This document discusses options for intraocular lens (IOL) implantation when the eye's natural capsular support is absent. It reviews causes of ectopia lentis and traumatic/surgical aphakia. Three main IOL options are described: scleral fixation, iris-claw fixation, and iris suturing of the IOL. Each option is evaluated based on surgical techniques, published studies, outcomes, complications, and patient factors. The document concludes by proposing protocols for IOL implantation based on individual patient and ocular characteristics to provide the best visual outcomes while minimizing risks of complications requiring long-term follow-up.
Update knowledge about Muntifocal IOL made by Asaduzzaman
Working as Associate Optometrist in Ispahani Islamia Eye Institute &Hospita, Dhaka 1215
Email:asad.optom92@yaho. com
Interventions to Reduce Myopia Progression in Children (Journal Club) (health...Bikash Sapkota
DIRECT DOWNLOAD LINK ❤❤https://healthkura.com/reduce-myopia/❤❤
Dear viewers Check Out my other piece of works at___ https://healthkura.com
Interventions to Reduce Myopia Progression in Children (Journal Club)
Objectives:
- To discuss about the different interventions to reduce myopia progression in children
- To determine the effectiveness of different interventions to slow down the progression of myopia in children
Interventions to Reduce Myopia Progression:
Environmental Considerations
- Time Spent Outdoors
- Near-Vision Activities
Spectacles & Contact Lenses
- Gas-Permeable Contact Lens Wear
- Bifocal & Multifocal Spectacles
- Soft Bifocal Contact Lenses
- Orthokeratology
Pharmacological Therapies
- Antimuscarinic Agents: Atropine & Pirenzepine
Under Correction of Myopia
Update knowledge about Muntifocal IOL made by Asaduzzaman
Working as Associate Optometrist in Ispahani Islamia Eye Institute &Hospita, Dhaka 1215
Email:asad.optom92@yaho. com
Interventions to Reduce Myopia Progression in Children (Journal Club) (health...Bikash Sapkota
DIRECT DOWNLOAD LINK ❤❤https://healthkura.com/reduce-myopia/❤❤
Dear viewers Check Out my other piece of works at___ https://healthkura.com
Interventions to Reduce Myopia Progression in Children (Journal Club)
Objectives:
- To discuss about the different interventions to reduce myopia progression in children
- To determine the effectiveness of different interventions to slow down the progression of myopia in children
Interventions to Reduce Myopia Progression:
Environmental Considerations
- Time Spent Outdoors
- Near-Vision Activities
Spectacles & Contact Lenses
- Gas-Permeable Contact Lens Wear
- Bifocal & Multifocal Spectacles
- Soft Bifocal Contact Lenses
- Orthokeratology
Pharmacological Therapies
- Antimuscarinic Agents: Atropine & Pirenzepine
Under Correction of Myopia
BELL'S PALSY IS AN IDIOPATHIC LMN TYPE FACIAL PALSY..THE SEMINAR TELLS YOU OF COURSE OF NERVE..FACIAL MUSCLES THEIR ACTION..HOW TO EXAMINE..THE SEQUELAE OF FACIAL PALSY...LOOK AT IT..
Ocular hypotony following reenclavation of a partially dislocated (disenclavated) retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome was presented and won best paper in the Pediatric Ophthalmology and Genetics Category at the 6th Asean Ophthalmology Congress in conjunction with the Philippine Academy of Ophthalmology Annual Convention, October 2023, SMX Convention Center, Pasay City, Philippines.
Reenclavation of a partially disenclavated retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome. Slide deck was the basis of an e-poster presented at the 6th Asean Ophthalmology Congress in conjunction with the Philippine Academy of Ophthalmology Annual Convention held at the SMX Convention Center, Pasay City, MetroManila, Philippines October 2023.
