SOOSAN JACOB, MS, FCRS,DNBSOOSAN JACOB, MS, FCRS,DNB

AMAR AGARWAL, MS, FRCS, FRCOpth; ATHIYA AGARWAL, MD, DO;AMAR AGARWAL, MS, FRCS, FRCOpth; ATHIYA AGARWAL, MD, DO;

GAURAV PRAKASH, MD; DHIVYA A KUMAR, MD; GAURAV PRAKASH, MD; DHIVYA A KUMAR, MD;

ARCHANA NAIR, MS; AKBAR SALEEM, MSARCHANA NAIR, MS; AKBAR SALEEM, MS

DR. AGARWAL’S GROUP OF EYE HOSPITALS DR. AGARWAL’S GROUP OF EYE HOSPITALS

&&

EYE RESEARCH CENTRE,EYE RESEARCH CENTRE,

CHENNAI, INDIACHENNAI, INDIA

PROF. AMAR AGARWAL IS A PAID CONSULTANT TO ABOTT MEDICAL OPTICS AND BAUSCH & LOMB. NONE OF THE OTHER AUTHORS HAVE ANY FINANCIAL DISCLOSURES.

BACKGROUNDBACKGROUND : : OPTIONS FOR CORRECTION OF OPTIONS FOR CORRECTION OF

APHAKIA IN THE ABSENCE OF ADEQUATE CAPSULAR APHAKIA IN THE ABSENCE OF ADEQUATE CAPSULAR

SUPPORT ARE – ANTERIOR CHAMBER IOL, IRIS FIXATED SUPPORT ARE – ANTERIOR CHAMBER IOL, IRIS FIXATED

IOL, SUTURED SCLERAL FIXATED IOL AND GLUED IOLIOL, SUTURED SCLERAL FIXATED IOL AND GLUED IOL

PURPOSEPURPOSE : : TO EVALUATE THE VISUAL OUTCOME TO EVALUATE THE VISUAL OUTCOME

AND COMPLICATIONS OF EYES OPERATED WITH AND COMPLICATIONS OF EYES OPERATED WITH

FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL

IMPLANTATION IN EYES WITH DEFICIENT IMPLANTATION IN EYES WITH DEFICIENT

POSTERIOR CAPSULE AT ONE YEAR FOLLOW UPPOSTERIOR CAPSULE AT ONE YEAR FOLLOW UP

FIBRIN GLUE ASSISTED FIBRIN GLUE ASSISTED SUTURELESS TRANS-SUTURELESS TRANS-SCLERAL HAPTIC FIXATED SCLERAL HAPTIC FIXATED POSTERIOR CHAMBER IOL POSTERIOR CHAMBER IOL IMPLANTATIONIMPLANTATION

RIGID PMMA IOL OR 3 PIECE RIGID PMMA IOL OR 3 PIECE FOLDABLE IOLFOLDABLE IOL

EXPERIENCE OF >300 EYES EXPERIENCE OF >300 EYES (FIRST CASE: 2007), 11 (FIRST CASE: 2007), 11 PEER REVIEWED PEER REVIEWED PUBLICATIONSPUBLICATIONS

INDICATIONS: INDICATIONS:

IN THE BAG IOL/ SULCUS IN THE BAG IOL/ SULCUS

SUPPORT NOT POSSIBLESUPPORT NOT POSSIBLE

>180º SUBLUXATION>180º SUBLUXATION

APHAKIAAPHAKIA

GLUED IOL IS AN OFF LABEL USE OF IOLs AND FIBRIN GLUED IOL IS AN OFF LABEL USE OF IOLs AND FIBRIN GLUEGLUE

AGARWAL A, KUMAR DA, JACOB S, AGARWAL A, KUMAR DA, JACOB S, ET AL. FIBRIN GLUE–ASSISTED SUTURELESS POSTERIOR CHAMBER ET AL. FIBRIN GLUE–ASSISTED SUTURELESS POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION IN EYES WITH DEFICIENT POSTERIOR CAPSULES. J CATARACT REFRACT SURG INTRAOCULAR LENS IMPLANTATION IN EYES WITH DEFICIENT POSTERIOR CAPSULES. J CATARACT REFRACT SURG 2008; 34: 1433–14382008; 34: 1433–1438

PRAKASH G, KUMAR DA, JACOB S ET AL. PRAKASH G, KUMAR DA, JACOB S ET AL. ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY–AIDED ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY–AIDED DIAGNOSIS AND PRIMARY POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION WITH FIBRIN GLUE IN DIAGNOSIS AND PRIMARY POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION WITH FIBRIN GLUE IN TRAUMATIC PHACOCELE WITH SCLERAL PERFORATION. J CATARACT REFRACT SURG 2009; 35: 782–784TRAUMATIC 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 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.TRANSPLANTATION WITH A NOVEL BIOSYNTHETIC GRAFT. EYE CONTACT LENS. 2010 MAR;36(2):130-6.

