cataract session - iv - All India Ophthalmological Society

CATARACT SESSION - IV 

119 

CATARACT-IV 

Chairman: Dr. Vikas Haribhau Mahatme, Co-Chairman: Dr. Ravi Kumar Reddy 

Convenor: Dr. Raja Datta, Moderator: Dr. Amit Tarafdar 

AUTHORS’S PROFILE: 

DR. ARCHANA PANDEY: M.B.B.S. (’91) and M.S. (’95) from Gajara Raja Medical College 

(Jiwaji University), Gwalior, M.P. Fellowship in Anterior Segment microsurgery & IOL and 

also in Pediatric Ophthalmology and strabismus from Sankara Netralaya, Chennai. Presently, 

Senior consultant in Shri Ganapati Netralaya, Jalna, Maharashtra. 

E-mail: archanapandey2000@yahoo.com 

Phacoemulsification and IOL Implanntation in Eyes with Cataract 

and Typical Congenital Coloboma of Iris (Safety, Visual Acuity 

and Complications) 

Failure of the embryonic fissure to fuse at 6 

weeks of gestation results in the typical form 

of congenital coloboma. This coloboma may be 

complete or incomplete involving the iris, ciliary 

body, the zonules, lens, retina, choroid, macula, 

and optic disc to a variable extent. Cataract 

surgery in such patients is a challenge with the 

higher risk of intra and postoperative 

complications. 

Purpose of our study was to evaluate the 

outcomes of phacoemulsification and IOL 

implantation in eyes with cataract and typical 

congenital coloboma of iris. 

Materials and Methods 

Retrospective study comprised of a series of 23 

eyes of 20 patients with congenital coloboma of 

iris and cataract. All underwent 

phacoemulsification and PCIOL implantation 

between Feb 2000 and Jan 2008. 

Preoperative Evaluation: Preoperative 

evaluation included BCVA, torchlight 

examination, slitlamp examination, IOP 

measurement, gonioscopy, posterior segment 

examination by binocular indirect 

ophthalmoscope and keratometry. Axial length 

was measured by A-scan USG and was 

confirmed with B-Scan USG. 

Surgical Technique : All cases were operated by 

single surgeon (Author) under peribulbar 

Dr. Archana Pandey, Dr. Nikita Bajpai 

(Presenting Author: Dr. Archana Pandey) 

anaesthesia. Super pinkie ball was not applied 

and digital massage was not given. Superior or 

temporal scleral tunnel was made. Viscoelastic 

(2% methylcellulose) was injected through 

sideport. Anterior chamber was entered through 

main tunnel with 3.2 mm keratome. Four 

paracentesis wound were made at 3,5,7 and 9 

o’clock position. 3 and 9 o’clock for irrigation and 

aspiration cannula and 5 and 7 for iris hooks. 

Anterior capsulorhexis was started with 

cystitome (bent 26 G needle) and completed with 

vannas scissors and utrata forceps. Iris retractors 

were used at 5 and 7 o’clock position to stretch 

the capsulorhexis edge to the scleral wall. Gentle 

and thorough hydrodissection was done. 

Phacoemulsification ( Legacy 20000 series with 

30 degree bent kelman tip) was done using 

power appropriate for the grade of cataract, low 

vacuum, low aspiration flow rate with minimal 

bottle height - a slow motion phacoemulsification 

technique. Soft nucleus was removed by 

aspiration technique and hard nucleus by phaco 

chop technique. The remaining cortex was 

removed by bimanual irrigation and aspiration 

with low aspiration flow rate, minimal bottle 

height and appropriate vacuum. C.T.R. was 

inserted only after removal of the residual cortex. 

