Modified Trisection Technique: One-Trip Explantation for Foldable Intraocular Lens.

To evaluate the clinical efficiency and safety of sulcus transscleral intraocular lens suture fixation with small incision through scleral tunnel in eyes the with posterior capsule defect or insufficient zonula support. Thirty nine eyes with severe posterior capsule defect and zonula damages caused by small-incision cataract surgery, and those with capsule absence or intraocular lens dislocation were selected in this investigation from February 2007 to December 2009. Sulcus transscleral intraocular lens suture combined with puncture needle-guided external approachab and "one- or two-point fixation" method in the small sclera tunnel incision were employed. The mean follow-up was 12.1 months (range from 3 to 28 months). Six eyes were complicated by some eye diseases postoperatively. The best-corrected visual acuity was 20/40 or better in other 34 eyes (87.17%). All eyes with secondary IOL fixation presented equal or better naked visual acuity than best-corrected visual acuity best-corrected preoperatively. No intraoperative and postoperative complications such as hemorrhage, retinal detachment, intraocular lens tilt and decentration occurred. Sulcus transscleral intraocular lens suture fixation via small sclera tunnel incision was easy to operate and master, required less operative time, and made primary intraocular lens fixation more effective in eyes with posterior capsule defect or insufficient zonula support in small sclera tunnel incision surgery. In addition, the technique was safe and efficient for secondary intraocular lens fixation.

Background: Intraocular lens (IOL) dislocation into the vitreous cavity is a well-documented complication of cataract surgery, with a reported incidence ranging from 0.2% to 3%.[1,2] Managing posteriorly dislocated IOLs sometimes, pose challenges during retinal surgery. Surgical planning typically involves explanting the dislocated IOL and achieving visual rehabilitation through secondary IOL implantation—either an anterior chamber IOL, an iris-fixated IOL, or a scleral-fixated IOL. In some cases, the same dislocated IOL can be re-fixated using various haptic fixation techniques such as Yamane[3,4] X-NIT,[5] or the Glued IOL technique.[6] Purpose: Traditionally, a bimanual approach is used for removing the dislocated IOL from the posterior segment. However, this method may result in anterior chamber instability due to sudden changes in fluid dynamics, particularly when using IOP-compensated fluid injection vitrectomy systems, which can lead to the IOL dropping back into the vitreous cavity. We describe a Unimanual Pronation-Supination (UPS) technique, which is a minimally invasive approach that ensures a stable, closed anterior chamber transfer, reducing intraocular instability and surgical risks. Synopsis: The surgical plan involves preplacing a scleral tunnel, performing a thorough pars-plana vitrectomy, and preferably placing perfluorocarbon liquid over the posterior pole for macular protection. This video demonstrates a systematic, stepwise unimanual technique for safely explanting posteriorly dislocated IOLs. By following the described steps, surgeons can consistently remove dislocated IOLs while maintaining anterior chamber stability. Highlights: The technique is described under three key headings to enhance understanding and support learning for beginners. IOL Orientation Step: Under wide-angle visualization, the IOL is oriented such that the inferior haptic tip is directed away from the forceps. The IOL’s long axis is positioned perpendicular to the long axis of the forceps. The optic is firmly held with vitreoretinal forceps (Straight/End-Gripping/Eckardt-type ILM forceps/Pick’s forceps), just behind the inferior haptic-optic junction, and is gently lifted anteriorly into the retro-pupillary space. Pronation Step: Under direct microscope visualization, the inferior haptic is brought above the iris by moving the IOL slightly superiorly beneath the iris while pronating the forceps-holding hand. This rotates the IOL along the forceps' long axis, resulting in the inferior haptic entering the inferior anterior chamber through the pupil. Meanwhile, part of the optic and the superior haptic remain behind the superior iris. Supination Step: Without releasing the IOL, the supination step is carried out. The inferior haptic already in the anterior chamber is slightly de-centred inferiorly while supinating the forceps-holding hand. This manoeuvre lifts the superior haptic above the superior iris, bringing the entire IOL into the anterior chamber. This technique allows the entire IOL to be safely and quickly transferred from the posterior vitreous cavity into the anterior segment within a closed-eye system—without requiring a change of hands. With practice, these movements can be executed by simply rotating the forceps along its axis—counterclockwise for pronation and clockwise for supination—using the sclerotomy port as a fulcrum (for a right-handed surgeon). The IOL can then be removed through the pre-placed sclero-corneal tunnel safely and efficiently. Teaching Points: By adhering to the structured sequence described in the UPS technique, surgeons can methodically remove dislocated IOLs from the posterior segment, eliminating intraoperative unpredictability. Precise orientation of the IOL and consistent gripping at the IOL at the same junction prior to lifting help standardize the manoeuvre, reducing variability during transfer. The Unimanual Pronation-Supination (UPS) technique provides a reproducible, reliable, and minimally invasive method for the safe and efficient removal of any type of posteriorly dislocated IOL. Video link: https://youtu.be/12xqaB2Tly8

