Conjunctival Dissection Research Articles

A Novel Technique for scleral fixation of Carlevale Intraocular Lens without conjunctival opening utilizing Hoffman Pockets

Purpose: To report a novel surgical technique for scleral fixation of Carlevale intraocular lens (IOL) without conjunctival dissection using Hoffman pockets. Methods: An 80-years-old female with IOL dislocation in her right eye required IOL exchange. After removing the dislocated IOL, a Carlevale IOL was implanted, securing the self-blocking harpoons within scleral pockets which were constructed using Hoffman technique. Results: Surgical procedure was uneventful. During the next 3 months follow up, Carlevale IOL remained stable within the scleral pockets, and no signs of IOL dislocation or decentration were observed. Visual acuity significantly improved from 20/200 preoperatively up to 20/32 postoperatively due to corneal scaring from previous herpetic keratitis. No postoperative complications were recorded. Conclusion: Creating scleral pockets without conjunctival dissection using Hoffman pockets technique, represent a reliable and effective method for achieving both secure fixation and effective scleral covering of Carlevale IOL haptics. Absence of conjunctival opening, apart from patient postoperative comfort, reduces risk of postoperative complications, including conjunctival erosion and infection. The presented technique offers a promising alternative for Carlevale IOL scleral fixation.

Intraluminal Suture Placement for Management of Hypotony After Glaucoma Drainage Device Surgery.

Intraluminal 3-0 Supramid stent placement can be an effective long-term solution for hypotony after glaucoma drainage device surgery. This procedure may obviate the need for conjunctival dissection. In some cases, additional procedures are required. To describe the utility of implantation of a multifilament polyamide suture (Supramid) in the tube lumen to reverse hypotony after glaucoma drainage device (GDD) surgery. Patients who underwent tube revision with intraluminal placement of a 3-0 Supramid stent, with or without external ligature, to manage hypotony following GDD surgery between January 2010 and October 2020. Resolution of hypotony was defined as IOP >5mm Hg and the absence of hypotony-related structural abnormalities. Overall success was the absence of failure criteria (IOP ≤5mm Hg, >21mm Hg, or <20% reduction below baseline IOP after 3 months for 2 consecutive study visits; additional glaucoma surgery; or loss of light perception), with or without adjunctive ocular hypotensive therapy. Nine eyes of 9 patients underwent placement of a 3-0 Supramid stent with a resolution of hypotony in all eyes with a mean follow-up duration of 33.3 ±24.0 months. Overall success was achieved in 7 of 9 eyes. Four eyes required intervention after stent placement: 1 eye required selective laser trabeculoplasty followed by replacement of the original stent with a shorter 3-0 Supramid suture and external ligature; 1 eye underwent revision for tube exposure; and 2 eyes underwent laser suture lysis to release an external suture ligature. In cases of hypotony after GDD, particularly when it is desirable to reduce the extent of additional conjunctival dissection, intraluminal placement of a 3-0 Supramid stent via an intracameral approach can be an effective long-term solution. Postoperative adjustments were required in many cases.

Two-way adjustable double-knots intrascleral fixation and single sclerotomy looping technique: a novel minimal invasive adjustable intraocular lens fixation technique

BackgroundIOL fixation without capsular support presents challenges for surgeons. Although innovative techniques were developed to address subluxated IOLs, adjustable IOL fixation methods are seldom reported. We introduce a novel two-way adjustable double-knots intrascleral fixation combined with single sclerotomy looping technique for fixing intraocular lenses (IOL) or IOL-capsular bags.MethodsA bent 30-gauge needle threaded with 8 − 0 polypropylene was introduced into the eye. A gripping forceps assisted the haptic looping. Two overhand knots were made with 8 − 0 polypropylene thread. The knots were incarcerated into a scleral tunnel made by a 30-gauge needle, with two ends of the thread left at each side of the tunnel. The IOL was adjusted to the premium position with adequate tension by pulling either end of the threads. The study included 19 eyes with aphakia, subluxated IOL-capsular bags, or subluxated crystalline lenses. The mean followed up period was 18.9 ± 7.1 months with evaluations of uncorrected visual acuity (UCVA), intraocular pressure, slit-lamp examination, and swept-source optical coherence tomography of the anterior segment.ResultsUCVA increased from 1.28 ± 0.74 at baseline to 0.44 ± 0.51 (logMAR) at final visit (P < 0.001). All IOLs were fixed well-centered. The mean IOL tilt was 3.5°±1.1°. Postoperative complications included transient IOP elevation (15.8%), hypotony (10.5%), and cystoid edema (5.3%) which resolved within 4 weeks.ConclusionsWe presented a novel adjustable technique for IOL fixation, which stabilize IOLs by using an intrascleral double-knots structure. This technique minimized surgical manipulations by using a single sclerotomy looping technique without large conjunctival dissection and scleral flap creation. The technique offers a reliable and optimal IOL positioning and improved visual outcomes in patients undergoing scleral fixed IOL implantation.

