Ciliary Sulcus Research Articles

Implantation of retropupillary iris-claw lenses: A review on surgical management and outcomes.

Iris-claw lenses have gained increasing popularity over the last years and are by many surgeons regarded as viable options in eyes with insufficient capsular or zonular support. The iris-claw lens has two haptics with fine fissures for folding (enclavating) the mid-peripheral part of the iris stroma and can either be placed in front of or posterior to the iris. In particular, the retropupillary implantation has been increasingly chosen probably due to having an anatomical position similar to that of the crystalline lens. The present review is based on a literature review and also on the authors' clinical experience with this lens, and it focuses on surgical techniques and outcomes especially related to the characteristics of this lens, having haptics with claws that fixate the lens to the posterior iris. Implanting retropupillary iris-claw lenses has a relatively short learning curve, and there are only few complications reported during surgery. Retropupillary iris-claw lenses have demonstrated generally favourable efficiency and safety. However, the outcomes are probably more influenced by the reason for surgery and eye comorbidity than the lens itself. Albeit seldom reported, the postoperative complications have mostly been related to atrophy of the iris at the site of the haptics, or IOL decentration or disenclavation of one of the haptics. To date, however, there are few randomized clinical trials comparing this lens to other lens alternatives in eyes exhibiting insufficient capsular or zonular support for placing the lens in the ciliary sulcus. In the future, prospective studies with large samples should be performed to gain insights into the long-term safety of retropupillary placed iris-claw lenses, and for comparisons with the various other techniques of lens fixation.

Microperipheral Iridectomy for Troublesome Posterior Synechiolysis in Secondary Intraocular Lens Implantation

Purpose To introduce an effective method for separating extensive posterior synechiae and those located under or adjacent to surgical incisions. Methods Pediatric patients who had been subjected to cataract surgery and developed troublesome posterior synechiae requiring secondary intraocular lens (IOL) implantation were recruited. All patients underwent microperipheral iridectomy at the 12 o'clock position. Then, an ophthalmic viscosurgical device was injected into the posterior chamber through the iris fistula to mechanically separate the posterior synechiae, using scissors to cut robust posterior synechiae if necessary. The results of posterior synechiolysis and the position of the implanted IOL were analyzed. Results Sixteen patients (median age, 51.56 months; range, 28–80 months) were included. The scope of posterior synechia in clock was 4.42 (range, 1–10). All troublesome posterior synechiae were successfully separated using the microperipheral iridectomy method, and all patients underwent IOL implantation in the ciliary sulcus. There was one case of peripheral iridectomy-related early intraoperative bleeding; no bleeding was observed at the end of surgery. Conclusions Microperipheral iridectomy is a useful method for the management of troublesome posterior synechiae during secondary IOL implantation in pediatric patients, which makes secondary IOL implantation an easier and safer method in some challenging cases.

Comment on: Comparison of femtosecond laser-assisted cataract surgery and conventional cataract surgery: a meta-analysis and systematic review.

