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Inside Eyetube.net | Nov/Dec 2012

Clever Techniques for Inside and Outside the OR

Surgeons provide a step-by-step analysis of some of the most watched videos on Eyetube.net.

This issue of CRST Europe debuts Inside Eyetube.net’s new format. Each month, physicians responsible for some of the most watched videos on Eyetube.net will provide a summary of their videos by discussing the clinical significance of the surgical steps involved. This format will allow CRST Europe to include more voices, especially of those who have helped to make Eyetube.net a popular ophthalmic video resource.

Amar Agarwal, MS, FRCS, FRCOphth; and Soosan Jacob, MS, FRCS, DNB

In our video, we present the IOL scaffold technique, whereby a threepiece IOL acts as a temporary platform to prevent nuclear fragments from falling into the vitreous cavity (Figure 1). We favor this technique in cases of posterior capsular rupture (PCR) in eyes with moderate to soft nuclei that have not been phacoemulsified and remain in the capsular bag.

To begin, we introduce an anterior chamber maintainer through a 1.2-mm stab incision made with a microvitreoretinal blade. The maintainer is positioned away from the PCR, and the flow is set to low. We perform anterior vitrectomy to remove the vitreous that prolapsed into the anterior chamber. Then, we pass an Agarwal globe stabilization rod (Katena Products, Inc.) through a sideport incision to push the fragment away from the ruptured posterior capsule.

After the nuclear fragments are brought up into the anterior chamber, we inject a foldable IOL via the existing corneal wound and maneuver the lens below the nucleus. The leading haptic of the IOL is positioned above the iris, and the trailing haptic is placed just outside the incision. Using a dialer in our nondominant hand, we maneuver the optic-haptic junction on the trailing side so that the IOL blocks the pupil; thus the IOL acts as a scaffold and prevents the fragments from falling into the vitreous cavity. Alternatively, we can implant the IOL in the sulcus above the capsulorrhexis if the anterior capsule is supported or place both of the haptics above the iris. We remove the nuclear fragments with a phaco probe on low flow and vacuum. Cortical material is removed using a vitrectomy probe with suction and low aspiration. With the nondominant hand, the trailing optic-haptic junction is adjusted so that the IOL is well centered over the pupil, where it acts as a scaffold while the nucleus is emulsified. Once cortical clean-up is complete, we place the IOL over the capsular remnants in the ciliary sulcus. At the conclusion of the procedure, we remove the anterior chamber maintainer and hydrate the wound.

Amar Agarwal, MS, FRCS, FRCOphth, is in private practice at Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Dr. Agarwal states that he has no financial interest in the products or companies mentioned. He may be reached at tel: + 91 44 2811 6233; e-mail: dragarwal@vsnl.com.

Soosan Jacob, MS, FRCS, DNB, is a Senior Consultant Ophthalmologist at Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Dr. Jacob states that she has no financial interest in the products or companies mentioned. She may be reached at tel: +91 44 2811; 6233; e-mail: dr_soosanj@hotmail.com.

Uday Devgan, MD

In my video, I present an IOL exchange and iris repair that ensued after complex cataract surgery. During the initial surgery, intraoperative floppy iris syndrome due to the alpha-blockers used to treat the patient’s enlarged prostate caused the iris to prolapse out of the phaco incision and led to subsequent loss of iris stromal tissue. A three-piece IOL was partially placed in the capsular bag, with the trailing haptic in the ciliary sulcus (Figure 2).

With careful dissection, I freed the IOL from the posterior chamber and brought it up into the anterior chamber. To protect the intact capsular bag from iatrogenic trauma from the microscissors, I placed the new IOL in the ciliary sulcus first and then bisected the initial IOL and removed it from the eye. The anterior and posterior capsular tissues were fused together, and the bag could not be opened to accept a new IOL; thus, the sulcus was chosen for IOL placement. Because the iris defect was about 2 clock hours in size, it could be closed with sutures. I placed sutures to approximate the residual tissue and re-form the pupil (Figure 3). I carefully avoided placing a suture at the pupillary margin, because the suture could restrict dilation as well as limit the ability to examine the posterior segment in the future.

One month later, I performed cataract surgery on the patient’s other (virgin) eye. As expected, the pupil dilated poorly, and the iris was floppy. This was a challenging case that fortunately went well. The most important take-home lessons from this case are these:

  • Complications happen to all surgeons, but it is possible to have a successful outcome even if it requires a second surgical procedure; and
  • If a patient has a complication from surgery on one eye, then he or she is likely to have a similar course in the other eye. Always give the first operating surgeon the benefit of the doubt.

Uday Devgan, MD, is in private practice at Devgan Eye Surgery in Los Angeles and Beverly Hills, California. He may be reached at tel: +1 800 337 1969; e-mail: devgan@gmail.com.

David R. Hardten, MD

Management of meibomian gland inspissation has evolved tremendously over the past several years. For a long time, lid hygiene, tears, and oral tetracycline were the only treatments available to manage blepharitis. With the ophthalmic field’s newfound understanding of the pathology, advanced treatments have become more common for patients with recalcitrant disease. My video reviews the practice protocol for aggressively managing meibomian gland inspissation with intense lid treatments. Meibomian gland probing (Maskin Meibomian Gland Intraductal Probe; Rhein Medical Inc.), intense pulsedlight therapy, and LipiFlow (TearScience, Inc.) are among the treatments I demonstrate (Figure 4).

David R. Hardten, MD, is the Director of Refractive Surgery at Minnesota Eye Consultants in Minneapolis. Dr. Hardten states that he has no financial interest in the instruments he developed for Rhein Medical Inc., but that he has performed consulting and research for TearScience, Inc. He may be reached at tel: +1 612 813 3632; e-mail: drhardten@mneye.com.

Rupal Shah, MD

I demonstrate how to perform ReLEx smile (Carl Zeiss Meditec), a minimally invasive, all-in-one laser vision correction procedure performed with the company’s VisuMax femtosecond laser platform. Using the laser, I carve out a refractive lenticule from within the corneal stroma. The application of ultrashort, high-intensity, tightly focused laser pulses to the cornea creates plasma bubbles in the focal center. When the bubbles fuse, I manually dissect the remaining bridges of tissue and remove the lenticule through a small incision of 3 to 5 mm (Figure 5). Refractive errors are corrected through the reshaping of the cornea. In my experience, visual recovery is similar to that after LASIK.

Rupal Shah, MD, practices at New Vision Laser Centers, Vadodara, India. Dr. Shah states that she is a consultant to Carl Zeiss Meditec AG. She may be reached at tel: +91 265 3058603; e-mail: rupal@newvisionindia.com.

Section Editor Elena Albé, MD, is a consultant in the Department of Ophthalmology, Cornea Service, Istituto Clinico Humanitas Ophthalmology Clinic, Milan, Italy. Dr. Albé states that she has no financial interest in the products or companies mentioned. She may be reached at e-mail: elena.albe@gmail.com.

Section Editor Damien F. Goldberg, MD, is in private practice at Wolstan & Goldberg Eye Associates in Torrance, California. Dr. Goldberg states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +1 310 543 2611; e-mail: damien.goldberg@wolstaneye.com.

Section Editor Mark Kontos, MD, is the senior partner at Empire Eye Physicians in Spokane, Washington. Dr. Kontos states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +1 509 928 8040; e-mail: mark.kontos@empireeye.com.