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Contemporary Anesthesia Perspectives for Ophthalmic Surgery: A Brief Review

In recent decades there have been few changes in the anesthesia management of eye surgery. By contrast, the 21st Century has witnessed major advancements in ophthalmic surgery with the adoption of minimally-invasive techniques, technologic innovations, and an expanding population seeking eye care. These factors have impacted intraoperative exposure such that many procedures are now performed on more complex patients, and completed in quicker time. Furthermore, in pursuit of economic savings and patient satisfaction there is a trend to divert eye surgeries away from the in-hospital setting to ambulatory centers or office locations. From an anesthesia perspective, these changes have imposed a demand on providers to shorten operating room turnover times and accelerate patient discharge while maintaining high standards of patient safety. This review will address five new avenues of anesthesia care, each of which offer possibilities in accommodating facets of this new order surgical experience. First, remimazolam is an ultra-short acting benzodiazepine that produces a predictable period of hypnosis and rapid, full recovery of consciousness because of its short context-sensitive half-time and inactive metabolites. A single 3-5 mg dose produces 11-15 minutes sleep that may be ideal for brief ocular interventions. Second, nasal CPAP/BiPAP and high flow nasal oxygen devices expand the profile of patients appropriately managed at an ambulatory center. Since their application improves arterial oxygenation and delays the onset of apneic hypoxemia, they are advantageous for patients afflicted by morbid obesity or severe obstructive sleep apnea. Third, open globe injuries have traditionally been managed under general anesthesia. However, recent studies attest to regional anesthesia as a viable alternative for many ocular insults, particularly for the elderly and patients with major organ dysfunction or risk for pulmonary aspiration. Fourth, the sub-Tenon block is a cannula-based regional ophthalmic skill performed predeominantly by ophthalmic surgeons because it necessitates conjunctival incision and dissection. Recently described variations of an incision-free, easily mastered sub-Tenon approach are likely to be included in residency and fellowship instruction, and so become an invaluable component of the anesthesiology armamentarium. This review concludes with a concise overview of the a2 agonist dexmedetomidine with the focus directed on its uses as an adjunct for adult sedation, and advantage in children for premedication and control of emergence delirium.

Goniotomy for initial and re-surgery for childhood glaucoma in Northern India.

Purpose:The aim of this study was to describe the effectiveness of goniotomy for childhood glaucoma in Indian eyes.Methods:Consecutive patients with pediatric glaucoma who underwent goniotomy between July 2017 and June 2020, in a single center in Northwest India were prospectively analyzed. Goniotomy was done as a primary procedure or a re-do surgery of the untreated angle in failed filtering surgery. Success was defined as intraocular pressure (IOP) ≦18 mm Hg with or without 2 topical medications.Results:A total of 172 eyes of 126 children underwent goniotomy during this period (37.9% of all pediatric glaucoma surgeries). Goniotomy comprised 132 of 211 (62.5%) primary pediatric glaucoma surgeries and 40 of 243 (16.5%) re-do surgeries. 145, 112, and 54 eyes had a six months, 1-year and 2-year follow-up, respectively. At 1 year, success rates in Primary Congenital Glaucoma (PCG) were 79.7% for primary surgery and 68.4% for re-do surgery. For non-PCG eyes, the success rate was 62% at 1 year. Among PCG subgroups, infantile and newborn glaucoma had 87.5% and 57.1% success rates, respectively. On logistic regression analysis, lower baseline IOP and lesser axial length at presentation were significantly predictive of successful outcomes (P = 0.03 and P = 0.02, respectively). At 1 year, in the primary surgery group, 50% had good vision (better than logMAR 0.5), 28.9% had moderate (better than LOGMAR 1.0) and 20% had severe visual impairment. There were no significant intraoperative or post-operative complications.Conclusion:Goniotomy appears to be an effective surgery for childhood glaucoma in Indian eyes. Being minimally invasive, it obviates the need for conjunctival and scleral dissection and antifibrotic agents.