Dear Editor, Intraocular lens (IOL) fracture is a relatively rare complication of cataract surgery during IOL implantation [1]. Foldable IOLs specifically are often fractured by either forceps or injector systems during IOL loading [2,3]. To improve the efficacy and safety of cataract surgery, many preloaded IOLs have been developed and are widely used. Here, we report the first optic fracture in a preloaded IOL during posterior chamber, hydrophobic, acrylic IOL insertion. A 75-year-old male patient was admitted for left eye cataract surgery. He had no recent systemic disease and no history of ocular trauma. During surgery, the lens nucleus was successfully removed. For IOL insertion, we prepared a preloaded, three-piece IOL (Hoya iSert PS AF-1 [UV], PC-60AD; Hoya, Tokyo, Japan) (Fig. 1A) after removal of the remnants of both the epinucleus and cortex (Fig. 1B). We lubricated the iSert system inside (Hoya) case. We firmly grasped the body and slowly inserted the system in one continuous motion using the slider. We gently pushed the plunger forward and slowly rotated the iSert system clockwise in order to engage the threads and allow insertion of the IOL (Fig. 1C and 1D). However, during IOL insertion, we heard a cracking sound. Upon investigation, we found that the IOL optic had unfolded and broken into two pieces, with small posterior capsule rupture (Fig. 1E and 1F). We widened the corneal incision and withdrew the IOL from the chamber (Fig. 1G and 1H). After ensuring that there had been no loss of vitreous, a three-piece IOL was fixed inside the ciliary sulcus, and we successfully completed the cataract surgery (Fig. 1I). There were no further postoperative complications in the 3 months following surgery. Fig. 1 The preloaded intraocular lens (Hoya iSert PS AF-1 [UV], PC-60AD; Hoya, Tokyo, Japan) and intraoperative clinical photographs. (A) The whole instrument. (B) Removal of the remnants of both the epinucleus and cortex. (C) Pushing the plunger forward. (D) ... Our case is unique due to optic fracture of the preloaded IOL during IOL insertion. The IOL was a three-piece lens with a 6.0-mm hydrophobic acrylic optic and polymethyl methacrylate chemically bonded haptics. The overall diameter was 12.5 mm. The IOL was preloaded into a unique system (iSert system) that reduces the time-consuming aspect of inserter preparation, cleaning, and sterilization. Moreover, using the iSert system, the IOL remains untouched throughout surgery, as it is contained within a disposable, closed, preloaded system. For this reason, one would expect fewer cases of lens damage. Although the majority of IOL fractures are the result of mechanical causes [1,2,3,4,5] and the possibility of mechanical causes due to surgeon- or manufacturer-related factors cannot be excluded, the authors have suggested other possible mechanisms. The IOL optic material has a glass transition temperature (Tg), the temperature above which an IOL becomes flexible and below which it remains rigid, of 11℃ [4]. As a result of this Tg, single and multi-piece hydrophobic IOLs can be folded and inserted through very small incisions, while still resisting damage at body temperature [5]. However, there are also a few disadvantages of this temperature. It is difficult to insert the IOL into the capsular bag using an injector system because of the rigid nature of the IOL at temperatures less than Tg. Eom et al. [4] have suggested that warmed ophthalmic viscoelastic devices (OVD) reduce the rigidity of the IOL, leading to decreased unfolding time. The same mechanism may have been important in our own case. Despite our operation room being maintained at 18℃ to 20℃, the OVD was stored in the refrigerator at 2℃ to 5℃. In addition, although we could not determine the exact mechanism of the IOL fracture in this patient, we suspect that the IOL may have been more rigid than desirable due to its storage at a temperature lower than its Tg. Deformation by pressure inside the preloaded injector may therefore have caused optic fracture of the IOL during insertion. In conclusion, optic fracture of a preloaded, hydrophobic, acrylic IOL can occur during insertion. The present fracture may have been caused by increased rigidity or by mechanical factors. It might have been related to the Tg, suggesting that warming an OVD may help with reducing IOL rigidity.

