Vertical fixation with fibrin glue-assisted secondary posterior chamber intraocular lens implantation in a case of surgical aphakia
A 55-year-old female patient presented to us on November 18, 2010. She had been operated in the left eye 5 years back elsewhere for cataract surgery. She was diabetic since 2 years and hypertensive since 11 years, controlled on treatment.\nOn examination the right eye had vision of 6/9 with -4.75 D Sphere and N6 with add of +3D. Left Eye was 6/12 with +8 D Sphere and N8 with +3 D add. Right eye showed a clear lens while left eye was aphakic with no capsule seen and intact vitreous face. Intraocular pressure (IOP) was 14 mm Hg right eye and 16 mm Hg left eye on applanation tonometry. Gonioscopy revealed open angles grade 4 in both eyes. Fundus examination showed myopic degenerative changes at macula with attached retina.\nIOL Master (Version 5, Zeiss, Germany) readings were as follows. K1 45.61D @ 80°, K2 46.49D @ 170°, AL 24.81mm, IOL power +14 D (A constant 118.4).\nThe patient was operated for vertical glued secondary IOL implantation with temporal clear corneal incision and anterior vitrectomy.\nThe surgery was performed with topical 0.5% Proparacaine (Sunways, Ahmedabad, India) and subtenons injection of preservative free 1% Lignocaine (Oculan, Sunways, India). After instillation of topical proparacaine, superonasal conjunctiva was cauterized and then conjunctiva and tenons were opened with sharp scissors. Two cc of 1% preservative free lignocaine was injected in the superonasal quadrant.\nA radial keratotomy marker was used to mark 2 diagonally opposite points exactly 180 degrees apart at 12 and 6 O″ clock. The conjunctiva was opened at the limbus and dissected to expose sclera adequately. A crescent knife was used to make partial lamellar scleral flaps of 2.5 × 2.5 mm centered at 12 and 6 O″ clock dissecting upto the limbus. A tunnelled clear corneal entry was made with a sideport knife and an anterior chamber maintainer was inserted at 8 O′ clock in the inferonasal quadrant. The infusion was turned on and this prevented globe collapse and hypotony in all subsequent surgical steps. Underneath the scleral flaps, an entry was made with 20 gauge micro vitreo-retinal (MVR) knife 1 mm from limbus at 12 and 6 O′ clock. The MVR knife was directed towards the centre of the globe and parallel entry was avoided so as to minimize risk of bleeding from the iris root. Anterior vitrectomy was performed with a 20 gauge vitrectomy cutter passed through the opening underneath the 12 O′ clock scleral flap. The IOL used was a 3 piece Sensar AR40e (AMO, USA) foldable implant (hydrophobic acrylic with UV absorber and blue PMMA modified C haptics). The IOL was injected via a temporal clear corneal tunneled incision of 2.8 mm. A 20 gauge intravitreal IOL holding forceps was introduced through the sclerotomy underneath the 6 O′ clock sclera flap till its tip could be visualized in the centre. Injection of the IOL was started and the leading haptic tip was grasped by the forceps. Exteriorization was done while injection of the IOL was gently continued. The leading haptic was grasped at the very tip so as to avoid snagging at the sclerotomy during exteriorization. Injection of the optic was completed while withdrawing the injector so that the trailing haptic remained outside the eye at the wound. The sponge tire of an iris retractor was used to plug into the exteriorized haptic at 6 O′ clock so that it did not slip back into the vitreous cavity while completing rest of the surgery. The intravitreal IOL holding forceps was then introduced through the sclerotomy port underneath the scleral flap at 12 O′ clock. A McPherson forceps was used to grasp the trailing haptic and this was flexed into the anterior chamber. The tip of this haptic was grasped with the IOL holding forceps and exteriorized at 12 o′clock. It was secured with another sponge tire of iris retractor. A partial thickness intra-scleral tunnel was created with a 26 gauge needle at the edge of the scleral flap parallel to limbus and along the haptic curve. The haptics were tucked into the scleral pocket. Centration of the IOl was adjusted by varying the degree of tuck of both haptics. The scleral bed was dried with a Weck-cel sponge, the infusion fluid being temporarily stopped. Vitrectomy was done at the sclerotomy ports to ensure that there was no incarceration of vitreous strands. Biological fibrin glue (Tisseel VH, Baxter AG, Vienna, Austria) was applied to the undersurface of the scleral flaps and the flaps were glued down. The conjunctiva at 12 and 6 o′clock was also closed with glue. The temporal clear corneal incision was hydrated. Intracameral injection of Moxifloxacin (Vigamox, Alcon, Fort Worth, TX, USA) 0.1 cc was given at the end of surgery. The patient was discharged without an eye patch.\nPostoperatively the patient was prescribed Vigamox drops 4 times a day for one week, Prednisolone acetate (Alcon, USA) 4 times a day, and Nepafenac (Nevanac, Alcon, USA) 3 times a day for a period of 4 weeks. The postoperative period was uneventful. On the first postoperative day the patient had uncorrected vision of 6/36 improving to 6/12 with pinhole. The cornea showed minimal edema and Descemets folds. Anterior chamber showed 1+ cells. IOP with non contact tonometry was 16 mm Hg. Fundus examination showed few vitreous cells and normal disc with attached retina. At the end of 1 week, the patient had a vision of 6/12 with −1 D sphere and near vision was N8 with add of +3D sphere. Corneal edema and descemets folds had cleared. Anterior chamber showed occasional cells. The IOL was well centered with IOP of 14 mm Hg on Goldman applanation tonometry and a normal fundus. At 4 weeks completed follow-up the patient had a vision of 6/9 with −1 D sphere and −0.5 D cylinder at 90 and near vision of N6 with +3D add. The cornea was clear with quietanterior chamber. The IOL was stable and well centered with IOP of 16 mm Hg. Fundus examination was normal. Glasses were prescribed at 4 weeks. At the 6 month completed follow-up the patient was maintaining a corrected vision of 6/9 N6 with a quiet eye, IOP of 15 mm Hg, stable IOL and normal fundus. [Figs. -].