A Non-expected and Extreme Complication of Phacoemulsification: Scleral Wall Rupture

Rupture of the scleral wall during intraocular surgeries is extremely rare even in patients with a history of trauma, underlying ocular or systemic autoimmune disease. In this report, we describe a single case of a partial scleral wall rupture during phacoemulsification. We aim to discuss this extreme complication and to highlight the importance of a trauma history before phacoemulsification. An 84-year-old patient was hospitalized with the plan of phacoemulsification surgery. During phacoemulsification, conjunctival chemosis appeared all around the limbus and subconjunctival hemorrhage at nasal side. After conjunctival dissection, partial scleral rupture was detected. Iris-choroid were expelled from the wound. Phacoemulsification was immediately stopped and wound was closed primarily. There were no signs or symptoms of prior inflammation, and rheumatologic workup was negative. Nevertheless, the patient had an old ocular blunt trauma history. During the examination of a patient with a trauma history, scleral wall structure should not be overlooked. Weakness in scleral wall could lead to detrimental complications during intraocular surgeries.

Novel use of an adjustable single 8\u20130 polypropylene suture of scleral fixation without conjunctival dissection

BackgroundThis report serves to describe the use of a novel adjustable single 8–0 polypropylene suture for scleral fixation without conjunctival dissection, and to describe related clinical outcomes associated with this approach.MethodsIn this study, we retrospectively reviewed 28 eyes from 27 patients that underwent scleral fixation of the intraocular lens (IOL) without conjunctival dissection using an adjustable single 8–0 polypropylene suture at the Beijing Tongren Eye Center between April 2018 and April 2019. For this surgical approach, a 23-gauge infusion cannula was set, after which two Hoffmann scleral pockets were created. Next, 8–0 polypropylene sutures were inserted into the eye guided by 10–0 polypropylene sutures of a long straight needle. The 8–0 suture was then used to fix the haptic IOs. Finally, these 8–0 polypropylene sutures were removed from the scleral pockets, and knots were tightened with the adjustable single suture. Primary outcomes included visual acuity and postoperative complication incidence.ResultsFor this study, outcomes for 28 eyes from 27 patients (9 female, 18 male) were assessed. Patients had a mean age of 54 ± 15.11 years-old and were followed for an average of 10.18 ± 2.76 months postoperatively. Uncorrected visual acuity in these patients improved significantly from a preoperative value of 1.269 ± 0.464 logMAR to a 3-month postoperative value of 0.409 ± 0.413 logMAR (p = 0.000). The majority of postoperative complications in these patients were temporary and self-limiting, including corneal edema (35.71%), hypotony (14.29%), elevated intraocular pressure (28.58%), and mild hyphema (7.14%). No evidence of exposure or erosion of the trimmed suture end was detected in any patients. An ultrasound biomicroscope was able to readily detect the IOL and all sutures, and IOLs were found to be well-centered without any dislocation, tilting, or subluxation upon follow-up.ConclusionsAn adjustable single 8–0 polypropylene suture can reliably and effectively be used for scleral fixation without conjunctival dissection for the treatment of patients with aphakia or inadequate posterior capsule support. The novel procedure described herein may therefore be an effective means of minimizing the risk of suture-related complications in patients undergoing scleral-fixated IOL implantation.Trial registrationRetrospective case series study, not applicable. NCT04476264.

Intrascleral Fixation of Flanged Polypropylene Suture(s) for Iridodialysis Repair.

