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@yahoo.co.in We do not have any financial interest in this presentation 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. Introduction To discuss about “To be ready for unplanned but fruitful intraoperative management of complicated cases.” Aim

2. Material 51 years old female Left Eye Complicated aphakia BCVA: HM only IOP: 17 mmHg Treatment Attempted Colour contact lenses- did not work because of improper fitting 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 Right Eye

3. Initial Clinical Picture Explanation & Exchange with Large Optic size IOL Suturing of Iris Explanation of IOL only Surgical Options 1 2 3

4. Method Conjunctiva opened for about 180 o around the limbus 2 corneal stab incisions were made at 10 & 2 o’clock position AC was formed with visco Bleeders were Cauterized

5. Method 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 1 2 345 6 7 8 It was not possible to put the IOL in the ‘bag’

6. Method 9 10 11 12 13 14 15 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.

7. Method 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 21 20 19 18 16 17

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. 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 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 Discussion

10. Conclusion Reposition with Scleral Fixation of same IOL Thanks for your time……. Initial Clinical Picture 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. Post Op. Photograph after 1 month