Challenging Situations:

1
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 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.
2
Material 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
3
Initial Clinical Picture
Explanation Exchange with Large Optic size IOL
Explanation of IOL only
Surgical Options
3
Suturing of Iris
1
2
4
Method
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
5
Method
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
6
Method
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
7
Method
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
8
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

9
Discussion

• 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.