Scleral Flap Research Articles

A new trabeculectomy technique for the treatment of glaucoma

PURPOSE. To develop a new modified technique of sinus trabeculectomy for the surgical treatment of primary open-angle glaucoma (POAG) aimed at reducing scarring and improving and prolonging the outflow of aqueous humor along newly formed pathways. METHODS. In the course of the surgery, superficial and deep scleral flaps were formed. After trabeculectomy, the lateral edges of the deep flap were turned inside out and superimposed on each other, forming a roller with "grooves" on its sides used for the outflow of aque-ous humor. The operation was performed in 52 patients (52 eyes) aged 43 to 84 years old (mean age 63.4 ± 1.49 years). Of these, 39 patients were diagnosed with POAG at advanced and far advanced stages, and 13 patients with POAG and a history of previous laser and surgical interventions. The patients were divided into groups: group 1 (main) — 25 patients (25 eyes) who underwent the modified sinus trabeculectomy involving the formation of grooves for the outflow of aqueous humor, and group 2 (controls) — 27 patients (27 eyes) who underwent standard sinus trabeculectomy. The follow-up lasted up to 24 months. Standard methods of examination were used (visometry, tonometry, computer perimetry, tonography, etc.). Optical coherence tomography of the anterior segment of the eye was performed in the early postoperative period, followed by ultrasound biomicroscopy. RESULTS. One month after surgery, the average level of intraocular pressure was comparable and remained low in all groups: 1 — 16.7 ± 0.6 mm Hg, 2 — 17.1 ± 0.7 mm Hg. After one year post surgery, IOP remained normalized in both groups. By 24 months, IOP normalization was preserved in 84 %, and including patients compensated on medication — 96 %. In the control group, the hypotensive success rate was 74 %, and including patients compensated on a medication regimen — 88.8 %. CONCLUSION. The newly developed sinus trabeculectomy technique for the surgical treatment of glaucoma achieves a prolonged hypotensive effect.

Modified suture-assisted canaloplasty in Asians with primary open-angle glaucoma: a prospective study with 12-month follow-up

BackgroundTo evaluate the efficacy and safety of modified suture-assisted canaloplasty in Asians with primary open-angle glaucoma (POAG).MethodsA prospective, consecutive cases study, evaluating a modified canaloplasty by twisted 6/0 suture was performed on Asian POAG patients. Three modifications of this canaloplasty included opening the Schlemm’s canal by viscocanalostomy, circumferential probing by a twisted 6/0 suture and loose suture of the superficial scleral flap. The twisted 6/0 suture was selected as a prober based on characteristical analysis of size and contact measurement as well as chemical composition conducted among 5/0, twisted 6/0 polypropylene sutures and the microcatheter. Success criteria were defined as intraocular pressure (IOP) ≤ 21 mmHg, 18 mmHg, 15 mmHg, and ≥ 20% reduction without (complete success) or with medications (qualified success). Efficacy was assessed by the success rate of circumferential catheterization, IOP values, the success rate of the surgery, the number of IOP-lowering medications, best-corrected vision acuity (BCVA), cup-to-disc ratio (C/D), and mean deviation (MD). Safety was evaluated by adverse events.ResultsForty eyes from 40 consecutive patients were included with a mean follow-up of 14.8 ± 3.0 months. Circumferential catheterization was successfully conducted in 36 eyes (90%). Mean IOP decreased from 26.2 ± 6.9 mmHg to 14.5 ± 2.7 mmHg at 12 months postoperatively. While medication numbers were reduced from 3.2 ± 0.6 to 0.5 ± 0.8 at month 12 (both p < 0.001). Qualified success rate was 97.2% [95% confidence interval (CI) 0.92–1.03], 86.1% (95% CI 0.74–0.98) and 66.7% (95% CI 0.51–0.83) at 12 months with three criteria. BCVA, C/D and MD did not show progression at 1-year follow-up (p > 0.05). Age, baseline IOP, and spherical equivalent negatively influenced the success rate significantly (all p < 0.05). Adverse events included hyphema (30.6%), IOP spike > 25 mmHg (8.3%), and peripheral synechia to the trabecular-Descemet’s membrane (2.7%).ConclusionTwisted 6/0 suture can be an ideal material for cannulation. Modified suture-assisted canaloplasty is an effective, safe alternative with a cost-efficient feature for patients with POAG, especially in developing countries.Trial registrationThis trial was registered in the Chinese Clinical Trial Registry (ChiCTR1900028618, 29/12/2019).

