Amar Agarwal

Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules

&NA; We report a new surgical technique that uses biological glue to implant a posterior chamber intraocular lens (PC IOL) in eyes with a deficient or absent posterior capsule. Two partial‐thickness limbal‐based scleral flaps are made 180 degrees apart diagonally, and the haptics of the PC IOL are externalized to place them beneath the flaps. Fibrin glue is used to attach the haptics to the scleral bed, beneath the flap. This simple method of PC IOL implantation requires no specially designed haptics. It provides good flap closure and IOL centration and stability without suture‐related complications.

Phakonit: phacoemulsification through a 0.9 mm corneal incision.

&NA; Advances in technique and equipment have led to a significant increase in the popularity of phacoemulsification and have increased its safety and efficiency. We describe a technique, phakonit, in which the lens is emulsified through a 0.9 mm clear corneal temporal incision. A cortical wash with bimanual irrigation/aspiration is followed by enlarging the incision to 2.0 mm and inserting a Staar sub‐2.0 mm foldable intraocular lens. Phakonit is a safe, precise method of phacoemulsification with minimal intraoperative or postoperative complications.

Efficacy of a capsular tension ring for phacoemulsification in eyes with zonular dialysis

Purpose: To determine the safety and efficacy of capsular tension ring (CTR) insertion in eyes with zonular dialysis of less than 150 degrees having phacoemulsification with posterior chamber intraocular lens (PC IOL) implantation. Setting: Dr. Agarwals Eye Hospital, Chennai, India. Methods: This prospective study comprised 21 eyes of 19 patients with zonular dialysis of less than approximately 150 degrees determined preoperatively or intraoperatively. After insertion of a CTR, phacoemulsification with PC IOL implantation was performed. The mean follow‐up was 242.33 days. Results: Capsule collapse did not occur in any eye with a CTR. Intraoperative extension of the dialysis occurred in 2 eyes (9.52%). The IOL was placed in the bag in all the eyes except 1 that had traumatic cataract and received a scleral‐fixated IOL during a subsequent surgery. Postoperatively, there was minimal corneal edema in 2 eyes (9.52%) and mild iritis in 5 eyes (23.80%). Three eyes (14.28%) developed raised intraocular pressure that responded well to medical therapy. The symptoms resolved in the 3 patients with preoperative diplopia. Fifteen eyes (71.42%) had a final visual acuity of 6/12 or better. Six eyes had a final best corrected visual acuity of worse than 6/12 because of coexisting fundus pathology. A dilated pupil examination at 6 months showed a well‐centered IOL in all eyes. Conclusions: Phacoemulsification with in‐the‐bag PC IOL and CTR implantation in eyes with zonular dialysis of up to approximately 150 degrees had a success rate of 90.47%. Visual recovery was not as good as in normal eyes because of the problems associated with zonular dialysis.

Trypan blue as an adjunct for safe phacoemulsification in eyes with white cataract

Purpose: To assess the feasibility, risks, and postoperative outcomes of phacoemulsification with posterior chamber intraocular lens (PC IOL) implantation in cases of white cataract with the use of trypan blue as an adjunct for performing continuous curvilinear capsulorhexis (CCC) in the absence of a red reflex. Setting: Dr. Agarwals Eye Hospital, Chennai, India. Methods: This prospective study comprised 52 eyes of 52 patients with white cataract that had phacoemulsification through a clear corneal temporal incision with PC IOL implantation. In all the cases, trypan blue was used under air to stain the anterior lens capsule and the karate‐chop technique was used to emulsify the nucleus. The mean follow‐up was 192.2 days. Results: Trypan blue adequately stained the anterior lens capsule in all cases. The CCC was completed uneventfully in 96.15% eyes; 3.85% of cases had to be converted to a conventional extraction technique because of the loss of the CCC. The mean phacoemulsification time was 2.2 minutes. Intraocular complications included incomplete capsulorhexis (3.85%) and pupillary miosis (3.80%). Postoperatively, 3 eyes (5.77%) had corneal edema (striate keratopathy) and 1 eye (1.9%) had fibrin in the anterior chamber. Five eyes (9.61%) had more than 2+ cells and flare at 2 weeks. All responded well to intensive topical and subconjunctival steroids. There were no cases of endophthalmitis. The mean central endothelial cell loss, measured in 37 eyes, was 8.5%. Of the 4 eyes (7.69%) that had increased intraocular pressure (IOP) postoperatively, all responded well to medications and the IOP was normal by the second postoperative week. Fifty eyes (96.16%) had a final best corrected visual acuity of 20/30 or better. In 2 cases, the final visual acuity was worse than 20/200 because of preexisting posterior segment pathology. Conclusion: Phacoemulsification using trypan blue was safe and effective in managing white cataract and had a high success rate.