We will describe a minimally invasive technique for the repair of iridodialysis, without conjunctival dissections, using intrasceral fixation of a 6-0 polypropylene suture with a flanged tip. A flange was created at the end of the suture with thermoplasticity. An ab interno passing of the needle attached to the suture was performed through the peripheral part of the iris and was further passed out from the eye 1.5 mm to 2 mm behind the limbus. Intrascleral fixation of the exterior suture was performed with the aid of the attached needle. After adjusting the tension of the iris relocation, the externalized end of the suture was cut flush to the sclera with scissors. For a wide dialysis, the same manipulations were repeated until the repair was completed. The technique was used in three eyes of three patients. No visual impairments of monocular diplopia and glare were observed after surgery. Postoperatively, the irises remained well positioned, with no suture erosion, suture loosening, hypotony, scleral atrophy, or chronic inflammation being observed within the follow-up period. Mild postoperative hyphema was observed in one eye of blunt trauma. The present technique provides minimal surgical invasion for the repair of iridodialysis without creations of scleral flap/groove/pocket and conjunctival dissection.

Intrapalpebral Extending Dysesthetic Bleb Revision with Fibrin Glue

ABSTRACTAimThis pilot study evaluates the safety and efficacy of a novel surgical technique using fibrin glue to treat bleb dysesthesia post-trabeculectomy due to intrapalpebral extension.BackgroundTrabeculectomy remains the gold standard for control of intraocular pressure (IOP) in refractory glaucoma. Bleb dysesthesia following antifibrotic-enhanced trabeculectomy is common, resulting in a significant decrease in quality of life. Symptoms include pain, foreign body sensation, and excessive tearing. Treatments include lubrication, topical nonsteroidal anti-inflammatory drugs (NSAIDs), bandage contact lens, bleb needling, compression sutures, Nd:YAG laser treatments, autologous blood injection, and cryopexy. These procedures can be time-consuming, risk bleb function, and may be ineffective at symptom control; thus, a novel technique is required.TechniqueThis is a retrospective case series of eyes undergoing bleb dissection with scleral cutdown and conjunctival closure with ARTISS fibrin tissue glue. Reported cases have been followed up for 6 months. Outcomes assessed include complications, IOP, medication usage, subjective pain score, visual field, and cup-to-disk (C:D) ratio.ConclusionThis small pilot series demonstrated that patients suffering from bleb dysesthesia due to intrapalpebral bleb extension can be successfully treated with a novel surgical approach combining conjunctival dissection to sclera with fibrin tissue glue closure. There was no significant effect on bleb function and no contribution to glaucoma progression over a 6-month period. A significant reduction in patient discomfort with no new surgical complications was noted.Clinical significanceThis demonstrates a safe and effective novel surgical approach to treat patients with this condition. The technique is easily learnt and can be employed in an outpatient setting. The technique is readily accepted by patients in group who are often reticent to undergo further intervention. Most importantly, it does not compromise bleb function or destabilize glaucoma control.How to cite this articleHolmes DP, Manning DK. Intrapalpebral Extending Dysesthetic Bleb Revision with Fibrin Glue. J Curr Glaucoma Pract 2020;14(1):37–42.

XEN\xae stent complications: a case series

BackgroundXEN® gel stent (Allergan, Dublin/Republic of Ireland) is a relatively new microinvasive glaucoma device providing an ab-interno approach to the subconjunctival space for aqueous drainage and reduction of intraocular pressure. It is thought to be less invasive, reduce surgical time and post-operative infection rates compared with traditional glaucoma procedures. Little information however, has been published regarding complications and subsequent management.Case presentationThe authors highlight five complicated cases of XEN® stent insertion, how they were managed and key learning points. Cases include: entire stent found at the bottom of the anterior chamber several months after uncomplicated insertion, stent broke into multiple pieces during manipulation within subconjunctiva, XEN45 stent migrated into the anterior chamber 7 months post-operatively and a case of limbal-based conjunctival dissection during open revision which lead to additional scarring around the stent and subsequent raised intraocular pressure.ConclusionsWe present some new and interesting complications of XEN implant as well as potential management options. This can assist clinical decision-making and enable better pre-operative discussions with patients regarding risks of surgery.

