Scleral Incision Research Articles

Anterior vestibule salvaging technique to limit silicone orbital implant extrusion following evisceration

ABSTRACTPurpose: The anterior vestibule salvaging (‘Birdcage’) technique may limit orbital implant extrusion following evisceration.Methods: A 10-year retrospective chart review from 2005 to 2015 of individuals who underwent evisceration procedures utilizing the vestibule salvaging technique was performed.Results: A total of 96 patients (61 male; 35 female; average age 64 years; range 17–96 years) underwent evisceration with a technique avoiding anterior scleral relaxing incisions. Three (3.1%) patients had documented extrusion of the silicone implant. Time from evisceration to extrusion ranged from 26 to 372 days.Conclusions: Maintenance of the anterior scleral vestibule during evisceration may decrease extrusion rates after surgery compared with traditional evisceration techniques that utilize anterior relaxing incisions.

Investigation of scleral thermal injuries caused by ultrasonic pars plana phacoemulsification and aspiration using pig eyes.

The purpose of this study was to investigate the thermal injuries caused by ultrasonic pars plana phacoemulsification and aspiration (PPPEA) using pig eyes. Using a 20-gauge (G) vitrectomy system (Accurus®, Fragmatome; Alcon Laboratories) in both the 'open-tip' and 'closed-tip' techniques, PPPEA was performed in pig eyes and the subsequent thermal injuries generated around the scleral wound were measured by infrared thermal imaging (thermography). Post surgery, the state of the scleral wound was observed under a microscope, and a tissue slice containing the scleral wound was then prepared and observed under an optical microscope. Thermography measurements revealed a slight temperature rise around the scleral wound in the open-tip case, yet a marked temperature rise in the closed-tip case. The scleral wound incision produced by the open tip was linear, while that produced by the closed tip was expanded. Histological examination revealed mild degeneration of the sclera around the wound in the open-tip case, yet marked tissue degeneration by thermal injuries in the closed-tip case. Our findings showed that in PPPEA, the temperature of the tip of a 20G vitrectomy system rapidly increases due to the closed-tip technique, thus producing obvious thermal damage to the scleral wound. In order to prevent thermal injuries to the scleral wound during PPPEA, it is important to shorten the time of ultrasonic oscillation during surgery as much as possible while the tip is occluded with nuclear fragments.

Effects of scleral tunnel incision or clear corneal incision with same length of phacoemulsification

Effects of scleral tunnel incision or clear corneal incision with same length of phacoemulsification

Comparative study of superior and temporal scleral tunnel incision in small incision cataract surgery (SICS)

Comparative study of superior and temporal scleral tunnel incision in small incision cataract surgery (SICS)

SILICONE MICROTUBE-ASSISTED SCLERAL FIXATION OF A POSTERIOR CHAMBER INTRAOCULAR LENS.

To report a novel technique for intrascleral fixation of a posterior chamber intraocular lens using a silicone microtube to manipulate the haptics into position. Intrascleral fixation was performed in six eyes and the results evaluated in this retrospective case series. A silicone microtube with a 0.2-mm external diameter was passed from a sclerocorneal incision through the chamber and a sclerotomy made using a 30-gauge needle. The tips of the intraocular lens haptics were connected to the silicone microtube outside the eye. After the intraocular lens was injected into the posterior chamber, the haptics were drawn through the scleral incision through their attachment to the silicone microtube. The mean postoperative corrected visual acuity was 0.62 logarithm of the minimum angle of resolution (20/43) with a mean refraction error of -0.06 ± 0.4 diopter, which did not differ significantly (P = 0.53) from the expected value. The postoperative complications included transient ocular hypotension, vitreous hemorrhage, and choroidal detachment. Our technique using a silicone microtube reduces the number of intraocular procedures compared with previous methods using forceps or needles for moving the intraocular lens haptics from the posterior chamber to the outside through sclerotomies.