Anterior chamber entry of main scleral tunnel 

was enlarged to 5.25 mm and viscoelastic was 

injected into anterior chamber. All PMMA single 

piece lens 5.25 mm optic size and overall length

120 AIOC 2009 PROCEEDINGS 

of 12 mm was implanted in the capsular bag in 

all cases. Special attention was made while 

making the capsulorhexis that it must cover 0.5 

to 1 mm of optic margins especially at the 

coloboma site so that subsequent fibrosis which 

prevents the halo of aphakic vision. IOL was 

dialed only so far as to move any haptic out of 

the iris coloboma to decrease postoperative 

glitter or glare. 

Post operatively all patients were given steroid – 

antibiotic eye drops, which was tapered over 5 

weeks. All patients were examined on 

postoperative days 1 and 7, then 1 month, 3 

months, 6 months, and then yearly. Every follow 

up included a thorough slit lamp examination, 

IOP measurement, best corrected VA, and 

detailed fundus examination (deferred at PO day 

1 and 7). 

Results were evaluated by determining the 

change in best corrected VA at 1 month followup 

after surgery. 

Results 

Our retrospective study includes 23 eyes of 20 

patients. (17 patients male and 3 females). Mean 

age was 40.0 years (range 21-56 yrs). Follow up 

range from 4 months to 7 years. 

Extent Of Coloboma : All eyes had coloboma of 

iris, lens,zonules, choroid and retina. 

Three eyes in addition had coloboma of macula 

and optic disc also. 

Visual Acuity: -20 out of 23 eyes had significant 

visual improvement with best corrected visual 

acuity of 17 eyes 6/6 , 2 eyes 6/ 7.5 and one eye 

6/9. All 20 eyes had near vision N/6 with the add 

of +3.0D. In 3 eyes with coloboma involving 

macula and optic disc also, visual acuity 

improved to counting finger 3 meter from 

counting finger 1 meter. 

Complications: (a) Intraoperative : In all cases 

surgical procedure was uneventful. (b) 

Postoperative : 

One eye had rhegmatogenous retinal detachment 

at 6 months follow up. 

Rest 22 eyes had no serious complications. 

Diplopia and glare were not observed in any 

case. 

Discussion 

Given the infrequent occurrence of this ocular 

malformation, any study on surgical outcome in 

eyes with cataract and congenital coloboma is 

limited, and prospective data acquisition is 

impractical. Our larger case series of 23 eyes 

confirms the relatively good visual outcome. Our 

surgical paradigm of closed chamber technique 

was invaluable. Iris retractors were used to 

temporarily support and stabilize the capsular 

bag for safer phacoemulsification and IOL 

implantation. Thorough but gentle 

hydrodissection helped us reduce the stress on 

the zonules during phacoemulsification.Using 

appropriate phaco power depending on the 

grade of cataract, accompanied by low aspiration 

flow rate, low vacuum and low bottle height 

which together cause minimal turbulence in the 

anterior chamber. This provides a safe and 

predictable outcome in colobomatous eyes. In 

our study, CTR was found to be useful. We 

noticed that on longterm followup, with in the 

bag fixation and with CTR, the IOL was well 

centered due to capsule stretching, stability and 

support. 

When colobomas include the macula, axial length 

measurements may be difficult to obtain because 

of irregularities in the posterior globe shape. 7 In 

our study we confirmed the axial length with B- 

scan USG in all eyes and found good result. 

There is increased risk of retinal detachment in 

eyes with coloboma. Michael L. Nordlund 

reported one case of retinal detachment in post 

op followup in their study. 7 We also reported 

one case of rhegmatogenous RD at 6 months post 

op followup. 

One study reported post operative monocular 

diplopia caused by the edge of the IOL optic 

bisecting the ectopic pupil. 7 In our study we did 

not report such complication because the anterior 

capsulorhexis (with subsequent fibrosis) covered 

the IOL edge. 

• Phacoemulsification with IOL implantation is 

safe and beneficial in patients with cataract 

and typical congenital coloboma of iris. 

