Conjunctival Opening Research Articles

Double implantation of Xen 45 gel stent in primary open-angle glaucoma: a pilot study.

To describe the outcomes of double implantation of Xen 45 Gel Stent (Xen) using an ab externo approach with closed conjunctiva. Retrospective single-centre case series of primary open-angle glaucoma patients with at least six months of follow-up after implantation of a second Xen in the same eye via ab externo technique without conjunctival opening. Eight pseudophakic eyes of 8 patients were included. Intraocular pressure (IOP) dropped from 30 ± 2.6mmHg pre-operatively to 22.4 ± 2.3mmHg one month after the first Xen implant (mean difference: -7.6mmHg [95% confidence interval: -9.4, -5.9mmHg], p = 0.0092). A second Xen was then implanted to achieve the target IOP. The procedure showed no significant intraoperative or postoperative complications. The IOP dropped to 16.1 ± 2.7mmHg six months following this second implant (mean difference: -6.3mmHg [95% confidence interval: -7.2, -5.3mmHg], p = 0.0183); however, 3 patients needed medical therapy to further reduce the IOP towards the target value. Sequential implantation of two Xen 45 Gel Stents using an ab externo approach with closed conjunctiva appears a promising procedure that showed a favorable safety and efficacy profile in this small case series. This pilot data might pave the way for further studies to evaluate the safety and efficacy of the procedure.

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.

Intrascleral anchoring knot on the double suture without peritomy for fixation of intraocular lens.

A new minimally invasive technique for universal fixation of any posterior chamber intraocular lens (IOL), iris prosthesis or capsular tension device (CTD), both for rescuing in case of dislocation and for secondary implantation, is described. It uses intrascleral anchoring knot on the reinforced double 9-0 polypropylene suture without conjunctival opening or scleral dissection. The technique was applied for scleral fixation of the S-shaped monoblock acrylic IOL dislocated into the vitreous cavity in 1 eye, and decentered IOL-CTD-capsular bag complexes in 3 eyes. In none of the cases, complications including knot slippage, suture exposure or hypotony were observed. All patients were followed up for 6 months. The uncorrected distance visual acuity was significantly improved and the IOLs positions remained stable. The described technique might be a simple, effective and safe alternative to flanged scleral fixation approaches.

One-Year Outcomes of Modified Technique for Scleral Fixation of a Three-Piece Intraocular Lens Without Conjunctival Opening.

PurposeThis study aimed to present the 1-year follow-up of a modified technique for scleral fixation of three-piece intraocular lens (IOLs) without conjunctival incision.Materials and MethodsA retrospective chart review of a consecutive series of 10 eyes of nine patients who underwent scleral IOL fixation using the modified technique was performed. Data were collected 1 year after surgery for all patients.ResultsThe range of follow-up time was between 1 year and 31 months. At the last follow-up point, the IOL was well-positioned and the visual acuity was good (as limited by primary diseases). Short-term complications included pupillary IOL capture (n = 1) and decreased intraocular pressure (n = 1), and no long-term complications were observed.ConclusionOutcome data support this technique as a viable option for the management of secondary IOL fixation with flexible usage of more designs of IOLs.

Интрасклеральное ущемление узлов без вскрытия конъюнктивы и обнажения склеры при склеральной усиленной шовной фиксации интраокулярной линзы: собственная модификация

Purpose. Development of new technique for scleral reinforced suture fixation of intraocular lens (IOL) in the absence of capsule support with intrascleral capture of knots without conjunctival opening. Material and methods. Three patients with «IOL-capsular bag» complex dislocation into the vitreous cavity underwent scleral fixation of the IOL in the new modification. The IOL was placed into ciliary sulcus on two 9-00 double polypropylene sutures brought out transsclerally without conjunctival opening. Both sutures were passed intrasclerally for 3.0 mm, sticking each of needles into the sclera at the points of sutures exit from conjunctiva, and brought out through conjunctiva. Threads were cut, leaving 2.0 mm free ends, and knots (2-1-1) were tied with the tension necessary to capture them in the scleral canals. At the points of exit of threads' ends from the conjunctiva, additional needles with looped double threads were sticked again, passed intrasclerally for 3.0 mm and were brought out through conjunctiva; ends of the threads fixing the IOL were captured in loops and dipped in the scleral canals. Results. During the follow-up, position of the IOL was correct, sites of neddles' sticks into the conjunctiva were epithelized, and no tendency to erosion of intrascleral threads was observed. Conclusions. New modification of scleral fixation of IOLs is technically simple, does not require conjunctival opening. It involves the use of double suture, which increases the durability of fixation. Technique can be used for fixation of any IOL model, as well as artificial irido-lens diaphragm, intracapsular ring or intracapsular segment. Key words: scleral fixation of intraocular lens.