The Correlation of Pars Plana Incision and Transient Hypotony After Silicone Oil Removal

To evaluate the correlation between pars plana incision and transient hypotony after silicone oil removal in aphakic eyes PATIENTS AND METHODS:Twenty-two patients with aphakia and a high degree of myopia with silicone oil tamponade were recruited for this prospective study and randomly scheduled to two groups for silicone oil removal: 3.5-mm corneal incision with suture corneal or 20-gauge pars plana incision with suture. Intraocular pressure (IOP) was measured and fundus and anterior structure were examined preoperatively on the first, third, and seventh postoperative day and at 1 month after surgery. IOPs in the pars plana group were significantly lower than the corneal group on the first and third day after surgery (P < .001). Nine of the 11 patients in the pars plana group suffered ciliary detachment accompanied by hypotony (IOP < 8 mm Hg), among whom three patients exhibited excessive hypotony (IOP < 5 mm Hg), whereas the ciliary bodies remained tightly attached and IOP was normal in the corneal group. Among these nine patients, six eyes were observed to have multiple silicone oil granules in the supraciliary cavity, three exhibited gaps of pars plana below the scleral incision site, and two had vitreous hemorrhage. Hypotony spontaneously relieved at the seventh postoperative day for all patients. Pars plana incision is the crucial cause of ciliary detachment and consequent transient hypotony after silicone oil removal. Using corneal limbus incision in patients with aphakic eyes to avoid the par plana incision is expected to reduce the incidence of hypotony with minimal complications. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e44-e51.].

Iris-claw intraocular lens implantation: Efficiency and safety according to technique

To evaluate the safety, refractive and visual results of an iris-claw intraocular lens for aphakia (Artisan) according to the technique used. Ophthalmology Department, Valme University Hospital and Oftalvist Clinic, Seville, Spain. Retrospective case series. This study evaluated the outcomes of iris-claw IOL implantations performed by the same surgeon between 2011 and 2017. The results were analyzed by the incision type (corneal versus scleral tunnel) and lens position (prepupillary versus retropupillary). Seventy-six eyes (75 patients) were included. The postoperative uncorrected (UDVA) and corrected (CDVA) distance visual acuities were significantly better than the preoperative acuities (P<.001). The UDVA was 20/40 or better in 41.7% of patients, and had the CDVA was 20/40 or better in 68.1% of patients. The mean UDVA was significantly better in the scleral tunnel incision group (0.29 logarithm of the minimum angle of resolution [logMAR]±0.41 [SD]) than in the corneal incision group (0.66±0.45 logMAR) (P<.001). The mean surgically induced astigmatism in the scleral tunnel incision group (0.73±0.62 diopter [D]) was significantly lower than in the corneal incision group (2.49±1.36 D) (P<.001). Although endothelial cell loss was lower in the retropupillary position, the difference was not significant (P=.07.) CONCLUSION: Implantation of the iris-claw IOL in the retropupillary position and through a scleral tunnel incision was an effective and safe alternative to aphakia without capsule support, providing better refractive results compared with other techniques.

Cyst Masquerading as Inadvertent Bleb After a Scleral-Fixated Intraocular Lens in Marfan Syndrome: A Case Report.

IntroductionTo present a case of an epithelial inclusion cyst masquerading as an inadvertent bleb in a patient with Marfan syndrome.Case ReportA woman with Marfan syndrome presented with a subluxed crystalline lens in her right eye, which progressively subluxed over the following 2 years. A lensectomy was performed with placement of an anterior chamber intraocular lens (IOL); however, the patient experienced blurred vision and photopsias and preferred IOL explantation. The IOL was removed and a scleral-fixated posterior chamber IOL was placed. Vision improved with an uncomplicated postoperative course. Five months later, the patient experienced sudden onset redness and sharp pain in this eye. A 3-mm cystic lesion with tan material was found over a prior scleral incision site. Intraocular pressure was normal and no aqueous leaked from the lesion. Owing to concerns of an infected inadvertent bleb, treatment with topical and oral antibiotics was started, but the lesion did not change in appearance and the patient experienced persistent pain. The lesion was surgically excised and histopathology revealed a conjunctival epithelial inclusion cyst with intralesional keratin. A month later, another conjunctival inclusion cyst developed and was excised per patient preference.ConclusionMarfan syndrome is characterized by defects in the FBN1 gene and may theoretically lead to an abnormal sclera, increasing the risk of bleb formation after scleral incision. Distinguishing between a filtering bleb and an epithelial inclusion cyst is critical in patient care. Although retained keratin from a cyst may mimic a bleb with purulence, intraocular pressure, aqueous leakage, and response to topical antibiotics may help distinguish between the two.

