Unsal Sari

Medium-term outcomes of three horizontal muscle surgery in large-angle infantile esotropia.

PURPOSE To evaluate the medium-term motor outcomes of three horizontal muscle surgery in patients with large-angle infantile esotropia. METHODS The charts of 18 patients with large-angle (> 55 prism diopters [PD]) infantile esotropia who underwent bilateral medial rectus muscle recession and one lateral rectus muscle resection were retrospectively reviewed. Preoperative and postoperative deviations at last examination, overcorrections and undercorrections, necessity of additional horizontal surgery, and follow-up durations were recorded. RESULTS The median age of patients at surgery was 22 months (range: 10 to 168 months). Orthotropia to within 10 PD or less was achieved in 14 of 18 patients (78%) in a median follow-up of 32 months (range: 5 to 63 months). The mean preoperative deviation of 68.8 ± 9.54 PD decreased to a median of 1 PD (range: esotropia 30 to exophoria 4 PD) postoperatively (P < .005). Marked residual esotropia necessitating additional surgery occurred in 4 patients, but significant overcorrection was not observed. CONCLUSIONS The success rate of the three horizontal muscle surgeries appears to be high enough in medium-term follow-up in patients with large-angle infantile esotropia. Overcorrection that necessitates additional horizontal muscle surgery does not seem to be significant in the medium term, according to this study.

Sutureless intrascleral posterior chamber intraocular lens fixation

Reply : Intraoperative miosis was one of the most significant intraoperative problems and complications in the early use of femtosecond laser–assisted cataract surgery. Dr. Yeoh described the role of NSAID drops, which has almost been forgotten in recent years because of the quick and safe phacoemulsification technique. We have also known that during the early phase of femtosecond laser–assisted cataract surgery, intraoperative miosis was more common than during routine phacoemulsification. The possible causes are the mechanical effect of the patient interface and the role of bubble and gas formation within the anterior chamber and within the lens. We have known for some time that prostaglandins are strong bioregulatory substances with high potential within the eye and within the entire body. Prostaglandins are synthesized by the cyclooxygenase pathway, and the most important intraocular source is the nonpigmented epithelial layer of the ciliary body. Mechanical and thermal stimuli may increase the level of prostaglandins in the aqueous humor. Our working team has studied intraoperative miosis, as have other authors. Recently, Schultz et al. reported that the prostaglandin level is elevated in the aqueous following femtosecond laser pretreatment. The cause might be the mechanical effect of the patient interface and the bubble formation within the anterior chamber. Based on the experiences of femtosecond laser surgeons, it is strongly advised that preoperative NSAIDs be included in the dilation regimen. The personal experiences of

Is this really sutureless scleral intraocular lens fixation

Is this really sutureless scleral intraocular lens fixation? In their recent article, Ohta et al. describe a technique of sutureless intrascleral fixation of a posterior chamber intraocular lens (IOL). This definition does not seem to be correct. As the authors fixated the haptics in the scleral bed in the scleral groove using a nonabsorbable suture to prevent slippage, this is a modified sutured technique. If they had used an absorbable suture, the definition would apply. Ohta et al. stated that they encountered difficulty placing the haptics in the scleral tunnel with the 24gauge needle technique of Gabor et al. We agree with the authors because placement of the haptics using this technique may be difficult in some cases. Therefore, we developed the trocar-assisted sutureless intrascleral fixation IOL method. In previously reported techniques of sutureless intrascleral fixation, a nonabsorbable suture was not used. In our trocar-assisted technique, we placed a nonabsorbable suture transconjunctivally after placing the haptics in the scleral groove for stabilization during the early postoperative period and removing it 1 week later. Ohta et al. obtained a triangular-shaped flap. They did not mention how much of the haptics were inserted into the scleral bed. Despite a permanent suture, they reported IOL-related complications as 5%,which is higher than the rates in previous studies of sutureless intrascleral IOL fixation (0% to 4.8% except traumatic dislocations). The authors concluded that their technique was more secure and simpler than the others. We do not agree with this for the reasons mentioned above. Our trocar-assisted technique appears to be simpler and quicker. In conclusion, the technique that Ohta et al. presented may be considered a modified intrascleral fixation of the IOL rather than a sutureless method. In this

On retrochop technique

On retrochop technique In their recent article, Falabella et al. described a retrochop technique for rock-hard cataracts. We have used the retrochop technique routinely for about 9 years and agree with the authors on the advantages, especially in dense cataract cases. As the authors stated, one of the most important aspects of the technique is the necessity of a large capsulorhexis. Instead of an oval 7.0 mm 5.5 mm diameter capsulorhexis, which Falabella et al. used, we prefer a 6.0 to 6.5 mm diameter circular capsulorhexis. After the nucleus is grabbed using strong suction, it is lifted from the capsular bag to facilitate access to the posterior pole of the nucleus with the chopper. Although an oval 7.0 mm 5.5 mm diameter capsulorhexis seems to be more advantageous in accessing the posterior pole, we usually do not encounter difficulty with a 6.0 mm diameter circular capsulorhexis. It is not easy to create an oval 7.0mm 5.5mm capsulorhexis every time because of the possibility of a tear extending to the periphery. We are aware of the disadvantages of a large capsulorhexis, such as increased likelihood of IOL decentration and an increased rate of posterior capsule opacification since the capsule edges do not overlap the optic edge circumferentially. However, we think the safety of the retrochop technique outweighs the drawbacks in dense cataracts and the complete division of the nucleus is warranted since it starts from the posterior pole, which is the most difficult part to crack. We encourage cataract surgeons to consider this technique for mature cataract cases.