Stab incision mitomycin C-assisted rapid trabeculectomy: A 'SMART' trabeculectomy alternative.

The aim of the present study was to introduce a new modified trabeculectomy technique, stab incision mitomycin C (MMC)-assisted rapid trabeculectomy (SMART), which requires less surgical time and tissue manipulation. A total of 41 eyes with indication for trabeculectomy underwent glaucoma surgery with the SMART technique; superior subconjunctival injection of 0.005 mg MMC mixed with 0.1 ml lidocaine, followed by small, fornix base conjunctival opening. A stab incision was made to enter the anterior chamber 1.5 mm post-limbus using a 2.4 mm cataract knife. Double 0.75 mm punch and peripheral iridectomy were performed. A releasable suture was placed in the scleral opening, and matrix sutures to close conjunctiva. The preoperative mean intraocular pressure (IOP) was 23.8 mmHg, with a mean number of medications of 3.3. The mean follow-up duration was 27.6 months, with a range of 12-46 months. A year post-surgery, the mean IOP was 11 mmHg, with a mean number of medications of 0.7, corresponding to a reduction of 12.8 mmHg in IOP and 2.6 in the number of medications. During follow-up, additional 5-fluorouracil injections were administered when needed. In conclusion, SMART with wound modulation appears to be a safe and quick alternative to classic trabeculectomy. Few minor and no major complications were observed during the first 2.5 years of follow-up, with all eyes maintaining an IOP <15 mmHg.

Efficacy and Safety of Conjunctival Cystectomy Using High-Frequency Radiowave Electrosurgery: A Preliminary Report.

To evaluate the efficacy and safety of conjunctival cystectomy using high-frequency radiowave electrosurgery. This retrospective study included 11 patients who underwent conjunctival cystectomy using high-frequency radiowave electrosurgery and had a follow-up of at least 6 months. Briefly, conjunctival opening with a diameter of 1 mm was made with using high-frequency radiowave electrosurgery (Ellman Surgitron; Ellman International, Inc., Hewlett, NY) in cut mode. The cyst was then extracted using a nontoothed forceps through the opening without rupture. Medical record of the patients was reviewed. In all the 11 patients, conjunctival wound healed in 1 week without any complication. No recurrence was detected in any patients over the 6-month follow-up. Conjunctival cystectomy with the adjunctive use of high-frequency radiowave electrosurgery was shown to be effective and safe.

Intraocular Degradation of XEN45 Gel Stent 3 Years After its Implantation

We report a case of XEN45 Gel Stent removal 3 years after its implantation. The stent had degraded with a closed lumen, so a new stent was implanted. A 63-year-old woman was scheduled for XEN45 Gel Stent implantation. Three years after the primary surgery and 2 years after a surgical revision, second revision surgery was required. The conjunctiva was opened, and the implanted XEN Gel Stent was stripped of the adhesive scar tissues. No aqueous humor flow was seen through the stent, and therefore, the stent was removed. The intrascleral and intracameral parts had degraded. The surface of the stent was irregular and cobbled. A part of the lumen in the middle of the stent had closed. We detected changes in the stent after its removal during the surgical revision with conjunctival opening, which is our standard approach for failed XEN Gel Stents. Most surgeons advise needling of the stent in cases of failure. However, in cases of needling, changes in the stent might not have been detected. Thus, the number of patients with similar changes as this report might be higher than the publications suggest. No unique characteristics distinguished this patient from those who had a functional XEN Gel Stent. The stent, in this case, might have been of inferior quality as an exception, or all stents might degrade over time. Therefore, gonioscopy should be performed carefully to detect any changes in the stent. In cases of suspected stent degradation, we recommend a revision surgery with conjunctival opening and removal of the stent in cases of degradation.

Segmental scleral buckling without sling sutures around the muscles.