Current practice of trabeculectomy in a cohort of experienced glaucoma surgeons in Australia and New Zealand

Background/ObjectivesTo evaluate current routine trabeculectomy technique preferences among Australian and New Zealand Glaucoma Society surgeons regularly performing trabeculectomy surgery.Subjects/MethodsSurvey of experienced surgeons who perform trabeculectomy.ResultsForty-nine surgeons (33 male:16 female) participated in the survey. Trabeculectomy was performed as day surgery (39/47, 83.0%) under local anesthesia (44/47, 93.6%). The surgical techniques most commonly used were a corneal traction suture (44/47, 93.6%), fornix-based conjunctival flap (43/47, 91.5%) and half-thickness scleral flap (38/47, 81.0%). Mitomycin C antifibrotic agent was used in routine cases by 45/46 (97.8%) surgeons. Surgeons applied the antifibrotic agent under the Tenon layer with a pledget (36/46, 78.2%) with a concentration of 0.02% (37/46, 80.4%) for 2 (11/46, 23.9%) or 3 min (30/46, 65.2%). The Kelly (26/46, 56.5%) and the Khaw Descemet (19/46, 41.3%) punches were used to perform the sclerostomy. Most surgeons performed a peripheral iridectomy in all phakic patients (46/47, 97.9%), but less commonly in pseudophakic patients (34/47, 72.3%). Techniques for closure of the limbal conjunctival edge were quite varied with a combination of suturing including purse string (21/47, 57.4%), wing (20/47, 42.6%) and horizontal mattress sutures (33/47, 70.2%). Surgeons reviewed their routine patients four times in the first month (29/47, 61.7%) and continued the postoperative topical steroids for 3–4 months (28/47, 59.6%).ConclusionsAlthough a wide range of techniques for trabeculectomy exists among surgeons, there are consistent procedures currently in use to optimize patient outcomes. This report will assist surgeons in choosing which surgical techniques fit their best practice.

Surgical outcomes of partial ciliary body direct suturing under the scleral flap for traumatic cyclodialysis cleft: A five-case series.

Cyclodialysis cleft is an uncommon finding due to blunt ocular trauma. A larger and more chronic cyclodialysis requires surgical repair. The aim of this study was to introduce a minimally invasive suturing technique for the lens-sparing repair of traumatic cyclodialysis cleft and evaluate outcomes. This study was a retrospective case series. The medical and surgical records of five patients with traumatic cyclodialysis cleft who underwent this surgery were reviewed. The surgeon (Y.S.) dissected a fornix-based conjunctival flap and created a 90° circumferential and limbal-based scleral flap. Several small incisions parallel to the limbus were made within the scleral bed 1.5 and 3 mm posterior to the limbus. After suprachoroidal fluid drainage, tiny bumps in the ciliary body were exposed from the incisions and sewn directly onto the scleral bed with 10-0 nylon sutures. The mean age of the patients was 37.8 ± 1.3 years. The mean duration from injury to surgery was 14.8 ± 16.7 months. Mean best-corrected visual acuity (BCVA) was 0.56 ± 0.70 and intraocular pressure (IOP) was 5.2 ± 1.9 mmHg. In all patients, IOP normalized and BCVA then returned to baseline following this procedure. Mean postoperative BCVA was 1.17 ± 0.86 and IOP was 17.8 ± 1.3 mmHg. Mean IOP and BCVA recovery times were 82.0 ± 139.6 and 294.3 ± 284.3 days, respectively. Partial ciliary body direct suturing under the scleral flap is a less invasive surgical option without lensectomy and considered safe and effective as a primary surgical repair for traumatic cyclodialysis cleft.

Iridodialysis repair - A simplified approach.