We read with interest the review of femtosecond laser–assisted cataract surgery (FLACS) and conventional cataract surgery (CCS) by Kolb et al.1 We feel that it is necessary to highlight the area about the reporting of posterior capsular complications. The article states that posterior capsule ruptures were reported in 0.42% of eyes with FLACS and 0.27% of eyes with CCS and a statistically significant difference was not found. A link to Supplemental Digital Content was then provided for those reading the article online.1 What is not evident to those reading the printed article with no access to the various links was that 75% of the posterior capsular complications occurred with the use of 2 of the 5 FLACS systems. Further subgroup analysis revealed that there was an unequal distribution of patients with 1 group reporting more than 60% of the patients who had posterior capsular complications. Readers of the printed copy would, therefore, accept the statement that there was no statistically significant difference in capsule rupture rates between FLACS and CCS as presented in the abstract. Those who accessed the article with links online would be directed to explore the evidence base and would rather accept the statement in the text that posterior capsule rupture seemed less with FLACS, which was of clinical importance even if statistical importance is missed. A recent prospective randomized trial showed a statistically significant decrease in posterior capsule rupture in patients undergoing FLACS.2 This is not unexpected because it has been suggested that most surgeons who convert from manual cataract surgery to FLACS are likely to note a decrease in their posterior capsule rupture rate.3,4 This study states that “visual and refractive results are the most important endpoints for patients' satisfaction.” The importance of this statement cannot be overemphasized. A ruptured posterior capsule predisposes to cystoid macular edema, retinal detachment, and secondary surgery. Patients now have a larger choice of intraocular lenses (IOLs), including multifocal IOLs and extended-depth-of-focus IOLs, the success of which depends on correct lens placement in the bag. A ruptured posterior capsule unable to support an IOL in the presence of a capsulorhexis either too large or too small to offer optic capture can lead to a very unsatisfied patient postoperatively. FLACS offers an anterior capsulotomy of precisely predetermined size, position, and circularity to cover the implanted IOL. This allows for anterior optic capture with haptics positioned in the ciliary sulcus if needed.5 The meta-analysis offers a review of trials published about the different outcomes between FLACS and CCS. It cannot be used as guidance in cases that have been excluded from the studies that would be uniquely suited for FLACS, such as those with intumescent cataracts or those with loose zonular fibers making capsulorhexis difficult. The achievement of a precise anterior capsulotomy, low rate of posterior capsular complications, and the decrease in ultrasound energy needed to remove a cataract should play a part in the decision whether to use FLACS, especially for surgeons who have a complication rate of more than 1%, in trainees, or when tackling difficult cases.

"Double Prosthesis Implantation": Biometry and Refractive Outcomes in Combined Intraocular Lens and Artificial Iris Surgery.

PurposeTo assess the biometry and postoperative refraction in iris repair using ArtificialIris in combination with an intraocular lens (IOL).SettingDepartment of Ophthalmology, University Hospital Heidelberg, University of Heidelberg, Germany.DesignRetrospective observational study.MethodsWe included 44 aniridic and aphakic eyes for IOL implantation in combination with iris prosthesis reconstruction. The iris prostheses were either sutured into the ciliary sulcus and fixed by transscleral suturing or were implanted together with a capsular tension ring and the IOL in the capsular bag. The primary outcomes measured were pre- and postoperative best corrected visual acuity (CDVA), objective and subjective refraction, anterior chamber depth and optical biometry comparing common IOL formulae.ResultsReasons for surgery were trauma (39 eyes), iatrogenic causes (1 eye), aniridic state after severe iritis (2 eyes) or iris tumor (2 eyes). Monocular CDVA improved significantly (p<0.0001) from median 0.55 logMAR (0.0 to 1.98) to 0.16 logMAR (−0.08 to 2.0). There were no significant differences between the postoperative target refraction calculated by the formulae “Haigis”, “Hoffer-Q”, “SRK/T” and “Holladay 1” (p=0.68). The absolute deviation from target refraction did not differ significantly between the formulae (p=0.87). Median target refraction was −0.42 D (−4.0 to 1.68). Postoperatively median spherical equivalent was 0.00 D (−5.38 to 2.38). Median absolute deviation from target refraction after 5 months of follow-up was 0.98 D (0.06 to 5.17).ConclusionPostoperative refraction using common techniques and using preoperative biometry revealed a well predictable postoperative refraction. There is no correction factor needed.

Secondary Piggyback Intraocular Lens for Management of Residual Ametropia after Cataract Surgery