Sutureless biplanar closure of leaking wounds in micro-incision vitreous surgery: A novel technique.

To describe a novel technique for sutureless hermetic closure of leaking scleral wounds in micro-incision vitreous surgery. This study is a two-centre, non-comparative, interventional case series. We studied 1240 scleral incisions on 870 eyes using different gauges (20, 23, 25) to evaluate the effectiveness of a new technique to seal scleral wounds without sutures. If wounds were found leaking after removing the trocar, we used the same trocar (or microvitreoretinal) blade to make an adjacent trans-scleral entry in the same direction as the main incision to access its internal flap supporting it from inside. Simultaneously, we applied a blunt smooth-surface instrument to massage the scleral wound from outside to close it hermetically. We treated 870 eyes using three types of tamponading agents, namely, silicone oil in 654 (75%) eyes, non-expansible gas in 128 (15%) eyes, and air in 88 (10%) eyes. We performed optical coherence tomography in the first 100 sclerotomies on the post-operative Day 1. We closed leaking incisions at the first attempt in 1231 (99.3%) cases; in 9 (0.7%) cases of 20-gauge incisions, we closed the wounds at the second attempt. We observed no hypotony at the end of surgery. The mean intraocular pressure was 16 mmHg (8-51 mmHg) on the post-operative Day 1. Our results show the biplanar closure technique may be used as an effective, quick, sutureless approach to close leaking wounds hermetically in micro-incision vitreous surgery procedures. It is safe, less traumatic, cost-effective, and easy-to-perform typical surgical settings.

Trailing-haptic-first modification of double-needle intrascleral haptic fixation technique

The Yamane double-needle intrascleral haptic fixation technique for posterior chamber intraocular lens (IOL) fixation in the setting of absent or inadequate capsule support is a minimally invasive IOL fixation technique that requires scleral incisions using needles to externalize the IOL haptics. Despite being a seemingly easy and intuitive procedure, there are significant challenges when learning this technique. The most difficult step is threading the trailing haptic with the needle for fixation. If using an IOL with weak haptics, this step can result in haptic kink or breakage, which renders the haptics useless for this technique and necessitating explantation of the IOL. Even when an IOL with strong and rigid haptics is used, the rigid haptics make threading the trailing haptic the most difficult step. The trailing-haptic-first technique is a distinct modification that enhances the ease and success of the double-needle technique.

Design and validation of a foldable and photovoltaic wide-field epiretinal prosthesis

Retinal prostheses have been developed to fight blindness in people affected by outer retinal layer dystrophies. To date, few hundred patients have received a retinal implant. Inspired by intraocular lenses, we have designed a foldable and photovoltaic wide-field epiretinal prosthesis (named POLYRETINA) capable of stimulating wireless retinal ganglion cells. Here we show that within a visual angle of 46.3 degrees, POLYRETINA embeds 2215 stimulating pixels, of which 967 are in the central area of 5 mm, it is foldable to allow implantation through a small scleral incision, and it has a hemispherical shape to match the curvature of the eye. We demonstrate that it is not cytotoxic and respects optical and thermal safety standards; accelerated ageing shows a lifetime of at least 2 years. POLYRETINA represents significant progress towards the improvement of both visual acuity and visual field with the same device, a current challenging issue in the field.