To introduce a modified technique for segmental buckling through a small in situ conjunctival opening without rectus muscle traction for minimally invasive repair of uncomplicated rhegmatogenous retinal detachment. This technique was performed in 15 eyes of 15 selected patients with primary retinal detachment. Conventional traction sutures placed beneath rectus muscles were replaced by an absorbable translimbal traction suture at lesion quadrant. The conjunctival incision was made 8-9 mm posterior and parallel to the limbus. After cryopexy, a minimal explant was fixed with one to two sutures through the conjunctival opening, expanded by a pediatric speculum. Retinal reattachments were achieved with correct buckle positions in all patients, with rapid cosmetic recovery. This modified buckling technique simplifies the buckling procedure, minimizes surgical invasiveness, preserves intact limbal conjunctiva, and relieves discomfort.

Robot-Assisted Simulated Strabismus Surgery.

PurposeThis study aims to investigate the feasibility of robot-assisted simulated strabismus surgery using the new da Vinci Xi Surgical System and to report what we believe is the first use of a surgical robot in experimental eye muscle surgery.MethodsRobot-assisted strabismus surgeries were performed on a strabismus eye model using the robotic da Vinci Xi Surgical System. On the lateral rectus of each eye, we performed a procedure including, successively, a 4-mm plication followed by a 4-mm recession of the muscle to end with a 4-mm resection. Operative time from conjunctival opening to closing and successful completion of the different steps with or without complications or unexpected events were assessed.ResultsRobot-assisted strabismus procedures were successfully performed on six eyes. The feasibility of robot-assisted simulated strabismus surgery is confirmed. The da Vinci Xi system provided the appropriate dexterity and operative field visualization necessary to perform conjunctival and Tenon's capsule opening and closing, muscle identification, suturing, desinsertion, sectioning, and resuturing. The mean duration to complete the whole procedure was 27 minutes (range, 22–35). There were no complications or unexpected intraoperative events.ConclusionsExperimental robot-assisted strabismus surgery is technically feasible using the new robotic da Vinci Xi Surgical System. This is, to our knowledge, the first use of a surgical robot in ocular muscle surgery.Translational RelevanceFurther experimentation will allow the advantages of robot-assisted microsurgery to be identified while underlining the improvements and innovations necessary for clinical use.

Peritomy-sparing scleral buckle

AbstracPurposeTo introduce a modified technique for encircling circumferential scleral buckling without peritomy thorough a small conjunctival opening for the repair of uncomplicated rhegmatogenous retinal detachment (RD).MethodsThis technique was performed in 10 eyes of 10 patients with primary rhegmatogenous RD who underwent encircling circumferential scleral buckling without peritomy. Transconjunctival traction sutures were placed in four rectus muscles. After transconjunctival location of the retinal break, a 5- to 6-mm radial conjunctival incision was performed in 4 quadrants without cutting the limbal conjunctiva–Tenon's capsule. A 240-silicone band in scleral belt loops was used for an encircling circumferential buckle. After drainage and cryopexy, SF6 was used for tamponade. The incision was closed via layered closure only ocassionally.ResultsPrimary attachment success of 100% was achieved by single procedure. The intraoperative and postoperative complications observed included subconjunctival hemorrhage observed in 5 (50%) of eyes. These disappeared in the postoperative period.ConclusionsMinimal conjunctival incision in scleral buckle without peritomy can achieve excellent anatomical success in patients with rhegmatogenous RD without distorting ocular surface anatomy. This is the first description of technique preserving corneal limbus anatomy that could convert buckling surgery to more attractive option for retina surgeons.

Conjunctival cystectomy assisted by pattern scan laser photocoagulation

BackgroundTo introduce a new technique of laser-assisted conjunctival cystectomy using pattern scan laser (PASCAL) photocoagulation.Case presentationA 50-years-old Asian woman presented with a conjunctival cyst in the left eye. Slit-lamp examination revealed a 5 mm × 2 mm sized freely movable conjunctival cyst. After a 1 mm × 1 mm sized conjunctival opening was made using PASCAL photocoagulation, the cyst was extracted using a non-toothed forceps without rupture. Two weeks later, complete re-epithelialization of the conjunctiva was observed without any complications. No evidence of recurrence was noted over the 6-month follow-up period.ConclusionConjunctival cystectomy with the adjunctive use of PASCAL photocoagulation can be an effective and safe treatment method.

Results of a new "mirror tuck technique" for fixation of lacrimal bypass tube in conjunctivodacryocystorhinostomy.