PurposeTo investigate the indications, clinical outcomes, and complications of secondary piggyback intraocular lens (IOL) implantation for correcting residual refractive error after cataract surgery.MethodsIn this prospective interventional case series, patients who had residual refractive error after cataract surgery and were candidates for secondary piggyback IOL implantation between June 2015 and September 2018 were included. All eyes underwent secondary IOL implantation with the piggyback technique in the ciliary sulcus. The types of IOLs included Sulcoflex and three-piece foldable acrylic lenses. Patients were followed-up for at least one year.ResultsEleven patients were included. Seven patients had hyperopic ametropia, and four patients had residual myopia after cataract surgery. The preoperative mean of absolute residual refractive error was 7.20 7.92, which reached 0.42 1.26 postoperatively (P 0.001). The postoperative spherical equivalent was within 1 diopter of target refraction in all patients. The average preoperative uncorrected distance visual acuity was 1.13 0.35 LogMAR, which significantly improved to 0.41 0.24 LogMAR postoperatively (P = 0.008). There were no intra- or postoperative complications during the 22.4 9.5 months of follow-up.ConclusionSecondary piggyback IOL implantation is an effective and safe technique for the correction of residual ametropia following cataract surgery. Three-piece IOLs can be safely placed as secondary piggyback IOLs in situations where specifically designed IOLs are not available.

Anterior Chamber Versus Ciliary Sulcus Ahmed Glaucoma Valve Tube Placement: Longitudinal Evaluation of Corneal Endothelial Cell Profiles.

An Ahmed glaucoma valve (AGV) tube in the ciliary sulcus (CS) is safer for the endothelium. At 4 years of follow-up, there was a significant decrease in endothelial cell count only with anterior chamber (AC) placement. Corneal endothelium (CE) damage is one of the most feared long-term complications that can result from glaucoma drainage devices. Nonetheless, there is a lack of studies evaluating longitudinal changes in CE cells. This study aims to compare CE changes after AGV implantation in eyes with AC or CS tube placement. This was a retrospective, nonrandomized, longitudinal study of pseudophakic eyes with open-angle glaucoma and medically uncontrolled intraocular pressure that received an AGV. Eyes with additional glaucoma surgeries performed during follow-up were excluded. The main outcome measure was endothelial cell density (ECD), which was evaluated 1 year±2 months and 4 years±2 months postoperatively. The average endothelial cell size (AS) and the distance from the tube tip to the cornea were also evaluated. Twenty-six eyes from 26 patients, with a mean age of 73±10 years, were included. The tube was placed in the AC in 15 eyes and in the CS in 11 eyes. The eyes with tube placement in the AC showed a significant AS increase (P=0.007) and ECD decrease (P=0.034), whereas eyes with tube placement in the CS had no significant AS (P=0.575) or ECD (P=0.445) change. In the eyes with tube placement in the AC, there was no correlation between DTC and ECD (P=0.260) or AS (P=0.428) changes. Tube placement in the AC seems to lead to significant CE cell loss over time, compared with tube placement in the CS.

Operative Complications of Glaucoma Drainage Implant Tube Insertion Through the Sulcus for Pseudophakic Eye.

Malposition of the tube through the ciliary sulcus is more frequently observed with the Ahmed glaucoma valve (AGV) than the Baerveldt drainage implant (BDI) due to the weaker rigidity of the Ahmed tube. To report intraoperative and early postoperative complications of ciliary sulcus tube insertion of glaucoma drainage implants (GDIs). We performed retrospective analysis of 104 eyes of 94 patients with GDI tube insertion through the ciliary sulcus were performed. The rigidities of tubes were also examined using a microcompression tester. The mean observation period was 20.0 (range, 6 to 60) months. Thirteen eyes were treated with the BDI and 91 were with the AGV. The mean age of the patients was 69.3 (34 to 90) years. The mean intraocular pressure was 27.9 mm Hg before surgery and 12.9 mm Hg after surgery (P<0.01). Upon tube insertion 42/91 eyes (46%) with the AGV required reinsertion of the tube due to malpositioning, whereas only 1/13 (8%) eyes with BDI did (P<0.01). Transient hyphema (12 eyes) and hypotony (12 eyes) were observed as early postoperative complications with the AGV. Seven eyes with hypotony were treated by proline stenting of the tube. We could not accomplish sulcus insertions in 4 eyes. Microcompression analysis of the tubes showed that the BGI tube was more rigid than that of the AGV. Ciliary sulcus insertion of the tube is an effective method to control intraocular pressure. The tube of the AGV was more difficult to insert through the sulcus than the BDI due to its weaker rigidity.