MYOPIA , basics , causes , types and treatmentssuserde6356
Myopia, also known as near-sightedness and short-sightedness, is an eye disease[5][6][7] where light from distant objects focuses in front of, instead of on, the retina.[1][2][6] As a result, distant objects appear blurry while close objects appear normal.[1] Other symptoms may include headaches and eye strain.[1][8] Severe myopia is associated with an increased risk of macular degeneration, retinal detachment, cataracts, and glaucoma.[2][9]
Myopia results from the length of the eyeball growing too long or less commonly the lens being too strong.[1][10] It is a type of refractive error.[1] Diagnosis is by the use of cycloplegics during eye examination.[11]
Tentative evidence indicates that the risk of myopia can be decreased by having young children spend more time outside.[12][13] This decrease in risk may be related to natural light exposure.[14] Myopia can be corrected with eyeglasses, contact lenses, or by refractive surgery.[1][15] Eyeglasses are the simplest and safest method of correction.[1] Contact lenses can provide a relatively wider corrected field of vision, but are associated with an increased risk of infection.[1][16] Refractive surgeries like LASIK and PRK permanently change the shape of the cornea. Surgeries like Implantable Collamer Lens (ICL) implant a lens inside the anterior chamber in front of the natural eye lens. ICL doesn't affect the cornea.[
Actual e-poster presented at the 6th Asean Ophthalmology Congress in conjunction with the Philippine Academy of Ophthalmology Annual Convention, SMX Convention Center, Pasay City, MetroManila, Philippines, October 2023
Case presentation-congenital & developmental cataractSivarathana
this case presentation is about congenital & developmental cataract, which is seen by me in our routine camp.and in this discussion many of things were dealt only theoretically not practically the case was seen in a camp as well.
Diagnòstico diferencial del retinoblastomacrisnemato
El retinoblastoma es el tumor ocular maligno más frecuente en la infancia. Algunas patologías pueden confundirnos. En esta charla se presentan algunos ejemplos de patologías similares y se comenta cómo diferenciarlas y cómo podemos minimizar los errores.
LOS OJOS EN EL NIÑO MENOR DE 3 AÑOS: ¿QUÉ NO SE LE PUEDE ESCAPAR AL PEDIATRA?crisnemato
La exploración oftalmológica del niño, en la visita rutinaria de pediatría, tiene que ir encaminada a descartar la patología ocular grave, para poder hacer el diagnóstico lo antes posible. Dicha exploración vendrá condicionada por la edad del paciente y las patologías propias de la edad pediátrica.
Ayudas visuales en la retinosis pigmentariacrisnemato
La Retinosis pigmentaria es una distrofia retiniana lentamente progresiva que habitualmente provoca una pérdida inicialmente de campo visual y puede acabar afectando a la visión central. A pesar de ser poco frecuente, es la distrofia retiniana más frecuente y abarca todo un grupo de enfermedades que comparten una degeneración progresiva de los fotorreceptores retinianos.
En esta presentación el Dr. Ramon Hirujo, experto en baja visión nos explica las ventajas de las diferentes ayudas ópticas que pueden ser de utilidad para estos pacientes.
La conjuntivitis es la principal causa de ojo rojo en el niño. La conjuntivitis siempre necesita un apellido, bacteriana, vírica o alérgica, para un correcto manejo y tratamiento del proceso. Suele ser un proceso autolimitado o que solo requiere tratamiento tópico (colirio o pomada) para su curación. La excepción es la conjuntivitis que aparece antes del primer mes de vida, que precisa siempre cultivo de las secreciones oculares, dado que es un cuadro más grave al afectar a bebes y algunos de los microorganismos que la causan necesitan ser tratados de forma sistémica (pastillas o inyecciones) y no con gotas.
Revisión completa de la retinosquisis ligada al X:
Historia: Josef Haas (1898)
Prevalencia: entre 1:5.000 to 1:25.000
Clínica: Manifestaciones, Diagnóstico, Diagnóstico diferencial, Complicaciones, Tratamiento
Biología Molecular:
Gen RS1 (MIM 300839) Xp22.13
Retinosquisina
Terapia génica
Conclusión y perspectivas futuras
Quimioterapia intraarterial para el retinoblastomacrisnemato
Resultados del tratamiento de retinoblastoma con quimioterapia intraarterial: la técnica introducida por Kaneko en 2004 y perfeccionada por Abramson en 2008. Esta es nuestra experiencia en la Unidad de Retinoblastoma del Hospital Sant Joan de Déu. Esplugues de Llobregat.
Surgical management of non pediatric ectopia lentiscrisnemato
Ectopia lentis is a partial displacement of the lens caused by the weakness of the zonule. Non traumatic cases can be primary or associated to diseases like Marfan syndrom, homocystinuria and others. The aim of our study is to compare two different surgical techniques for the management of severe cases of ectopia lentis using escleral fixation procedures vs iris-claw lenses.