Results of pediatric laser in situ keratomileusis

PURPOSE To evaluate the results of laser in situ keratomileusis (LASIK) for uniocular high myopia in pediatric eyes. SETTING Dr. Agarwals Eye Hospital, Chennai (Madras), India. METHODS Sixteen eyes that were treated by LASIK for uniocular high myopia were retrospectively analyzed. The mean patient age was 8.4 years +/- 1.83 (SD) (range 5 to 11 years). Laser in situ keratomileusis was performed using the Technolas Keracor 217 excimer laser and the Automated Corneal Shaper microkeratome, which created a 160 microm corneal lamellar flap. Postoperatively, patients were reviewed at 1 day, 1 week, and 1, 6, and 12 months. The examination included uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), refraction, anterior segment evaluation, grading of haze based on a 5-point scale, intraocular pressure, corneal topography, and fundus evaluation. The Student t test was used for statistical analysis. RESULTS The charts of all patients were analyzed at the 12 month visit. The mean preoperative spherical equivalent (SE) was -14.88 +/- 3.69 diopters (D) (range -9.00 to -23.00 D) and the mean postoperative SE, -1.44 +/- 1.14 D (range 0 to -2.50 D) (P < .05). The safety index was 1.01 (mean postoperative BCVA 0.54 and mean preoperative BCVA 0.53; P = .77). The efficacy index was 0.53 (mean postoperative UCVA 0.28 and mean preoperative BCVA 0.53). None of the eyes had an induced astigmatism of more than 0.5 D. Twelve eyes regained their BCVA, 2 lost 1 line of BCVA, and 2 gained 1 line. Three eyes had grade 2 haze. No retinal complications were observed. CONCLUSION In this study, LASIK for uniocular high myopia in pediatric eyes provided encouraging results in the management of select cases of anisometropic amblyopia when other measures failed. A larger study with a longer follow-up is necessary to determine the long-term effects.

Comparison of fourier-domain and time-domain optical coherence tomography for assessment of corneal thickness and intersession repeatability.

PURPOSE To compare Fourier-domain optical coherence tomography (FD-OCT) with time-domain OCT (TD-OCT) for agreement in corneal pachymetry in the central (2-mm) zone and paracentral (2- to 5-mm) zone, minimum corneal thickness, and instrument intersession reliability in candidates with normal cornea. DESIGN Prospective comparative trial. METHODS The study was performed at a tertiary care ophthalmic hospital. One hundred normal candidates with no ocular pathology except mild refractive error were included. FD-OCT and TD-OCT were used for pachymetric analysis within 15 minutes of each other. Repeat testing on both machines was done on the next day. One eye from each patient was randomly selected for analysis of both comparison and reliability. RESULTS The mean thickness was significantly more for FD-OCT (difference being 5.8, 11.1, and 19.2 mum for central, paracentral, and minimal thickness). Highest correlation, best linear fit, and smallest range of 95% limits of agreement (LoA) was seen for central corneal thickness, followed by paracentral and minimum corneal thickness (R(2) values for the 3 best fit lines were 0.93, 0.86, and 0.58, respectively). In terms of intersession reliability, FD-OCT was better (coefficients of reliability <1.5% vs 4.5% of TD-OCT) with smaller 95% LoA range, suggesting its better performance. CONCLUSIONS The corneal thickness measurements between TD-OCT and FD-OCT were highly correlated but not similar. Conversion equations may be used for central and paracentral, but not for minimum, corneal thickness. Even though both the OCT instruments had good reliability, FD-OCT was better.

Wavefront- and topography-guided ablation in myopic eyes using Zyoptix

Purpose: To evaluate the results of wavefront‐ and topography‐guided ablation in myopic eyes using Zyoptix (Bausch & Lomb). Setting: Eye Research Center and Dr. Agarwals Eye Hospital, Chennai, India. Methods: This observational case study comprised 150 eyes with myopia and compound myopic astigmatism. Preoperatively, the patients had corneal topography with Orbscan® IIz (Bausch & Lomb) and wavefront analysis with the Zywave® aberrometer (Bausch & Lomb) in addition to the routine workup before laser in situ keratomileusis (LASIK). The results were assimilated using Zylink® software (Bausch & Lomb), and a customized treatment plan was formulated. Laser in situ keratomileusis was performed with the Technolas® 217 system (Bausch & Lomb). The patients were followed for at least 6 months. Results: The mean preoperative best corrected visual acuity (BCVA) (in decimal equivalent) was 0.83 (20/25) ± 0.18 (SD) (range 0.33 to 1.00) and the mean postoperative (6 months) BCVA, 1.00 (20/20) ± 0.23 (range 0.33 to 1.50). Three eyes (2%) lost 2 or more lines of best spectacle‐corrected visual acuity. The safety index was 1.20. The mean preoperative uncorrected visual acuity (UCVA) was 0.06 (20/350) ± 0.02 (range 0.01 to 0.50) and the mean postoperative UCVA, 0.88 (20/25) ± 0.36 (range 0.08 to 1.50). The efficacy index was 14.66. The mean preoperative spherical equivalent (SE) was −5.25 ± 1.68 diopters (D) (range −0.87 to −15.00 D) and the mean postoperative SE (6 months), −0.36 ± 0.931 D (range −4.25 to +1.25 D). At 6 months, the UCVA was 1.00 (6/6) or better in 105 eyes (69.93%) and 0.5 (6/12) or better in 126 eyes (83.91%). The postoperative aberrations were decreased compared with the preoperative aberrations. One eye (0.66%) had a free cap during LASIK with subsequent loss of 2 lines of BCVA and induced higher‐order aberrations (HOAs). Nine patients (11.2%) complained of halos at night. Conclusions: Wavefront‐ and topography‐guided LASIK leads to improve visual performance by decreasing HOAs. Scotopic visual complaints may be reduced with this method.

