sign in sign up
<<
Home , Iridodialysis, Stuck with Me

OCULAR TRAUMA s SEVERAL SURGEONS SHARE CASES THAT HAVE THE STORIES BEHIND THE CASES STUCK WITH ME THEY’LL NEVER FORGET BY ALLON BARSAM, MD, MA, FRCOPHTH; MARK KONTOS, MD; SOOSAN JACOB, MD, FRCS, DNB; MICHAEL E. SNYDER, MD; AND ELIZABETH YEU, MD

ALLON BARSAM, MD, MA, FRCOPHTH

Severe Blunt Trauma | A positive outcome for a patient who had been told that nothing could be done.

A few years ago, I treated a SURGICAL PROCEDURE the stabilization of the IOL­–capsular 41-year-old man who had suffered After the creation of the main bag complex. severe blunt trauma to one eye many incision, I injected an OVD to Phacoemulsification was carried years earlier. The patient experienced tamponade the anterior hyaloid out with low flow settings. I used a severe glare as a result of the trauma, membrane in the region of the zonular stop-and-chop technique to ensure such that he had to wear sunglasses defect. A cohesive OVD was then that minimal force was placed on whenever he was outdoors or even injected, and three hooks were the already weak zonular structures in a well-lit room. Also, his vision had placed to keep the iris back and to (Figure 2). Using a Simcoe cannula, decreased progressively since the prevent propagation of the iridodialysis I performed manual irrigation and incident because of the development of during phacoemulsification. aspiration of the epinuclear shell and a traumatic . Doctors advised I used a double-pass technique to soft matter to ensure that the force the patient that nothing could remedy create the capsulorhexis, centered exerted on the contents of the capsular the glare and that treating the cataract on the capsular bag instead of the bag was gentle. The tension on the would be too difficult and risky. to ensure optimum size and CTS was reduced slightly to facilitate Upon seeing another ophthalmologist, centration. I sought to preserve as the removal of the soft lens matter however, the patient was referred to my much of the anterior capsular rim under the device if required. The CTS practice. as possible to facilitate placement of was released, the bag was filled with a a capsular tension segment (CTS). I cohesive OVD, and a capsular tension CLINICAL FINDINGS injected an OVD to create a space ring was placed in the capsular bag. An examination found a moderately between the dense cataract and An 8-0 double-ended PTFE suture dense cataract, iridodialysis, and trauma the anterior lens capsule. A CTS was placed through the eyelet into to the sphincter of the iris (Figure 1). was dialed underneath the anterior the capsular tension segment and The crystalline lens was subluxated, capsule. Next, a central iris hook was docked into a 25-gauge needle. I used and the equator of the lens was almost reversed 180º and used to pull the micrograspers to facilitate the docking. bisecting the visual axis. central eyelet of the CTS and ensure The suture was passed through the

Figure 1. Traumatic cataract, iridodialysis, and trauma to Figure 2. Phacoemulsification was performed with low Figure 3. A one-piece aspheric IOL was placed. Figures 1-5 courtesy of Allon Barsam, MD, MA, FCROphth the iris sphincter. flow settings using a stop-and-chop technique to limit the force exerted on the weakened zonular structures.

MAY 2020 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 27 BIT.LY/BARSAM0520 WATCH IT NOW s Initially, things seemed to go well,go to seemed things Initially, I performed LASIK on thaton LASIK performed I socially withdrawn. Before the injury,the Before withdrawn. socially waswho kid outgoing smart, a was he popularvery been had and athletic very injurythe event, the After school. in thatlawsuit subsequent a in resulted andfriend best his lose to him caused Hefriends. common their of many organizedplay to able longer no was andinjury eye his of because sports did not result in a happy ending for thefor ending happy a in result not did man.young theto adjusting be to seemed he and hishowever, day, One situation. new washe said and aside me took mom becomehad and school in struggling complaint was a feeling of imbalanceof feeling a was complaint D-3.00 of error refractive the of because eye. contralateral the in Afteremmetropia. achieve to eye 20/10,was UCVA surgery, refractive extremelywas patient the and satisfied. A pellet gun injury changed the course of a young boy’s life. A pellet gun injury changed the course of a young boy’s life. Next, I passed a 10-0 double-ended10-0 a passed I Next, IOLthe surgery, after month One prosthesis was placed with very goodvery with placed was prosthesis thisUnfortunately, results. cosmetic the left eye at close range by his besthis by range close at eye left the prominenta of member (a friend clearwas It community). our in family wasinjury the that examination on likelynot would eye the that and severe totalking was I As vision. useful recover distraught,visibly was who mother, the Sheacquainted. were we realized I atworked who mother single a was heroicseveral After club. country our ourme, by eye the save to attempts surgeon, our and surgeon, aand removed, eventually was eye the was well centered, and the patient the and centered, well was symptoms glare of resolution a reported onlyHis 20/16. was UCVA 5). (Figure ingun pellet a with shot accidentally polypropylene suture through the through suture polypropylene micrograspersthe using roots iris hand- a and traction counter for thebetween technique over-hand holders.needle the and micrograspers eyethe inside suture the pulled then I reapproximateto tension directed and Thewall. scleral the with root iris the incident. without concluded case OUTCOME (Miochol-E, Bausch + Lomb) into the into Lomb) + Bausch (Miochol-E, and it, dispersed chamber, anterior OVD. cohesive a placed Figure 5. One month after surgery, the IOL is well centered (left and right). Figure 5. One month after surgery, | MAY 2020

