Dhivya Ashok Kumar

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.

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.

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.

Glued intrascleral fixation of posterior chamber intraocular lens in children.

PURPOSE To evaluate the short-term results of glued intrascleral fixation of posterior chamber intraocular lens (glued IOL) in children without adequate capsular support. DESIGN Noncomparative retrospective observational case series. PATIENTS SETTING Institutional practice. METHODS Forty-one eyes of 33 children who underwent glued IOL implantation were retrospectively evaluated. The indications were postsurgical aphakia, subluxated cataract, ectopia lentis, traumatic subluxation, and decentered IOL. MAIN OUTCOME MEASURES Visual acuity (VA), endothelial cell changes, intraoperative and postoperative complications. RESULTS The mean age at the time of glued IOL was 10.7±3.6 years (range 5-15). The mean duration of follow-up after surgery was 17.5±8.5 months (range 12-36). The mean postoperative best spectacle-corrected visual acuity (BCVA in decimal equivalent) was 0.43±0.33 and there was significant change noted (P<0.001). Postoperatively, 20/20 and >20/60 BCVA was obtained in 17.1% and 46.3% of eyes respectively. BCVA improvement more than 1 line was seen in 22 eyes (53.6%). The mean postoperative refraction was myopic (-1.19±0.7 diopters [D]) in 19 eyes and hyperopic (+1.02±0.7 D) in 22 eyes. The mean endothelial loss was 4.13% (range 1.3%-5.94%). The 3 causes of reduced BCVA were the preexisting corneal, retinal pathology, and amblyopia. Postoperative complications included optic capture in 1 eye (2.4%), macular edema in 2 eyes (4.8%), and clinical decentration in 2 eyes (4.8%). There was no postoperative retinal detachment, IOL dislocation, endophthalmitis, or glaucoma. CONCLUSION Short-term results in children after glued IOL were favorable, with a low rate of complications. However, regular follow-ups are required since long-term risks are unknown.

Femtosecond-assisted keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation: new triple procedure.

&NA; We report a surgical technique for managing bullous keratopathy secondary to anterior chamber intraocular lens (AC IOL). The technique comprises femtosecond laser–assisted penetrating keratoplasty and AC IOL exchange with fibrin glue–assisted sutureless posterior chamber intraocular lens (PC IOL) implantation (“glued IOL”). This new triple procedure combines the unique benefits of the femtosecond laser and the glued IOL, leading to stable wound configuration, decreased open‐sky time, and less pseudophacodonesis, and there is less risk for the suture‐related complications of transscleral suture fixation.

Reliability and Reproducibility of Assessment of Corneal Epithelial Thickness by Fourier Domain Optical Coherence Tomography

PURPOSE To analyze the intra-user reliability and inter-user reproducibility of assessment of corneal epithelial thickness by Fourier domain optical coherence tomography. METHODS In this consecutive cross-sectional case series performed at a tertiary ocular care institution, 210 eyes of 210 subjects underwent anterior segment Fourier domain optical coherence tomography (FDOCT). A caliper tool software was used to measure the corneal thickness. For the reproducibility measures, the examination was done by 2 examiners (user 1, user 2) within 30 minutes of each other. For the reliability measure, the retest was done by user 1 on the next day, within 30 minutes of the previous tests time. The total corneal thickness, epithelial thickness, and corneal thickness excluding the epithelium were measured. RESULTS The mean corneal thickness of the population measured by user 1 was 519.5 ± 31.1 μm, 58.6 ± 4.2 μm, and 460.95 ± 31.4 μm for total cornea, epithelium, and non-epithelial cornea, respectively. The difference in results between user 2 and user 1 was 0.8 ± 7.2 μm, 0.23 ± 3.3 μm, and 0.7 ± 8.2 μm for total, epithelium, and non-epithelial cornea, respectively, and the difference in results between the repeated series by user 1 was 0.49 ± 5.7 μm, -0.13 ± 2.7 μm, 0.61 ± 5.4 μm total, epithelium, and non-epithelial cornea, respectively (paired t-test, P > 0.05). Intraclass correlations ranged from 0.87 to 0.99, coefficients of repeatability from 4.5 to 14.11, and coefficient of variation from 2.3% to 11.1%. CONCLUSIONS Fourier domain anterior segment optical coherence tomography is reproducible and reliable for the measurement of epithelial thickness at vertex.

Contact lens-assisted collagen cross-linking (CACXL): A new technique for cross-linking thin corneas.