To describe a technique for intraocular lens (IOL) implantation that lessens the degree of surgical invasiveness by implanting a tightly rolled IOL through a small incision without touching the eye with the cartridge tip. An IOL was inserted through an incision by first allowing the leading haptic to protrude slightly from the cartridge tip. It was then injected through the incision without allowing any part of the cartridge to touch the eye during IOL implantation. In one eye, the entire circumference of the beveled portion of the cartridge tip was inserted into the anterior chamber to implant the IOL, whereas in the other eye, the IOL was inserted through the incision by first allowing the leading haptic to protrude slightly from the cartridge tip. It was then injected through the incision without allowing any part of the cartridge to touch the eye during IOL implantation. We analyzed the incision width before and after IOL implantation and the degree of surgically induced astigmatism on the day after surgery and at 1 and 3 months after surgery. Using our technique, both the amount by which the wound was enlarged and the hydration rate were significantly lower compared with conventional IOL implantation. Our method enables IOL implantation to be carried out through a small incision at a width that was only previously possible with forcible insertion. Our IOL implantation technique can be performed using both hands with no need to immobilize the eyeball.

Objective To compare and analyze the visual outcome and safety of phacoemulsification with small incision non-phacoemulsification for cataract and provide a reference for the selection of surgery methods in Tibet. Methods A prospective cohort study was performed.Eighty eyes of 80 consecutive patients with age-related cataract were included in Titet Autonomous Region Tibetan Tradition Medicine Hospital from July to August 2016.The eyes were assigned to non-phacoemulsification extracapsular cataract extraction with small incision combined with intraocular lens (IOL) implantation group (small incision group) and phacoemulsification extracapsular cataract extraction combined with IOL implantation group (phacoemulsification group), with 40 eyes for each group.The uncorrected visual outcome and complications were compared between the two groups after surgery. Results There were no significant differences in gender, age, preoperative visual acuity, and lens nuclear hardness between the two groups (all at P>0.05). The eyes in various post-operative uncorrected visual acuity outcome was not significantly different 1 day and 5 days after surgery between the two groups (both at P>0.05). In the fifth day after surgery, the eye number in various post-operative uncorrected visual acuity outcome was not significantly different in the eyes with grade Ⅱ and Ⅲ nuclei between the two groups (Z=0.503, P=0.478; Z=0.952, P=0.329). The eye number of acuity ≥0.5 in the small incision group was significantly more than that in the phacoemulsification group in the eyes with grade Ⅳ nuclei (Z=4.501, P=0.034). The eye number with post-operative transiently ocular hypertension was increased in small incision group compared with phacoemulsification group. Conclusions Non-phacoemulsification surgery with small incision has comparable visual outcome with phacoemulsification surgery, and small incision non-phacoemulsification surgery combined with IOL implantation can serve as the preferred surgical method in basic level medical institutions of Tibet. Key words: Cataract/surgery; Small incision extracapsular cataract extraction; Phacoemulsification; Tibet; Comparative study

Optical and Visual Quality of the Visian Implantable Collamer Lens Using an Adaptive-Optics Visual Simulator

Soft intraocular lenses (IOLs) have been developed to be folded during insertion to allow implantation through a small incision. The surface of the IOL is of great importance in postoperative inflammation and long-term acceptance of the implant. Rough and sharp edges can damage delicate intraocular tissues. The purpose of this study was to analyze new, foldable silicone IOLs for surface quality prior to and following folding. Eleven silicone IOLs of different types were included in this study (four one-piece plate-haptic silicone IOLs and seven three-piece silicone IOLs with polypropylene, PMMA or polyimid haptics). We performed scanning electron microscopy on brand-new IOLs prior to and following folding either with forceps or inserter. Special attention was given to the silicone optic surface, optic edges, haptic-optic junctions and the haptic itself. Photographs were taken at 5-350 times magnification. All IOLS demonstrated a smooth and homogeneous optic surface at low magnification. At high-power magnification (X 350), distinctive surface patterns were evident in some IOLs, which turned out to be artefacts. The edge finish showed surplus silicone material and molding flash in six of 11 IOLs. Positioning holes of the 4 plate-haptic IOLs were, except in one IOL, rounded and not rough. Photographs of the haptic-optic junctions revealed surplus material or clefts between the haptic and optic in six of the 7 three-piece IOLs; the loop ends of two IOLs showed a roughened or irregular surface. We did not detect any IOL changes produced by folding. The silicone IOLs tested demonstrated generally acceptable surface properties, but most IOLs had regional surface irregularities of varying magnitude. The clinical impact of these remains to be established, but surplus material or surface defects might result in deposition of inflammatory cells, protein or microorganisms and synechia formation. Folding of the IOLs did not produce superficial defects.

