Sunita Agarwal

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.

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.

No-anesthesia clear corneal phacoemulsification versus topical and topical plus intracameral anesthesia: Randomized clinical trial

Purpose: To compare the intraoperative pain scores during clear corneal phacoemulsification under no anesthesia, topical anesthesia, and topical plus intracameral anesthesia. Setting: Dr. Agarwals Eye Hospital and Eye Research Center, Chennai, India. Methods: Seventy‐five patients were randomized to have phacoemulsification under no anesthesia, topical anesthesia, or topical plus intracameral anesthesia. Uncooperative or illiterate patients and those with hard cataract, a shallow anterior chamber, or small pupils were excluded. A protocol was established for supplemental anesthesia in case of breakthrough pain during the surgery. Each patient was asked to grade the overall severity of intraoperative pain immediately after surgery on a 10‐point visual analog scale. Also evaluated were the general discomfort during surgery, discomfort from the microscope lights, surgeon stress during surgery, and total surgical time. Comparison among the 3 groups was performed using an analysis of variance. Results: No supplemental anesthesia was required in any group. No significant difference was noted in the mean scores of the subjective sensation of pain with or without topical anesthesia (P = .610). The mean scores of patient discomfort from the microscope lights and surgical time were also statistically insignificant. Patient discomfort and surgeon stress during surgery were significantly greater in the no‐anesthesia group than in the topical and topical plus intracameral groups (P = .0235 and P = 0.0206, respectively). Conclusion: No‐anesthesia clear corneal phacoemulsification was performed by a highly experienced, skilled surgeon without causing an unacceptable level of pain. However, this technique is not suitable for every cataract surgeon or patient.

Clear lens extraction with intraocular lens implantation for hyperopia

Purpose: To analyze the results of clear lens extraction (CLE) with posterior chamber intraocular lens (IOL) implantation to correct hyperopia. Setting: Eye Research Center and Dr. Agarwals Eye Hospital, Chennai, India. Methods: This prospective study comprised 20 hyperopic eyes of 12 patients between 19 and 50 years who had CLE with posterior chamber IOL implantation. Five patients had peripheral iridectomy during CLE as the angles were occludable. The mean hyperopic spherical equivalent refraction was +6.66 diopters (D) ± 2.17 (SD) (range +4.75 to +13.00 D). The IOL power was calculated using the Holladay 2 formula. The mean follow‐up was 16.96 months (range 6 to 35 months). Results: The mean postoperative uncorrected visual acuity was 0.45 ± 0.25 (range 0.10 to 1.00), a mean improvement of 3 Snellen lines from preoperatively. The mean postoperative best corrected visual acuity (BCVA) was 0.63 ± 0.30, a mean improvement of 1 Snellen line. Three patients gained 2 lines of BCVA and 2 patients, 1 line. One patient lost 1 line of BCVA. Seventy percent of patients were within ±0.50 D of the intended refraction. Conclusion: The results indicate that CLE with posterior chamber IOL implantation is safe, predictable, and effective.

Phakonit with an AcriTec IOL

1. Hagan JC. Irrigation/aspiration handpiece with changeable tips for cortex removal in small incision phacoemulsification. J Cataract Refract Surg 1992; 18:318–320 2. Seibel BS. Phacodynamics; Mastering the Tools and Techniques of Phacoemulsification Surgery, 3d ed. Thorofare, NJ, Slack Inc, 1999; 242–243 3. Hagan JC. A new cannula for removal of 12 o’clock cortex through a sideport corneal incision. Ophthalmic Surg 1992; 23:62–63