PURPOSE To report a novel method of contact lens-assisted corneal cross-linking (CACXL) in eyes with thin corneas. METHODS Patients diagnosed as having progressive keratectasia with a minimum corneal thickness less than 400 and greater than 350 μm after epithelial abrasion were included. After epithelial abrasion, the iso-osmolar riboflavin 0.1% in dextran was applied every 3 minutes for 30 minutes. An ultraviolet barrier-free soft contact lens (0.09-mm thickness, 14-mm diameter) soaked in iso-osmolar riboflavin 0.1% for 30 minutes was placed on the cornea. Once the minimum corneal thickness value was confirmed to be greater than 400 μm, the ultraviolet-A irradiance was started along with instillation of iso-osmolar riboflavin 0.1% in the pre-corneal and pre-contact lens region. Intraoperative minimum corneal thickness changes were recorded with ultrasound pachymetry and optical coherence tomography. Postoperative visual acuity, corneal topography (Orbscan; Bausch & Lomb, Rochester, NY), endothelial cell loss (EM-3000; Tomey, Nagoya, Japan), and stromal demarcation line (Visante; Carl Zeiss Meditec, Jena, Germany) were measured. RESULTS Fourteen eyes underwent the procedure. Mean preoperative minimum corneal thickness after epithelial abrasion was 377.2 ± 14.5 μm (range: 350 to 398 μm). There was a significant difference in minimum functional corneal thickness (Friedman test, P = .000) intraoperatively, before epithelial abrasion, after epithelial abrasion, and with contact lens and riboflavin film. Mean minimum functional corneal thickness after the contact lens was 485.1 ± 15.8 μm (range: 458 to 511 μm). Mean absolute increase in the minimum corneal thickness along with the contact lens and pre-corneal riboflavin film was 107.9 ± 9.4 μm (range: 90 to 124 μm). Mean depth of stromal demarcation line was 252.9 ± 40.8 μm (range: 208 to 360 μm). There was no significant endothelial loss (P = .063) and the corneal topography was stable at the last follow-up (P = .505). CONCLUSIONS CACXL technique was effective and safe in performing cross-linking in corneas less than 400 μm after epithelial abrasion and appeared effective based on stromal demarcation line depth.

Complications and visual outcomes after glued foldable intraocular lens implantation in eyes with inadequate capsules

Purpose To evaluate the complications and visual outcomes of glued intrascleral‐fixated foldable intraocular lens (IOL) in eyes with deficient capsules. Setting Dr Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Design Case series. Methods Data were evaluated from the records of patients with a primary glued foldable IOL for intraoperative capsular loss or subluxated lens or secondary glued foldable IOL for aphakia. Exclusion criteria included preoperative glaucoma, aniridia, macular scar, traumatic subluxation, combined surgeries, incomplete operative medical records, and postoperative follow‐up less than 6 months. The intraoperative and postoperative complication rates, reoperation rate, and visual outcomes were analyzed. Results The study comprised 208 eyes (185 patients). The mean follow‐up was 16.7 months ± 10.2 (SD). The intraoperative complications were hyphema (0.4%), haptic breakage (0.4%), and deformed haptics (0.9%). Early complications occurred in 29 eyes (13.9%) and included corneal edema (5.7%), epithelial defect (1.9%), and grade 2 anterior chamber reaction (2.4%). Late complications occurred in 39 eyes (18.7%) and included optic capture (4.3%), IOL decentration (3.3%), haptic extrusion (1.9%), subconjunctival haptic (1.4%), macular edema (1.9%), and pigment dispersion (1.9%). Reoperation was required in 16 eyes (7.7%). Haptic position was altered in eyes with IOL decentration. Corrected distance visual acuity (CDVA) improved or remained unchanged in 84.6% of eyes. The postoperative CDVA was 20/40 or better and 20/60 or better in 38.9% and 48.5% of eyes, respectively. Conclusions The foldable glued‐IOL procedure showed satisfactory visual outcomes without serious complications. Intraocular lens decentration was due to haptic‐related problems. Financial Disclosure Dr. Agarwal is a paid consultant to Staar Surgical Co. No author has a financial or proprietary interest in any material or method mentioned.

Evaluation of Intraocular Lens Tilt With Anterior Segment Optical Coherence Tomography

PURPOSE To determine the ability of anterior segment optical coherence tomography (OCT) to detect intraocular lens (IOL) tilt evaluation in relation to the limbus. DESIGN Observational case series. METHODS The IOL position of 123 eyes of 92 patients was examined with anterior segment OCT (Carl Zeiss Meditec, Dublin, California, USA). All eyes underwent uneventful phacoemulsification with the IOL in the bag. Images were obtained in 4 axes (180 to 0 degrees, 225 to 45 degrees, 315 to 135 degrees, and 270 to 90 degrees). Using MatLab software version 7.1 (Mathworks), the OCT images were analyzed. The distance between the iris margin and the anterior surface of IOL, the slope ratio between IOL and limbus, and the angle (θ; position of IOL with reference to the limbus) were determined and were correlated with the astigmatism and vision. RESULTS The mean slope of the limbus and the IOL in all axes was 0.003 ± 0.09 and -0.002 ± 0.12, respectively. The average slope ratio was 1.1 ± 1 (range, -2.09 to 3.82) and the angle (θ) was 1.52 ± 0.9 degrees (range, 0.04 to 3.6 degrees). The mean ocular residual astigmatism was 0.2379 ± 0.469 diopters. There was no significant correlation of ocular residual astigmatism with slope ratio (r = -0.171; P = .060) and slope angle (r = -0.132; P = .147). There was significant correlation of ocular residual astigmatism with total astigmatism (r=0.602, p=0.000). The mean distances between the iris margin and the anterior surface of IOL at the pupillary plane were 0.80 ± 0.6 mm and 0.83 ± 0.57 mm, respectively. CONCLUSIONS The normal in-the-bag IOL maintains an angle with reference to the limbus and a slope ratio without causing a significant tilt. Anterior segment OCT can be used as an alternative in IOL tilt evaluation by the analysis of its position in relation to the limbus.