Phacoemulsification, pinhole pupilloplasty, and pre-Descemet抯 endothelial keratoplasty for keratoconus with Fuchs� endothelial dystrophy

The comorbidity of keratoconus with Fuchs� endothelial dystrophy with cataract is a rare clinical combination. We present an amalgamation of surgical techniques to manage the above clinical conditions and its complications in single setting. The modified triple procedure, namely, the phacoemulsification, pinhole pupilloplasty, and pre-Descemet抯 endothelial keratoplasty (PDEK) in the order of description is followed in single sitting. Lens removal by phacoemulsification, correction of irregular astigmatism by pinhole pupilloplasty (pinhole optics), and exchanging the endothelial layer for PDEK forms the main segments of the triple procedure. This combination of techniques may decrease the risk of multiple surgeries and its related complications. Moreover, it will allow the patient for faster visual rehabilitation by improving the uncorrected visual acuity and visual quality.

Hypersonic vitrectomy in intraoperative posterior capsular rupture with retained nuclear fragments

In our report, we present the hypersonic vitrectomy (Vitesse, Bausch and Lomb) being employed for anterior vitreous liquefaction and removal in posterior capsular rupture. The capsular tear with nucleus drop during conventional phacoemulsification was managed by vitrectomy using the hypersonic vitrector after posterior-assisted levitation followed by intraocular lens (IOL) implantation. The minimal cortical and epinuclear lens particles in the anterior chamber and vitreous were also liquefied with a stoke length of 30 to 40 ?m and aspirated via the Vitesse vitrectomy system. The same probe performs the vitrectomy and the nucleus removal. The postoperative period was uneventful with clear cornea, normal fundus, and 20/20 best-corrected visual acuity (BCVA). The hypersonic vitrectomy utilizes the ultrasound power of 29.5 kHz and a stoke length of 0 to 60 ?m for liquefaction of the vitreous. It can be a safe alternative for vitrectomy and lens removal in a single setting.

When the savior becomes a demon: Silicon oil synechia-induced glaucoma

Background: Silicon oil is an important adjunct for achieving internal tamponade in the treatment of retinal detachment. Silicone oil tamponade often leads to narrowing of the angle and development of adhesions between the iris and anterior chamber angle structures, with consequential elevation of the intraocular pressure. The video showcases the management of these challenging scenarios. Purpose: To highlight the management of early synechial closures due to silicon oil tamponade. Synopsis: The video highlights the management of early synechial closure following silicon oil tamponade. Surgical pupilloplasty has been demonstrated to break the peripheral anterior synechias on intraoperative gonioscopy as well as on anterior segment optical coherence tomography (AS?OCT). Performing pupilloplasty in the early phase of development of peripheral anterior synechias (PAS) helps to break the existing synechias and prevent angle closure and sequential deterioration of vision. Highlights: Surgical pupilloplasty helps to relieve the post silicon oil?induced secondary angle closure glaucoma by breaking the peripheral anterior synechias and significantly opening the anterior chamber angles.

Twofold technique for iridodialysis repair

Background: Disinsertion of iris leads to debilitating sequelae like diplopia and glare. Hence, iridodialysis repair is essential to optimize the visual quality. Iris base repair often leads to corectopia that necessitates an additional procedure to optimize the pupil shape and size. Twofold technique helps to achieve both the aspects. Purpose: To highlight the technique of twofold iridodialysis repair. Synopsis: The video highlights the method of twofold iridodialysis repair, wherein nonappositional repair is followed by single?pass four?throw (SFT) pupilloplasty thatallows adequate closure of varied degrees of iridodialysis along with centration of eccentric pupil. Highlights: The twofold technique is a combination of nonappositional iris repair and SFT procedure. It can be clinically applied in all cases of iridodialysis with varied degrees of severity

Semilunar sign of cornea: A multimodal analysis of the posterior corneal opacity in non-infectious anterior scleritis

