Rasik B. Vajpayee-Sinha

To describe a new technique of stratified phacoemulsification of the nucleus to protect the vulnerable posterior capsule in posterior polar cataracts. Dr Om Parkash Eye Institute, Amritsar, India. Prospective interventional study. Twenty-six eyes of twenty-two patients with posterior polar cataracts and nuclear sclerosis of Grade 2 and above, undergoing phacoemulsification surgery, were included in the study. No hydro procedures were performed intentionally to prevent the pressure build-up within the bag or the occurrence of accidental hydrodissection in any of the eyes. Stratified separation was used to separate the nucleus from the surrounding epinucleus mass along natural separational planes in moderate to hard nuclei. Nuclear fragment was emulsified, leaving the epinucleus shell intact. This process of stratified separation and emulsification was repeated for all nuclear fragments without disrupting the epinucleus shell. The epinuclear shell acted as a scaffold and prevented fluidic turbulence and mechanical forces transmission to the fragile posterior capsule. Finally, the epinucleus shell and cortical lens matter were aspirated, and an intraocular lens was implanted. Our technique of stratified phacoemulsification, which entails chopper-assisted manual delineation of the nucleus, yielded excellent outcomes. Our study included Twenty-six eyes of twenty-two patients with posterior polar cataract and nuclear sclerosis grade 2 or higher. Posterior capsular rupture occurred in one case, which showed pre-existing dehiscence with a moth-eaten appearance on Anterior Segment Optical Coherence Tomography. The pre-existing posterior capsular rent did not result in any intraoperative complications. The technique of stratified phacoemulsification can achieve safe and successful cataract surgery in posterior polar cataracts with Grade 2 or higher nuclear sclerosis, without the use of hydro maneuvers or expensive femtosecond lasers. The technique entails using standard instruments to form an epinuclear shell that protects the posterior capsule during nuclear emulsification.

To describe the use of a narrow calibrated side-port incision technique in preventing Intraoperative Floppy Iris Syndrome (IFIS). Dr Om Parkash Eye Institute, Amritsar, India. Prospective interventional study. Four hundred and fifty eyes of patients using alpha-1 antagonist drug Tamsulosin were included in the study. Phacoemulsification surgery was performed with a calibrated side-port incision integrated to the existing preferred techniques in patients taking Tamsulosin. Our technique involved creating a narrow 500 microns (µm) side-port incision, paired with a differentially calibrated chopper shaft measuring 400 to 450 µm, with a 50 µm variation along the shaft. This precise calibration between the side-port and chopper sizes minimized fluid leakage, preventing surgical impediments and side-port wound distortion. The reduced fluid efflux through the side-port incision stabilized the anterior chamber near the side port, decreased iris contact with the chopper and eliminated the risk of iris prolapse. Integration of side-port calibration into the existing techniques helped prevent IFIS from developing around the side-port incision site. Our technique of calibrated side-port incision, which requires perfect calibration of the incision with the chopper, gave excellent results. Our study comprised of a total of 450 eyes from patients on Tamsulosin undergoing phacoemulsification were included. IFIS was completely absent in 271 eyes. Minimal IFIS, characterized by iris billowing, was observed in 179 eyes, while no cases of moderate or severe IFIS occurred. When added to existing surgical techniques, a calibrated side-port incision significantly improves patient outcomes in managing IFIS during phacoemulsification in patients taking alpha-1 antagonist drugs. This modification helps prevent the side-port incision from becoming a focal point for IFIS, thereby enhancing surgical safety and efficacy.

An integrated cell, tissue, and eye bank is vital to meet the evolving needs of ocular transplant therapies. In addition to traditional corneal transplant tissues, it encompasses processing and delivery of transplant materials for newer treatments like cell-based therapies and gene-modified products, adhering to rigorous standards, optimizing tissue utilization with comprehensive services for surgeons.

A 34-year-old woman with quiescent bilateral intermediate uveitis maintained on once-daily dexamethasone 0.1% eyedrops, complicated by left cataract and glaucoma controlled with a single antiglaucoma medication, presented for cataract surgery. Her left corrected distance visual acuity (CDVA) was 20/40 because of a posterior subcapsular lens opacity. The anterior chamber angles appeared closed in all 4 quadrants on gonioscopy. Ultrasound biomicroscopy (UBM) confirmed the gonioscopy findings and, in addition, revealed a crystalline lens thickness of 5.53 mm, normal ciliary body structure, and multiple localized chorioretinal scars with membranes over the pars plana region. She underwent left phacoemulsification, goniosynechiolysis, and in-the-bag implantation of a single-piece monofocal hydrophobic acrylic intraocular lens (IOL). On the first postoperative day, she achieved pinhole vision of 20/70 (-6 diopters [D] myopia to balance with the fellow eye). There was mild anterior chamber cellular activity and flare, consistent with postoperative inflammation. Her intraocular pressure (IOP) was 16 mm Hg without antiglaucoma therapy. She was advised to continue the prednisolone acetate 1% eyedrops 6 times daily and to reduce it to 4 times daily after a week for the next 4 weeks. At 1 month, she was refracted to 20/40 N5, and the eye was quiescent. Optical coherence tomography showed that the macular was normal. The topical steroids were gradually tapered to the preoperative level. However, a month later, she returned complaining of deteriorating vision while using twice-daily steroid eyedrops. Her CDVA was 20/60. Slitlamp examination revealed anterior capsule fibrosis and capsular phimosis, resulting in partial obstruction of the visual axis and mild decentration of the IOL superior temporally (Figure 1JOURNAL/jcrs/04.03/02158034-202310000-00013/figure1/v/2023-09-28T161738Z/r/image-tiff). The anterior segment was quiescent. The pupil could only be dilated to 4.5 mm despite the absence of posterior synechiae. Fundus examination revealed a normal-looking quiescent posterior segment. Her IOP was 16 mm Hg. UBM showed a thickened anterior capsule, intact zonular fibers, and a posteriorly bowed and decentered IOL within the capsular bag (Figure 2JOURNAL/jcrs/04.03/02158034-202310000-00013/figure2/v/2023-09-28T161738Z/r/image-tiff). She was referred for further management. Discuss how you would manage this problem, explaining your decisions. How would you be able to avoid the same problem when operating on her fellow eye?

Corneal perforations in eyes with dry eye disease (DED) are difficult to manage due to the interplay of several factors such as the unstable tear film, surface inflammation, and the underlying systemic disease affecting the wound healing process, and the eventual outcome. A careful preoperative examination is required to identify the underlying pathology, and status of ocular surface and adnexa, rule out microbial keratitis, and order appropriate systemic workup in addition to assessing the perforation itself. Several surgical options are available, which include tissue adhesives, multilayered amniotic membrane grafting (AMT), tenon patch graft (TPG), corneal patch graft (CPG), and penetrating keratoplasty (PK). The choice of procedure depends upon the size, location, and configuration of the perforation. In eyes with smaller perforations, tissue adhesives are effective treatment modalities, whereas AMT, TPG, and CPG are viable options in moderate-sized perforations. AMT and TPG are also preferable in cases where the placement of a bandage contact lens may be a challenge. Large perforations require a PK, with additional procedures such as tarsorrhaphy to protect the eyes from the associated epithelial healing issues. Conjunctival flaps are considered in eyes with poor visual potential. The management of the acute condition is carried out in conjunction with measures to improve the tear volume bearing in mind the chances of delayed epithelialization and re-perforation in these cases. Administration of topical and systemic immunosuppression, when indicated, helps improve the outcome. This review aims to facilitate clinicians in instituting a synchronized multifaceted therapy for the successful management of corneal perforations in the setting of DED.