Title: Challenging Situations:
1Challenging Situations Multiple Possible
Solutions.. But Ultimately Wow !!
Dr. Ashok P. Shroff, MD, Dr. Hardik A.
Shroff, MD Dr. Dishita H. Shroff, MD, Dr. V. D.
Vaishnav, MD
SHROFF EYE HOSPITAL Near Railway Station, Navsari
India. Email sehnavsari_at_yahoo.co.in
We do not have any financial interest in this
presentation
Introduction
If cases, needing surgery, are not handled well
intraoperatively, the chances of unforeseen,
unexpected and unpleasant outcome are more. Not
only that, even if the preoperative planning is
not done properly, then also many surprises are
seen. One such patient had poor anatomical and
visual outcome following uneventful phaco with
implant surgery. To manage this case there were
many options available and preparation was done
accordingly, but. The whole plan had to be
changed intraoperatively.
Aim
To discuss about To be ready for unplanned but
fruitful intraoperative management of complicated
cases.
2Material 51 years old female
- Left Eye
- Complicated aphakia
- BCVA HM only
- IOP 17 mmHg
- Right eye
- Congenital coloboma of lower iris
- Contracted and opaque capsular bag with phimopsis
of rrhexis - Pseudophakia Centre flex IOL was used
- Coloboma of choroid extending up to disc
- IOP 14 mmHg
- BCVA 20/200 N/36 with addition of 3.0 Dsph
- Treatment Attempted
- Colour contact lenses- did not work because of
improper fitting
Right Eye
3Initial Clinical Picture
Explanation Exchange with Large Optic size IOL
Explanation of IOL only
Surgical Options
3
Suturing of Iris
1
2
4Method
Conjunctiva opened for about 180o around the
limbus
Bleeders were Cauterized
2 corneal stab incisions were made at 10 2
oclock position
AC was formed with visco
5Method
1
3
4
5
2
- Capsular bag was opened with iris spatula (1, 2)
- Thick anterior capsule was removed using scissor
forceps (3, 4, 5, 6) - IOL could be dialed, separated and brought out of
the bag (7, 8) - Anterior vitreous face was intact
6
7
It was not possible to put the IOL in the bag
8
6Method
9
10
11
- Suddenly it was decided to fix the same IOL to
the sclera in such a way that most of
colobomatous opening in lower iris would be
covered - Triangular partial thickness scleral flaps were
made diagonally opposite each other (9, 10, 11,
12) - Both heptic ends were brought out through inner
sclerotomy wound using intravitreal forceps (13,
14) - One end was threaded using 9-0 monofilament
nylon suture (15). Similar procedure was repeated
on the other side.
12
13
15
14
7Method
17
16
- Both sides sutures were fashioned through scleral
lips (16, 17, 18) and gently tied after doing
centration of IOL (19) - Scleral flaps were closed (20, 21)
- Conjunctiva was closed
19
19
18
21
20
8Observations
- IOL was well centered during entire postoperative
period - IOP was within normal limits
- Vision improved to 20/100 with additional
correction of -1.0 Dsph / -1.00 Dcyl - Near vision also improved to N/12
- Patient was much more happy
9Discussion
- Hence it was not wise to put IOL in the sulcus
(to prevent anterior dislocation of heptic) - The optic of the IOL was sufficiently large so
that, if it could be placed slightly inferior,
still it could cover the colobomatous area
without compromising the vision - It was also felt difficult to suture the heptics
with iris that too in the lower part (enough iris
was not available due to coloboma) - All of a sudden thought has came to mind that why
not to fix the same IOL to the sclera? We have
done scleral fixation of IOL in many cases either
using the same IOL or using 4 point / 2 point
(specially designed IOLs) but not this type of
IOL. - Posterior capsule was clear, and vitreous face
was intact, hence subsequent manoeveration was
easy - IOL design (centre flex) also helped because
threading of IOL was easy and convenient - Postoperatively patient has behaved very well
anatomically and functionally - Till date all parameters like IOP etc are within
normal limits and posterior segment is also OK
- Phimosis of central opening (rhhexis) happened
probably due to very small rhhexis - Fibrosis produced contraction which resulted in
upward decentration of IOL and the whole bag,
which had compromised the quality of vision - Colobomatous area became aphakic hence near
vision was grossly affected - When a case gets complicated then one has to
consider different options because there may not
be standard protocol for particular situation - As patient was one eyed and that too with
congenital deformities, it was decided to manage
with minimum intraoperative handling - Separation of anterior capsule did not help much
- Enlarging the rhhexis by cutting thick anterior
capsule was rather easy - IOL could be brought out of the bag
- But bag was rather fibrosed and contracted, hence
it was not possible to put large IOL in the bag - Surgical closure of iris coloboma was not
possible because it was too large
10 Conclusion
- One eyed person with congenital coloboma of iris
and choroid had poor visual recovery following
cataract surgery due to upward decentration of
bag and IOL. - Removal of thick anterior capsule and fixing same
IOL to sclera slightly inferiorly proved to be
better with good anatomical and visual outcome.
Reposition with Scleral Fixation of same IOL
Initial Clinical Picture
Post Op. Photograph after 1 month
Thanks for your time.