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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: email@example.com.
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.
We do not have any financial interest in this presentation
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.
To discuss about “To be ready for unplanned but fruitful intraoperative management of complicated cases.”
51 years old female
Explanation & Exchange with
Large Optic size IOL
Explanation of IOL only
Suturing of Iris
Conjunctiva opened for
about 180o around
2 corneal stab incisions were made
at 10 & 2 o’clock position
AC was formed
It was not possible to put the IOL
in the ‘bag’
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 OKDiscussion
Reposition with Scleral Fixation
of same IOL
Post Op. Photograph
after 1 month
Thanks for your time…….