RETROSPECTIVE CASE SERIES, IRB RETROSPECTIVE CASE SERIES, IRB

APPROVED, INFORMED CONSENT APPROVED, INFORMED CONSENT

TAKENTAKEN

DECEMBER 2007 TO MAY 2008: 59 DECEMBER 2007 TO MAY 2008: 59

EYES (OF 56 PATIENTS )EYES (OF 56 PATIENTS )

ALL UNDERWENT FIBRIN GLUE ALL UNDERWENT FIBRIN GLUE

ASSISTED POSTERIOR CHAMBER IOL ASSISTED POSTERIOR CHAMBER IOL

IMPLANTATION WITH TRANS- IMPLANTATION WITH TRANS-

SCLERAL HAPTIC FIXATIONSCLERAL HAPTIC FIXATION

FOLLOW UP: 1, 3, 6, 12 MONTHSFOLLOW UP: 1, 3, 6, 12 MONTHS

STATISTICAL ANALYSIS: SPSS STATISTICAL ANALYSIS: SPSS

VERSION 16.1(SPSS INC, USA). VERSION 16.1(SPSS INC, USA).

DIFFERENCES CONSIDERED DIFFERENCES CONSIDERED

STATISTICALLY SIGNIFICANT AT STATISTICALLY SIGNIFICANT AT

P<0.05. WILCOXON SIGNED RANK P<0.05. WILCOXON SIGNED RANK

TEST USEDTEST USED

ANALYSIS AT ONE YEAR OF:ANALYSIS AT ONE YEAR OF:

POSTOPERATIVE BEST POSTOPERATIVE BEST

CORRECTED VISUAL ACUITY CORRECTED VISUAL ACUITY

(BCVA)(BCVA)

UNCORRECTED VISUAL ACUITY UNCORRECTED VISUAL ACUITY

(UCVA) (UCVA)

SPECULAR COUNT SPECULAR COUNT

INTRA OCULAR PRESSURE (IOP)INTRA OCULAR PRESSURE (IOP)

CELLULAR REACTION (SUN CELLULAR REACTION (SUN

CLASSIFICATION)CLASSIFICATION)

CENTRAL MACULAR THICKNESS CENTRAL MACULAR THICKNESS

(CMT)(CMT)

INTRAOPERATIVE INTRAOPERATIVE

COMPLICATIONSCOMPLICATIONS

POSTOPERATIVE POSTOPERATIVE

COMPLICATIONSCOMPLICATIONS

IOL TILT IOL TILT

IOL CENTERATION IOL CENTERATION

INFUSION CANNULA INFUSION CANNULA INSERTEDINSERTED

TWO LAMELLAR TWO LAMELLAR SCLERAL FLAPS 180 SCLERAL FLAPS 180 DEGREES APART WERE DEGREES APART WERE MADE MADE

SCLEROTOMY WAS SCLEROTOMY WAS MADE UNDER EACH MADE UNDER EACH FLAP 1 MM FROM THE FLAP 1 MM FROM THE LIMBUSLIMBUS

THE IOL HAPTIC WAS THE IOL HAPTIC WAS GRASPED WITH 23 G GRASPED WITH 23 G MST FORCEPS AND MST FORCEPS AND EXTERIORIZED UNDER EXTERIORIZED UNDER THE FLAPTHE FLAP

BOTH HAPTIC TIPS BOTH HAPTIC TIPS WERE TUCKED INTO WERE TUCKED INTO SCLERAL TUNNELS AT SCLERAL TUNNELS AT THE EDGE OF THE THE EDGE OF THE FLAPSFLAPS

FIBRIN GLUE WAS USED FIBRIN GLUE WAS USED TO SEAL THE FLAPTO SEAL THE FLAP

SCLERAL FLAPS IOL INTRODUCED HAPTIC GRASPEDWITH 23 G MST FORCEPS

OPPOSITE HAPTIC SIMILARLY EXTERIORIZED

HAPTIC EXTERIORIZED TUNNEL AT EDGE OF FLAP MADE WITH 26 G NEEDLE

HAPTIC TUCKED INTOSCLERAL TUNNEL

FIBRIN GLUE APPLIED FLAPS SEALED

A B C

D E F

G H I

Scleral flaps 180 º apartLeading haptic graspedHaptic exteriorizedTrailing haptic grasped