Context:Conjunctivodacryocystorhinostomy (CDCR) is the procedure of choice for proximal canalicular blocks. However, the complications of tube migration and extrusion limit its widespread practice.Aim:The aim of this study is to evaluate the efficacy and complications of the new “mirror tuck technique” for fixation of lacrimal bypass glass tube without holes in proximal canalicular blocks in laser CDCR.Materials and Methods:A prospective interventional study was conducted in forty consecutive eyes of adult patients, undergoing 980 nm diode laser CDCR for proximal canalicular blocks. After creating the tract under endoscopic guidance, the collar of the glass tube was fixed to the conjunctiva with 6-0 prolene suture by “mirror tuck technique.” Success was defined as the absence of extrusion of tube with patent tract and relief in epiphora at 1 year of follow-up.Results:Both anatomical and functional success was achieved in 39 (97.5%) cases. Tube displacement occurred in one patient suffering from allergic conjunctivitis in which the tube had to be removed. A temporary heaviness was reported by 5 (12.5%) patients till about 2 weeks. Conjunctival overgrowth over the tube occurred in 1 (2.5%) eye at 5 months which was excised and treated with application of 0.02% mitomycin C with no subsequent recurrence. There were no cases of suture abscess or suture intolerance warranting tube removal.Conclusion:“Mirror tuck technique” is an effective method for tube fixation (for tube without holes) in CDCR. However, it is important to position the conjunctival opening so as to leave sufficient space for passage of sutures for anchorage medially.

Minimal in situ conjunctival incision for segmental scleral buckling surgery.

To introduce a modified technique for minimal segmental buckling through a small in situ conjunctival opening for minimally invasive repair of uncomplicated rhegmatogenous retinal detachment. This technique was performed in 46 eyes of 46 patients with primary retinal detachment. Transconjunctival traction sutures were placed in four rectus muscles after retrobulbar anesthesia was administered. After transconjunctival location of the retinal break, a 5- to 6-mm radial conjunctival incision was performed corresponding to the retinal break without cutting the limbal conjunctiva-Tenon's capsule. After cryopexy, a minimal explant was fixed with one to two sutures through the conjunctival opening, expanded by a pediatric speculum. The incision was closed via layered closure. Retinal reattachments were achieved with correct buckle positions in all 46 cases, with rapid cosmetic recovery. This modified minimal segmental buckling technique simplifies the buckling procedure, minimizes surgical invasiveness, and preserves an intact limbal conjunctiva.

Lacrimal sac diverticulum presenting as a lower eyelid mass with a secreting fistula

Lacrimal sac diverticula are outpouchings of the lacrimal sac. Their various clinical symptoms complicate differential diagnosis. Here we report two patients of distinctive type of lacrimal sac diverticula. Each of them presented with a mass inferior to the medial canthus with a secreting fistula. Irrigation demonstrated lacrimal drainage system patency. The orificium fistula was located at lower palpebral conjunctiva. This distinctive type of lacrimal diverticulum had never been reported in the literature as we know. The mass had no apparent connection with lacrimal sac according to the results of computed tomography dacryocystography and B-scan ultrasonography. All patients underwent surgical exploration and mass removal under general anesthesia. The mass was confirmed as lacrimal sac diverticulum by pathological examination.

Clinical observation of conjunctival opening incision and rinsing after serious alkali burn

Objective To evaluate the clinical effectiveness of the conjunctival incision and rinsing after serious alkali burn.Methods A retrospective analysis of the data of 67 eyes of 46 cases injured from alkali burn and treated in our hospital was performed.Among them,the therapeutic group had 32 cases(45 eyes) which were treated by conjunctival incision and rinsing.The control group also had 14 cases(22 eyes) which were treated by continuous conjunctival sac rinsing.Results At the end of the course,there were 34 eyes (75.6％) obtained good eyesight (uncorrected visual acuity ≥0.5) among the therapeutic group,and 9 eyes (40.9％) among the control group.The difference between two groups was statistically significant (x2 =7.715,P ＜ 0.05).There were 29 eyes (64.4％) in which cornea restored transparency among the therapeutic group,and 8 eyes(36.4％) among the other group.The difference between two groups was statistically significant (x2 =4.712,P ＜ 0.05).Conclusion With conjunctival incision and rinsing,the pH values of ocular surface,inflammatory response and complications can be reduced quickly,and further damage to the eye can be stopped,then better eyesight will be obtained. Key words: Burn, alkali; Surface, ocular; Rinsing; Treatment, emergency

Scleral Fixation Underneath an Intact Conjunctiva

To describe a technique for the fixation of intraocular lenses or capsular tension rings through the ciliary sulcus or pars plana. This alternative technique allows burial of the knot and the free suture ends within the sclera, without using a scleral flap or pocket or even a conjunctival opening. No suture exposure has occurred with the use of the suture burial technique in approximately 25 eyes in 4 years. Additional benefits include less patient discomfort and an improved anatomic and cosmetic outcome starting from the first postoperative day. This technique causes minimal tissue damage and scarring with almost no postoperative discomfort.