Comparison on dry eye symptom between scleral tunnel incision and transparent corneal incision in phacoemulsification

Objective To compare dry eye symptom between scleral tunnel incision and transparent corneal incision in phacoemulsification and IOL implantation. Methods The data of 200 eyes of 194 cases with cataract underwent phacoemulsification and intraocular lens implantation were collected. They were divided randomly into the transparent corneal incision group , 100 eyes of 98 cases, and scleral tunnel incision group, 100 eyes of 96 cases. The dry eye symptom and Schirmer I test (SⅠt) after surgery were compared between the two groups. Results The dry eye symptom scores of the two groups were increased and decreased after a period of time.The dry eye symptom scores of the two groups at 1, 7 and 14 days after surgery were significantly higher than those before operation (P 0.05). In scleral tunnel incision group the dry eye symptom scores at 1, 7 and 14 days after surgery were significantly higher than those in transparent corneal incision group (P<0.05). Postoperative SⅠt of two groups were firstly increased and then decreased, and two groups of corneal fluorescein staining scores were decreased after increased (P<0.01). In scleral tunnel incision group SⅠt scores at 1, 7, 14 and 30 days after surgery were significantly lower than those in the transparent corneal incision group (P<0.05). After surgery breakup time (BUT) of two groups were decreased at first and then increased (P<0.01). The BUT in scleral tunnel incision group was significantly higher than that of the transparent cornea group (P<0.01). Conclusion Through scleral tunnel incision phacoemulsification can effectively reduce the influence of stability of tear film in early postoperative period, but the symptom of dry eye is more severe than that with clear corneal incision. The dry eye symptom effect of two incisions is not obvious at the end of the follow-up time. Key words: Phacoemulsification; Lens, intraocular; Scleral tunnel incision; Transparent corneal incision; Dry eye

Continuation of Aspirin Therapy before Cataract Surgery with Different Incisions: Safe or Not?

Purpose To assess whether to continue aspirin therapy while having uncomplicated phacoemulsification cataract surgery with different incisions. Methods Consecutive patients having cataract surgery under topical anesthesia with different incisions between May 2016 and August 2017 were followed. 236 eyes of 166 patients on routine aspirin therapy were randomized into 2 groups: continuation group, 112 eyes; discontinuation group, 124 eyes. 121 eyes of 94 patients on no routine anticoagulant therapy were used as the control group. Patients were examined 1 day preoperatively and 1 day and 7 days postoperatively. Intraoperative and postoperative complications were recorded. Results Statistically, there was no significant difference about postoperative BCVA among three groups. A higher incidence of subconjunctival hemorrhage was shown in the continuation group than in the discontinuation group and the control group (17.0% versus 8.1%, p=0.038; 17.0% versus 7.4%, p=0.025, resp.). Although corneal edema was greater in clear corneal incision cases than that of scleral tunnel incision cases (22.5% versus 12.0%, p=0.009), subconjunctival hemorrhage was greater in scleral tunnel incision cases (14.9% versus 6.6%, p=0.011). Subgroup analyses revealed that patients of scleral tunnel incision who continued taking aspirin had a higher incidence of subconjunctival hemorrhage compared with those who discontinued (25.5% versus 10.9%, p=0.038), but no same conclusion in clear corneal incision cases (8.8% versus 5.0%, p=0.483). Conclusions The outcomes indicated that phacoemulsification cataract surgery under topical anesthesia could be safely performed without ceasing systemic aspirin therapy. Clear corneal incision could be a better choice in patients treated with aspirin.

Cataract surgery in eyes with keratoconus: a review of the current literature.

