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GLUED POSTERIOR CHAMBER IOL IN DEFICIENT CAPSULAR SUPPORT: ONE YEAR RESULTS

GLUED POSTERIOR CHAMBER IOL IN DEFICIENT CAPSULAR SUPPORT: ONE YEAR RESULTS. SOOSAN JACOB, MS, FCRS,DNB AMAR AGARWAL, MS, FRCS, FRCOpth ; ATHIYA AGARWAL, MD, DO; GAURAV PRAKASH, MD; DHIVYA A KUMAR, MD; ARCHANA NAIR, MS; AKBAR SALEEM, MS DR. AGARWAL’S GROUP OF EYE HOSPITALS &

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GLUED POSTERIOR CHAMBER IOL IN DEFICIENT CAPSULAR SUPPORT: ONE YEAR RESULTS

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  1. GLUED POSTERIOR CHAMBER IOLIN DEFICIENT CAPSULAR SUPPORT: ONE YEAR RESULTS SOOSAN JACOB, MS, FCRS,DNB AMAR AGARWAL, MS, FRCS, FRCOpth; ATHIYA AGARWAL, MD, DO; GAURAV PRAKASH, MD; DHIVYA A KUMAR, MD; ARCHANA NAIR, MS; AKBAR SALEEM, MS DR. AGARWAL’S GROUP OF EYE HOSPITALS & EYE RESEARCH CENTRE, CHENNAI, INDIA PROF. AMAR AGARWAL IS A PAID CONSULTANT TO ABOTT MEDICAL OPTICS AND BAUSCH & LOMB. NONE OF THE OTHER AUTHORS HAVE ANY FINANCIAL DISCLOSURES.

  2. PURPOSE • BACKGROUND : OPTIONS FOR CORRECTION OF APHAKIA IN THE ABSENCE OF ADEQUATE CAPSULAR SUPPORT ARE – ANTERIOR CHAMBER IOL, IRIS FIXATED IOL, SUTURED SCLERAL FIXATED IOL AND GLUED IOL • PURPOSE :TO EVALUATE THE VISUAL OUTCOME AND COMPLICATIONS OF EYES OPERATED WITH FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION IN EYES WITH DEFICIENT POSTERIOR CAPSULE AT ONE YEAR FOLLOW UP

  3. GLUED IOL • FIBRIN GLUE ASSISTED SUTURELESS TRANS-SCLERAL HAPTIC FIXATED POSTERIOR CHAMBER IOL IMPLANTATION • RIGID PMMA IOL OR 3 PIECE FOLDABLE IOL • EXPERIENCE OF >300 EYES (FIRST CASE: 2007), 11 PEER REVIEWED PUBLICATIONS • INDICATIONS: • IN THE BAG IOL/ SULCUS SUPPORT NOT POSSIBLE • >180º SUBLUXATION • APHAKIA GLUED IOL IS AN OFF LABEL USE OF IOLs AND FIBRIN GLUE AGARWAL A, KUMAR DA, JACOB S, ET AL. FIBRIN GLUE–ASSISTED SUTURELESS POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION IN EYES WITH DEFICIENT POSTERIOR CAPSULES. J CATARACT REFRACT SURG 2008; 34: 1433–1438 PRAKASH G, KUMAR DA, JACOB S ET AL. ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY–AIDED DIAGNOSIS AND PRIMARY POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION WITH FIBRIN GLUE IN TRAUMATIC PHACOCELE WITH SCLERAL PERFORATION. J CATARACT REFRACT SURG 2009; 35: 782–784 JACOB S, PRAKASH G, ASHOK KUMAR D, NAIR V, AGARWAL A, AGARWAL A. ANTERIOR SEGMENT TRANSPLANTATION WITH A NOVEL BIOSYNTHETIC GRAFT. EYE CONTACT LENS. 2010 MAR;36(2):130-6.

  4. METHODS • ANALYSIS AT ONE YEAR OF: • POSTOPERATIVE BEST CORRECTED VISUAL ACUITY (BCVA) • UNCORRECTED VISUAL ACUITY (UCVA) • SPECULAR COUNT • INTRA OCULAR PRESSURE (IOP) • CELLULAR REACTION (SUN CLASSIFICATION) • CENTRAL MACULAR THICKNESS (CMT) • INTRAOPERATIVE COMPLICATIONS • POSTOPERATIVE COMPLICATIONS • IOL TILT • IOL CENTERATION • RETROSPECTIVE CASE SERIES, IRB APPROVED, INFORMED CONSENT TAKEN • DECEMBER 2007 TO MAY 2008: 59 EYES (OF 56 PATIENTS ) • ALL UNDERWENT FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION WITH TRANS-SCLERAL HAPTIC FIXATION • FOLLOW UP: 1, 3, 6, 12 MONTHS • STATISTICAL ANALYSIS: SPSS VERSION 16.1(SPSS INC, USA). • DIFFERENCES CONSIDERED STATISTICALLY SIGNIFICANT AT P<0.05. WILCOXON SIGNED RANK TEST USED

