Surgical technique

Surgical techniqueSurgical technique

Incision opened up to 3.8mm , Using Incision opened up to 3.8mm , Using Monarch injector, Acrysof IOL MA 30 in Monarch injector, Acrysof IOL MA 30 in first 11 cases subsequently single piece first 11 cases subsequently single piece inserted first . The Hema IOL is inserted inserted first . The Hema IOL is inserted with a holder folder is placed over it. Both with a holder folder is placed over it. Both in the bag in the bag

Single suture 10/0 Nylon applied Single suture 10/0 Nylon applied

Intraocular Implants using Intraocular Implants using Bagged Disc Hema with AcrysofBagged Disc Hema with Acrysof

( Alcon) IOL in babies( Alcon) IOL in babies

9 month child 9 month child with gradual fall with gradual fall in vision. in vision.

Intraocular Implants using Bagged Disc Intraocular Implants using Bagged Disc Hema with Acrysof( Alcon) IOL in babiesHema with Acrysof( Alcon) IOL in babies

Side port with Side port with MVR blade, MVR blade, supporting from the supporting from the opposite sideopposite side


Diamond knife tunnel Diamond knife tunnel corneal incision . corneal incision . Care to make a deep Care to make a deep tunnel .tunnel .


Rhexis Rhexis commenced with commenced with sharp pointed sharp pointed Utrata forceps Utrata forceps


Hydrodissection Hydrodissection with blunt with blunt cannula cannula


Phaco with high Phaco with high aspiration , aspiration , occasional pulse occasional pulse


Fragments aspirated Fragments aspirated out carefully . Note out carefully . Note edge of rhexis edge of rhexis


Final fragments Final fragments aspirated out. aspirated out.


Posterior rhexis Posterior rhexis with the Utrata with the Utrata forcepsforceps


Posterior rhexis Posterior rhexis completedcompleted


Incision widened to Incision widened to 3.8 mm using a 3.8 mm using a keratome. Note keratome. Note width of tunnel width of tunnel


Acrysof lens Acrysof lens prepared for prepared for injection insertioninjection insertion


Loading lens in the Loading lens in the Monarch injector Monarch injector cartridgecartridge


Acrysof lens being Acrysof lens being injected into the injected into the posterior chamber posterior chamber


Note Acrysof lens Note Acrysof lens going below the going below the rhexis , into the rhexis , into the bag. Care to be bag. Care to be taken that it does taken that it does not snag on the not snag on the edge of the edge of the posterior rhexisposterior rhexis


Acrysof lens in Acrysof lens in placeplace


Hema domed Hema domed IOL implant . 9.5 IOL implant . 9.5 mm in diameter, mm in diameter, 5.00 mm optics, 5.00 mm optics, periphery very periphery very thin . Note bevel thin . Note bevel on edge to permit on edge to permit easy insertion. easy insertion.


Lens placed in the Lens placed in the folder to permit folder to permit easy holding . The easy holding . The lens is folded on lens is folded on itself like a roll in itself like a roll in the folder.the folder.


Hema IOL inserted Hema IOL inserted into the chamber , into the chamber , note its rolled statenote its rolled state


Hema lens opening Hema lens opening up. Care must be up. Care must be taken to insert the taken to insert the rim under the iris rim under the iris edge and under the edge and under the rhexisrhexis


Lens is tyre ironed Lens is tyre ironed under the rhexis under the rhexis rim and gradually rim and gradually worked into the worked into the position. It goes in position. It goes in surprisingly easily surprisingly easily due to the edge due to the edge bevelbevel


Final edge is Final edge is slipped in slipped in


It’s a very easy It’s a very easy procedure. Both procedure. Both IOL’s are stable. IOL’s are stable. Thanks to the Thanks to the beveled edge of the beveled edge of the IOL, insertion IOL, insertion under the rhexis is under the rhexis is easy. easy.

Unilateral or Unilateral or bilateral cataractbilateral cataract

Children Number Unilateral

Percentage Number Bilateral

Percentage

16 5 31.25% 11 68.75%

Age at ImplantationAge at Implantation

Age at Implantation

Number Males Females

2 months 5 4 1

3 months 3 1 2

5 months 4 3 1

7 months 5 3 2

8 months 5 1 4

10 months 3 3 0

13 months 1 0 1

15 months 1 1 0

TOTAL 27 16 11

Age at Hema Explantation

Number %

18 months 3 11.1

22 months 4 14.8

25 months 6 22.2

28 months 14 51.9

Total 27 100

Age at Explantation of the Hema IOLAge at Explantation of the Hema IOL

Residual ametropia after removal of Hema Residual ametropia after removal of Hema IOLIOL

Residual ametropia Residual ametropia NoNo % % +/- +/- 0.500.50 33 9.79.7+/- 1.00+/- 1.00 44 12.912.9+/- 1.50+/- 1.50 66 19.419.4