Pigmentary Glaucoma After Cataract Surgery with Single-Piece Hydrophobic Intraocular Lens Implanted into the Ciliary Sulcus: Case Report

A 59 years old man presented with a history of phacoemulsification with an hydrophobic intraocular lens implant in his left eye 4 years ago. The biomicroscopy revealed pigments in the corneal endothelium (Krukenberg’s spindle), peripheral transillumination of the iris and intraocular pressure of 52 mmHg in the left eye. Gonioscopy revealed hyperpigmentation of the posterior trabeculate. Posterior segment examination and visual field revealed a cup/disc 0.9 with significant field damage in strategy 10-2. Biomicroscopic ultrasonography showed asymmetric implantation of the IOL loops in the left eye (one loop in the ciliary sulcus and the other in the capsular bag). He underwent antiglaucomatous treatment with adequate control of intraocular pressure, with no need for surgical intervention.

Retrospektywna ocena powikłanych operacji zaćmy z implantacją na torebkę przednią jednoczęściowych zwijalnych soczewek wewnątrzgałkowych

Cel pracy: Ocena odległych wyników leczenia w grupie pacjentów poddanych operacji fakoemulsyfikacji zaćmy z fiksacją na torebkę przednią jednoczęściowych zwijalnych soczewek wewnątrzgałkowych.&#x0D; Materiał i metody: Grupę badaną stanowiło 24 oczu u 24 pacjentów, którzy w latach 2008–2015 zostali poddani operacji fakoemulsyfikacji zaćmy na Oddziale Okulistyki Centralnego Szpitala Klinicznego MSWiA w Warszawie. W grupie tej po śródoperacyjnym przerwaniu torebki tylnej soczewki zastosowano implantację jednoczęściowej zwijalnej soczewki wewnątrzgałkowej do komory tylnej z fiksacją na torebce przedniej soczewki. Oceniano ostrość wzroku, ciśnienie wewnątrzgałkowe, odcinek przedni i tylny oczu przed zabiegiem chirurgicznym, w 1. i 7. dobie po operacji oraz w okresie 6–84 miesięcy od zabiegu.&#x0D; Wyniki: W obserwacji trwającej od 6 miesięcy do 7 lat wykazano poprawę najlepszej skorygowanej ostrości wzroku (BCVA, best corrected visual acuity) średnio o 2 linie na tablicy Snellena oraz stwierdzono: u 25% badanych podwyższone ciśnienie wewnątrzgałkowe lub konieczność modyfikacji leczenia przeciwjaskrowego, u 42% pacjentów dyspersję barwnika z listka barwnikowego tęczówki, u 17% transiluminację tęczówki.&#x0D; Wnioski: Zastosowanie jednoczęściowej zwijalnej soczewki tylnokomorowej do fiksacji na torebce przedniej soczewki w sytuacji uniemożliwiającej jej implantację śródtorebkową u 67% pacjentów pozwoliło na poprawę pooperacyjnej ostrości wzroku. Jeśli decydujemy się na takie rozwiązanie, powinniśmy zapewnić pacjentom możliwość częstych kontroli, gdyż u 25% spośród nich możerozwinąć się jaskra wtórna. W przypadku gdy nie dysponujemy trzyczęściową soczewką tylnokomorową, wyżej opisany sposób fiksacji jednoczęściowej zwijalnej soczewki jest względnie bezpieczną techniką chirurgiczną.

Intraocular endoscopy: A review.

Optimal visualization is one of the most challenging aspects of performing vitreoretinal surgery. In situations where conventional microscopic techniques provide poor posterior visualization, the adjunctive skill set of endoscopic visualization may be needed. This allows for by-passing the opaque anterior segment media and getting access to the posterior segment pathology. Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical set-up of endoscopy allows for clinical approaches that are impossible with regular microscope viewing systems. These include the ability to observe across optically significant anterior segment opacities and directly visualize the posterior segment of the eye. It also allows for visualizing the difficult-to-access retroirideal, retrolental, and anterior retinal structures. Surgical access to anatomic spaces like the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens is tedious. This is made simpler by endoscopy. In this review, we summarize and review the usage of the intraocular endoscope as a diagnostic and therapeutic armamentarium across a wide spectrum of ocular pathologies.

