Transcript Document

Challenging 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: [email protected]
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.”
Material
51 years old female
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
Left Eye
Complicated aphakia
BCVA: HM only
IOP: 17 mmHg
Treatment Attempted
Colour contact lenses- did not
work because of improper
fitting
Right Eye
Initial Clinical Picture
Explanation & Exchange with
Large Optic size IOL
Explanation of IOL only
Surgical Options
3
Suturing of Iris
1
2
Method
Conjunctiva opened for
about 180o around
the limbus
2 corneal stab incisions were made
at 10 & 2 o’clock position
Bleeders were
Cauterized
AC was formed
with visco
1
2
3
4
Method
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
It was not possible to put the IOL
in the ‘bag’
6
7
8
5
9
10
11
Method
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
14
15
Method
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
16
17
18
19
20
21
19
Observations
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
Discussion
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
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
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.
Initial Clinical
Picture
Reposition with Scleral Fixation
of same IOL
Post Op. Photograph
after 1 month
Thanks for your time…….