. Blebitis occurred in 5.7% of eyes at a mean follow-up of 35.4 months, and endophthalmitis occurred in 0.8% of eyes at 15 months; 14.9% of eyes lost 4 lines of visual acuity. The single predictor for the development of late-term hypotony was IOP 1 month after operation (P < 0.05). CONCLUSIONS: Primary mitomycin trabeculectomy significantly lowers IOP at 5 years but is associated with a high incidence of delayed hypotony.