MARK KONTOS, MD | Toll of Ocular Trauma Psychological The I was called to the emergency roomemergency the to called was I The injury itself was not so unusual,so not was itself injury The Managing patients with ocularwith patients Managing I removed the iris hooks andhooks iris the removed I After implanting a one-piece one-piece a implanting After and the consequences of the injurythe of consequences the and overme with stayed have that him for years. the ansee to afternoon summer a on beenhad who boy a to injury eye our memory. Some don’t though. Somethough. don’t Some memory. our ofone is case This vividly. remember we remember.to those aof eye the to shot gun pellet a aftermaththe was It boy. 12-year-old trauma is a pretty common occurrencecommon pretty a is trauma Mostophthalmologists. most for ofbackground the into fade patients to ensure the centration of the of centration the ensure to complex. bag IOL–capsular revealing OVD, the aspirated iridodialysisthe of extent the acetylcholineinjected then I 4). (Figure I applied tension to centralize thecentralize to tension applied I toslipknot a used then I bag. capsular on.later titrated be to tension allow by manufactured IOL aspheric 3), (Figure bag capsular the in Rayner CTS the on pressure increased I bed of the scleral flap. The needle wasneedle The flap. scleral the of bed waspass second a and straightened, centralthe to adjacent out carried thenwere loops suture The eyelet. CTSthe and eye, the into pulled bag. capsular the into directed was Figure 4. Iridodialysis visible after iris hooks have been after iris hooks have been Figure 4. Iridodialysis visible removed and OVD aspirated. CATARACT & REFRACTIVE SURGERY TODAY EUROPE

28 s OCULAR TRAUMA OCULAR TRAUMA s

the associated loss of binocularity. His Over the next couple of years, he Oregon. She lost all contact with him dreams of playing football in high school seemed to be managing as well as could and had become very depressed over and being in the military had vanished. be expected, and I was no longer in close the situation. I too, was saddened by I started to notice the changes over contact with his family. His mother had the course his life was taking. time as well and felt he was at risk for left her job at the club, and I was seeing It was hard not to think that the depression and its consequences. He did him only for yearly examinations. When trajectory of his life would have been not have a father figure in his life, so I he missed an appointment, I contacted much different had that pellet just tried to do what I could to help without his mother. Unfortunately, the news grazed his face instead of doing the being too intrusive. I was able to get one was not good. He had dropped damage it did to his eye. He was a of the professional golfers at the club out of school and had developed a happy, well-adjusted young man with a to help, and we got the boy involved in significant drug addiction. After several life full of possibilities. That all changed golfing and the snowboarding camp at unsuccessful rehabilitation attempts, the day he lost his eye. And I remember our ski mountain. he left home and moved to Portland, it like it was yesterday.

SOOSAN JACOB, MS, FRCS, DNB

Traumatic Subluxated In–the-Bag IOL | Managing a complex case using the Jacob Paperclip Capsule Stabilizer.

