SPS-113 Cataract - Challenging Cases | ASCRS
2020 ASCRS Virtual Annual Meeting

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Papers in this Session
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Safety and Efficacy of Custom Foldable Silicone Artificial Iris Implantation: A Prospective Compassionate-Use Case Series
Authors
Clemence Bonnet, MD
Kevin M. Miller, MD

Purpose
To assess the preliminary safety and efficacy of custom silicone artificial iris implantation for surgical iris reconstruction.

Methods
Prospective consecutive single-surgeon surgical case series. Medical records of patients implanted with the artificial iris and followed for one year were reviewed. Safety data included changes in corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell count (ECC), surgical complications, secondary interventions, and adverse events. Efficacy measures included CDVA with glare, subjective scoring of daytime and nighttime glare, and subjective cosmetic appearance.

Results
20 eyes (19 patients) were implanted. Safety data were mixed. CDVA improved in 12 eyes (60%) and worsened in 6 (30%). 4 eyes (20%) experienced elevated IOP. There was significant ECC loss (1918 ± 870 cells/mm2 versus 1405 ± 705, P = 0.02). 8eyes (40%) experienced postoperative complications. 4 eyes (20%) underwent secondary surgical interventions. Efficacy outcomes were uniformly positive. CDVA with glare improved from 1.49 ± 0.64 logMAR to 0.67 ± 0.79 (P < 0.01). Mean subjective daytime glare decreased from 8.85 ± 1.84 to 2.70 ± 2.58 (P < 0.01) and nighttime glare from 7.85 ± 1.84 to 2.50 ± 2.65 (P < 0.01). Mean cosmetic score improved from 2.15 ± 1.63 to 8.80 ± 2.07 (P < 0.01).

Conclusion
Custom artificial iris implantation is risky but effective at reducing light and glare sensitivity and improving the cosmetic appearance of the eye.
FOUR-Flanged 5.0 Polypropylene Intrascleral Intraocular LENS Fixation Technique: NO Flaps, NO Knots, NO Glue
Authors
Sergio F. Canabrava, MD
Mayara C. Grigorio, MD
Gustavo G. Rodrigues, MD
Thiago F. Galvao, MD

Purpose
To develop a novel sutureless intraocular lens (IOL) intrascleral fixation technique based on Double Flanged 5.0 Polypropylene Suture.

Methods
The novel method uses a 5.0 polypropylene suture and a bipolar cautery to create 2 flanges in the eyelets of the IOL and 2 flanges outside, in order the insert them inside the scleral tunnel and thus fixate the IOL.

Results
This technique had been applied in 12 patients with aphakia following phacoemulsification complications. The mean preoperative and postoperative correct distance visual acuities were 0.45 ± 0.17 and 0.67 ± 0.27 (Snellen decimal units), respectively.

Conclusion
The four flanged technique improves and simplifies the existing single-piece, non-foldable IOL intrascleral fixation techniques.
Reflux of Trypan Blue Under the Pupillary Margin into the Anterior Chamber during Its Removal As a Sign of Zonular Weakness.
Author
Didar S. Anwar, MD

Purpose
To report a new sign of zoular weakness during cataract surgery. To our knowledge, this is the first time this sign of zonular weakness is reported.

Methods
Ten eyes underwent cataract surgery using phacoemulsification by one surgeon (DA). Mean age was 74 years. They all have visually significant cataracts. Preoperatively, during slit-lamp exam, zonular weakness was not noted. Intraoperoperatively, during removal of the trypan blue out of the anterior chamber, reflux of the trypan blue under the pupillary margin back into the anterior chamber was noted. When surgery continued, other well-known signs of zonular weakness were observed.

Results
All ten eyes underwent cataract surgery had zonular weakness. This was confirmed by observing other well-known signs of zonular weakness during cataract surgery. Two of the eyes also needed capsular tension ring implantation to stabilize the lens capsular bag.

Conclusion
It seems that zonular weakness causing the lens to displace posteriorly causing more space between the lens and the iris that acts a pocket and holds more trypan blue during anterior capsule staining. During removal of the trypan blue with anterior chamber washout, more trypan blue is refluxing into the anterior chamber from this pocket.
Refractive Outcomes of Intrascleral Haptic Fixation (No Audio)
Authors
Matthew T. Feng, MD
Maximiliano Feldman Fuentes, MD
Francis W. Price Jr., MD
Marianne O. Price, PhD

Purpose
To describe a nomogram for intrascleral haptic-fixated IOL power adjustment based on refractive outcomes from one technique at a United States tertiary referral center.

Methods
Retrospective interventional case series of consecutive eyes undergoing intrascleral haptic fixation. Inclusion criteria included adult age, Yamane technique, and use of a hydrophobic acrylic 3-piece IOL with polyvinylidene fluoride haptics. Exclusion criteria included CDVA < logMAR 0.3, optic tilt, placement/repositioning of an alternative/unknown IOL, and subsequent/combined surgeries apart from cataract or vitrectomy that alter refraction--e.g., keratoplasty, scleral buckle, silicone oil placement, or pupilloplasty. Predictive spherical equivalent error was calculated against the Holladay II formula. Multivariate analysis included white-to-white, keratometry, axial length, and IOL power.