Background:Iris root is the thinnest and weakest portion of the iris stroma. It can detach easily due to blunt trauma or accidental engagement of the iris during intraocular surgery resulting in glare, photophobia and monocular diplopia. Multiple techniques described for iridodialysis repair such as hang back technique, stroke and dock technique and sewing machine technique are technically challenging.Purpose:To describe an simplified approach of iridodialysis repair using 9-0 prolene suture.Synopsis:We demonstrate the technique of iridodialysis repair using animation for better understanding. Scleral flap is made adjacent to the iridodialysis area and a paracentesis is made oppsite to the iridodialysis. One arm of the double armed straight needle with 9-0 prolene suture is passed through the paracentesis into the iris root and docked in the 26G needle which is passed underneath the scleral flap 1.5mm posterior to the limbus. Then the needle is pulled out underneath the scleral flap and the manoeuvre is repeated for the second arm as well. The sutures are secured with 5-6 knots under the scleral flap. Intra-operative surgical videos of two patients with traumatic cataract and iridodialysis following blunt trauma are shown. After stabilizing the detached iris using iris hooks, phacoemlsification is done with implantation of foldable acrylic IOL, followed by iridodialysis repair as described above. Both the patients were relieved of their pre-operative symtoms and had good visual recovery.Highlights:We describe a simplified approach of iridodialysis repair that can significantly reduce the patient’s troublesome symptoms such as glare and monocular double vision.Online Video Link: https://youtu.be/-axYnSfWSb0

Intraocular Lens Fixation Technique Without Corneal Incision in Minimally Invasive Vitrectomized Eyes.

IntroductionTo introduce a modified technique for primary/secondary intraocular lens (IOL) fixation without corneal incision in vitrectomized eyes.MethodsConsecutive case series who had undergone previous or concomitant pars plana vitrectomy (PPV) to have primary/secondary IOL fixation were prospectively included. A self-sealing scleral incision was made underneath the superior scleral flap, through which the IOL was inserted into the anterior chamber. The suture tied with the IOL passed through the sclera to fix the IOL in the ciliary sulcus. Patients were followed up for at least 3 months. Main outcomes were best corrected visual acuity (BCVA), intraocular pressure (IOP), surgically induced astigmatism (SIA), and intraoperative and postoperative complications.ResultsA total of 31 patients were included in the study. The mean follow-up time was 5.35 ± 4.14 months. The BCVA (log MAR unit) improved from 0.97 ± 0.58 preoperative to 0.42 ± 0.36 postoperative (P < 0.001). Mean IOP remained unchanged (preoperative IOP 14.03 ± 2.90 mmHg, postoperative IOP 13.26 ± 3.46 mmHg, P = 0.130). The mean SIA was 0.91 ± 0.76 diopters. No obvious intraoperative and postoperative complications were observed.ConclusionThis method has favorable postoperative visual recovery and IOP control. This modified method could be taken into account as an option by surgeons in vitreoretinal surgery.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-022-00464-4.

Bleb-Independent Glaucoma Surgery to Activate the Uveolymphatic Route of Non-Trabecular Aqueous Humor Outflow: Short-Term Clinical and OCT Results.

The deep sclerectomy technique was modified to enhance aqueous humor (AH) outflow via the non-trabecular pathway. A pilot study was carried out to assess its safety and effectiveness. Thirty-eight patients were under observation. After superficial scleral flap (4 × 4 mm), deep scleral layers were divided into three parts by three parallel-to-limbus incisions. Deep sclerectomy without creating a window in the Descemetes’ membrane was carried out in the distal part. A collagen implant was placed under the sclera of the remaining two parts with one end in the intrascleral pool. The third proximal part was excised to expose the uvea and implant. A Nd:YAG laser trabeculotomy at the surgery site was made on postoperative days 7–10. Outcome measures were IOP change, use of hypotensive medication(s), complications, and the need for a second surgery. At six months, the mean IOP decreased from 29.1 ± 9.2 mm Hg to 14.0 ± 4.3 mm Hg (p = 1.4 × 10−9); hypotensive medication use reduced from 2.9 ± 0.9 to 0.6 ± 1.0 (p = 1.3 × 10−10); complete success was achieved in 68.4% of cases and partial success was achieved in 31.6% of cases. Intraoperative and postoperative complications were rare and manageable. The OCT of the surgery site revealed the absence of bleb in all cases. Lymphatic vessels with characteristic bicuspid valves in their lumen were detected in conjunctiva near the operation site and over it in 32 patients. IOP decrease in the proposed technique was achieved by activation of the uveolymphatic route of AH outflow.

Effect of Trabeculectomy on Mean and Centroid Surgically Induced Astigmatism.

