Transcript DSAEK with glued IOL

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 .
 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
 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.

RETROSPECTIVE CASE SERIES, IRB
APPROVED, INFORMED CONSENT

ANALYSIS AT ONE YEAR OF:

CORRECTED VISUAL ACUITY
TAKEN

DECEMBER 2007 TO MAY 2008: 59 EYES
(BCVA)

(OF 56 PATIENTS )

UNCORRECTED VISUAL ACUITY
(UCVA)
ALL UNDERWENT FIBRIN GLUE

SPECULAR COUNT
ASSISTED POSTERIOR CHAMBER IOL

INTRA OCULAR PRESSURE (IOP)
IMPLANTATION WITH TRANS-SCLERAL

CELLULAR REACTION (SUN
CLASSIFICATION)
HAPTIC FIXATION

FOLLOW UP: 1, 3, 6, 12 MONTHS

STATISTICAL ANALYSIS: SPSS VERSION

CENTRAL MACULAR THICKNESS
(CMT)

INTRAOPERATIVE
COMPLICATIONS
16.1(SPSS INC, USA).

POSTOPERATIVE BEST
DIFFERENCES CONSIDERED

POSTOPERATIVE COMPLICATIONS
STATISTICALLY SIGNIFICANT AT

IOL TILT
P<0.05. WILCOXON SIGNED RANK TEST

IOL CENTERATION
USED

INFUSION CANNULA
INSERTED

TWO LAMELLAR SCLERAL
FLAPS 180 DEGREES
APART WERE MADE
A
SCLERAL FLAPS

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
D
HAPTIC EXTERIORIZED
G
HAPTIC TUCKED INTO
SCLERAL TUNNEL
B
IOL INTRODUCED
E
OPPOSITE HAPTIC
SIMILARLY
EXTERIORIZED
H
FIBRIN GLUE APPLIED
C
HAPTIC GRASPED
WITH 23 G MST
FORCEPS
F
TUNNEL AT EDGE OF
FLAP MADE WITH 26 G
NEEDLE
I
FLAPS SEALED
B
A
Scleral flaps 180 º apart
E
C
Leading haptic grasped
F
Both haptics exteriorized
I
Haptic exteriorized
G
Scleral tunnel at flap edge Haptic tucked into tunnel
J
Fibrin glue applied
D
K
Flap sealed
Opposite flap sealed
Trailing haptic grasped
H
Both haptics tucked
L
Post-op day 1: 20/30
 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%)
S
C
A
T
T
E
R
P
L
O
T

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 POST OP SPECULAR COUNT =

190.8±5.9MICRONS
2197 ± 318.7CELLS /MM2.

MEAN CMT (1 YEAR POST OP ON STRATUS OCT) =
PERCENTAGE LOSS OF ENDOTHELIAL CELLS

IRIDODONESIS = 16.9%
(PREOP TO ONE YEAR POST OP) = 5.33±3.5%

CLINICAL PSEUDOPHACODONESIS = 0

ENDOPHTHALMITIS = 0

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
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

ABSOLUTE MEAN SLOPE OF LINE (L1) THROUGH LIMBUS =
0.032 ± 0.09

ABSOLUTE MEAN SLOPE OF LINE (L2) THROUGH IOL OPTIC =

MEAN RATIO OF SLOPE = 1.04 ± 0.28

MEAN DISTANCE B/W IRIS AND IOL = 0.92 ± 0.27MM IN OCT
0.034 ± 0.1
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
ONE YEAR RESULTS OF FIBRIN GLUE
ASSISTED POSTERIOR CHAMBER IOL
IMPLANTATION SUGGEST GOOD VISUAL
OUTCOME WITH MINIMAL COMPLICATIONS
IN EYES WITH DEFICIENT CAPSULAR
SUPPORT