An interesting case that has stuck with me over the years is postoperatively. Intraoperatively, if required, capsular bag that of a middle-aged man who presented after sustaining ocular support can be increased by the translimbal placement of trauma from a shuttlecock while playing badminton. The patient capsular hooks that are removed after IOL implantation. had undergone a few years earlier. On examina- After first using this technique in this patient, I designed a tion, he had zonulodialysis and a subluxated in-the-bag IOL. modified version of the capsular hook: the Jacob Paperclip The traditional choice of treatment for this patient would Capsule Stabilizer (Morcher; Figure 6). have been to use sutured CTSs or a capsular tension ring to fixate the bag to the . At the time, however, I was ADVANTAGES OF TECHNIQUE developing a new technique for sutureless transscleral fixation No extensive capsular bag dissection required. There is of the capsular bag—the glued capsular hook technique. The no need for extensive dissection of the capsular bag in order

many disadvantages associated with suture fixation included Courtesy of Soosan Jacob, MD, FRCS, DNB increased surgical time, more complex and difficult surgery, A B difficulty with centration and adjustability, and the long-term possibility of suture-related complications. I therefore decided to use the glued capsular hook technique technique in this patient. Fortunately, the surgery was easy to perform, and the results were excellent.

THE TECHNIQUE Sutureless fibrin glue–assisted transscleral fixation of the C D capsular bag entails passing a modified capsular hook into the plane between the anterior capsule and the posterior surface of the iris through a sclerotomy created under a lamellar scleral flap and using the hook to engage the rim of the capsulorhexis. The haptic of the capsular hook then passes out through the sclerotomy and onto the scleral surface, at which point the haptic is trimmed and tucked into Figure 6. A subluxated capsular bag-IOL complex (A). A Cionni Ring for Scleral Fixation (B), a 26-gauge limbus-parallel intrascleral Scharioth tunnel. The an Ahmed Capsular Tension Segment (C), and a Jacob Paperclip Capsule Stabilizer (D), all scleral flap and the are closed with fibrin glue, from Morcher, are shown superimposed on the image. The amount of dissection of the bag providing transscleral centration and stabilization of the bag required to implant the Paperclip Capsule Stabilizer is the least and can be accomplished and obviating the need for other stabilization techniques more easily, even in fibrosed bags.

MAY 2020 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 29 An IOL was implanted into theinto implanted was IOL An Capsular Tension Ring was threadedwas Ring Tension Capsular capsulethe and bag, capsular the into ringthe tethering by recentered was permanenta with wall scleral the to suture. CustomFlexthe and bag, capsular theto trephined was Iris Artificial theinto implanted and size correct usedwas dye blue Trypan bag. capsular devicethe while capsule the visualize to becausebag capsular the in unfolded whenvisible longer no is reflex red the open.to begins device opaque the removedwas tissue iris necrotic The can be constructed in the desired area desired the in constructed be can theinto interiorized haptic the and withback it retracting simply by eye hapticThe microforceps. end-gripping throughagain exteriorized be then can undersclerotomy constructed newly a tuckedand flap scleral lamellar new the Then,tunnel. Scharioth new a into usingdown glued be can flaps both CapsulePaperclip Jacob The glue. fibrin stability long-term good offers Stabilizer surgery.of ease and Figure 8. The Cionni ring and iris prosthesis are Figure 8. The Cionni ring and iris prosthesis are visible within the capsular bag postoperatively. The capsulorhexis is visible overlying the prosthesis, and the suture securing the Cionni ring is visible in its anterior chamber path and along the episcleral surface under the conjunctiva in the upper right corner of the image. The color match of the device compares favorably to the residual native iris tissue, which can be seen temporally. That said, I find that rectifyingthat find I said, That Agent Iris became patient No. 1 in1 No. patient became Iris Agent After 6 months, the Departmentthe months, 6 After haptic is tucked into the intrascleralthe into tucked is haptic sutured with as Just tunnel. Scharioth of placement accurate fixation, scleral shouldflap the important; is flap the todialysis of zone the on centered be bag– capsular the of decentration avoid complex.IOL wronglya to secondary decentration with easier much is flap positioned suturedwith than technique this flapscleral lamellar new A segments. exposed aphakic space duringspace aphakic exposed Cionni1G type A phacoemulsification. unwilling to issue a CUDE for the devicethe for CUDE a issue to unwilling theof launch the of anticipation in toback go to had Iris Agent study. IDE waiting. THE SURGERY aftermonths 20 study IDE FDA US the a with began surgery His presentation. vitrectomyanterior plana pars one-port gel.vitreous prolapsed the remove to toused was OVD dispersive highly A remainingthe protect and tamponade cases. Unfortunately, the Departmentthe Unfortunately, cases. employmentmanages which Labor, of verywas employees, FBI for benefits thefor payment approve to slow waited.and waited Iris Agent so device, forpayment approved Labor of CUDEa and device, customiristhe FDA.US the to submitted was request investigationalFDA’s US the However, protocolstudy (IDE) exemption device underalready was CustomFlex the for wasagency the and negotiation, States. We therefore planned to obtainto planned therefore We States. USthe of use making by device the DeviceUse Compassionate FDA’s whichprogram, (CUDE) Exemption ofhandful a in used previously had we The tale of a traumatic cataract and three federal agencies. The tale of a traumatic cataract and three federal | MAY 2020