Intraoperative conversion rate to a large, limbal opening in minimally invasive strabismus surgery (MISS)

To evaluate which factors predispose to an intraoperative conversion to the usual limbal approach in minimally invasive strabismus surgery (MISS). This study included 451 consecutive patients operated on by one surgeon at Kantonsspital St Gallen, Switzerland, with minimally invasive rectus muscle surgery between February 2003 and December 2007. We evaluated the intraoperative conversion rate to the usual limbal approach over time, and performed a retrospective determination of date of surgery, age of patient, motility of the eye, primary or revision surgery, and the type and dose of surgery in 982 consecutive rectus muscle procedures. In 3.6% (35/982) of MISS procedures, an intraoperative conversion to a large, limbal approach was necessary. The overall conversion rate decreased over time, from 8.4% in 2003 to 0.4% in 2007. The multivariate regression analysis showed a significant negative influence between the date of surgery and the conversion rate (p < 0.005). Muscle resections were associated with a higher conversion rate (p < 0.001). The other evaluated factors had no significant influence on an intraoperative enlargement of the conjunctival opening. This study confirms the reliability of the new MISS technique, and shows a low conversion rate to the usual limbal approach. The conversion rate decreased over time with increasing surgical experience. Muscle resections were associated with a higher conversion rate, while the age of the patient, the motility of the eye, revision surgery and the dose of surgery had no significant influence on an intraoperative conversion.

Vitreoretinal surgery using transconjunctival sutureless vitrectomy.

This report presents the effectiveness of 25-gauge Transconjunctival Sutureless Vitrectomy (TSV) for various vitreoretinal disorders. We performed vitreoretinal surgery on 6 patients using 25-gauge TSV. Minimal or no leakage of intraocular fluid or gas was observed at the entry site. No case required a suture to close the conjunctival or scleral opening site, and no complications resulted from the opening site. Median preoperative visual acuity was 0.04 and median postoperative best corrected visual acuity (BCVA) with a mean follow-up of 12 weeks, was 0.45. Median preoperative intraocular pressure was 12.67 mmHg, and median intraocular pressure on the first postoperative day was 15.67 mmHg. Because transconjunctival sutureless surgery is minimally invasive, it increases the efficiency of vitrectomy, hastens postoperative recovery, and improves outcomes due to the simplified surgical procedure. We feel that the adoption of the 25-gauge TSV would lead to improved patient comfort, care, and management.

New surgical treatment for superior limbic keratoconjunctivitis and its association with conjunctivochalasis

PurposeTo introduce a new surgical procedure for treating superior limbic keratoconjunctivitis (SLK) and to suggest the association of SLK with conjunctivochalasis. DesignInterventional case series. MethodsSix eyes of five patients with long-standing severe ocular irritation unresponsive to treatment with topical steroid and artificial tears were operated on using our new procedure. This technique consists of four steps as follows: (1) Rose bengal (RB) staining is used to localize the abnormal conjunctival area; (2) an arc-like conjunctival incision is placed from the 2 to the 10 o’clock position adjacent and distal to the RB-stained area; (3) the conjunctiva is resected to form a crescent using the arc-like incision as the base; the size of the resection is determined by conjunctival redundancy after removal of the subconjunctival connective tissue; and (4) the crescent conjunctival opening is closed with interrupted sutures. In two eyes, the new surgical procedure was performed together with surgery for inferior bulbar conjunctivochalasis. ResultsIn all operated eyes, RB staining had disappeared by the end of the second postoperative week; recovery from symptoms and loss of inflammation were recorded by 1 month after treatment. In the case with the longest follow-up (14 months), there was cytologic evidence of goblet cell recovery at 3 months after the operation. In another, there was normalization of the nucleo/cytoplasmic ratio of conjunctival cells without the appearance of goblet cells. ConclusionsOur treatment very effectively resolved symptoms associated with SLK, even in eyes unresponsive to conventional therapy with eye drops. Considering that we did not address the diseased part of the conjunctiva but rather the adjacent conjunctival redundancy, we propose that superior bulbar conjunctivochalasis is involved in the pathogenesis of SLK.