Analysis of Difference between Target and Postoperative Spherical Equivalent in Combined Vitrectomy and Intraocular Lens Trans-scleral Ciliary Sulcus Fixation

Analysis of Difference between Target and Postoperative Spherical Equivalent in Combined Vitrectomy and Intraocular Lens Trans-scleral Ciliary Sulcus Fixation

Three-Year Outcomes of Cionni-Modified Capsular Tension Ring Implantation in Children Under 8 Years Old With Ectopia Lentis

This study evaluated visual outcomes and complications at 3 years post-implantation of a Cionni-modified capsular tension ring (MCTR) with an intraocular lens (IOL) in ectopia lentis patients ≤8 years old. Prospective clinical cohort study. Included were 101 eyes from 57 patients <8 years of age, who underwent surgery for nontraumatic ectopia lentis between November 2015 and December 2016. Exclusion criteria were planned IOL fixation in the ciliary sulcus, severe intraoperative complications, and incomplete follow-up. All eyes received in-the-bag implantation of a posterior IOL and Cionni-MCTR. Posterior capsulectomy and anterior vitrectomy were performed through the pars plana in 23 eyes of children <5 years of age. Patients were examined at 1day, and 1, 6, and 12months, and at 2 and 3 years postoperatively. Outcome; measurements included best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and posterior capsule opacification (PCO). In all eyes, BCVA improved significantly after surgery, especially during the first 12months (P < .05). Three years post-operatively, 44 eyes had BCVA 0.9 or better. Prophylactic Nd:YAG laser capsulotomy was performed 3months post-surgery in 24 eyes; 34 eyes underwent this; procedure 6months post-surgery because of PCO. A second surgery was; warranted in 4 eyes because of severe IOL decentration and combined anterior capsule contraction. No severe postoperative complications, such as retinal detachment or endophthalmitis, occurred. Implantation of in-the-bag IOL with Cionni MCTR is effective for visual rehabilitation in young children with ectopia lentis. A close follow-up of these patients is necessary to monitor IOL centration and stability.

Placement of dual capsular tension rings for the combined management of traumatic cyclodialysis cleft and zonular dialysis

BackgroundTo evaluate the efficacy and safety of placing dual capsular tension rings for the combined management of traumatic cyclodialysis cleft and zonular dialysis.MethodsA modified capsular tension ring was inserted into the ciliary sulcus and a capsular tension ring or modified capsular tension ring was inserted into the capsular bag in 20 eyes in 20 consecutive patients showing signs of ocular hypotony and ectopia lentis. Outcome measures included intraocular pressure, best-corrected visual acuity, and postoperative complications.ResultsDual capsular tension ring placement was performed in 20 patients with a mean age of 48.7 years. The cyclodialysis cleft extended over 2.9 clock hours (range 0.5–6.5). The modified capsular tension ring was successfully inserted into the ciliary sulcus and a capsular tension ring or modified capsular tension ring in the capsular bag in all eyes. At the last follow-up, the cyclodialysis cleft was closed in 16/20 (80.0%) eyes. The intraocular lens was stable in all patients postoperatively. Best-corrected visual acuity, in terms of the logarithm of the minimal angle of resolution, improved from 1.3 ± 0.8 before surgery to 0.4 ± 0.3 after surgery (P < 0.001). Intraocular pressure increased significantly from 10.6 ± 3.2 mmHg before surgery to 13.0 ± 4.8 mmHg after surgery (P = 0.040). Postoperative complications included a painful reversible intraocular pressure spike in four patients (20.0%). Logistic regression revealed no significant factors associated with successful cleft closure and a stable final intraocular pressure of ≥ 10 mmHg.ConclusionsThe placement of two capsular tension rings into the ciliary sulcus and the capsular bag is a safe, successful procedure combined for repairing a traumatic cyclodialysis cleft and managing zonular dialysis.

