A Novel Hinged Scleral Patch Graft for the Repair of Overfiltration and Bleb Leaks.

INTRODUCTION: The repair of the scleral flap is often needed in cases of severe hypotony or bleb leaks with overfiltration. We present a simple novel technique to restore the hinged flap using a scleral patch graft. MATERIALS AND METHODS: We present 4 eyes of 4 patients who presented with hypotony [intraocular pressure(IOP) <6 mm Hg] from overfiltration secondary to loose scleral flap (2 eyes) and bleb leak (2 eyes). A scleral patch from a human donor, preserved in 95% ethanol, was cut in a trapezoidal shape and placed over the area of filtration after a conjunctival peritomy. The scleral graft was secured anteriorly with a single double-armed 9-0 nylon suture in a double-mattress manner so as to create a hinged flap. Permanent or releasable sutures were placed posteriorly to control aqueous outflow. RESULTS: All 4 patients had complete resolution of hypotony and bleb leaks with increase in their IOP to early teens. All maintained aqueous flow posteriorly with preservation of bleb function. CONCLUSION: Reestablishing the original anatomy of the hinged scleral flap can maintain bleb function without risk of overfiltration or loss of IOP control. This can be achieved through a simple repair using a scleral patch graft.

Slit-lamp Needling of the Anterior Capsule for Aqueous Misdirection After Hyaloido-zonulectomy and Iridectomy.

INTRODUCTION: We present a case of persistent aqueous misdirection, after Ahmed glaucoma valve surgery, despite undergoing an anterior vitrectomy with hyaloido-zonulectomy and iridectomy. CASE REPORT: A 73-year-old female patient, 4 months after phacotrabeculectomy, was referred with persistent high intraocular pressure (IOP). Postoperatively, she developed aqueous misdirection with a flat anterior chamber (AC) but with an IOP of 15 mm Hg. On presentation, her AC was shallow with peripheral iris-cornea touch, and her IOP was 39 mm Hg. Posterior Nd:Yag capsulotomy with disruption of anterior hyaloid face partially deepened the AC. With failure of the trabeculectomy and high IOP, an Ahmed valve was placed. On the first operative day the AC was deep with an IOP of 10 mm Hg. On day 6 the patient presented with pain, flat AC, and an IOP of 10 mm Hg. Fundus examination revealed no choroidal effusion. Despite repeated reformation with viscoelastic, the AC failed to deepen. An anterior vitrectomy with hyaloido-zonulectomy was performed. Initially, the AC was deep, but, a few days later, it was flat. Multiple reformations and vitreous tap failed to keep the AC deep. A 30-G needle was passed at the slit lamp across the temporal cornea, iris, and anterior capsule into the anterior vitreous cavity. The needle was then partially withdrawn and used to create a space between the intraocular lens and anterior capsule. This immediately deepened the AC and remained so for the duration of follow-up (4 mo). CONCLUSION: Slit-lamp needling of the anterior lens capsule can be successfully performed to help resolve a persistent case of aqueous misdirection after anterior vitrectomy.

Slitlamp needle revision of capsular block syndrome.

I describe a technique of slitlamp needle revision in eyes with capsular block syndrome (CBS) with distention of the capsular bag and forward displacement of the intraocular lens (IOL) in the capsular bag. After topical anesthesia and povidone-iodine are applied to the eye, a 30-gauge needle is introduced in a beveled fashion across the peripheral cornea into the anterior chamber and used to gently push the IOL posteriorly into the capsular bag, reversing CBS. In 8 patients, the technique instantly resolved the CBS and the induced myopic shift. No patient experienced complications or had a recurrence of CBS.

Phacoanaphylactic endophthalmitis secondary to capsular block syndrome.

A 65-year-old white man presented with sudden onset of painless decrease in vision and a red eye 5 days after cataract surgery. The visual acuity was 20/400 with mild injection. Marked iritis was present, and a hypopyon could be seen behind the intraocular lens (IOL) in the capsular bag. The posterior segment was clear. The iritis worsened despite 4 days of hourly topical corticosteroid treatment. Anterior chamber washout was performed, with clearing of the material behind the IOL. The iritis subsided 4 weeks later, and visual acuity recovered to 20/20. Capsular block syndrome can present as phacoanaphylactic endophthalmitis if cortical material is left in the capsular bag, requiring surgical intervention.

Closure of persistent cyclodialysis cleft using the haptics of the intraocular lens.

PURPOSE: To evaluate a technique for ab-interno repair of cyclodialysis cleft in conjunction with placement of an intraocular lens (IOL). DESIGN: Interventional case reports. METHODS: setting: Clinical practice. patients: Two eyes of two patients, one phakic and one aphakic, present with hypotony secondary to traumatic cyclodialysis cleft. intervention: A single piece all-polymethyl methacrylate intraocular lens (PMMA IOL) 13.5 mm in diameter was placed in the ciliary sulcus with the haptics placed in the area of cyclodialysis cleft during cataract surgery and secondary placement of IOL. main outcome measures: Intraocular pressure (IOP). RESULTS: Hypotony resolved in both patients on the first postoperative day and the IOP was maintained above 10 mm Hg for more then 36 months postoperatively. CONCLUSIONS: In the setting of hypotony from a traumatic cyclodialysis cleft, the haptics of an IOL can be used as an internal cerclage during cataract or secondary IOL surgery to effectively close the cleft by direct apposition of the ciliary body to the overlying sclera.