• Potential complications like extension of 

zonular dehiscence, vitreous loss, monocular 

diplopia and glare can be prevented by a 

meticulous surgical technique and 

capsulorhexis.


121 

1. Jesberg DO, Schepens CL. Retinal detachment 

associated with coloboma of the choroids. Arch 

Ophthalmol 1961;65:163-73. 

2. Hovland KR, Schepens CL., Freeman HM. 

Developmental giant retinal tears associated with 

lens coloboma. Arch Ophthalmol 1968;80:325-31. 

3. Watt RH. Inferior congenital iris coloboma and IOL 

implantation (letter). J. Cataract Refracct Surg 

1993;19:669-71. 

4. Volcker HE, Terz MRm Daus W. Cataract surgery 

in eyes with coloboma. Dev Opthalmol 1991;22:94- 

100. 

5. Nixseaman DH. Cataract extraction in case of 

congenital coloboma of the iris. Br J Ophthalmol 

1968;52:625-7. 

References 

6. Jaffe NS, Clayman HM. Cataract extraction in eyes 

with congenital colobomata. J Cataract Refract Surg 

1987;13:54-8. 

7. Michael L. Nordlund; Phacoemulsification and 

intraocular lens placement in eyes with cataract and 

congenital coloboma, J. C. R. S. 2000;26:1035-40. 

8. Merriain JC, Zheng L. Iris hooks for 

Phacoemulsification of the subluxated lens. J 

Cataract Refract Surg. 1997;23:1295-7. 

9. Cionne RJ, Osher RH. Endocapsular ring approach 

to subluxated cataractous lens. J Cataract Refract 

Surg. 1995;21:245-9. 

10. Vasavada AR, Desai JP. Stop, chop, chop and stuff. 

J Cataract Refract Surg 1996;22:526-9. 


DR. (LT. COL.) J.K.S. PARIHAR: MS, DOMS, DNB, MAMS. Post Doctoral, Ant. Segment, 

Micro Surgery & Laser, AIIMS. Recipient of Dr. S.D. Athavala Gurad (‘05) & Satayavati S. 

Madan Memorial Award (2003). Presently Prof. & Head, Dept. of Ophthalmology, Command 

Hospital (EC), Alipore Road, Kolkata-700027 

Contact: (033) 2222-6389/6391; E-mail: jksparihar@hotmail.com 

Comparative Evaluation of Structural and Functional Outcome 

Following Bilateral Implantation of Multifocal Intraocular Lenses 

Over Monofocal Single Piece Hydrophobic IOL Implants 

Dr. (Col.) J.K.S. Parihar, Dr. (Maj Gen.) D.P. Vats, Dr. (Lt. Col.) Rakesh Maggon, 

Dr. (Lt. Col.) Vijay Mathur, Dr. (Lt. Col.) S.K. Mishra, Dr. S.K. Gupta 

(Presenting Author: Dr. (Col.) J.K.S. Parihar) 

There has been tremendous change in the 

concept of Cataract surgery and IOL 

implants particularly in the recent past. 

Phacoemulsification with conventional Foldable 

IOL implantation is no more the method of 

choice for the management of cataract alone. The 

present concept demands Keratorefractive 

surgery in true sense which should provide 

emmetropia for full range and all types of vision. 

Each and every aware patient dreams of having 

complete freedom from spectacles for any 

purpose. Bimanual Micro phaco, Ultra thin, 

Multifocal or Accommodative IOL implants are 

step towards ultimate goal of full range, all 

purpose emmetropia. 

Modern generation of multifocal IOL implants 

are latest revolution in cataract surgery that is 

breaking all barriers to achieve full range all time 

vision following cataract surgery. Recent 

introduction of newer generation multifocal IOL 

implants based on Apodized Diffractive concept 

and other techniques have substantiated one step 

forward towards full range of vision. The present 

study is aimed at evaluating the efficacy of 

Multifocal IOL implant in terms of various 

occupational need as well as their functional and 

structural compatibility in Indian eyes. 


