Som Prasad

Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation

PURPOSE: To report the intermediate multicenter results of a technique of sutureless intrascleral fixation of a standard 3‐piece posterior chamber intraocular lens (PC IOL) in the ciliary sulcus. SETTING: Four European ophthalmology centers. METHODS: A technique for sutureless intrascleral fixation of the haptics of a standard 3‐piece PC IOL was retrospectively evaluated. The technique uses standardized maneuvers to fixate the PC IOL without need for special haptic architecture or preparation or haptic suturing. All patients having IOL implantation by the technique were evaluated for preoperative status (visual acuity, refractive error, preexisting ocular conditions, optical biometry), postoperative status, complications, and need for further surgery. RESULTS: The study evaluated 63 consecutive patients from 4 institutions (4 surgeons). The median follow‐up was 7 months. Two dislocated PC IOLs (3.6%) were decentered; the other 61 IOLs (96.8%) were stable and well centered. There were no cases of recurrent dislocation, endophthalmitis, retinal detachment, or glaucoma. CONCLUSION: Fixation of PC IOL haptics in a limbus‐parallel scleral tunnel provided exact centration and axial stability of the IOL and prevented distortion and subluxation in most cases. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

A prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: clinical presentation, microbiology, management and outcome.

Background/Aims This is the first prospective and nationwide study aiming to provide epidemiological data relating to presentation, microbiology, management and outcome of endophthalmitis following vitrectomy. Methods Two years of prospective and nationwide surveillance for cases of presumed infectious endophthalmitis within 6 weeks of pars plana vitrectomy was completed. The study obtained case reports via the established British Ophthalmological Surveillance Unit (BOSU) system. Results Thirty-seven cases were reported and 28 met the diagnostic criteria for presumed infectious endophthalmitis following vitrectomy. Mean age was 61 years and 67% were male. Nineteen cases were 23/25 gauge and 9 cases were 20 gauge. Mean time from surgery to endophthalmitis was 5 days. Blurred vision (85.2%), pain (77.8%) and a hypopyon (77.8%) were the commonest presenting symptoms and signs. Seventeen cases (60.7%) had a positive culture. Culture-positive endophthalmitis, relative to culture-negative endophthalmitis, was no different with respect to time to presentation, symptoms, signs or outcome. Outcome was poor, with 29.6% of eyes being eviscerated or having no perception of light or perception of light. Conclusions This study helps surgeons promptly identify cases of endophthalmitis following vitrectomy and informs them about the various management options currently used and the likely outcome of this devastating complication.

A prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: incidence and risk factors

Background/aims This is the first nationwide prospective study to investigate the incidence and risk factors of endophthalmitis following pars plana vitrectomy (PPV). Methods This was a prospective, nationwide case–control study. Cases of presumed infectious endophthalmitis within 6 weeks of PPV were reported via the established British Ophthalmological Surveillance Unit. The surveillance period was 2 years. Controls (patients who had PPV but no endophthalmitis) were recruited from nine randomly selected UK centres. Results 37 reports were received and 28 cases met the diagnostic criteria for presumed infectious endophthalmitis following PPV. The incidence of endophthalmitis following PPV was 28 cases per 48 433 PPVs (1 in 1730 with a 95% CI of 1 in 1263 to 1 in 2747). 272 controls were randomly recruited from nine UK centres. Smaller gauge port sizes were not found to be a risk. Immunosuppression (OR 19.0, p=0.001) and preoperative topical steroids (OR 131.4, p<0.001) increased the endophthalmitis risk. Operating for retinal detachment was associated with a reduced risk of endophthalmitis (OR 0.10, p=0.005). Conclusions Endophthalmitis following PPV is rare. Operating with smaller gauge port sizes does not increase the risk of endophthalmitis.