Combined 23-gauge transconjunctival vitrectomy and scleral fixation of intraocular lens without conjunctival dissection in managing lens complications

BackgroundTo evaluate the safety and efficacy of combined 23-gauge transconjunctival pars plana vitrectomy and scleral fixation of intraocular lens (IOL) without conjunctival dissection.MethodsA retrospective study in Chang Gung Memorial Hospital, Keelung and Taoyuan, Taiwan. Patients receiving combined 23-gauge transconjunctival pars plana vitrectomy and scleral fixation of IOL without conjunctival dissection were enrolled. The ocular findings, causes of lens complication, surgical procedures, type of IOL used, and complications were documented.ResultsWe included 40 eyes from 39 patients (27 male, 12 female) with a mean age of 59.5 [standard deviation (±) 14.8] years old. The mean follow-up duration was 6.8 ± 5.4 months. The cause of lens complications was ocular trauma in 24 (60%) eyes, cataract surgery complications in 11 (28%) eyes, and spontaneous subluxation of crystalline lens in 5 (13%) eyes. The overall best corrected visual acuity (BCVA) (logMAR) improved from 1.359 ± 0.735 to 0.514 ± 0.582 (p < 0.001). The BCVA also improved significantly in each group with different causes of lens complications. Preoperative BCVA was the only factor associated with the postoperative visual outcome (p = 0.008). Most surgery-related complications were self-limited, including mild vitreous hemorrhage (5%), microhyphema (5%), transient elevated intraocular pressure (3%), and transient hypotony (3%). Cystoid macular edema and IOL decentration was found in 3 (8%) eyes and 1 (3%) eye respectively.ConclusionsCombined 23-gauge transconjunctival vitrectomy and scleral fixation of IOL without conjunctival dissection is effective and safe in managing a wide variety of lens complications, with good postoperative comfort and visual recovery.Trial registrationRetrospective study, not applicable.

Agreement between intraoperative measurements and optical coherence tomography of the limbus-insertion distance of the extraocular muscles

Objective To assess the agreement between intraoperative measurements of the limbus-insertion distance of the extraocular muscles with those measured by spectral domain optical coherence tomography. Methods An analysis was made of a total of 67 muscles of 21 patients with strabismus. The limbus-insertion distance of the horizontal rectus muscles were measured using pre-operative SD-OCT and intra-operatively in 2 ways: (1) direct, after a conjunctival dissection in patients who underwent surgery, or (2) transconjunctival in patients who were treated with botulinum toxin, or in those who were not going to be operated. The intraclass correlation coefficient and Bland–Altman plots were calculated to determine the concordance between the 2 methods. Results The mean age was 45.9 ± 20.9 years (range 16 to 85), with 52% being women. The percentage of identification by direct intraoperative measurement was 95.6% (22/23), by transconjunctival intraoperative measurement 90.9% (40/44), and by OCT 85% (57/67), with 22 muscles finally being analyzed for the agreement study between direct intraoperative measurement and OCT measurements, and 35 muscles for the agreement between transconjuctival intraoperative measurement and OCT. The intraclass correlation coefficient showed good agreement with OCT and direct intraoperative measurements (0.931; 95% confidence interval (95% CI): 0.839–0.972; P < .001), and with transconjunctival intraoperative measurements (0.889; 95% CI: 0.790–0.942; P < .001). Conclusions The SD-OCT is an effective technique to measure the distance from the insertion of the horizontal rectus muscles to the limbus, with a high agreement with intraoperative measurements being demonstrated.

Scleral fixation of a foldable intraocular lens with polytetrafluoroethylene sutures through a Hoffman pocket

Scleral fixation of intraocular lenses (IOLs) is traditionally performed after conjunctival dissection and preparation of scleral flaps. The Hoffman pocket technique creates scleral pockets without conjunctival dissection. We describe a technique that uses a Hoffman pocket and 7-0 polytetrafluoroethylene (Gore-Tex) sutures for scleral fixation of a foldable posterior chamber IOL in patients with insufficient capsule support. The technique eliminates the need for conjunctival dissection, scleral cauterization, knot rotation, and sutured wound closure. The favorable properties of the suture material and the use of a small incision to insert a foldable IOL are additional advantages. None of the authors has a financial or proprietary interest in any material or method mentioned.