We performed an interventional consecutive case. The first group included 10 eyes from 5 patients were treated with lens aspiration and Cionni ring scleral fixation and in the bag intraocular IOL or scleral fixated IOL. In the second group we have included 12 eyes from 6 patients treated with pars plana lensectomy, iridectomy and iris-claw anterior IOL. The patients underwent a full ophthalmologic examination including: CVA, keratometry, pachymetry, slit-lamp evaluation, intraocular pressure measurement, posterior segment evaluation, endothelial cell count.
Patients aged 2 to 16 yo. Minimum postoperative follow-up was 2 years in the first group and 6 months in the second group. All patients improved visual acuity by 2 or more Snellen lines after surgery. Complications included scleral-fixated complex subluxation in 2 eyes, IOL dislocation in 1 eye, retinal detachment in 3 eyes and endophthalmitis in 1 eye.
Both techniques are useful for the management of ectopia lentis. Complications in both groups were similar. Scleral-fixated IOL have a higher rate of dislocation and iris-claw IOL require a close follow-up of corneal endothelial cells count. Our actual choice is the second technique because of its simplicity and easier reversibility.
Desprendimiento de retina en la edad pediátrica.crisnemato
Serie de 97 casos de desprendimiento de retina pediátricos con un seguimiento mínimo de 1 año, intervenidos en el Hospital Sant Joan de Déu de Esplugues de Llobregat en Barcelona.
Patologia oftàlmica en el pacient diabètic2010crisnemato
Presentación sobre oftalmología y diabetes mellitus realizada en la Facultad de Medicina de Bellvitge el día 14 de enero de 2010 dentro del curso de postgrado sobre "Pie diabético" organizado por el departamento de Podología.
Extracto de la presentación sobre desprendimiento de retina en niños expuesto durante el congreso de la Sociedad Europea de Oftalmología Pediátrica (EPOS) en París el 2 y 3 de octubre de 2009. Retinal detachment has a lower incidence in children than in adults. 15 % of all retinal detachments happen in paediatric patients; most of them are in boys and a 25% of the patients develop a bilateral retinal detachment.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
1. Choices of IOL implantation
when there is no capsular
support
Jaume Català-Mora, MD
Hospital Sant Joan de Déu. Esplugues de Llobregat
Oftalpilar. Barcelona
No financial relationships to disclose
2. IOL in the absence of capsular support
• Aetiologies
• Ectopia lentis
• Traumatic/surgical aphakia
• Initial approach
• Surgical pearls and videos
• Correction of aphakia
• Meta analysis
• Proposal of a protocol & conclusion
3. Causes of ectopia lentis
• Secondary ectopia lentis:
• Traumatic dislocation:
• Blunt trauma
• Penetrating injury
• Buftalmos
• Aniridia
• Chronic uveitis
• High myopia
• Silicone oil tamponade
• Congenital weakness of
zonula/capsula:
• Non systemic involvement:
• Isolated ectopia lentis
• Ectopia lentis et pupillae,…
• Systemic involvement:
• Marfan disease
• Homocystinuria
• Weil-Marchesiani, sulphite oxidase
deficiency, hyperlysinaemia, …
Dureau, P. Pathophysiology of zonular diseases. Current Opinion in Ophthalmology. 2008; 19: 27–30
4. Ophthalmic examination ectopia lentis
• Age, history of trauma or surgery
• BCVA, amblyopia, Strabismus
• Retinoscopy and refraction: myopia
& astigmatism
• Slit lamp examination
• Corneal diameter (megalocornea)
• Iris & Pupillae
• Lens position, visual axis & lens edge
• IOP
• Fundus examination
• Think about systemic involvement
5. Causes absence of capsular/zonular support
• Penetrating injury
• Complicated cataract surgery
• Previous Lensectomy
7. Indication for surgery
Ectopia Lentis
• VA loss due to lens subluxation
with visual axis involvement
• Anterior chamber lens luxation
• Vitreous lens luxation with good
potential VA
Traumatic/Surgical aphakia
Good potential VA
• Unable or unwilling to use
aphakia spectacles
• Intolerance to contact lens
Endothelial Cell Count
Eye Biometry
8. Conservative Aphakia management
• Aphakia spectacle correction
• Safe, reliable, easily adjustable
• Optical aberration, non suitable for
unilateral cases, poor cosmetics
• Extended-wear contact lens
correction + Binocular spectacle
• Reliable and easily adjustable
• Difficult management, potential
complications, intolerance
• Good temporary option in young
children
9. Intraocular lens implant in the absence of
capsular support
Requirements:
• Good potential VA
• Close life-long follow-up
• Postop bifocal correction
Contraindications:
• Uncontrolled glaucoma
• Active, chronic or recurrent uveitis
• Severe anterior segment structural
abnormalities
• ECC < 2000 cs; AC depth< 3 mm (prepupillary
IOL options: Iris claw lens)
• Scleral fixated IOL
• Iris Claw IOL:
• Prepupillary
• Retropupillary
• Iris Sutured IOL
10. Ectopia lentis: surgical management
• Lensectomy in the bag
• Posterior vitrectomy
• Acetylcholine
• Superior iridectomy
• Aphakia/IOL implant
11. Traumatic o surgical aphakia: surgical
management
• Vitreoretinal approach:
• Infusion line (pressurize/stabilize
the eye)
• Eliminate any vitreous adherences
to the iris or anterior chamber
• Check the capsular remnants. Will
they be able to support an IOL?