Objective To compare and evaluate the effect of inversed frown shaped scleral tunnel incision cataract extraction with different Cutting Angles on corneal astigmatism. Methods A tangent was made from the vertex of inversed frown shaped scleral incision, the angle formed by the tangent and preoperative corneal astigmatism axis was called Cutting Angle. A total of 131 patients (135 eyes) were divided into three groups, each group contained 45 eyes. Group A performed with 0° Cutting Angle; Group B performed with 45° Cutting Angle; Group C performed with 90° Cutting Angle. All the patients were performed by small sutureless incision cataract extraction through 6mm inversed frown shaped scleral incision and implanted one piece of 5.5mm PMMA intraocular lense (IOL). The visual acuity and corneal astigmatism were measured at postoperative 1 week, 1 month and 3 months. Results At 3 months after surgry, there were statistical significant difference in visual acuity between group A, B and C (P <0.01). Compared postoperative corneal astigmatism at 1 week with that before surgery, there were no significant difference in statistics in group A, but there were statistical significant difference in group B and C. At 3 months after surgery, there were statistical significant difference in the average changes of corneal astigmatism among three groups (P <0.01). Conclusions Better visual acuity and less postoperative astigmatism can be obtained with small sutureless incision cataract extraction when choose 0 ° Cutting Angle. Key words: Small incision; Non-phacoemulsification; Lens, Intraocular; Astigmatism

Foldable intraocular lenses and vitreoretinal surgery

To describe a novel technique of combined Descemet stripping automated endothelial keratoplasty (DSAEK) with implantation of a new scleral fixated, sutureless, posterior chamber intraocular lens (IOL) (Carlevale, Soleko). A new surgical technique description. We describe a novel surgical approach, namely combining implantation of a new scleral-fixated sutureless posterior chamber IOL with DSAEK for the management of IOL dislocation and corneal endothelial decompensation. The existing, dislocated IOL was removed, and 2 scleral radial incisions were performed 180 degrees apart. Two partial thickness scleral pockets were created along each scleral radial incision, followed by a 23 G sclerotomy. The IOL was placed in the posterior chamber by using 23 G vitreoretinal forceps, and each plug was secured under the 2 pockets. A standard DSAEK procedure was then performed. Four months postoperatively, the corneal graft was attached and clear. The Carlevale IOL was well positioned, and an improvement in the patient's vision was observed. Combining implantation of a new scleral fixated foldable sutureless IOL (Carlevale, Soleko) with DSAEK could represent a viable and effective option for patients with IOL dislocation or aphakia, accompanied by corneal endothelial dysfunction.

Objective To investigate the clinical efficacy of the small incision non phacoemulsification cataract surgery and intraocular lens implantation.Methods The preoperative visual acuity of 1370 patients (1370 eyes) with cataract was from light perception (+) to 0.3,no surgical contraindications.Under surface anesthesia for the small incision non phacoemulsification cataract surgery and intraocular lens implantation was performed.Compound tobramycin eye drops were given postoperatively. Results One day after operation,the patients with visual acuity ≥0.5 taken up 915 eyes (66.79％),2 days after operation taken up 1201 eyes (87.66％),and the 3 months after operation taken up 1235 eyes (90.15％). Conclusions The small incision non phacoemulsification cataract surgery and intraocular lens implantation have the advantages of small incision,no sutures,no expensive medical equipment,rapid and safe,easy to master,suitable for the current condition of our cotntry and being operated easily in the base hospital. Key words: Small incision; Extracapsular cataract extraction surgery; Intraocular lens