Clinical outcomes of triamcinolone-assisted anterior vitrectomy after phacoemulsification complicated by posterior capsule rupture

Purpose To compare the clinical outcomes in patients who had triamcinolone acetate–assisted anterior vitrectomy and patients who had anterior vitrectomy without triamcinolone acetate after phacoemulsification complicated by posterior capsule rupture and vitreous loss. Setting Arrowe Park Hospital, Wirral, United Kingdom. Design Retrospective consecutive case note review. Methods Consecutive case notes of patients who had anterior vitrectomy assisted by triamcinolone acetonide (triamcinolone group) or without triamcinolone acetate (no‐triamcinolone group) after posterior capsule rupture between January 2007 and January 2011 were identified and examined. Data recorded at the clinic visit preoperatively and 1 day and 3 months postoperatively were collated. Information recorded on the pro forma included visual acuity, ocular comorbidities, intraocular pressure (IOP), vitreous strands in the anterior chamber, and other adverse events. Results No statistically significant difference was found in the visual acuity or IOP between 17 patients in the triamcinolone group and 34 patients in the no‐triamcinolone group at any time point. Vitreous strands in the anterior chamber were noted in 1 patient in the triamcinolone group and 7 patients in the no‐triamcinolone group. Cystoid macular edema (CME) was present in 3 patients in the no‐triamcinolone group, including 1 patient with vitreomacular traction. Conclusions There was no significant increase in IOP after triamcinolone acetate–assisted anterior vitrectomy. Higher rates of CME and residual anterior chamber vitreous strands in the no‐triamcinolone acetate group support the clinical use of triamcinolone acetate. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Sutureless scleral-fixated posterior chamber intraocular lens

Sutureless scleral-fixated posterior chamber intraocular lens In their article on the long-term results of scleralfixated posterior chamber intraocular lenses (PC IOLs), McAllister and Hirst reviewed the records of patients with sutured scleral-fixated PC IOLs operated on from 1993 to 2008. In this retrospective case series, complications included suture breakage (6.1%), suture exposure (11%), and endophthalmitis. Sixteen surgical procedures were performed 1 week after scleral-fixated PC IOL insertion, and 6 of these were suture related (5 suture breakage, 1 scleral graft for suture exposure). We would like to share our experience with sutureless PC IOL implantation techniques in eyes with deficient capsule support. Scharioth et al. introduced intrascleral haptic fixation of a standard 3-piece PC IOL without sutures and reported good intermediate results, with no cases of anterior or posterior chamber inflammation, acute postoperative endophthalmitis, or late endophthalmitis. In the glued IOL procedure introduced by Agarwal et al., good IOL centration without sutures was documented. In the 1-year follow-up by Kumar et al., there were no suture-related complications or endophthalmitis. A total of 210 glued IOL eyes with a follow-up of 6 to 41 months were analyzed. Decentration was found in 4 eyes (1.9%) and chronic macular edema in 3 eyes (1.4%). There was no endophthalmitis or postoperative glaucoma. Glued IOLs have been shown to have good stability and therefore less pseudophacodonesis. In follow-up examinations of glued IOL eyes, no haptic extrusions were noted. Moreover, good scleral flap appositions were observed. When the eye moves, it acquires kinetic energy from the muscles and attachments and the energy is distributed to the internal fluids as it stops. Thus, pseudophacodonesis is the result of oscillations of the fluids in the anterior and posterior segment of the eye. In a scleral-fixated IOL suspended with the suture, there is more pseudophacodonesis and this may lead to posterior segment complications in the long term. This is seen by the incidence of retinal detachment (4.9%) and chronic macular edema (7.3%) in McAllister and Hirsts review. However, no significant retinal problems were seen in the follow-up of the glued IOL procedure. We hypothesize that because a large part of the haptic is buried in scleral tunnels in sutureless scleral fixation techniques, the IOL is inherently more stable and less prone to pseudophacodonesis. McAllister and Hirst reported ocular hypertension as the most common complication in 30.5% of the

Management of cataract caused by inadvertent capsule penetration during intravitreal injection of ranibizumab

We describe an approach to phacoemulsification of complicated cataract with preexisting posterior capsule tear caused by an intravitreal injection. Careful preoperative planning and attention to fluidics, low bottle height, appropriate incisions, careful hydrodelineation without hydrodissection, avoidance of nuclear rotation, and use of a dispersive ophthalmic viscosurgical device to tamponade vitreous allows safe phacoemulsification with secure posterior chamber intraocular lens implantation. Biaxial microincision cataract surgery can achieve efficient removal of the lens matter without rotating the nucleus, reducing the chance of capsule tear extension and loss of nuclear fragments into the posterior pole.