Condon, G. P. Simplified small-incision peripheral iris fixation of an AcrySof intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003;29:1663–1667.
12. Scleral fixated IOL
• Scleral flaps at 2/4 & 8/10
• Insertion and suture of the IOL
haptics
• Limbal or scleral 7 mm incision
• Implant and center IOL behind
the iris
• Removal of viscoelastic
Corneal/Scleral suture & IC
cefuroxime
14. Iris Claw IOL
• Biometry. AC constant:
• Prepupillary: 115
• Retropupillary: 116.9
• Avoid IOL sutures
• Superior Iridectomy
• Limbal or scleral 6 mm incision
• Dispersive viscoelastic
• Implant of the IOL
• Enclavation technique:
• Anterior (prepupillary)
• Posterior (retropupillary)
• Removal of viscoelastic
• Limbal/scleral suture& IC Cefuroxime
15. Iris claw IOL (prepupillary)
Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Endothelial loss Complications
Sminia ML 2011 Retrospective 20 10 Marfan, Idiopathic 7,50 12,00 N/A
comparable to
mean normal but
wider range
N/A
Sminia ML 2007 Retrospective 5 5 Traumatic 7,80 11,00
100 % improve
vision
40 % mean 1 RD
Cleary C 2012 Prospective 8 5 Marfan, Idiopathic 12,60 2,00
62,5 % improve
vision
14% loss Endothelial loss
Siddiqui SN 2012 Retrospective 18 11 Marfan, Idiopathic 11,58 1,00 17,1% loss Endothelial loss
Català J 2014 Prospective 27 14 Marfan, Idiopathic 6,80 3,40
80 % improve
vision
18,4% loss
RD,
desinclavation,
aseptic uveitis
GLOBAL 78 45
Marfan,
Idiopathic,
Trauma
9,26 5,88
Endothelial
cell loss, IOL
luxation
Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Endothelial loss Complications
Gonnermann J 2013 Retrospective 7 4 Marfan, Idiopathic 12 2
100% improve
vision
6,4% loss
1 traumatic
dislocation
Iris claw IOL (retropupillary)
16. Iris sutured IOL
• Limbal 3.5 mm incision
• 3 piece acrylic IOL
• Moustache IOL folding & implant
• Haptics in posterior chamber &
optic captured above the iris
• 10/0 prolene suture the haptics to
the iris (Siepser iris suture)
• Placement of the optic posterior to
the iris
• Removal of viscoelastic
• Corneal suture & IC cefuroxime
Stutzman RD, Stark WJ. Surgical technique for suture fixation of an acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1658-1662
Siepser, S. B. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol 1994;26(3):71–72
17. Iris sutured IOL
Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Suture Complications
Dureau, P 2006 retrospective 17 9
Marfan,
idiopathic
4,80 1,30
100 % improve
VA
Prolene 10/0
Hyphema, ectopia
pupillae, aseptic
uveitis
Yen KG 2009 retrospective 17 12
Marfan,
idiopathic, trauma
7,20 1,00
76% improve
vision
Prolene 10/0
RD, Dislocation,
Iris capture
GLOBAL 34 21
Marfan,
idiopathic,
trauma
6,00 1,15
IOL
dislocation,
Ectopia
pupillae,
Hyphema
18. Discussion
• Scleral fixated IOL:
• No iris support
• Combination with iris prosthesis
• Polypropylene 9/0 or Goretex 8/0
sutures are recommended
• Iris Claw IOL:
• Easier & quicker technique
• Corneal endothelial risk
• Consider retropupillary
enclavation
• Iris sutured IOL:
• Smaller corneal incision
• Difficult management/exchange
• Risk of prolene degradation & IOL
dislocation
Hirashima DE, Soriano ES, Meirelles RL, et al. Outcomes of iris-claw anterior chamber versus iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome. Ophthalmology. 2010;117(8):1479–85
Gonnermann J, Torun N, Klamann MKJ, et al. Posterior iris-claw aphakic intraocular lens implantation in children. Am J Ophthalmol. 2013;156(2):382–386.e1
Buckley EG. Pediatric sutured intraocular lenses: trouble waiting to happen. Am J Ophthalmol. 2009;147(1):3–4
19. Protocol for surgical management
of ectopia lentis
< 4 yo
Inability to follow-up
VA< 0.3 due to lens luxation