BY MICHAEL E. SNYDER, MD | Traumatic Cataract Easy centration adjustment. At the time, the CustomFlex ArtificialCustomFlex the time, the At An FBI agent—let’s call him Agent him call agent—let’s FBI An

Centration of the capsular bag andbag capsular the of Centration or increasing by achieved is IOL thewhich to degree the decreasing techniques such as the placement of anof placement the as such techniques or Segment Tension Capsular Ahmed (bothFixation Scleral for Ring Cionni a complexno Moreover, Morcher). from whichrequired, are maneuvers suturing procedure.the simplifies to insert the capsular hook, a stepa hook, capsular the insert to fixation other with necessary is that RED TAPE RED TAPE Unitedthe in available not was Iris (Figure 7). After a lengthy discussion ofdiscussion lengthy a After 7). (Figure undergoto elected Iris Agent options, withcataract the of phacoemulsification Cionnia of implantation and vitrectomy CustomFlexand Ring Tension Capsular (HumanOptics). Iris Artificial eye during a training exercise. The injuryThe exercise. training a during eye photophobiasignificant with him left duevision reduced markedly and cataractmisshapen mature, a to iridodialysis hour 4.5–clock a and tissueiris of bridge necrotic a with Iris—suffered a blunt injury to his lefthis to injury blunt Iris—suffereda Figure 7. After a blunt injury to the left eye, a dense Figure 7. After a blunt injury to the left eye, a dense cataract, capsular plaque, iridodialysis, and zonules tethering the lens edge superonasally were observed. Pigment in the prolapsed vitreous is evident in the anterior chamber. Figures 7 and 8 courtesy of Michael E. Snyder, MD Snyder, E. Michael of courtesy 8 and 7 Figures CATARACT & REFRACTIVE SURGERY TODAY EUROPE

30 s OCULAR TRAUMA OCULAR TRAUMA s

using a vitrector, and the surgery involved, is not unique with regard early experience with CUDEs had to was completed uneventfully. Agent to the administrative challenges that wait 8 years to get approval, which Iris achieved a happy outcome with patients with traumatic eye injuries came only after the device had been marked reduction in , no face, especially when they have approved by the US FDA for more glare, and a UCVA of 20/16 at his final other comorbid ocular injuries, such than a year. visit (Figure 8). as the iris damage in this patient. Fortunately for similar patients today, His case was finally resolved after the CustomFlex Artificial Iris is now CHALLENGES NOT UNCOMMON 2 years, but I have had other patients US FDA approved and covered by This story, although unique in who had to wait even longer. One Medicare and an increasing number of the layers of federal bureaucracy patient who presented during my commercial insurers.

BY ELIZABETH YEU, MD

Roman Candle Injury | Treating a remarkable child’s thermal injury taught me several lessons early in my career.