The Variants of Technologies of Suture Fixation in Case of IOL-Capsular Bag Complex III–IV Degree Dislocation

Purpose . To present the results of several technologies for suture fixation in case of IOL-capsular bag complex III–IV-degree dislocation and to estimate their impact on IOP. Patients and Methods. We have analyzed 42 cases of IOL-capsular bag complex dislocation complicated by absence of capsular support which were divided into three groups. Group 1 included 4 cases of complex fixation to the sclera (presence of capsular ring, IOLs with closed loop haptics such as T-26, T-28, single-piece IOLs with massive haptics such as Asphina). Suture fixation was performed in the ciliary sulcus projection with capture of haptics or capsular ring and buried knots in capsular pockets. Group 2 included 27 cases with iris suture fixation with capture of haptics or fibrotic capsular bag on a 30G needle. Reposition and support of dislocated IOL-capsular bag complex was performed with a bent 30G needle inserted through pars plana. Group 3 included 11 cases with iris suture fixation with additional surgical manipulations (anterior vitrectomy, removal of fibrotic anterior and posterior capsules, complete removal of the capsular bag with cortex, surgical dissection of opacified posterior capsule). The specific feature was the use of vitreotome needle for IOL-capsular bag complex centration and fixation as well as for subsequent removal of capsular bag fibrosis, secondary cataract or cortex. Results . Intraoperative complications included 3 cases of slight bleeding during iris perforation. Postoperative complications included 4 cases of inflammatory reaction in the form of fibrin in the pupil. No cases of hemophthalmia associated with the insertion of 30 G needle or port in the eye cavity were marked. Two patients developed pseudoexfoliation glaucoma treated with hypotensive drops. In the early and late postoperative period in all patients of all the groups stable position of IOL-capsular bag complex was marked. Conclusion . Use of discussed techniques gives a possibility to obtain high visual prognosis, low probability of IOP elevation and stable position of IOL-capsular bag complex in all the three groups.

Secondary in-the-bag Intraocular Lens Implantation in Aphakic Eyes After Vitrectomy and Silicone Oil Tamponade for Rhegmatogenous Retinal Detachment.

To describe a novel technique for capsular bag reopening and secondary in-the-bag intraocular lens (IOL) implantation in aphakic eyes after vitreoretinal surgery and intraocular tamponade. We enrolled 14 eyes of 14 patients who underwent primary vitreoretinal surgery with silicone oil tamponade for rhegmatogenous retinal detachment between September 2018 and September 2019. The novel technique was used for capsular bag reopening and foldable single-piece IOL implantation. Patients were followed up at least 24 weeks with routine ophthalmic examinations, corneal endothelial cell density, and IOL tilt and decentration measurement. The procedure was successfully completed in 13 cases; in one case, because of posterior capsular tear, the IOL was implanted with ciliary sulcus fixation. After a mean follow-up of 48.8 ± 14.8 (range, 24.9-65.9) weeks, the best-corrected visual acuity (before 20/76 Snellen, 0.63 ± 0.23 logarithm of the minimum angle of resolution equivalent and after 20/35 Snellen, 0.32 ± 0.32 logarithm of the minimum angle of resolution equivalent; P = 0.001) and spherical equivalent (before +8.22 ± 4.08, after -2.39 ± 1.77 D; P < 0.001) improved, intraocular pressure (before 15.93 ± 4.40, after 16.25 ± 4.25 mmHg; P = 0.743) remained unchanged. The IOL was well centered with a mean horizontal and vertical tilt of 0.5070 ± 0.3319° and 0.4652 ± 0.3465°, respectively, and decentration of 0.1705 ± 0.1334 mm and 0.1712 ± 0.1576 mm, respectively. With this technique, capsular bag reopening and secondary in-the-bag IOL implantation could be achieved in most cases with satisfactory visual outcome and IOL position.

In vivo evaluation of a 1-piece foldable sutureless intrascleral fixation intraocular lens using ultrasound biomicroscopy and anterior segment OCT.