There are an increasing number of keratoconic eyes, requiring cataract surgery. We review the preoperative planning, intraoperative options, and postoperative management that aid in successful outcomes. Management of keratoconic eyes requiring cataract surgery requires a multifaceted approach. Preoperatively, corneal crosslinking and intrastromal corneal ring segments can be considered in order to provide stable keratometry values for intraocular lens (IOL) calculations. Deciding between toric and monofocal IOLs requires a thorough evaluation. Intraoperatively, the decision of clear corneal incisions with or without sutures versus scleral incisions is important to mitigate postoperative complications. Postoperatively, irregular astigmatism should be evaluated and updated rigid gas permeable or scleral lenses provided. Patients needing irregular astigmatism correction postoperatively should not have toric IOL implantation; however, in select cases of keratoconus, it is an option. The use of stabilizing procedures prior to optical biometry can aid in preoperative lens selection and provide predictable surgical outcomes. Decisions on intraoperative wound construction and toric versus monofocal lenses should be based on the severity, regularity, and central nature of the keratoconus. Postoperative use of rigid gas permeable or scleral lenses can help patients achieve their best visual potential.

Simple Technique For The Management Of A Cataract Surgery Wound Site Scleral Abscess and Endophthalmitis

To report satisfactory outcome in a patient with scleral abscess at scleral incision cataract surgery wound site, along with endophthalmitis. Simple adjunctive measures enhance the success of conservative management for such cases. Method: Seventy-year-old female was diagnosed as scleral abscess with acute post operative endophthalmitis after one week of an uneventful scleral incision cataract surgery. The patient was managed with surgical wound debridement adjunctive to topical, intravitreal and systemic antibiotics. Results: Satisfactory final best corrected visual acuity of 20/40 was achieved at the last follow-up at 20 weeks. Conclusion: Post cataract surgery scleral abscess and endophthalmitis pose a significant management challenge. This condition may respond favourably with adjunctive meticulous surgical wound debridement.

Safety and efficacy of fibrin glue versus infinity suture in SICS with extended scleral flap.

Purpose:To study the safety and efficacy of biologic fibrin glue (FG) in comparison with infinity suture in SICS with compromised scleral flap.Methods:A retrospective comparative study of patients who were treated with FG (Group A) with 10–0 nylon (Group B) as sealing agent for intraoperative compromised tunnels in SICS. Parameters noted were postoperative inflammation, wound integrity, anterior chamber (AC) depth, intraocular pressure (IOP), and surgically induced astigmatism (SIA) at postoperative day 1, 4 weeks, 6 weeks, and 6 months, respectively. Epi Info 7 software and SIA calculator, Version 2.1 were used to analyze the result.Results:We reviewed the two groups of 18 patients each and noted that there was no statistically significant difference in postoperative inflammation (P > 0.05), AC depth (P > 0.05), and IOP (P > 0.05) between both groups at each postoperative visit. One patient in Group A showed postoperative shallow AC and subconjunctival bleb. Exposed sutures causing foreign body sensation had to be removed in five patients in Group B. At the end of 6-month postoperative period, no statistically significant difference was found in SIA (P = 0.92) between the two groups.Conclusion:Biologic FG can be safely used in securing the compromised scleral incisions in SICS. It also avoids suture-related complications.

Outcomes of small gauge pars plicata vitrectomy for patients with persistent fetal vasculature: a report of 105 cases.

To evaluate the surgical outcomes in eyes with persistent fetal vasculatures (PFV) managed by small gauge pars plicata vitrectomy. Consecutive patients with PFV treated by small gauge pars plicata vitrectomy at Beijing Tongren Eye Center between January 2010 and January 2013 were retrospectively reviewed. A total of 118 eyes of 105 patients with PFV were included and undergone small gauge pars plicata vitrectomy, of which 84 (71.2%) eyes had lensectomy and 16 (13.6%) eyes had lens aspiration and immediate intraocular lens implantation. The percentage of sutured scleral incision of 23 gauge vitrectomy (71.7%, 33/46) was higher than that of the 25 gauge vitrectomy (18.1%, 13/72). At last follow-up, visual acuity remained stable in 34 eyes (28.8%) and improved in 84 eyes (71.2%). Age at surgery (less than 2y), anterior type of PFV, and immediate IOL implantation were associated with postoperative improved visual acuity. Sixty five (55.1%) eyes had retinal detachment preoperatively, among which 33 (50.8%, 33/65) eyes had retinal reattachment or partial retinal reattachment. The results suggest that cases with PFV have a potential for developing good visual acuity after small gauge pars plicata vitrectomy with favorable anatomic outcomes and acceptable rate of serious surgical complications.