Both haptics exteriorizedScleral tunnel at flap edgeHaptic tucked into tunnel Both haptics tucked

Fibrin glue applied Flap sealed Opposite flap sealed Post-op day 1: 20/30

A B C D

E F G H

I J K L

23 FEMALE/ 33 MALE23 FEMALE/ 33 MALEMEAN AGE = 50.63±18.75 YRSMEAN AGE = 50.63±18.75 YRSPRIMARY PROCEDURE = 69.4%PRIMARY PROCEDURE = 69.4%SECONDARY PROCEDURE = 30.5%SECONDARY PROCEDURE = 30.5%INDICATIONS:INDICATIONS:

INTRAOPERATIVE POSTERIOR CAPSULAR RUPTURE INTRAOPERATIVE POSTERIOR CAPSULAR RUPTURE

WITH ABSENT SULCUS SUPPORT (37.2%) WITH ABSENT SULCUS SUPPORT (37.2%)

APHAKIA (33.8%) APHAKIA (33.8%)

SUBLUXATED CATARACT (28.8%)SUBLUXATED CATARACT (28.8%)

MEAN IOP MEAN IOP (1 YR POST-OP) = 14.17±3.5mmHg(1 YR POST-OP) = 14.17±3.5mmHg GRADE II GRADE II AC CELLULAR REACTION AC CELLULAR REACTION ON DAY 1ON DAY 1

POST-OP PERIOD (RESOLVING WITHIN 48 HRS OFPOST-OP PERIOD (RESOLVING WITHIN 48 HRS OF

MEDICAL MANAGEMENT) = 3/59 EYESMEDICAL MANAGEMENT) = 3/59 EYES MEAN CMT MEAN CMT (1 YEAR POST OP ON STRATUS OCT) =(1 YEAR POST OP ON STRATUS OCT) =

190.8±5.9MICRONS190.8±5.9MICRONS IRIDODONESISIRIDODONESIS = 16.9% = 16.9% CLINICAL PSEUDOPHACODONESIS CLINICAL PSEUDOPHACODONESIS = 0 = 0 ENDOPHTHALMITISENDOPHTHALMITIS = 0 = 0 MEAN POST OP SPECULAR COUNT =MEAN POST OP SPECULAR COUNT =

2197 ± 318.7CELLS /MM2. 2197 ± 318.7CELLS /MM2.

PERCENTAGE LOSS OF ENDOTHELIAL CELLSPERCENTAGE LOSS OF ENDOTHELIAL CELLS

(PREOP TO ONE YEAR POST OP) = 5.33±3.5%(PREOP TO ONE YEAR POST OP) = 5.33±3.5%

SSCCAATTTTEERR PPLLOOTT

ULTRASOUND BIOMICROSCOPY USEDULTRASOUND BIOMICROSCOPY USED

LINE WAS DRAWN ALONG LIMBUS AS PLANE LINE WAS DRAWN ALONG LIMBUS AS PLANE

OF REFERENCEOF REFERENCE

SECOND LINEWAS DRAWN ALONG LONG AXIS SECOND LINEWAS DRAWN ALONG LONG AXIS

OF IOL OPTICOF IOL OPTIC

OPTIC WAS CONSIDERED NOT TILTED WHEN OPTIC WAS CONSIDERED NOT TILTED WHEN

REFERENCE LINE ALONG LIMBUS AND IOL REFERENCE LINE ALONG LIMBUS AND IOL

OPTIC WERE PARALLELOPTIC WERE PARALLEL

ACCORDING TO EQUATION OF STRAIGHT LINE, ACCORDING TO EQUATION OF STRAIGHT LINE,

Y = MX + CY = MX + C, SLOPE OF LINE THROUGH LIMBUS , SLOPE OF LINE THROUGH LIMBUS

AND IOL WAS DETERMINEDAND IOL WAS DETERMINED

SLOPES WERE CALCULATED AS SLOPES WERE CALCULATED AS M = (Y2-Y1)/(X2-X1) M = (Y2-Y1)/(X2-X1) WHERE (X1, Y1) & (X2, Y2) ARE ANY TWO WHERE (X1, Y1) & (X2, Y2) ARE ANY TWO POINTS ON THE 2 LINES. POINTS ON THE 2 LINES.