To evaluate the optic plate and haptics of a specially designed sutureless intrascleral-fixated intraocular lens (IOL) using ultrasound biomicroscopy and anterior segment optical coherence tomography (AS-OCT). Department of Ophthalmology, San Marino Hospital, Republic of San Marino. Retrospective observational case series. Eyes that underwent intrascleral fixation with IOL implantation (Carlevale) were included. Preoperative and postoperative refractive outcomes were reported. Optic plate tilt and haptics position were assessed with ultrasound biomicroscopy, whereas intrascleral plug depth and conformation were evaluated with AS-OCT. The study comprised 10 aphakic eyes. Postoperative visual acuity improved in all patients. At postoperative month 3, 3 eyes (30%) had a vertical tilt of more than 100 μm, whereas no horizontal tilt was observed in any patient. The mean vertical intraocular tilt was 0.19 ± 0.22 mm. Of 20 haptics, 13 (65%) passed through the ciliary sulcus, 4 (20%) posterior to the ciliary body, and 3 (15%) through the ciliary body. AS-OCT scans showed a mean intrascleral plug depth of 247.20 ± 62.82 μm in the nasal sector and 265.50 ± 30.11 μm in the temporal sector, with adequate integration of the T-shaped plugs in the scleral tissue. This secondary IOL showed good intraocular stability and safe haptics fixation, making it suitable for the intrascleral fixation technique. The specific foldable design results in a low predisposition to optic plate tilt and haptic torsion. In long eyes, the sulcus-to-sulcus distance should be carefully evaluated preoperatively because the flexible structure of the IOL could be subjected to excessive stretching.

Comparison of refractive deviations after phacovitrectomy according to the intraocular lens insertion method.

This study aimed to compare refractive deviations between in-the-bag insertion, trans-scleral ciliary sulcus fixation, ciliary sulcus insertion, and ciliary sulcus insertion with optic capture after phacovitrectomy. Single-unit, single-surgeon, retrospective study. Consecutive patients who underwent phacovitrectomy and intraocular lens (IOL) out-of-the-bag insertion simultaneously were retrospectively reviewed. Patients who underwent phacovitrectomy with IOL in-the-bag insertion were also included for comparison with those who underwent phacovitrectomy with out-of-the-bag insertion. Patients were classified into four groups based on the IOL insertion method. The average difference from the target spherical equivalent (SE) to postoperative SE was defined as the refractive deviation. Refractive deviations of the groups were compared. The refractive deviation for the in-the-bag insertion (43 eyes) was -0.18 ± 0.50 Df, -0.84 ± 0.81 D for the trans-scleral ciliary sulcus fixation (43 eyes), -0.93 ± 0.68 D for the ciliary sulcus insertion (25 eyes), and -0.27 ± 0.50 D for the ciliary sulcus insertion with optic capture group (24 eyes). The trans-scleral ciliary sulcus fixation and ciliary sulcus insertion groups had significantly different deviations than the in-the-bag group (p < 0.001). There was no significant difference between the ciliary sulcus insertion with optic capture and the in-the-bag insertion groups (p = 0.100). Refractive deviation was significantly different between the eyes that underwent trans-scleral ciliary sulcus fixation or ciliary sulcus insertion and the eyes that underwent in-the-bag insertion. However, there was no significant deviation among the eyes that underwent ciliary sulcus insertion with optic capture.

Spontaneous rotation of a toric implantable collamer lens related to abnormal ciliary body morphology: a case report

BackgroundThis is a case of spontaneous toric implantable collamer lens (TICL) rotation that occurred twice in the left eye of a patient.Case presentationA 24-year-old gentleman received TICL implantation for treatment of myopic astigmatism encountered with spontaneous rotation of approximately 90° from its original position. TICL reposition procedure was performed with visual outcome of 20/16. Surprisingly, a re-rotation of TICL occurred. The patient underwent a replacement of non-toric ICL with a larger size after careful re-evaluation with final visual outcome of 20/20. A short and small ciliary process with shallow ciliary sulcus and posteriorly positioned ciliary body was found by Ultrasound Biomicroscopy (UBM).ConclusionsThe unique morphology of the ciliary body may have a potential association with the vault and instability of implanted ICL. Careful examination of the ciliary body morphology is essential in preoperative evaluation.