Vitreous or AC lens luxation
Contact lenses
&/or aphakia
spectacles
> 4 yo
ECC pre & every 6 months
AC OCT/BMU yearly
Lensectomy +
iridectomy
Damaged/absent iris Normal iris
Lensectomy + Scleral
sutured IOL Prolene
9/0 +
Iris reconstruction
Lensectomy +
iridectomy
Retropupillary iris claw
ECC pre & every 6 months
AC OCT/BMU yearly
20. Protocol for secondary IOL implant
in the absence of capsular support
Uveitis
Uncontrolled
glaucoma
Inability to follow-up
Good potential VA
Inability/Intolerance/Unwilling
Spectacles/Contact lens
Surgery
contraindicated
Damaged/absent iris Normal iris
Scleral sutured IOL
Prolene 9/0 +
Iris reconstruction
Retropupillary iris claw
ECC pre & every 6 months
AC OCT/BMU yearly
21. Conclusion
• No evidence of the best option of IOL implant
• Aphakia correction & primary vs secondary IOL implant:
• Age
• Aetiology
• Cornea & Iris status
• Surgeon preference
• Traumatic patients require individualized management
• Implanted patients will require a life-long follow-up:
• Endothelial Cell Count
• AC OCT/BMU
• Risk of IOL dislocation
• Retinal detachment
• Glaucoma
• Bifocal / Multifocal optical correction
22. Aknowledgements
• Dr. Jesús Díaz-Cascajosa
• Ophthalmology department HSJD
• Optometry team HSJD & Oftalpilar
• Surgical team HSJD
Editor's Notes
Good Morning I will like to thank the EPOS organization his invitation to attend this meeting. I will talk about the choices of IOL implantation when there is no capsular support
The two main situations are ectopia lentis and traumatic or surgical aphakia. We’ll review the initial approach. I will show different surgical pearls and videos of the different options for the aphakia correction. We’ll dive in a metaanalysis of these different options and I will propose a protocol of management of these patients.
If we look at the causes of ectopia lentis, Blunt trauma & Buftalmos are the most frequent cases of secondary ectopia lentis. Congenital causes include isolated ectopia lentis and different systemic diseases like Marfan or homocystinuria.
Marfan disease AD: Chr 15, FBNI gene. 1/10000; Cardiovascular disease, hiperlaxity,
Weill–Marchesani syndrome (ar: ADAMTS10 gene, AD: fibrilline gene) connective tissue disorder: short stature, brachydactyly and joint stiffness, microespherophakia, myopia, glaucoma
Homocystinuria (ar) Clinical similar to Marfan disease + protrombotic disease (tx: supplement with pirodoxine) Dx: blood and urinary dosage of homocysteine
Sulphite oxidase deficiency (ar): profound mental retardation, epylepsia, spasticity, ectopia lentis (substitution of cysteine) Dx: elevated urinary thiosulfate level. No treatment, very poor prognosis
Hyperlysinaemia (ar) half of the patients are healthy. Others: psychomotor retardation, epilepsy, spasticity, ataxia, short stature, joint laxity and spherophakia. Dx: plasma levels of lysine.
When we examine these patients we have to ask for trauma or previous surgery. At the slit lamp we should evaluate the position of the lens edge related to the visual axis and it is important to keep in mind an associated systemic disease.
On the other hand we can find an absence of capsular and zonular support after a penetrating injury, a complicated cataract surgery or a previous lensectomy.
Best corrected visual acuity and possibility of amblyopia should be documented. We have to look for vitreous in the anterior chamber and existence and disposition of capsular remnants.
Indications for surgery in ectopia lentis is visual acuity loss due to lens subluxation, usually with visual axis involvement; anterior chamber lens luxation or vitreous lens luxation with good potential visual acuity.