This study aimed to investigate the arithmetic mean of surgically induced astigmatism (M-SIA) and the centroid of surgically induced astigmatism (C-SIA) after standard trabeculectomy. We comprised 185 eyes of 143 consecutive patients (mean age ± standard deviation, 67.7 ± 11.6 years) who underwent trabeculectomy and completed at least a 3-month routine follow-up. In all cases, the scleral flap was made at the nasal-superior location. Corneal astigmatism was measured with an automated keratometer. We calculated the M-SIA and the C-SIA using vector analysis and applied the astigmatism double angle plot. The magnitude of corneal astigmatism increased significantly, from 1.17 ± 0.92 D preoperatively to 1.77 ± 1.05 D postoperatively (paired t-test, p < 0.001). The M-SIA was 1.12 ± 0.55 D, and the C-SIA was 0.73 D @64° ± 1.02 D in the right eye group, and the M-SIA was 1.08 ± 0.48 D and the C-SIA was 0.60 D @117° ± 1.03 D in the left eye group. The C-SIA showed an astigmatic shift toward the nasal-superior location of the scleral flap creation. Our results revealed that trabeculectomy induced the SIA in the direction of the scleral flap location and that the C-SIA was much lower than the M-SIA in eyes undergoing trabeculectomy.

Factors Affecting Final Surgical Outcome of Combined Trabeculotomy-Trabeculectomy in Primary Congenital Glaucoma.

PurposeTo evaluate different pre-operative variables on the success of combined trabeculotomy–trabeculectomy (CTT) surgery in patients with primary congenital glaucoma (PCG) to predict those at higher risk for surgical failure and for proper parent counseling.Patients and MethodsSixty-three eyes of patients with PCG were treated either with CTT without augmentation, or CTT augmented with mitomycin-C (0.2 mg/mL) in both subconjunctival space and under scleral flap for 3 minutes, or with CTT augmented with a collagen implant under both the scleral flap and the conjunctiva. Cases showed surgical failure was reported and evaluated in relation to different pre-operative variables.ResultsComplete success (IOP ≤21 mmHg) was achieved in 52 cases (82.5%). Cumulative success probability was calculated using Kaplan-Meier survival analysis, proving that higher pre-operative intraocular pressure (IOP) was associated with higher failure rates (28.6% for pre-operative IOP ≥30 mmHg versus 4.8% for IOP <30 mmHg), with P value = 0.007.ConclusionCTT is an effective surgical intervention in PCG patients without sight threatening complications. Univariate survival analysis showed higher rates of surgical failure in patients with higher pre-operative IOP, while other pre-operative variables were irrelevant.

Sutureless technique for repositioning and scleral fixation of the capsular bag-intraocular lens complex with permanent use of iris retractors.

A new sutureless technique used for repositioning and scleral fixation of the capsular bag-intraocular lens (IOL) complex in the surgical treatment of subluxated lenses is described. Iris retractors were used not only to induce a tent effect on the capsule but also to permanently fix the capsular bag to the sclera in this method, without the need to prepare scleral or conjunctival flaps. Surgery with the use of a capsular tension ring (CTR) and iris retractors, the ends of which were brought out through the sclera and cauterized, was performed in 7 eyes of 7 patients with moderate or severe subluxation of the crystalline lens. In all cases, simultaneous use of a CTR and iris retractors ensured good centration of the capsular bag-IOL complex. The method was safe and effective in fixing the capsule to the sclera in the case of significant damage to the ligamentous apparatus of the lens.

“Glautex” in refracter glaucoma fistulizing surgery

One of the problems of fistulizing surgery in glaucoma is the appearance of the healing process in the area of the intervention and in a number of cases the pressure changes are gradually limited. The Intraocular Pressure is rising again. To prevent this disadvantage, new surgical methods are proposed to avoid these evolutionary deficiencies. Elaboration and development in clinical practice of new ways and remodeling of pathogenic orientation for glaucoma microsurgery techniques to ensure safe and sustainable reduction of IOP as well as stabilization of the visual functions of patients with glaucoma. The authors propose the inclusion under the scleral and conjunctival flap of different auto or allodrainage.[1] However, we propose the use of bioabsorbent drainage „Glautex” model DDA and SDA in refractory glaucoma surgery.The study included 24 glaucoma patients, the age of the patients being between 4263 years, who previously underwent fistulizing intervention. Preoperatively, all patients underwent complex examination. In all patients, surgery was performed on the previously unaffected area. The observation period was 1 year, during which time the patients were examined in a complex schedule every 1-3-6-12 months. The implantation of the “Glautex” drainage model DDA and SDA allowed the reduction of IOP and the maintenance of hypotensive effect in the early postoperative period in all cases and at a distance of 1 year postoperatively, IOP being 20.5 ± 2.5 mmHg, at 17 eyes (70, 8%) without the use of drug therapy, in 4 (16.6%) cases on a monotherapy background, in 2 eyes (8.3%) they needed combined drugs, in one case IOP was undercompensated (4.1%). Moderately diffuse filtration bubble in 95.9% of cases, and in 4.1% of cases the bubble is flat. Trabeculectomy with bioabsorbent drainage implant “GLAUTEX” a new variant that aims to prevent the sclero-scleral and sclero-conjunctival healing process.