Results
Over 18 months, five surgeons used the Yamane technique in 62 eyes of 59 patients. 25 eyes of 23 patients met criteria. Indications were dislocated IOL (n=16), aphakia (n=5), dislocated cataract (n=2), and Marfan-related zonulopathy (n=2). Mean final CDVA was logMAR 0.115 ±0.08 and mean follow-up, 4 months. Median predictive error (PE) was +0.39 ±0.58 D. The error was >±0.25 D in 11 eyes (44%) and >+1.0 D in 3 eyes (12%). Pearson correlation analysis and multivariate general linear method showed the most significant correlations with PE came from IOL power and white-to-white (WTW). A formula describing the relationship is: PE =0.13*power +0.68*WTW -10.53.

Conclusion
Aiming -0.25 to -0.5 D was appropriate for most eyes undergoing the Yamane technique with IOL power calculated using Holladay II. Clinically significant PE--hyperopic surprises--were associated with IOL powers ≥+19.0 D and WTW >12.2 mm. Prospective studies will show if IOL power adjustment can improve refractive outcomes especially in these eyes.
Efficacy of Calibrated Side Port Incision in Preventing Progression of Intraoperative Floppy Iris Syndrome in Patients Using Tamsulosin.
Authors
Rohit Om Parkash, MS
Tushya O. Parkash, MS
Shruti Mahajan, MS

Purpose
To evaluate the efficacy of calibrated side port incision in preventing progression of Intraoperative Floppy Iris Syndrome

Methods
Randomised prospective study was done between January 2018 and April 2019 in 105 patients undergoing Phacoemulsification using Tamsulosin with dilated pupillary diameter of more than 5.0 mm. Tropicamide 0.8%(with/without phenylephrine 5%) and Flubiprofen eye drops0.03% were used pre operatively. Intracameral epinephrine was used to dilate the pupil. Surgical technique of long anterior corneal tunnel, gentle hydrodissection, visco mydriasis with sodium hyaluronate 2.3%, active fluidics with low 38 mm IOP, iris plane nuclear emulsification, switching continuous irrigation off and gentle stromal hydration was used. Calibrated side port incision with 25 G needle & calibrated chopper was used.

Results
Side port calibration decreased chamber fluctuation. Subsequently, the decreased flow of BSS in the posterior aspect of iris reduced iris billowing and trauma to iris. Parameters studied were iris billowing, iris prolapse, pupillary constriction, and change in pupillary size pre and post phacoemulsification. There was no IFIS observed in 38 eyes, 67 eyes had iris billowing, no eye had iris prolapse or progressive pupillary constriction. The change in mean pupillary diameter observed was 0.8 mm +/- 0.56 mm.

Conclusion
The addition of calibrated side port incision to the surgical protocols used in Tamsulosin patients allows stable anterior chamber settings, thereby preventing IFIS progression.
3 Point Suture Fixation of Dislocated IOL/Capsular Tension Ring Complex - 24 Months Results (No Audio)
Authors
Christoph F. Kranemann, MD
Keli Matheos, MD

Purpose
to determine the medium term outcomes of a 3 point fixation of dislocated IOL/Capsular tension ring complexes.

Methods
Consecutive patients who presented with a dislocated capsular bag/IOL/CTR complex underwent a 3 point scleral fixation. They were followed for a minimum of 24 months for refractive change and stability as well as changes in intraocular pressure and secondary complications. A 'Y-hitch' approach was used for the placement of the Prolene sutures securing the CTR to the sclera.

Results
A total of 11 patients were followed. The mean refractive change was -.8 diopters of sphere and 0.3 diopters of cylinder at month 18. The mean IOP was reduced by 1.2 mm HG - NS. There were no clinical corneal or retinal changes nor any reduction in best corrected visual acuity.

Conclusion
3 point suture fixation of the capsular bag/IOL/CTR complex appears to result in a stable outcome with minimal to no effect on IOL tilt and should be considered in dealing with these patients.
Clinical Outcomes of Yamane Intrascleral Haptic Fixation: My First 150 Cases
Authors
Amal M. Alwreikat, MD
Naveen K. Rao, MD, ABO
Amer Alwreikat, MD
Mohammed AL-yarabi, MD
Ahmed AL-Rawi, MD
Hesham Al-Rawashdeh, MD
Mansoor AL Yarbi, MSc

Purpose
To present visual outcomes and complications of Yamane Intrascleral Haptic Fixation.

Methods
150 eyes of patients who underwent Yamane ISHF by one Cornea/anterior segment surgeon. Indications for surgery were aphakia, dislocated IOL, or subluxated crystalline lens. Data was collected for eyes with minimum 12 months follow up.

Results
Mean BCVA improved from 0.51 pre-operatively to 0.22, 0.21, 0.18, 0.17 logMAR units on day one, 3, 6 and 12 months, (p<0.001 for all time points). Complications included ocular hypertension 5 eyes (3.3%), vitreous hemorrhage in 3.3%, CME in 5 eys 3.33%, transient corneal edema in 0.67%, iris capture in 1.3%, there were no incidence of dislocation, slippage or endophthalmitis.

Conclusion
Yamane ISHF is a safe and effective technique for fixation of a three-piece IOL to the sclera with a good safety profile at 1 year of a followup

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