Managing ocular trauma can be with a large graft, reforming the LESSON NO. 3: physically and emotionally draining for fornices and covering the palpebral Collagenase activity is fierce. all involved—the patient, the patient’s and bulbar conjunctiva with the I saw how quickly a cornea can support system, and the clinicians. AMT. A large-diameter soft contact decompensate and melt away after One case that taught me several lessons lens was placed, followed by a a thermal injury, and, coupled with occurred early in my career. The patient temporary tarsorrhaphy. I prescribed the metabolism of a young child, the was a 4-year-old boy who came in as an topical moxifloxacin four times per day, process literally seemed to happen emergency with a Roman candle injury prednisolone acetate 1% four times per overnight. The central corneal to the right eye that had occurred 1 or day, and 500 mg vitamin C daily. perforation enlarged within a few days 2 days earlier. He was mature for his age as it underwent deturgescence. The and allowed me to perform a thorough LESSON NO. 2: patient required a tectonic penetrating slit-lamp examination. Young children have very robust keratoplasty (PKP). I explained to his healing potential. This patient parents that for vision rehabilitation LESSON NO. 1: required daily visits because his the patient would almost certainly Thermal injuries can devastate clinical examination changed quickly. require repeat corneal transplantation the eye very quickly. The initial Even the silk suture of the bolstered and a possible allograft AMT. Thus, examination surprised me, as there temporary tarsorrhaphy loosened back we went to the OR for a tectonic was already symblepharon beginning much more quickly than in an adult PKP, multilayered AMT to the surface, to form superiorly and inferiorly. The patient. The AMT dissolved away large-diameter bandage , paracentral cornea had a small 0.5 mm within 3 days. The large-diameter soft and a temporary tarsorrhaphy. by 1 mm perforation with iris plugging contact lens was allowing almost full This time, the cornea had a it, and the anterior chamber was conjunctival epithelialization without very difficult time reepithelializing formed. The corneal epithelium was further symblepharon formation. postoperatively, and the patient’s denuded, with stromal thinning that The corneal surface was healing with peripheral cornea began to was thinnest near the perforation. What conjunctivalized epithelium, which thin further. We decreased the a nightmare for this young child. was not unexpected but unfortunate, topical medications, switched to In the OR, I performed repair of as I knew this meant limbal stem cell preservative-free dexamethasone 0.1%, the corneal perforation. I released transplantation would be in his future. and maintained the oral vitamin C. the iris plug and placed cyanoacrylate The main worrisome sign was slow The sutures loosened quickly. The glue to close the small hole. After reepithelialization of the central cornea. clinical course necessitated multiple releasing the conjunctival adhesions The corneal stroma was quite thin in the repeat returns to the OR for this within the superior and inferior central 3 mm surrounding the area of child, who willingly obliged, for fornices, I performed amniotic the perforation. The anterior chamber suture removal or replacement and membrane transplantation (AMT) was deep, which was a promising sign. repeat AMTs.

MAY 2020 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 31 Global Advisory Board Global Advisory Executive Advisory Board Executive Advisory Board CRST CRST Europe CRST Member, [email protected] Financial disclosure: None Member, [email protected] pending (Jacob Financial disclosure: Patent Clinical Research Board of Governors and Chair, University Associate Professor of , Member, [email protected] Financial disclosure: Consultant and royalties Cataract, corneal and refractive surgeon, Virginia Eye Consultants, Norfolk, Virginia Cataract and Services, Dr. Agarwal’s Eye Eye Glaucoma Services, Dr. Agarwal’s Cataract and India Hospital, Chennai, and modified versions) Paperclip Capsule Stabilizer Eye Institute, Cincinnati Steering Committee, Cincinnati of Cincinnati (HumanOptics); Shareholder (VEO Ophthalmics)     n n n n n n MICHAEL E. SNYDER, MD n n n n n ELIZABETH YEU, MD n Editorial Board n CRST Europe Financial disclosure: Consultant (Rayner) Financial disclosure: Consultant Senior Partner, Empire Eye Physicians, Spokane, [email protected] Financial disclosure: None Director and Chief, Dr. Agarwal’s Refractive Director and Founding Partner, Ophthalmic Ophthalmic Director and Founding Partner, Member, [email protected]; www.oclvision.com Washington, and Coeur d’Alene and Hayden, Idaho and Cornea Foundation and Senior Consultant, Consultants of London       n MARK KONTOS, MD n n n SOOSAN JACOB, MS, FRCS, DNB n injuries. The resultant damage maydamage resultant The injuries. necessitatingnature, in progressive be theand procedures, sequential extensivefor guarded is prognosis injuries. FRCOPHTH ALLON BARSAM, MD, MA, n n n | MAY 2020

Ocular trauma can take devastatingtake can trauma Ocular After the eye was removed, he removed, was eye the After After all these heroic efforts, theefforts, heroic these all After always returned for his appointments,his for returned always importance the understood fully wasand protection, monocular of polycarbonate wearing with compliant times. all at spectacles chemicalor thermal especially turns, boy knew what this meant for him. Hehim. for meant this what knew boy tears,in was who mother, his to turned haveto ready was he that her told and wantdidn’t he because removed eye the anymore. him over cry to her patient presented four weeks afterweeks four presented patient follow-up.scheduled a for PKP the endophthalmitisbut pain, no had He waswhich eye, the consumed had anteriorlyexudate with filled completely thewithin exudate gas-forming and precocious This cavity. vitreous entire A BRAVE PATIENT A BRAVE PATIENT CATARACT & REFRACTIVE SURGERY TODAY EUROPE

32 s OCULAR TRAUMA