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Challenging Situations: Multiple Possible Solutions.. But Ultimately – Wow !!. Dr. Ashok P. Shroff, MD, Dr. Hardik A. Shroff, MD Dr. Dishita H. Shroff, MD, Dr. V. D. Vaishnav, MD. SHROFF EYE HOSPITAL Near Railway Station, Navsari – India. Email: sehnavsari@yahoo.co.in.

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Presentation Transcript
slide1

Challenging Situations:

Multiple Possible Solutions..

But Ultimately – Wow !!

Dr. Ashok P. Shroff, MD, Dr. Hardik A. Shroff, MD

Dr. Dishita H. Shroff, MD, Dr. V. D. Vaishnav, MD

SHROFF EYE HOSPITAL

Near Railway Station, Navsari – India.

Email: sehnavsari@yahoo.co.in

We do not have any financial interest in this presentation

Introduction

If cases, needing surgery, are not handled well intraoperatively, the chances of unforeseen, unexpected and unpleasant outcome are more. Not only that, even if the preoperative planning is not done properly, then also many surprises are seen. One such patient had poor anatomical and visual outcome following uneventful phaco with implant surgery. To manage this case there were many options available and preparation was done accordingly, but…. The whole plan had to be changed intraoperatively.

Aim

To discuss about “To be ready for unplanned but fruitful intraoperative management of complicated cases.”

slide2

Material

51 years old female

Left Eye

  • Complicated aphakia
  • BCVA: HM only
  • IOP: 17 mmHg

Right eye

  • Congenital coloboma of lower iris
  • Contracted and opaque capsular bag with phimopsis of rrhexis
  • Pseudophakia – Centre flex IOL was used
  • Coloboma of choroid extending up to disc
  • IOP: 14 mmHg
  • BCVA: 20/200 & N/36 with addition of +3.0 Dsph
  • Treatment Attempted
  • Colour contact lenses- did not work because of improper fitting

Right Eye

slide3

Initial Clinical Picture

Explanation & Exchange with

Large Optic size IOL

Explanation of IOL only

Surgical Options

3

Suturing of Iris

1

2

method
Method

Conjunctiva opened for

about 180o around

the limbus

Bleeders were

Cauterized

2 corneal stab incisions were made

at 10 & 2 o’clock position

AC was formed

with visco

method5
Method

1

3

4

5

2

  • Capsular bag was opened with iris spatula (1, 2)
  • Thick anterior capsule was removed using scissor & forceps (3, 4, 5, 6)
  • IOL could be dialed, separated and brought out of the bag (7, 8)
  • Anterior vitreous face was intact

6

7

It was not possible to put the IOL

in the ‘bag’

8

method6
Method

9

10

11

  • Suddenly it was decided to fix the same IOL to the sclera in such a way that most of colobomatous opening in lower iris would be covered
  • Triangular partial thickness scleral flaps were made diagonally opposite each other (9, 10, 11, 12)
  • Both heptic ends were brought out through inner sclerotomy wound using intravitreal forceps (13, 14)
  • One end was threaded using 9-0 monofilament nylon suture (15). Similar procedure was repeated on the other side.

12

13

15

14

method7
Method
  • Both sides sutures were fashioned through scleral lips (16, 17, 18) and gently tied after doing centration of IOL (19)
  • Scleral flaps were closed (20, 21)
  • Conjunctiva was closed

17

16

19

19

18

21

20

observations
Observations
  • IOL was well centered during entire postoperative period
  • IOP was within normal limits
  • Vision improved to 20/100 with additional correction of -1.0 Dsph / -1.00 Dcyl
  • Near vision also improved to N/12
  • Patient was much more happy
discussion
Phimosis of central opening (rhhexis) happened probably due to very small rhhexis

Fibrosis produced contraction which resulted in upward decentration of IOL and the whole bag, which had compromised the quality of vision

Colobomatous area became aphakic hence near vision was grossly affected

When a case gets complicated then one has to consider different options because there may not be standard protocol for particular situation

As patient was one eyed and that too with congenital deformities, it was decided to manage with minimum intraoperative handling

Separation of anterior capsule did not help much

Enlarging the rhhexis by cutting thick anterior capsule was rather easy

IOL could be brought out of the bag

But bag was rather fibrosed and contracted, hence it was not possible to put large IOL in the bag

Surgical closure of iris coloboma was not possible because it was too large

Hence it was not wise to put IOL in the sulcus (to prevent anterior dislocation of heptic)

The optic of the IOL was sufficiently large so that, if it could be placed slightly inferior, still it could cover the colobomatous area without compromising the vision

It was also felt difficult to suture the heptics with iris that too in the lower part (enough iris was not available due to coloboma)

All of a sudden thought has came to mind that why not to fix the same IOL to the sclera? We have done scleral fixation of IOL in many cases either using the same IOL or using 4 point / 2 point (specially designed IOLs) – but not this type of IOL.

Posterior capsule was clear, and vitreous face was intact, hence subsequent manoeveration was easy

IOL design (centre flex) also helped because threading of IOL was easy and convenient

Postoperatively patient has behaved very well anatomically and functionally

Till date all parameters like IOP etc are within normal limits and posterior segment is also OK

Discussion
conclusion
Conclusion
  • One eyed person with congenital coloboma of iris and choroid had poor visual recovery following cataract surgery due to upward decentration of `bag’ and IOL.
  • Removal of thick anterior capsule and fixing same IOL to sclera slightly inferiorly proved to be better with good anatomical and visual outcome.

Reposition with Scleral Fixation

of same IOL

Initial Clinical

Picture

Post Op. Photograph

after 1 month

Thanks for your time…….