Purpose: To analyze the morphological outcomes of the posterior corneal opacity or 搒emilunar sign� in noninfectious anterior scleritis using multimodal imaging. Methods: This was a prospective observational case series. Patients with anterior scleritis from January 2018 to January 2019 were included. Clinical and demographic data were collected. Posterior cornea was visualized using the digital slit lamp photography (Elite, mega digital vision), spectral domain optical coherence tomography (MS39), and specular count analyzer (EM?3000). 揝emilunar sign� was defined by the (1) presence of posterior corneal opacity, (2) concave semilunar pattern, (3) absence of blood vessels, and (4) normal anterior cornea. Incidence, clinical characteristics and significance, correlation with Mantoux sensitivity, and role of multimodal valuation were assessed. Results: Overall 76 eyes of 72 patients were recruited with anterior scleritis. Fifteen eyes of 11 patients (15.3%) presented with semilunar sign. The scleritis was both nonnecrotizing (n = 8) and necrotizing (n = 7). The semilunar configuration appeared as isolated (n = 9) and continuous lesion (n = 6). The extent was directly related to the scleral disease extent (P = 0.002). The mean thickness measured 212.5 � 129.3 ?m. The mean central endothelial cell density (ECD) was 2540.8 � 351.7 cells/mm2, which was significantly higher than the involved peripheral cornea (P = 0.05). The mean surface area of the semilunar sign was 7.7 � 5.2 mm2. There was no significant correlation between the opacity thickness and the best?corrected visual acuity (P = 0.895, r = ?0.39), ECD (P = 0.52, r = ?0.188), and Mantoux (P = 0.696, r =? 0.142). Conclusion: Corneal semilunar sign of scleritis affected the peripheral cornea and caused no functional abnormality in early presentation. Multimodal analysis can aid in clinical assessment and severity.

The “correct shake” for “handshake” in glued intrascleral fixation of intraocular lens.

We hereby describe the correct method to perform a “handshake technique” and easy transfer of haptics from one hand to another for glued intrascleral fixation of an intraocular lens (glued IOL). The procedure was implemented in 57 cases that necessitated the application of performing a glued IOL procedure and it resulted in an appropriate and easy externalization of haptic in all the cases. The surgeons’ positioning with reference to the scleral flap is an essential component and the surgeon should always be positioned perpendicular to the plane of scleral flaps and the plane of haptic maneuver. The surgeons who intend to perform glued IOL should adopt this technical point.

Clinical outcomes of pars plicata anterior vitrectomy: 2‑year results.

Purpose: To demonstrate the safety and outcome of a surgical approach that uses pars plicata site for anterior vitrectomy during phacoemulsification procedure complicated by posterior capsule rupture and residual cortical matter. Design: Single center, retrospective, interventional, noncomparative study. Materials and Methods: Medical records of a consecutive series of 35 eyes of 35 patients who underwent pars plicata anterior vitrectomy (PPAV) were reviewed. The main outcome measures were corrected and uncorrected distance visual acuity (CDVA, UDVA), early and late postoperative complications and intraocular pressure (IOP). Ultrasound biomicroscopic (UBM) evaluation of sclerotomy site and spectral domain optical coherence tomography analysis for central macular thickness (CMT) was performed. The final visual outcome at 2 years was evaluated. Results: At 2 years follow‑up, the mean postoperative UDVA (logarithm of the minimum angle of resolution [logMAR]) and CDVA (logMAR) was 0.49 ± 0.26 and 0.19 ± 0.14, respectively. There was no significant change in the IOP (P = 0.061) and the mean CMT at 2 years was 192.5 ± 5.54 μm. The postoperative UBM image of the sclerotomy site at 8 weeks demonstrated a clear wound without any vitreous adhesion or incarceration. Intraoperative hyphema was seen in 1 (2.8%) case and postoperative uveitis was seen in 2 (5.7%) cases, which resolved with medications. No case of an iatrogenic retinal break or retinal detachment was reported. Conclusions: PPAV enables a closed chamber approach, allows thorough cleanup of vitreous in the pupillary plane and anterior chamber and affords better access to the subincisional and retropupillary cortical remnant with a significant visual outcome and an acceptable complication rate.