Veritti et al. described a promising new technique for scleral fixation of the foldable intraocular lens (IOL) through a 1.80 mm corneal incision that provided excellent IOL stability.1 In their technique, they used the single-piece hydrophobic acrylic foldable IOL (enVista MX60, Bausch & Lomb, Inc.) of which the eyelets located at the junction of the optic and C-loop haptics can be used for suture placement, and inserted the IOL with an injector system though a 1.80 mm corneal incision. The authors suggested the obvious advantage of this technique is that it can reduce astigmatism with less complication and greater IOL stability owing to small corneal incision. Another advantage of this technique is that the sutures are located on the IOL eyelets at the junction of the optic and haptics. We have historically conducted scleral suture fixation of IOLs at one third of the end of each haptic (or premade hole in the haptic) and then insert it in the sulcus with or without optic capture.2 This technique, with a modification to the location of IOL sutures at the optic–haptic junction, make it possible to insert the IOL in the bag with the haptic sutured (with opposite ends of Prolene sutures fixated through the sclera) (Figure 1). In case of zonular deficiency, such as pseudoexfoliation syndrome, previous vitreoretinal surgery, a history of trauma, long axial length, and uveitis, this can help prevent late IOL–bag dislocation.3Figure 1.: The knot on the haptic is made nearer to the optic–haptic junction (eyelet), which allows the intraocular lens to locate into the bag through the large anterior continuous curvilinear capsulotomy.The location of sutures on the IOL haptic nearer to the optic–haptic junction can facilitate easy insertion of the IOL into the bag. It is recommended to make the anterior continuous curvilinear capsulotomy larger than the optic size of a commercial IOL, which is usually 6.0 mm or less, so the fixation knot point on the haptic will be minimally affected by the capsulorhexis margin. There are 2 additional advantages of this modification of suture location on the IOL eyelets at the optic–haptic junction. First, locating sutures close to the optic–haptic junction can add more geometric stability than the historical one third of haptic location.4 Second, using this haptic suture location with scleral fixation, we can insert the IOL easily in the bag. In cases of zonular deficiency, IOL insertion in the bag with haptic sutures can preserve anatomical stability of the IOL–capsular bag complex (both optic and haptics in the bag), which can prevent total capsular phimosis or bag shrinkage because of an absence of the IOL haptics in the bag.5 This improves IOL–capsular bag complex stability without additional endocapsular supporting devices, such as modified capsular tension rings and capsular anchoring devices.

Evaluation of a 3-piece silicone intraocular lens with poly(methyl methacrylate) haptics

Keratometric cylinder and visual performance following phacoemulsification and implantation with silicone small-incision or poly(methyl methacrylate) intraocular lenses

Objective To observe the incidence rate of corneal edema in two different kinds of surgeries:cataract extraction of either small incision or phacoemulsification with intraocular lens implantation.Methods A clinical case-control study.Cataract patients were collected from January 2011 to December 2012 in Shijiazhuang,Aier Ophthalmic Hospital.They were divided into two groups,group A of 163 cases (186 eyes) received cataract extraction with small incision combined with intraocular lens implantation; group B of 176 cases (200 eyes) recieved phacoemulsification cataract extraction combined with intraocular lens implantation.The corneal edema on different nucleus cataract was observed one day after surgery.Results There were 55 eyes existed corneal edema (29.6％ incidence rate) in Group A (186 eyes) and 74 eyes of corneal edema (37.0％ incidence rate) in Group B (200 eyes).There was no statistical significant difference (x2=0.368,P =0.110).Meanwhile,with grade Ⅰ～Ⅱ cataract nucleus,there were 18 eyes occurs corneal edema among 66 eyes in Group A (27.3％ incidence rate) and 19 eyes (22.4％ incidence rate) in 85 eyes in Group B,also had no statistically significant difference (x2=0.486,P =0.486).With grade Ⅲ ～Ⅴ cataract nucleus of the 120 eyes in Group A,there were 37 eyes occurred corneal edema with 30.8％ incidence rate and 115 eyes in group B,55 eyes with 47.8％,there was statistical significant difference (x2=3.472,P =0.003).Moreover,on grade Ⅲ ～ Ⅴ nuclear in group A and group B,corneal edema occurred at different degrees,there were comparative statistically significant differences between two groups (Z =2.959,P =0.003).Conclusions It shows that the incidence of corneal edema after cataract surgery associate with nucleus hardness and also relate to the operation method.The grade Ⅰ or Ⅱ nucleus has no significant difference on the incidence of comeal edema in two types of surgeries.While,in the grade Ⅲ to level Ⅴ nucleus,the incidence and the degree of corneal edema are significantly higher in phacoemulsification group than the small incision cataract extraction with intraocular lens implantation. Key words: Cataract; Phacoemulsification, Cataract extraction with small incision; Corneal edema