Concordancia de la distancia desde la inserción hasta el limbo de los músculos rectos entre la medida intraoperatoria y con tomografía de coherencia óptica

ObjectiveTo assess the agreement between intraoperative measurements of the limbus-insertion distance of the extraocular muscles with those measured by spectral domain optical coherence tomography. MethodsAn analysis was made of a total of 67 muscles of 21 patients with strabismus. The limbus-insertion distance of the horizontal rectus muscles were measured using pre-operative SD-OCT and intra-operatively in 2 ways: 1) direct, after a conjunctival dissection in patients who underwent surgery, or 2) transconjunctival in patients who were treated with botulinum toxin, or in those who were not going to be operated. The intraclass correlation coefficient and Bland-Altman plots were calculated to determine the concordance between the 2 methods. ResultsThe mean age was 45.9 ±20.9 years (range 16 to 85), with 52% being women.The percentage of identification by direct intraoperative measurement was 95.6% (22/23), by transconjunctival intraoperative measurement 90.9% (40/44), and by OCT 85% (57/67), with 22 muscles finally being analysed for the agreement study between direct intraoperative measurement and OCT measurements, and 35 muscles for the agreement between transconjuctival intraoperative measurement and OCT. The intraclass correlation coefficient showed good agreement with OCT and direct intraoperative measurements (0.931; 95% confidence interval (95% CI): 0.839–0.972; P<.001), and with transconjunctival intraoperative measurements (0.889; 95% CI: 0.790–0.942; P<.001). ConclusionsThe SD-OCT is an effective technique to measure the distance from the insertion of the horizontal rectus muscles to the limbus, with a high agreement with intraoperative measurements being demonstrated.

Is this really sutureless intrascleral pocket technique of transscleral fixation?

Dear Editor, Cho et al. [1] described the Sutureless intrascleral pocket technique of transscleral fixation of intraocular lens in previous vitrectomized eyes in April issue. The authors prepare two scleral pockets with a crescent knife 2 mm from the limbus and opposed 180 degree each other without any conjunctival dissection. Following, they enter into the posterior chamber with a 26-gauge needle including 10/0 nylon suture transsclerally and transconjunctivally at a point of 1.5 mm posterior from the limbus. Following clear corneal incision (CCI), prolene sutures were exteriorized through the CCI pocket and a three-piece foldable acrylic intraocular lens was injected via CCI and the ends of the haptics were exteriorized through the CCI. The prolene sutures for each haptic in the intrascleral pocket bed were then tied and knots were buried under scleral flaps, in their technique. To us, this description and title were not completely true. This technique is not a sutureless one. In fact, it is a modified sutured and intrascleral pocket technique of transscleral fixation of intraocular lens. In sutureless techniques defined until now, a permanent suture was not used inherently [2,3,4,5]. In the trocar-assisted technique of sutureless intrascleral posterior chamber foldable intra-ocular lens fixation which we described, we put a non-absorbable 10/0 nylon suture transconjuncivally after the placement of the haptics into the scleral groove and take it out 1 week after [2,3]. We aimed to stabilize the haptics at early postoperative period. The authors defined their technique as the first scleral fixation method without conjunctival dissection and emphasized that it has the advantage of lack conjunctival dissection and lesser risk of conjunctival bleeding [1]. We disagree with authors about that. In the trocar assisted sutureless technique we developed, we have been entering into the eye with 25-gauge vitrectomy trocars without any opening of conjunctiva performing two 3 mm long scleral tunnels parallel to the limbus apart from 180 degree each other and angulating 10 degree with scleral surface. We performed vitrectomy entering by through these two cannulas. One haptic of the intraocular lens which implanted through a CCI is held with a forceps that inserted through CCI and grasped in the eye with a forceps that inserting into and removed from the eye via trocar cannula and placed into the tunnels. We put a 10/0 nylon suture encircling the haptic for security and take it out 1 week after. By repeating same processes for other haptic, both haptics became implanted into the scleral tunnels. The advantages of our technique are lack of conjunctival dissection and scleral flaps in addition to minimal possible damage to circumferential tissues. We do not encountered with any complication such as decentralization or tilt of intraocular lens, endophthalmitis, glaucoma and retinal detachment [2,3]. In terms of simplicity, we think that our method is simpler and needs shorter surgical time as it does not need to prepare conjunctival dissection and scleral flaps.