+/-+/- 2.00 2.00 0 0 00.000.0

+/- 2.50+/- 2.50 33 9.79.7+/- 3.00+/- 3.00 55 16.116.1+/- 3.50+/- 3.50 44 12.912.9+/- 4.00+/- 4.00 11 3.23.2+/- 4.50+/- 4.50 33 9.79.7

- 5.50- 5.50 11 3.23.2- - 7.007.00 11 3.23.2

Complications n =27Complications n =27

Complications Number Percentage

Corneal abrasion 2 7.4

Shallow A/C 9 33.3

Iritis 6 22.2

Hema IOL Pupil capture

2 7.4

Raised IOP : Temporary

7 25.9

Raised IOP : Needed Surgery

3 11.1

Hyphema 5 18.5

Criteria for selection of IOLCriteria for selection of IOL

Under anesthesia, measure corneal curvature with Under anesthesia, measure corneal curvature with auto keratometer on table. Take axial length auto keratometer on table. Take axial length reading with A- Scan , using SRK –T formula , reading with A- Scan , using SRK –T formula , calculate IOL power.calculate IOL power.

Extrapolate to age of two years based on reading Extrapolate to age of two years based on reading ( a baby at 3 months , with an IOL power of 28 –( a baby at 3 months , with an IOL power of 28 –30 D will be 23 D at 2 years).30 D will be 23 D at 2 years).

Place the anticipated IOL power as Acrysof in Place the anticipated IOL power as Acrysof in the bag first, place the residue as Hema over it.the bag first, place the residue as Hema over it.

Choice of LocationChoice of Location

1.1. Primary posterior chamber IOL's have been placed Primary posterior chamber IOL's have been placed in the bag and in the sulcus with good success.in the bag and in the sulcus with good success.

2.2. Secondary posterior chamber IOL's may be placed Secondary posterior chamber IOL's may be placed in the sulcus if the residual capsular leaflets offer in the sulcus if the residual capsular leaflets offer sufficient support for the IOL. Some dissection may sufficient support for the IOL. Some dissection may be necessary to recreate the sulcus in these cases.be necessary to recreate the sulcus in these cases.

3.3. Sutured posterior chamber IOL's have been used if Sutured posterior chamber IOL's have been used if capsular support is inadequate, but the long-term capsular support is inadequate, but the long-term safety of these lenses is uncertainsafety of these lenses is uncertain

Why No A/C IOL in a childWhy No A/C IOL in a child

A/C IOL's are to be avoided at all costs because of A/C IOL's are to be avoided at all costs because of intense postoperative inflammatory reaction, intense postoperative inflammatory reaction, risk of angle fibrosis and glaucoma, risk of angle fibrosis and glaucoma, corneal decomposition, corneal decomposition, changing dimensions of the angle in the growing changing dimensions of the angle in the growing

child. child.

If a secondary IOL is sought with no capsular If a secondary IOL is sought with no capsular support, an PC IOL's should and must be support, an PC IOL's should and must be

sutured in placesutured in place..

Criteria for removal of IOLCriteria for removal of IOL

When anticipated IOL refraction reaches –4.00 , When anticipated IOL refraction reaches –4.00 , remove IOL. Example. Baby placed IOL at 3 remove IOL. Example. Baby placed IOL at 3 months of 31 D , 23.00D as Acrysof , + 6 D as months of 31 D , 23.00D as Acrysof , + 6 D as Hema ( under correcting by 20%). Will reach –Hema ( under correcting by 20%). Will reach –4.00 at age of 18 months when IOL removed. 4.00 at age of 18 months when IOL removed.

We use the rule of 4 as a variation of 4 dioptres We use the rule of 4 as a variation of 4 dioptres from emetropia rarely induces significant from emetropia rarely induces significant amblyopia. *amblyopia. *

* ( * ( Isenberg S. Torczynski E:Mosby 2Isenberg S. Torczynski E:Mosby 2ndnd Ed 36-50 Eye in Infancy 1994 ) Ed 36-50 Eye in Infancy 1994 )

SummarySummary

The Hema domed IOL gives a format which is easy The Hema domed IOL gives a format which is easy to insert, stable in the eye, very quiet in the eye & to insert, stable in the eye, very quiet in the eye & induces no adhesions .induces no adhesions .

It is easy to insert via 3.4 mm incision and just as It is easy to insert via 3.4 mm incision and just as easy to remove without cutting or splitting it.easy to remove without cutting or splitting it.

The concept of multiple IOL with phased removal is The concept of multiple IOL with phased removal is a concept which is feasible thus giving the best hope a concept which is feasible thus giving the best hope for controlling deprivation amblyopia in infantsfor controlling deprivation amblyopia in infants

Surgical technique

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