Valve cyclodialysis with implantation of a non‐absorbable collagen implant in the cyclodialysis tunnel in surgical management of open‐angle glaucoma: long‐term results

AbstractPurposeTo assess long‐term efficacy and safety of valve cyclodialysis (VC) with implantation of a non‐absorbable collagen implant (NCI) in cyclodialysis tunnel (CT) in decreasing intraocular pressure (IOP) in open‐angle glaucoma patients.MethodsSixty‐one patients (25 male, 36 females; average age ‐ 73.4±8.8 years; 61 eyes) were included in this study. Surgical technique included dissection of a superficial scleral flap, creation of a scleral valve (2*1mm) out of deep scleral layers 4 mm away from limbus, creation of a CT (2*4mm) and implantation of a NCI in the CT. The scleral valve helped to minimize trauma to ciliary body while inserting NCI. Among other patients, 20 patients (32.8%) with failed filtering surgeries and 45 patients (73.8%) with cataract were included. Thirty‐three patients (54.1%) had advanced stage of glaucoma. Post‐operative follow‐up was up to 24 months. Outcome measures were: IOP change, reduction in hypotensive medication use, need for repeat surgery and intra‐ and postoperative complications. The data were processed by the method of variation statistics.ResultsBaseline mean IOP was 28.0±5.5 mmHg [95% confidence interval (CI) 24.8‐29.2]. At 18 and 24 months, mean IOP decreased to 19.2±1.8 mmHg (n=61, 95% CI 18.1‐19.0) and 18.9±1.8 mmHg (n=30, 95% CI 18.2‐19.5), making a decrease by 29.5±11.4% and 28.0±12.4% respectively. The hypotensive drugs use was reduced from 2.6±0.9 to 0.5±1.0 and 0.5±1.0 respectively. Repeat surgery was required in 2 cases at 18 months. Intraoperative hemorrhage while creating the CT was observed in 6 patients (9.8%). In the early postoperative period hyphema was prevalent in 1 patient, shallow AC – in 2 patients, hypotony – in 1 patient, and some exudative reaction in 3 patients. No complication was noticed in any of the cases in the late postoperative period.ConclusionsLong‐term results showed that VC with implantation of a NCI in the CT is an effective and safe surgical glaucoma procedure.

A modified non‐penetrating bleb less glaucoma surgery to activate uveolymphatic outflow of aqueous humor – short‐term clinical and optical coherence tomography evaluation results

AbstractPurposeTo study the safety and effectiveness of a modified bleb less glaucoma surgery in decreasing intraocular pressure (IOP) in open‐angle glaucoma (OAG) patients having visually significant cataract (VSC).MethodsTwenty OAG patients with VSC underwent combined surgery. After fashioning out a superficial scleral flap, a scleral bridge (4*1 mm) 2 mm away and parallel to limbus was dissected from deep scleral layers. Sclera posterior to bridge was excised exposing uvea. Deep sclerectomy anterior to bridge deroofing the Schlemm’s canal was performed. No trabeculo‐Descemet’s window was created. A strip of dry collagen implant (5*2*0.1 mm) was inserted under the scleral bridge. Superficial scleral flap was sutured back. YAG laser trabeculotomy was performed after 7–10 days after surgery. Minimum follow‐up – 3 months. Surgery sites were evaluated by optical coherence tomography (OCT). Outcome measures: IOP change, reduction in hypotensive drugs use, complications and need for repeat surgery.ResultsAt 3 (n = 20) and 6 months (n = 13) mean IOP decreased from 26.5 ± 8.2 mmHg to 13.6 ± 4.8 mmHg and 15.3 ± 3.5 mmHg, making a decrease by 46.1 ± 18% and 37.8 ± 22.7%; the hypotensive drugs use reduced from 2.8 ± 0.9 to 0.3 ± 0.8 and 0.5 ± 1.1 and target IOP with or without medications could not be achieved in 1 patient (5%) and 4 patients (30.7%) respectively. No complication was encountered intraoperatively. Postoperative period was smooth. On OCT no bleb was detected in any of the case. Instead lymphatic vessels with bicuspid valves were detected near to surgery sites. With time the lymphatics reduced in size and number. In failure cases, there were no detectable lymphatics vessels.ConclusionsThe proposed technique is safe and effective in managing glaucoma in cataract patients. The absence of bleb formation and aqueous humor outflow via lymphatics was confirmed by OCT. For predictable hypotensive outcomes, every caution should be taken in glaucoma surgery to preserve the lymphatics.