Corneal Parameters after Tube-Shunt Implantation through the Ciliary Sulcus

To monitor bilateral corneal parameters after unilateral Baerveldt 350 tube-shunt implantation (Advanced Medical Optics, Santa Ana, CA) through the ciliary sulcus. Retrospective, interventional case series. Patients from 1 private glaucoma practice with severe uncontrolled glaucoma treated with sulcus tube-shunt implantation in 1 pseudophakic eye. Specular microscopy data were collected before and after unilateral sulcus tube-shunt implantation from the surgical and the glaucomatous fellow eyes. Central corneal endothelial cell density (CECD), coefficient of variation (CV), percent of hexagonal cells, central corneal thickness (CCT), intraocular pressure (IOP), IOP-lowering medications, visual acuity, and complications. Forty-six patients (mean age, 69.9 years; standard deviation [SD], 4.6 years; range, 20-88 years; male gender, 41.3%) were identified. After surgery, IOP and the number of IOP-lowering medications decreased significantly by 42.3% (P < 0.0001) and 32.1% (P < 0.0001), respectively, in the surgical eye group. Preoperative CECD measured 1807 cells/mm2 (SD, 172 cells/mm2) and 1825 cells/mm2 (SD, 172 cells/mm2) in the surgical and fellow eyes, respectively (P= 0.92), and compared with baseline, it decreased by 8.6% (P= 0.17) and 3.1% (P=0.65), respectively, by 24 months. Preoperative CV, percent of hexagonal cells, and CCT were similar in both groups and remained stable. All corneal parameters remained unchanged in a subgroup of 15 patients with low preoperative CECD (1273 cells/mm2; SD, 99 cells/mm2). Best-corrected visual acuity remained stable in bothgroups. Hyphema occurred in 23.9% of the surgical eyes and resolved with no intervention. We found no sight-threatening complications or corneal failures during follow-up. Tube-shunt implantation through the ciliary sulcus in pseudophakic eyes appears relatively safe to the corneal endothelium, demonstrating a small and nonsignificant decline in central CECD compared with baseline and with glaucomatous fellow eyes. No significant disruption to corneal endothelial cell morphologic features, increased corneal thickness, or corneal failures were found during the 24-month follow-up period. A prospective head-to-head comparison to assess the effects of the various methods of tube-shunt implantation on the corneal endothelium is needed.

Plateau Iris and Severity of Primary Angle Closure Glaucoma

To compare the distribution of plateau iris in eyes across varying severity of primary angle closure glaucoma (PACG) using standardized ultrasound biomicroscopy (UBM) criteria. Cross-sectional study. UBM was performed on 210 patients with PACG who had previously undergone laser peripheral iridotomy. Plateau iris was defined as the presence of all the following UBM criteria in ≥2 quadrants of the angle: anteriorly directed ciliary body, absent ciliary sulcus, iris angulation, flat iris plane, and iridotrabecular contact. Disease severity was based on the visual field mean deviation (MD) and classified as early-to-moderate (MD ≥-12 dB), advanced (-12.01 dB to-20 dB), and severe (MD <-20 dB). Of 210 subjects recruited, 23 were excluded because of poor quality UBM images. The remaining 187 patients were categorized as having early-to-moderate (n= 103), advanced (n= 38), and severe PACG (n= 46). Of these subjects, 48.1% were male, and 90.9% were of Chinese ethnicity. The overall proportion of plateau iris was 36.9%, with 32.0% (33/103) in early-to-moderate, 34.2% (13/38) in advanced, and 50% (23/46) in severe PACG (P= .03, comparing severe PACG with early-to-moderate groups). Among the severe PACG group, those with plateau iris configuration had significantly smaller anterior chamber area (P= .03) and volume (P= .01) compared with those without plateau iris. The higher proportion of plateau iris configuration in eyes with severe PACG compared with early-to-moderate PACG suggest that this may be a contributory factor for disease severity.