Manual tunnel incision cataract surgery with sandwich technique in eyes with microcornea

Manual tunnel incision cataract surgery with sandwich technique in eyes with microcornea The consultation section in the February 2014 issue involved a 41-year-old man with bilateral microcornea, inferonasal uveal coloboma, and mature cataract with modest inferior subluxation. 1 There is an erratum in the fourth paragraph of the case presentation. The text says “there is moderate pseudophakodonesis...” in this cataractous eye. However, the term should be phacodonesis since the eyewas cataractous, not pseudophakic. On therapeutic options, we generally agree with all the consultants as well as the case editor in terms of the preference of a scleral incision. Since the eye has a microcornea with a corneal diameter of 8.5 mm, any corneal incision will result in much more endothelial cell damage than a scleral, more peripheral incision and will compromise the corneal transparency. We would prefer a scleral tunnel incision in the case, as did the consultants. In addition, we would prefer the sandwich technique described by Fry. We began using manual

Manual tunnel incision cataract surgery with sandwich technique may be a rationale alternative for mature cataracts.

Dear Editor, We read with interest the article of Yang et al. appearing on April issue of Indian J Ophthalmology.[1] As the surgeons performing manual small incision cataract surgery since 1996,[2,3,4,5,6] we would like to note couple of points about Yang et al.s paper: There is an erratum on the results section of abstract. It has been written that “self-sealing wound was achieved in 112 eyes (98.2%).” However, the study had consisted 112 eyes. The correct number should be “110 eyes (98.2%).” This technique necessitates an incision at the location of 135° for right-handed surgeon and of 45° for left-handed surgeon. Hence, it will not be easy to perform it in the surgery of left eyes for right-handed surgeon and in the surgery of right eyes for left-handed surgeon, especially in the eyes with prominent eyebrows and big nose. It is not easy to arrange the incision according to steep-axis in Yang et al.s technique. Hence, the surgeon will not correct the preexisting astigmatism in some cases. Indeed, the authors has given a bigger mean value of postoperative astigmatisms (1.5 D) than of preoperative astigmatism (0.71 D). The authors implanted a polymethylmethacrylate (PMMA) intraocular lens (IOL). While PMMA IOLs are cheap IOLs, they have significant spherical aberration. Today, there are cheap foldable IOLs that do not have such significant spherical aberration and can be use for this type of surgery. Yang et al. perform a large, 7 mm capsulorrhexis. This can increases likelihood of the decentralization of the IOL and probably increased posterior capsule opacification rate since the capsular edges do not overlap the optic edge circumferentially. Due to this, we prefer a 6.0 mm diameter circular capsulorrhexis and an IOL of 6 mm optic diameter. We do not encounter with any difficulty to prolapse the nucleus into the anterior chamber with 6 mm capsulorrhexis. We have been preserving the manual small incision cataract surgery in hard, brunescent cataract cases and in the cataract cases of vitrectomized eyes in which we consider that phacoemulsification may be risky.[5,6] We think that sandwich technique presents some advantages in mature cataract cases. In this method, the nucleus firmly grasped between two instruments, irrigating vectis and spatula. So an incision length of a diameter of the nucleus or 1 mm more is enough to be able to extract the nucleus out to the eye. Furthermore, we consider that removing the nucleus via sandwiching it firmly between two instruments prevents the corneal endothelium more than extracting it via just only vectis or exerting a pressure on the scleral wound lip, since the spatula in front of the nucleus would ensure to stay it away from the endothelium. In conclusion, We congratulate Yang et al. for this novel and interesting technique, which is a valuable contribution, especially for the surgeons who do not have enough instrumental possibilities to carry out phacoemulsification in undeveloped areas.

Intra-scleral fixation of the iris hooks for trans-scleral capsular bag fixation in patient with zonular dialysis

PurposeTo report a technique of intra-scleral fixation of the iris hooks for trans-scleral capsular bag fixation in patient with zonular dialysis.MethodsTwo scleral flaps, two scleral tunnels and two sclerotomies were formed. The anterior capsule was captured and pulled by the iris hooks resulting in the IOL adopting an appropriate position at which point the iris hooks extracted from the sclerotomies. The tips of the iris hooks were implanted into the scleral tunnels. Each of them was fixed with a 10.0 nylon suture to the scleral bed. The scleral flaps and conjunctiva were sutured. One of the iris hooks was seen loosened at the first-week postoperative examination but the IOL remained centralized. The loosened hook was removed.ResultsNo complications were witnessed during the patient’s 24-month follow-up.ConclusionIntra-scleral fixation using iris retractors in the capsular bag for patients having suffered dislocation of IOL despite the attachment of a capsular hook because of zonular dialysis can be safely implemented.