Retinal Pigment Epithelium Tear after Glaucoma Surgery

Retinal pigment tear (RPE) is a very rare complication of glaucoma filtering surgeries. The right eye of a 65-year-old woman underwent an Ex-Press shunt implantation to treat uncontrolled primary open-angle glaucoma. On day 3, the intraocular pressure (IOP) was 5 mmHg with an over-filtering bleb. Wide-field fundus color and autofluorescence images showed peripheral choroidal detachment, RPE detachment (arrow), RPE tear, and macula-off exudative retinal detachment (Fig A-B). Additional sutures were placed on the scleral flap to achieve an increase in IOP.

Usage of E-Polytetrafluoroethylene (e-PTFE) Membrane for Managing Trabeculectomy Flap- Related Over-Filtration Due to Unavailability of Scleral Patch Graft during Nation-Wide Lockdown

Scleral flap tears during trabeculectomy are difficult to repair in a predictable fashion. Donor scleral flap reinforcements are commonly preferred for managing trabeculectomy flap-related over-filtration, leading to shallow anterior chamber (AC). Due to the advent of COVID-19 lockdown, especially in the initial phases, eye banking activities almost came to a standstill, with almost no corneal and/or scleral tissue retrievals. Hence, in this manuscript we have presented a mini case series with follow-up of two of our cases; where Gore-Tex (e-polytetrafluoroethylene) implant was used as an alternative to scleral patch graft, for managing trabeculectomy flap-related over-filtration, with their pros and cons. Though Gore-Tex implant stability in both cases were contentious, it still served the purpose of managing the flap-related over- filtration and subsequent shallow AC.

Enhanced surgical technique for sutureless intrascleral fixation of intraocular lenses.

A simplified intrascleral fixation technique involving implantation of the Carlevale intraocular lens (IOL) in the posterior chamber is described, which lodges the T-shaped IOL haptics in the scleral wall, not requiring scleral flaps. This surgical modification reduces operative time, limits iatrogenic damage to the sclera, and avoids friction between haptics and the conjunctiva, which may cause conjunctival erosion and infection in the long term. 13 patients with crystalline lens or IOL dislocation/subluxation had surgery to implant the Carlevale IOL in the posterior chamber. Mean corrected distance visual acuity preoperatively was 0.75 ± 0.5 logMAR (range, 0.2 to 1.5 logMAR) and improved to 0.28 ± 0.3 logMAR (range, 0 to 1.0 logMAR) postoperatively. Complications rarely occurred and were not sight-threatening. The sutureless scleral fixation of the Carlevale IOL using the modified surgical technique may represent a safe and effective procedure to restore visual function in patients with damaged zonular-capsular support.

A Modified Intrascleral Intraocular Lens Fixation Technique Using 27-Gauge Blunted Needles with Fewer Intraocular Manipulations.

A new method for intraocular lens (IOL) fixation in the scleral tunnel using two common 27G blunted needles and an ultrathin 30G needle with fewer intraocular manipulations was developed. Half-depth scleral flaps were prepared, and vertically angled sclerotomies were performed under each scleral flap, 2 mm from the limbs with a 20G microblade or a 26G needle. Two bent 27G blunted needles connected the sclerotomy and corneoscleral incisions. One haptic was inserted into this bent 27G blunted needle extraocularly and extruded through the sclerotomy site. Each haptic was inserted into the lumen of the preplaced ultrathin 30G needle and buried into the scleral tunnel. In this retrospective study, we reviewed the outcomes of this new technique in patients with at least 3 months' follow-up data. Iris capture of the IOL was not observed in any case, and IOL repositioning was not performed either. Astigmatism induced by intraocular aberration was almost as same as that with other methods. Our technique can be performed in any operation room without any extra instruments. This trial is registered with UMIN000044350.