Laser in situ keratomileusis for residual myopia after primary LASIK

Purpose: To analyze the results of secondary laser in situ keratomileusis (LASIK) for residual myopia after primary LASIK. Setting: Dr. Agarwals Eye Hospital, Chennai, India. Methods: A retrospective study of 50 eyes of 29 patients who had a secondary LASIK procedure was carried out. After a mean follow‐up of 5.84 months ± 3.24 (SD) after the primary procedure, the mean myopic residual refraction was −4.30 ± 1.83 diopters (D). In 10 eyes, the primary corneal flap was lifted by blunt dissection. In 40 eyes, the flap was made with a second cut. The secondary LASIK was performed using the Chiron Technolas Keracor 217 excimer laser and the Automated Corneal Shaper® microkeratome (Bausch & Lomb). Results: The mean follow‐up was 16.58 ± 3.06 months. At 12 months, the mean spherical equivalent was −0.45 ± 0.68 D (P < .05). Thirty‐one eyes were emmetropic, 13 eyes were within ±1.00 D of emmetropia, and 5 eyes were within ±2.00 D. The mean uncorrected visual acuity improved from 20/80 (range 20/60 to 20/200) to 20/40 (range 20/20 to 20/200) (P < .005). Seventeen eyes gained 1 line of best spectacle‐corrected visual acuity; 1 eye lost 1 line because of a decentered ablation with an induced postoperative astigmatism of −3.50 D cylinder. No sight‐threatening complications such as a free cap, flap irregularity, corneal ectasia, or retinal complication occurred postoperatively. Epithelial ingrowth developed in 5 eyes and corneal thinning, in 1 eye. Three eyes had night glare. Conclusion: Secondary LASIK was a safe, stable, and effective method for the treatment of residual myopia after primary LASIK.

Laser in situ keratomileusis for residual myopia after radial keratotomy and photorefractive keratectomy.

Purpose: To evaluate the visual outcome, stability, and complications of laser in situ keratomileusis (LASIK) for residual myopia after radial keratotomy (RK) and photorefractive keratectomy (PRK). Setting: Dr. Agarwals Eye Hospital, Chennai, India. Methods: Twenty eyes that had LASIK treatment for residual myopia after RK (10 eyes) or PRK (10 eyes) were retrospectively analyzed. Laser in situ keratomileusis was performed after a mean period of 24.3 months ± 0.75 (SD) in the RK group and 22.0 ± 1.07 months in the PRK group. Results: At the last follow‐up, the mean spherical equivalent was reduced from −6.05 ± 1.98 diopters (D) to –1.26 ± 0.32 D (P < .05) in the RK group and from –3.38 ± 1.30 D to –0.55 ± 0.40 D (P < .005) in the PRK group. The mean uncorrected visual acuity improved from 20/300 (range 20/600 to 20/200) to 20/40 (range 20/60 to 20/20) (P < .05) and from 20/200 (range 20/800 to 20/80) to 20/25 (range 20/40 to 20/20) (P < .05), respectively. Two eyes in the RK group and 3 in the PRK group gained 1 line of best corrected visual acuity, and 2 eyes in the RK group lost 1 line. No sight‐threatening complications such as a free flap, corneal ectasia, or a retinal complication occurred. There was no statistically significant difference in corneal haze before and after LASIK. Two eyes in the RK group required repositioning of the flap because of irregular apposition to the stromal bed. Conclusion: Laser in situ keratomileusis was safe, effective, and stable in the treatment of residual myopia after RK and PRK.

Safety and efficacy of gas-forced infusion (air pump) in coaxial phacoemulsification.

PURPOSE: To evaluate the safety and efficacy of gas‐forced infusion (air pump) in uncomplicated coaxial phacoemulsification. SETTING: Dr. Agarwal’s Eye Hospital, Chennai, India. DESIGN: Comparative case series. METHODS: Specular microscopy and optical coherence tomography were used to analyze the endothelium, central macular thickness (CMT), and peripapillary retinal nerve fiber layer (RNFL) thickness before and approximately 1, 7, 30, and 90 days after coaxial phacoemulsification with (infusion group) or without (control group) gas‐forced infusion. Surgical time, surge, phaco energy, irrigation fluid volume, surgical ease, complications, and visual gain in the 2 groups were compared. RESULTS: The mean endothelial cell loss was lower in the infusion group than in the control group (6.98% ± 8.46% [SD] versus 10.54% ± 11.24%; P = .045) and the irrigation/aspiration time significantly shorter (54 ± 39 seconds versus 105 ± 84 seconds; P = .0001). The surgery was rated as easier with gas‐forced infusion (scale 1 to 10: mean 8.3 ± 2.1 versus 6.6 ± 1.6; P = .00002). However, the amount of irrigating fluid volume was higher in the infusion group (117 ± 37 mL versus 94 ± 41 mL; P = .003). No surge occurred in the infusion group; it occurred a mean of 3.00 ± 4.16 times in the control group (P<.0001). The rate of visual gain, CMT, peripapillary RNFL thickness, phaco time, and amount of phaco energy were comparable in the 2 groups. CONCLUSION: Gas‐forced infusion was safe and effective in controlling surge and increased the safety, ease, and speed of coaxial phacoemulsification. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.