Observation on 25-gauge vitrectomy for the treatment of IOL-capsular tension rings dislocating

Objective To observe the clinical efficacy of 25-gauge vitrectomy for the treatment of IOL-capsular tension rings(CTR)dislocating into vitreous. Methods Seven eyes of 7 patients of IOL-CTR dislocating into vitreous were treated with 25-gauge vitrectomy.The capsular tension rings were removed through scleral tunnel incision, the surgeries of 5 eyes combined with suspension in ciliary sulcus. All cases were followed up for 3 months. The postoperative visual acuity and stability of the intraocular lens were observed. Results The last followed up time, the visual acuity were the same as preoperative one in 3 eyes.The location of intraocular lens of all cases were stable. Conclusion IOL- CTR dislocating into vitreous treated with 25-gauge vitrectomy is safe and effective. Key words: Len, intrcocular; Dislocation, capsular tension rings; Vitrectomy, 25-gauge

Astigmatism and Refractive Outcome After Late In-The-Bag Intraocular Lens Dislocation Surgery: A Randomized Clinical Trial.

To compare surgically induced astigmatism (SIA) and refractive outcomes between two operation methods for late in-the-bag IOL dislocation. In this prospective, randomized, parallel-group clinical trial, 104 patients (eyes) were assigned to IOL repositioning by scleral suturing 1.5- to 2-mm posterior to limbus (n = 54) or IOL exchange with a retropupillar iris-claw IOL using a 5.5-mm scleral pocket incision (n = 50). The SIA was determined by vector analysis through conversion of corneal cylinders to Cartesian coordinates, and is presented as magnitude in diopters @ direction in degrees (D @ °). Follow-up was 6 months. The SIA was 0.24 D @ 8° for IOL repositioning and 0.65 D @ 171° for IOL exchange, which was a nonsignificant group difference (X coordinate: P = 0.08; Y coordinate: P = 0.16). Mean SIA magnitude was 0.60 ± 0.50 D and 1.12 ± 0.85 D, respectively (P < 0.001). Mean postoperative spherical equivalent was -1.6 ± 1.6 D after IOL repositioning and -0.5 ± 1.0 D after IOL exchange (P < 0.001). For IOL repositioning, this represented a mean myopic shift of -0.7 ± 1.1 D compared with before the IOL dislocation (P < 0.001). For IOL exchange, it was within ±1 D of target refraction in 83% of the patients. Surgically induced astigmatism was modest in both operation groups, albeit with a tendency of being more pronounced for IOL exchange. Repositioning surgery led to a myopic shift, whereas exchange surgery provided good refractive predictability.

A Modified Technique for the Transconjunctival and Sutureless External Drainage of Subretinal Fluid in Bullous Exudative Retinal Detachment Using a 24-G i.v. Catheter

Purpose: To present the use of a 24-G Optiva® i.v. catheter for external drainage of subretinal fluid (SRF) in bullous exudative retinal detachment (RD). Methods: Thirteen eyes with bullous exudative RD were included in our study. SRF drainage was accomplished via a transconjunctival scleral incision with a 24-G catheter followed by laser treatment, vitrectomy, or anti-VEGF treatment, as needed. Data on age, indications, visual acuities, the number of drainage times, drainage duration, complications, and fundoscopy were collected. Results: Two females and 11 males, with a mean age of 4.2 ± 2.7 years, were included. Surgical indications included exudative RD caused by Coats disease (12 eyes) and Sturge- Weber syndrome (1 eye). Successful drainage was achieved in all cases. The mean duration of the SRF drainage procedure was 63.5 ± 16.9 s. Except for 1 case of localized subretinal haemorrhage, no complications were noted. Conclusions: External drainage of SRF using a 24-G Optiva® i.v. catheter is safe, efficient, and useful.