Sutureless Intrascleral Pocket Technique of Transscleral Fixation of Intraocular Lens in Previous Vitrectomized Eyes

In this case series, we assessed a new technique, the intrascleral pocket procedure of transscleral fixation (TF) of the intraocular lens (IOL) in post-vitrectomized eyes. We performed the transscleral fixation of IOL in four aphakic patients who underwent pars plana vitrectomy. Two points 180° apart were marked at the limbus. A 2-mm-sized intrascleral pocket was created by lamellar dissection using a crescent blade without conjunctival dissection. A 2.8-mm clear corneal incision (CCI) was made using a keratome. Prolene sutures were exteriorized through the CCI pocket and a three-piece foldable acrylic IOL was injected via CCI and the ends of the haptics were exteriorized through the CCI. The prolene sutures for each haptic in the intrascleral pocket bed were then tied and knots were buried under scleral flaps. No patient had complaints such as conjunctival irritation, and visual acuity was almost identical to preoperative best-corrected visual acuity at day 1 postoperatively. IOLs were well placed without tilting or subluxation. They had no wound dehiscence or endophthalmitis postoperatively. The intrascleral pocket procedure of TF without the need for conjunctival dissection is a successful method for sulcus fixation in post-vitrectomized eyes predisposed to developing glaucoma.

Minimally Invasive External Mini-Glaucoma Shunt Implantation Without Conjunctival Dissection

The current method for implantation of the Ex-PRESS Glaucoma Filtration Device requires a conjunctival peritomy and shunt insertion under the guarded protection of a scleral flap. This technique requires suture closure of the flap and conjunctiva. A new minimally invasive technique for Ex-PRESS shunt implantation allows for insertion through a scleral tunnel originating from a grooved clear corneal incision. This new method avoids the need for conjunctival dissection and closure and offers the advantages of eliminating conjunctival wound leaks while maintaining the protection of a partial thickness scleral covering. This new technique may offer a faster safer means for shunt implantation with the potential for less conjunctival scarring.

Scleral Fixation of a One-Piece Toric Intraocular Lens

To describe a novel technique for toric intraocular lens (IOL) repositioning and fixation in the absence of adequate capsular support. Case report and literature review. Two cases are presented with scleral fixation of a one-piece toric IOL (SN6AT series; Alcon Laboratories, Inc., Fort Worth, TX). In both cases, toric IOLs initially placed within the capsular bag became decentered due to poor capsular support. To avoid the potential complications of lens explantation and maintain the astigmatic benefits of the toric IOL, scleral fixation of the lenses was performed. The Hoffman technique was used to create reverse scleral pockets without conjunctival dissection. A 10-0 non-dissolvable suture was used to capture and then secure the lens haptics in a lasso-type fashion. Sutures were then buried within the previously created scleral pockets. Both patients had well-centered lenses postoperatively that remained stable at last follow-up, 30 months postoperatively. In the absence of adequate capsular support, scleral fixation is a viable option for one-piece toric IOL fixation to avoid IOL explantation.

Ab Interno Management of Blocked Ahmed Valve in the Posterior Segment

To report a case of late failure of a posterior segment placed Ahmed valve in a uveitic eye with a corneal graft and a minimally invasive, ab interno approach in restoring valve function, pressure control, and preservation of vision. Case report. A 25 gauge trans-conjunctival 3-port pars plana vitrectomy was performed to inspect and clean the ostium of the Ahmed valve of any vitreous debris. The Ahmed valve was not disturbed externally and conjunctival dissection was not performed. A 27-gauge blunt cannula was introduced through the vitrector site and used to cannulate the tube and flush it with balanced salt solution. A bleb was immediately re-established and all instruments were removed requiring no sutures. Intraocular pressure returned to target levels and a filtration bleb was re-established. Corneal graft clarity was restored with resolution of preoperative microcystic edema. Postoperative inflammation was minimal and vision was restored. A nonfunctioning tube shunt residing in the vitreous cavity may be revised ab interno without disturbing the shunt placement or the conjunctiva under which it resides to re-establish filtration.