Ab externo approach to treat bilateral haptic extrusion secondary to scleral erosion of an intrascleral sutureless-fixated intraocular lens.

Surgical management of haptic extrusion of an intrascleral sutureless-fixated intraocular lens (IOL) (FIL-SSF Carlevale, Soleko) by repositioning the IOL without lens extraction was reported. The patient presented an early extrusion of both IOL harpoons just 4 weeks after the initial surgery. New scleral flaps were created 30 degrees superior to the nasal harpoon and 30 degrees inferior to the temporal harpoon so that the IOL was rotated clockwise. Each haptic was grasped with a 25-gauge forceps and introduced into the vitreous cavity and regrasped with another forceps through a new port, 1.5 mm posterior to the limbus, and underneath a new scleral flap. The Carlevale IOL is specially designed for sutureless intrascleral fixation with excellent anatomic and visual results but may also show specific complications. To the authors' knowledge, this is the first report on how to efficiently manage harpoon erosion using this simple technique.

Combined transconjunctival sutureless three-port vitrectomy and scleral fixation of intraocular lens.

The aim of this article is to describe an innovative and minimally invasive surgical technique for posterior vitrectomy combined with secondary intraocular lens implantation, using a sutureless scleral fixation Carlevale intraocular lens (I71 FIL SSF Carlevale lens. Soleko IOL Division, Italy). The technique was conducted with only three transconjunctival sclerotomies and a corneal tunnel to perform intraocular lens explantation, posterior vitrectomy and Carlevale intraocular lens implantation. It is easier, quicker, and less invasive than the traditional technique with conjunctival peritomy, two scleral flaps and five sclerotomies. Surgery was performed uneventfully on three eyes of three patients. Two of them presented a luxation of the intraocular lens into the vitreous chamber, while one patient presented an intraocular lens subluxation. No complications were observed after a 5 to 8 months of follow-up. The intraocular lenses were well positioned, no conjunctival erosion was noted, and the intraocular pressure remained normal at all stages. This is the first report of a combined procedure of IOL explantation, posterior vitrectomy and secondary IOL implantation using only three transconjunctival sclerotomies. This appears to be less invasive and it causes less discomfort to the patient. We suggest considering this technique in all those cases requiring a combined procedure in absence of a proper capsular support.

Results of Rectangular and Triangular Shaped Scleral Flaps in Trabeculectomy in Terms of Control of Intra Ocular Pressure (IOP) and Complications

Purpose: To compare between the results of rectangular and triangular shaped scleral flaps in trabeculectomy for primary open angle glaucoma.&#x0D; Study design: Quasi experimental study&#x0D; Place and Duration of Study: Khalid eye clinic, Karachi, from July 2018 to June 2019.&#x0D; Methods: This study included 24 patients of either gender and age from 40 to 65 years. Patients with a diagnosis of primary open angle glaucoma refractory to medical treatment were included by convenient sampling technique. They were divided into two groups. Group A underwent trabeculectomy with rectangular shaped scleral flap whereas Group B underwent trabeculectomy with triangular shaped scleral flap. The main outcome measures were intraocular pressure reduction, anterior chamber depth and post-operative complications. All patients were followed up for a period of two months.&#x0D; Results: Mean age was 52.1± 6.72 years. Mean pre-operative intraocular pressure in group A was 24.4±2.13 mmHg and 23.5±1.64 mmHg in group B. Mean post-operative IOP was 11.6±1.51 mmHg in group A and 13.4±1.67 mmHg in group B with p-value of 0.11. Pre-operative anterior chamber depth (ACD) was grade 4 both groups. It remained same in all patients of group A but two patients of group B changed to grade 3 ACD. Two patients of group B developed hypotony on the first post-operative day. They did not require revision suturing and were managed conservatively.&#x0D; Conclusion: Both types of scleral flap are effective in reducing IOP but rectangular scleral flap reduced IOP more as compared to triangular scleral flap but the difference was not statistically significant.&#x0D; Keywords: Trabeculectomy, Intra ocular pressure, Open angle glaucoma.