Pre-Descemet's endothelial keratoplasty (PDEK)

A new surgical technique for endothelial keratoplasty is described, in which the composite of pre-Descemets layer (Duas layer) with Descemets membrane and endothelium is transplanted subsequent to the removal of the recipients Descemets membrane. The technique was performed in five eyes of five patients, with successful attachment of the graft and good postoperative visual recovery in all cases. Postoperative optical coherence tomography showed good graft attachment without interface abnormalities and a mean graft thickness was 28±5.6 μm. This study demonstrates the practicality of the technique, termed pre-Descemets endothelial keratoplasty (PDEK), which can be a viable option in endothelial keratoplasty with some potential advantages.

Glued intraocular lens: a major review on surgical technique and results.

Purpose of review To review the changes and results of glued intraocular lens (IOL) procedure in eyes with inadequate capsule. Recent findings The recent review of 735 eyes with glued IOL showed 486 rigid glued IOL, 191 foldable IOL, 10 glued iris prosthesis, 16 eyes with glued IOL with pupilloplasty and 32 eyes with glued IOL with penetrating keratoplasty. The postoperative best corrected visual acuity (BCVA) in eyes with the rigid glued IOL was 0.38 ± 0.27. There was a significant improvement in BCVA (P = 0.000). The mean postoperative BCVA in foldable glued IOL was 0.39 ± 0.29. IOL optic-related complications included optic capture and decentration. Haptic-related complications seen are haptic extrusion, haptic dislodgement, broken haptic and subconjunctival haptic. Most of the haptic-related problems are due to improper scleral tucking. The second surgeries in rigid glued IOL included IOL repositioning (2.2%), haptic repositioning (1%), conjunctival peritomy closure (0.8%), posterior segment surgery (1.2%) and IOL explantation (0.4%). The surgical modifications included glued IOL scaffold and vertical glued IOL. Glued IOL, which was combined with corneal procedures such as penetrating keratoplasty, Descemet stripping automated endothelial keratoplasty and Descemets membrane endothelial keratoplasty, showed good visual and anatomical outcome. Summary Glued IOL and its surgical modifications showed good visual outcome with minimal complications in the recent review of its results and complications profile. However, long-term functional and anatomical outcome has to be observed in future.

High-speed Optical Coherence Tomography for Imaging Anterior Chamber Inflammatory Reaction in Uveitis: Clinical Correlation and Grading

PURPOSE To evaluate the anterior chamber (AC) inflammatory reaction by anterior segment high-speed optical coherence tomography (OCT). DESIGN A prospective, nonrandomized, observational case series. METHODS Sixty-two eyes of 45 patients were studied for AC reaction clinically and by anterior segment OCT. Hyperreflective spots suggesting the presence of cells in the AC from the OCT images were counted manually and by a custom made automated software using MATLAB (Mathworks, Natick, Massachusetts, USA) and correlated with clinical grading of AC cells using Standardization of Uveitis Nomenclature criteria. RESULTS In manual method, mean hyperreflective spots were 3 +/- 1.8 in grade 1, 12 +/- 3.5 in grade 2, 33.8 +/- 10.2 in grade 3, and 61.4 +/- 9.6 in grade 4. Automated method showed mean 3 +/- 1.9 hyperreflective spots in grade 1, 12.4 +/- 3.6 in grade 2, 33.2 +/- 9.6 in grade 3, and 74.8 +/- 17 in grade 4. Significant difference seen in mean values between the manual and automated method in grade 4 (P = .009). AC cells were detected in 12 (19.3%) eyes with corneal edema with central corneal thickness ranging from 702 to 1020 microns (mean, 843 +/- 109 microns). Out of 62 eyes, grade 4 aqueous flare was detected by OCT imaging in 7 eyes and clinically in 5 eyes. CONCLUSION Anterior segment OCT can be used as an imaging modality in detecting AC inflammatory reaction in uveitis and also in eyes with decreased corneal clarity and compromised AC visualization attributable to corneal edema. Automated method is sensitive in higher grades of uveitis.