Eyeworld

EW NEWS & OPINION 16 Amar Agarwal, Dr. Agarwal's Eye Hospital, Chennai, India, describes a technique for IOL fixation in eyes lacking adequate capsular support I n 2007, my colleagues and I proposed the glued IOL tech- nique for PCIOL fixation in eyes with absent or insufficient capsular support. Since then, a large number of cases have used this technique with the longest follow- up being more than 3 and a half years. Here, I present a step-by-step ap- proach to the technique. First, a radial keratotomy marker is used to mark two points exactly 180 degrees apart. Then, the con- junctiva is dissected in the areas concerned. Two partial lamellar scle- ral flaps of 2.5 x 2.5 mm are created, centered on these marks up to the limbus. Next, an anterior chamber (AC) maintainer or a 23-gauge sutureless trocar infusion cannula is fixed in the infero-temporal quadrant. The tip of the infusion cannula (if used) should be seen within the vitreous cavity before turning the infusion on. A 20-gauge needle is then used to create a sclerotomy 1 mm from the limbus under the scleral flap. The needle is directed toward the center of the globe as parallel entry may cause the needle to push on the iris root. To release any vitreous adhe- sions or strands, an anterior and mid vitrectomy is performed. The infu- sion cannula prevents the globe from collapsing during all steps of surgery. Inserting the IOL A 2.8 mm keratome is used to make a corneal incision. This may be en- larged very slightly so as to allow easy insertion. One should never try wound-assisted injection in a three- piece IOL as the IOL can break dur- ing insertion. The three-piece foldable IOL is loaded into the injec- tor and the injector tip is introduced into the AC. Always keep the tip of the haptic slightly out of the car- tridge so that when you go to grasp June 2011 by Amar Agarwal, M.S., F.R.C.S., F.R.C.Ophth. A step-by-step approach to the glued IOL technique accomplished in under 60 seconds, in comparison to the 15-20 minutes required for conventional anterior segment sutures. The 2010 ASCRS Survey of U.S. Trends in Refractive Surgery Richard J. Duffey, M.D., and David Leaming, M.D. The ASCRS Survey of U.S. Trends in Refractive Surgery completed its 15th year of data collection, and for the first time in 5 years there was an increase in laser vision correction procedures done by the member- ship. LASIK still dominates for re- fractive errors between –10 diopters to +3 diopters, with phakic IOLs dominating greater than –10 and re- fractive lens exchange dominating greater than +3. VISX (Abbott Med- ical Optics, Santa Ana, Calif.) has re- mained the dominant excimer laser used by 74% of respondents, un- changed for the past 5 years. The family refractive surgery index indi- cates that refractive surgeons and their family members (spouses, sib- lings, and children) have had refrac- tive surgery performed on their own eyes at a rate 4- 5 times the general population, emphasizing that those closest to refractive surgery are con- fident in the quality of visual out- comes despite the current attack on laser vision correction in the public media and further FDA study. Over- all, refractive surgeons prefer thin- ner flaps (down to 100 microns) and more residual stromal bed remaining following laser vision correction (275 microns or more), and there has been a gradual increase in re- spondents who favor bilateral pha- kic IOL procedures (19%) and refractive lens exchange procedures (7%) at the same surgical setting. Fi- nally, post-LASIK ectasia appears to be stable with no increase in num- bers and a decrease in rate over the past 4 years. EW Best continued from page 13 Richard S. Hoffman, M.D., is not only one of the most technically proficient cataract surgeons I know, but he is also an incredi- ble innovator. Having already devised the ingenious "Hoffman pocket" concept for scleral suturing an IOL, his clever and mini- mally invasive mini-glaucoma shunt proce- dure won the Grand Prize at the recent ASCRS Film Festival. Realizing that sur- geons need more step-by-step instruction in order to learn new techniques—the de- tails that are missing from podium presen- tations or broader articles—I approached Rich about directing a monthly EyeWorld feature that teaches advanced techniques. Rich is the perfect person to lead this column, which will be called "Tools & techniques," and I hope this will help you to master the many tricks and maneuvers that he plans to highlight. David F. Chang, M.D., chief medical editor The Tools & techniques section of EyeWorld is a new column that will present in-depth step-by-step approaches for successfully performing some of ophthalmic surgery's most challenging and valuable procedures. Repair of pupil defects, subluxed lenses, or the best approach for a difficult and chal- lenging posterior polar cataract or pseu- doexfoliation patient are just some of the examples of cases in which novice or more seasoned surgeons could improve their skills. What is the best way to utilize a Cionni ring or Ahmed ring segment? How do you easily rescue an errant capsulorhexis? What are some pearls for fixating IOLs to the iris? These and many other topics will be reviewed monthly in this column by in- ternational surgeons known for their partic- ular expertise and superb teaching abilities. The hope is that these articles and linked videos will function as a valuable resource and toolbox that surgeons can access when confronted with the challenging case. In this month's column, Amar Agarwal presents his detailed approach for fixating IOL haptics within scleral tunnels without the use of su- tures. The technique can be used for dislo- cated posterior chamber IOLs or for secondary IOL implantations. Dr. Agarwal has been championing this method for sev- eral years and his insight and experience with this alternative method for IOL fixation should be a useful reference for surgeons wishing to add this technique to their surgi- cal armamentarium. Richard S. Hoffman, M.D. Tools & techniques IOL insertion. A) Injector is passed through the corneal incision. IOL haptic is held with the forceps while injecting the lens. IOL haptic is externalized under the scleral flap. B) IOL haptic flexed into the AC. Haptic end is grasped with another forceps. Both the haptic ends externalized under the flaps

• Cover