Phacoemulsification Surgery in Eyes with Neovascular Age-Related Macular Degeneration

Purpose. To evaluate the visual outcomes and effect of phacoemulsification surgery on the progression of neovascular age-related macular degeneration (AMD). Methods. Retrospective, noncomparative, and interventional case series. Thirty eyes from 29 subjects with neovascular AMD treated with intravitreal antivascular endothelial growth factor (VEGF) injections who underwent phacoemulsification and had a postsurgery follow-up of 6 months were included. LogMAR best corrected visual acuity (BCVA) was assessed preoperatively; 1 month, 3 months, and 6 months postoperatively; and finally at the last visit. The frequency of anti-VEGF therapy, calculated as the number of intravitreal injections per month, and central macular thickness (CMT) before and after cataract surgery were determined. Results. Median (range) logMAR BCVA was 0.69 (0.16 to 1.32) preoperatively; 0.55 (−0.04 to 1.32) at 1 month, 0.52 (−0.1 to 1.32) at 3 months, and 0.50 (0.0 to 1.32) at 6 months postoperatively; and 0.6 (0.0 to 1.4) at final visit (P = 0.0011). There was no difference in the frequency of anti-VEGF injections between the immediate 6 months before and after phacoemulsification, which was equal to 0.1667 injections per month (P = 0.6377). Median CMT measured 203 μm preoperatively, which temporarily increased to 238 μm at 1 month after surgery (P = 0.0093) and then spontaneously returned to baseline, measuring 212.5 μm at 3 months postoperatively (P = 0.3811). Conclusion. Phacoemulsification surgery significantly improved vision in patients with neovascular AMD, with no increased need for anti-VEGF injections to keep the macula dry postoperatively.

Simultaneous correction of aniridia and aphakia.

43.39 G 1.52 D (range 40.45 to 46.72 D). There was no significant relationship between either of these variables and the refractive outcome (PZ.89 and PZ.53, respectively). We agree that capsular distension syndrome cannot occur in the presence of posterior capsule rupture and pointed this out in the manuscript. The references were added to draw attention to this potential confounder if optic capture is used with an intact capsule.dEoghan R.A. Millar, MB ChB, David H.W. Steel, MD, FRCOphth

A review of endophthalmitis following vitrectomy

In the past decade there have been many changes in the field of vitreoretinal surgery. Transconjunctival sutureless systems have revolutionized some of the approaches to pars plana vitrectomy as the introduction of smallgauge trocar cannula systems allows entry into the vitreous cavity without dissecting conjunctiva and requires no suture to close routinely at the end of surgery. Smaller ports and sutureless surgery have a number of benefits for the patient and surgeon and hence have been widely adopted. However, there are some concerns that smaller gauge or sutureless vitrectomy surgery could increase the risk of endophthalmitis – a devastating infectious complication of intraocular surgery. The aim of this review is to present the changes that have occurred in vitreoretinal surgery in recent years and to summarize the evidence relating to endophthalmitis following vitrectomy.

Microincision cataract surgery: technology and techniques

Cataract surgery continues to evolve, embracing smaller incisions that allow quicker recovery, better wound strength and increased surgical control, resulting in lower complication rates and better outcomes. We describe the emergence of microincision phacoemulsification through a sub-2-mm incision, explaining the technological developments that have allowed this technique to develop, the pros and cons of biaxial compared with coaxial approaches, and the intraocular lenses that are available for microincision surgery. Tips to ease the transition to microincision surgery are discussed. A section on how this field may evolve over the next few years is also included.