IF TWO STRAIGHT LINES ARE PARALLEL, IF TWO STRAIGHT LINES ARE PARALLEL, THERE SLOPES WILL BETHERE SLOPES WILL BEEQUAL; OR THE RATIO WILL BE 1. EQUAL; OR THE RATIO WILL BE 1.

RATIO BETWEEN SLOPE OF LINE 1 & LINE 2 RATIO BETWEEN SLOPE OF LINE 1 & LINE 2 WAS CALCULATEDWAS CALCULATED

ABSOLUTE MEAN SLOPE OF LINE ABSOLUTE MEAN SLOPE OF LINE (L1) (L1) THROUGH LIMBUS = THROUGH LIMBUS = 0.032 ± 0.090.032 ± 0.09

ABSOLUTE MEAN SLOPE OF LINE ABSOLUTE MEAN SLOPE OF LINE (L2) (L2) THROUGH IOL OPTIC = THROUGH IOL OPTIC = 0.034 ± 0.1 0.034 ± 0.1

MEAN RATIO OF SLOPE = 1.04 ± 0.28MEAN RATIO OF SLOPE = 1.04 ± 0.28

MEAN DISTANCE B/W IRIS AND IOL = 0.92 ± 0.27MM IN OCTMEAN DISTANCE B/W IRIS AND IOL = 0.92 ± 0.27MM IN OCT

DECENTRATION OF THE GEOMETRIC CENTER DECENTRATION OF THE GEOMETRIC CENTER OF THE IOL OPTIC (a1) WITH RESPECT TO OF THE IOL OPTIC (a1) WITH RESPECT TO LIMBUS (a) WAS DETERMINED AS r (MM)LIMBUS (a) WAS DETERMINED AS r (MM)

MILD DECENTERATION DETECTED IN MILD DECENTERATION DETECTED IN AN EYE IN EARLY POST OPERATIVE AN EYE IN EARLY POST OPERATIVE PERIODPERIOD

•SERIAL DIGITAL SLIT LAMP IMAGES OF THE EYE WITH FULL PUPILLARY SERIAL DIGITAL SLIT LAMP IMAGES OF THE EYE WITH FULL PUPILLARY DILATATION WERE TAKEN TO ASSESS IOLCENTERATIONDILATATION WERE TAKEN TO ASSESS IOLCENTERATION•IMAGE PROCESSING WITH MATLAB VERSION 7.1 (MATHWORKS, INC) WAS DONE IMAGE PROCESSING WITH MATLAB VERSION 7.1 (MATHWORKS, INC) WAS DONE TO QUANTIFY DECENTERATIONTO QUANTIFY DECENTERATION•GEOMETRIC CENTRE OF THE LIMBUS (a) AND THE IOL OPTIC (a1) WAS DEDUCTED GEOMETRIC CENTRE OF THE LIMBUS (a) AND THE IOL OPTIC (a1) WAS DEDUCTED AFTER COMPLETE PUPILLARY DILATATIONAFTER COMPLETE PUPILLARY DILATATION•DISTANCE (r) BETWEEN THE TWO GEOMETRIC POINTS WERE CALCULATED IN MM DISTANCE (r) BETWEEN THE TWO GEOMETRIC POINTS WERE CALCULATED IN MM ON EACH VISITON EACH VISIT•AMOUNT OF DECENTRATION OF THE GEOMETRIC CENTER OF THE IOL OPTIC WITH 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 RESPECT TO THE X-AXIS AND Y-AXIS OF A 2-DIMENSIONAL CARTESIAN SYSTEM (THE CORONAL PLANE) WAS DETERMINED(THE CORONAL PLANE) WAS DETERMINED

AT LAST FOLLOW AT LAST FOLLOW UP :UP :•MEAN r MEAN r = = 0.08±0.19MM0.08±0.19MM

•MEAN X AND Y MEAN X AND Y SHIFT SHIFT = = 0.08±0.19MM AND 0.08±0.19MM AND 0.01±0.05MM0.01±0.05MMRESPECTIVELY. RESPECTIVELY.

ONE YEAR RESULTS OF FIBRIN GLUE ONE YEAR RESULTS OF FIBRIN GLUE

ASSISTED POSTERIOR CHAMBER IOL ASSISTED POSTERIOR CHAMBER IOL

IMPLANTATION SUGGEST GOOD VISUAL IMPLANTATION SUGGEST GOOD VISUAL

OUTCOME WITH MINIMAL OUTCOME WITH MINIMAL

COMPLICATIONS IN EYES WITH COMPLICATIONS IN EYES WITH

DEFICIENT CAPSULAR SUPPORTDEFICIENT CAPSULAR SUPPORT