  5. SURGICAL TECHNIQUE • INFUSION CANNULA INSERTED • TWO LAMELLAR SCLERAL FLAPS 180 DEGREES APART WERE MADE • SCLEROTOMY WAS MADE UNDER EACH FLAP 1 MM FROM THE LIMBUS • THE IOL HAPTIC WAS GRASPED WITH 23 G MST FORCEPS AND EXTERIORIZED UNDER THE FLAP • BOTH HAPTIC TIPS WERE TUCKED INTO SCLERAL TUNNELS AT THE EDGE OF THE FLAPS • FIBRIN GLUE WAS USED TO SEAL THE FLAP A B C SCLERAL FLAPS IOL INTRODUCED HAPTIC GRASPEDWITH 23 G MST FORCEPS D E F HAPTIC EXTERIORIZED OPPOSITE HAPTIC SIMILARLY EXTERIORIZED TUNNEL AT EDGE OF FLAP MADE WITH 26 G NEEDLE G H I HAPTIC TUCKED INTO SCLERAL TUNNEL FIBRIN GLUE APPLIED FLAPS SEALED

  6. SURGICAL TECHNIQUE B A C D Scleral flaps 180 º apart Leading haptic grasped Haptic exteriorized Trailing haptic grasped E F G H Both haptics exteriorized Scleral tunnel at flap edge Haptic tucked into tunnel Both haptics tucked I J K L Fibrin glue applied Flap sealed Opposite flap sealed Post-op day 1: 20/30

  7. RESULTS • 23 FEMALE/ 33 MALE • MEAN AGE = 50.63±18.75 YRS • PRIMARY PROCEDURE = 69.4% • SECONDARY PROCEDURE = 30.5% • INDICATIONS: • INTRAOPERATIVE POSTERIOR CAPSULAR RUPTURE WITH ABSENT SULCUS SUPPORT (37.2%) • APHAKIA (33.8%) • SUBLUXATED CATARACT (28.8%)

  8. RESULTS

  9. RESULTS SCATTER PLOT • MEAN IOP (1 YR POST-OP) = 14.17±3.5mmHg • GRADE II AC CELLULAR REACTION ON DAY 1 POST-OP PERIOD (RESOLVING WITHIN 48 HRS OF MEDICAL MANAGEMENT) = 3/59 EYES • MEAN CMT (1 YEAR POST OP ON STRATUS OCT) = 190.8±5.9MICRONS • IRIDODONESIS = 16.9% • CLINICAL PSEUDOPHACODONESIS = 0 • ENDOPHTHALMITIS = 0 • MEAN POST OP SPECULAR COUNT = 2197 ± 318.7CELLS /MM2. • PERCENTAGE LOSS OF ENDOTHELIAL CELLS (PREOP TO ONE YEAR POST OP) = 5.33±3.5%

  10. IOL TILT • ULTRASOUND BIOMICROSCOPY USED • LINE WAS DRAWN ALONG LIMBUS AS PLANE OF REFERENCE • SECOND LINEWAS DRAWN ALONG LONG AXIS OF IOL OPTIC • OPTIC WAS CONSIDERED NOT TILTED WHEN REFERENCE LINE ALONG LIMBUS AND IOL OPTIC WERE PARALLEL • ACCORDING TO EQUATION OF STRAIGHT LINE, Y = MX + C, SLOPE OF LINE THROUGH LIMBUS AND IOL WAS DETERMINED • ABSOLUTE MEAN SLOPE OF LINE (L1) THROUGH LIMBUS = 0.032 ± 0.09 • ABSOLUTE MEAN SLOPE OF LINE (L2) THROUGH IOL OPTIC = 0.034 ± 0.1 • MEAN RATIO OF SLOPE = 1.04 ± 0.28 • MEAN DISTANCE B/W IRIS AND IOL = 0.92 ± 0.27MM IN OCT SLOPES WERE CALCULATED AS M = (Y2-Y1)/(X2-X1) WHERE (X1, Y1) & (X2, Y2) ARE ANY TWO POINTS ON THE 2 LINES. IF TWO STRAIGHT LINES ARE PARALLEL, THERE SLOPES WILL BE EQUAL; OR THE RATIO WILL BE 1. RATIO BETWEEN SLOPE OF LINE 1 & LINE 2 WAS CALCULATED

  11. IOL CENTERATION • AT LAST FOLLOW UP : • MEAN r = 0.08±0.19MM • MEAN X AND Y SHIFT = 0.08±0.19MM AND 0.01±0.05MM • RESPECTIVELY. DECENTRATION OF THE GEOMETRIC CENTER OF THE IOL OPTIC (a1) WITH RESPECT TO LIMBUS (a) WAS DETERMINED AS r (MM) MILD DECENTERATION DETECTED IN AN EYE IN EARLY POST OPERATIVE PERIOD • SERIAL DIGITAL SLIT LAMP IMAGES OF THE EYE WITH FULL PUPILLARY DILATATION WERE TAKEN TO ASSESS IOLCENTERATION • IMAGE PROCESSING WITH MATLAB VERSION 7.1 (MATHWORKS, INC) WAS DONE TO QUANTIFY DECENTERATION • GEOMETRIC CENTRE OF THE LIMBUS (a) AND THE IOL OPTIC (a1) WAS DEDUCTED AFTER COMPLETE PUPILLARY DILATATION • DISTANCE (r) BETWEEN THE TWO GEOMETRIC POINTS WERE CALCULATED IN MM ON EACH VISIT • AMOUNT OF DECENTRATION OF THE GEOMETRIC CENTER OF THE IOL OPTIC WITH RESPECT TO THE X-AXIS AND Y-AXIS OF A 2-DIMENSIONAL CARTESIAN SYSTEM (THE CORONAL PLANE) WAS DETERMINED

  12. CONCLUSIONS ONE YEAR RESULTS OF FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION SUGGEST GOOD VISUAL OUTCOME WITH MINIMAL COMPLICATIONS IN EYES WITH DEFICIENT CAPSULAR SUPPORT

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