Patients with traumatic or surgical aphakia with good potential visual acuity will be considered for surgery it they are unable or unwilling to use aphakia spectacles or if the don’t tolerate contact lens.
We should perform an endothelium cell count and eye biometry prior to surgery.
In certain cases of ectopia lentis the best and safest option will be aphakia with spectacle correction or contact lens, but many times it is only a temporary option.
Many times patients or families prefer an IOL implant. We consider these option in cases with good potential VA, when patients will be able of a closed follow-up. Patients should know that they will need a postop bifocal correction. Contraindications for IOL implant include uncontrolled glaucoma, active uveitis, severe anterior abnormalities and low endothelium cell count if we are planning to implant a prepupillary iris claw IOL.
We
Surgical management of ectopia lentis will include a lensectomy in the bag followed by a posterior vitrectomy. Acetylcholine injection will provoke myosis so a superior iridectomy with the vitreous cutter is easily done. At these point we can leave the patient aphakic or we’ll choose an IOL implant.
When we deal with traumatic or surgical aphakia we prefer a vitreoretinal approach. The infusion line helps to pressurize an stabilize the usually soft pediatric eyes. We should eliminate any vitreous adhesions in the anterior chamber and check for the capsular remnants. If they are not able to support a sulcus placed IOL then we have to choose one of the techniques of suspension of the IOL
In the placement of an scleral fixated IOL we suture the haptics to the scleral bed and then we implant and center the IOL behind the iris.
In 1999 Zettersröm published the first pediatric series of cases with scleral fixated IOL.
Since then most of the papers report good visual results, but in the long term polypropylene suture breakage and IOL luxation occur in 24 % of children after 5 years and it is a life-long concern in these children.
10-0 polypropylene suture cannot be relied on to secure a posterior chamber IOL to the sclera over the lifetime of a child
Caution should be exercised in the use of 10-0 polypropylene suture to fixate an IOL to the sclera in children, and an alternative material or size (such as 9-0 polypropylene) should be considered
Fortunately, the IOL is not long enough (13.5 mm) to reach the macular area
Iris Claw IOL were proposed to solve these problems. The IOL can be placed prepupillary or retropupillary.
Prepupillary IOL in children have been used for 40 years and the main concern is the endothelial cell loss. Our prospective series of patients with anterior chamber IOL placement shows a worrying endothelial cell loss in some of the patients. To solve these problem, in the last years there is a trend towards the retropupillary placement of Iris claw IOL that seems safer for the endothelium.
Iris sutured IOL have the advantage of a smaller incision whereas the implantation technique is way more difficult and time-consuming.
In the series published in children the main complication was IOL dislocation and Prolene degradation.
Caution on the long term use of Prolene 10/0, Iritis, Pigmentary dispersion
Iris claw IOL are an easy, quick an reversible technique. Retropupillary enclavation could solve the endothelium cell loss in the long-term.
Iris sutured IOL have the advantage of a smaller corneal incision but the technique is difficult and time-consuming, the risk of polypropylene degradation has also to be considered.
Finally Scleral fixated IOL are the best option in cases where there is not iris support. We recommend the use of Prolene 9/0 to prevent suture breakage.
Our protocol for the surgical management of ectopia lentis include patients with visual loss due to lens luxation. In patients under 4 yo or non collaborative we perform lensectomy and iridectomy and they are managed with contact lenses or aphakia spectacles.
More collaborative patients, usually over 4 yo with damaged iris have a lensectomy and scleral sutured IOL with prolene 9/0 and iris reconstruction. If the iris is normal we perform lensectomy, iridectomy and retropupillary iris claw implant.
Difficult endothelial follow-up
Eye-rubbing
Secondary IOL implant when intolerance
When we are facing a secondary IOL implant we have to consider that patients with active uveitis, uncontrolled glaucoma or unable to be followed shouldn’t be operated.
Children with good potential visual acuity and intolerance to contact lens with damaged iris are managed with scleral sutured IOL with prolene 9/0 while those with normal iris receive a retropupillary iris claw.
In conclusion there is no clear evidence of one best option of IOL implant in the absence of capsular support.
Aphakia correction and IOL implant will depend on the age of the patient, aetiology, cornea and iris status and also on surgeon preference.
Traumatic patients usually require an individualized management.
All the implanted patients will require a life-long close follow-up. All children will require bifocal optical correction.