This prospective study comprised of 70 cases of 

uncomplicated cataracts of identical nuclear 

grading, is to evaluate the pattern of structural 

changes and visual functional outcome following 

implantation of refractive and diffractive types of 

multifocal intraocular lenses (IOLs) over 

monofocal IOL implants Randomized selection 

of type of IOL implanted was done. Of these 35 

cases each had received bilateral diffractive


multifocal Tecnis ZM 900 (AMO) (n = 35, 70 eyes) 

and Apodized diffractive Restore IOLs (n=35, 70 

eyes) respectively. Results were compared with 

single piece hydrophobic acrylic monofocal IOL 

implantation in 50 cases ( n=50 ,100 eyes) 

Emphasis was made on critical evaluation of 

efficacy and adaptability of these IOL implants in 

different occupational situations in context to the 

Indian scenario. Detailed evaluation was based 

on surgical technique, operative constraints, 

postoperative complications, pattern of visual 

functions both in mesopic and photopic 

conditions and ultimate visual outcome as well 

as on patient's rehabilitation. All these cases had 

undergone detailed ocular examination prior to 

Phaconit surgery. Evaluation of hardness of the 

nucleus was based on slit lamp examination. The 

power of intraocular lens was calculated by IOL 

master using a new generation IOL calculation 

formula like SRKIT for better accuracy. Patients 

with any other associated ocular conditions like 

glaucoma and iridocyclitis or any systemic 

disease were excluded from the study. 

Basic technique of Phacoemulsification by clear 

corneal incision and central chopping under 

topical anaesthesia was applied in all cases in this 

study. A well centered and circular capsulorhexis 

of approximately 5.5 mm in size was aimed in all 

cases. Implantation of IOL through IOL delivery 

injector system designed for specific IOL 

implants was used. The most important step was 

to align central ring in the centre of visual axis by 

negotiating its position through post IOL 

implantation miotic pupil. Subconjunctival 

injection of dexamethasone, 4mg and 

gentamycin, 20mg was given. No eye pad was 

given in any case. Post -op visual recovery and 

astigmatism were evaluated in all cases. 

Results 

We did not notice any significant intraoperative 

complications except in two eyes. In different 

cases insertion of the trailing haptic into the bag 

required repeated manipulations due to 

inadvertent intra operative miosis. Incidentally 

both these IOLs were Tecnis IOL implants. One 

of these eyes had trace of hyphaema which was 

cleared by irrigation and aspiration. However 

postoperative period remained uneventful in all 

the cases including these two cases. All patients 

had full visual recovery within 48 hours. Mean 

binocular distance best corrected visual acuity 

(BSCVA) was 6/9 for controls, 6/6 for multifocal 

IOLs. Mean binocular near visual acuity was N/6 

in monofocal as compared to N/5 in multifocal 

IOLs in photopic conditions. Monofocal IOLs had 

attained better contrast sensitivity than the 

multifocal IOLs. Independence from spectacle 

was achieved in 92.85% cases of ReSTOR and 

90% in Tecnis group. Decentration of central zone 

of multifocal IOL was seen in 2 eyes with Tecnis 

and one eye with ReSTOR IOLs resulting in 

significant glare and distortion of image and 

required additional refractive corrections. PCO 

was seen in 10% with Tecnis and Monofocal and 

8.57% with ReSTOR IOLs after 24 months. 

Discussion 

Keys for Successful outcome following multifocal 

IOL implantation is exclusively based on 

judicious selection of the patients, accurate 

biometry, and IOL Power Calculation as well as 

on intraoperative precision of highest order. 

While selecting patients age, functional and 

occupational requirements, degree of general 

alertness, patients visual demands, expectation 

for near vision needs should be considered. 

Hypercritical patients, patients with unrealistic 

expectations, complex anterior segment 

structural configuration like in high corneal 

astigmatism of more than 1.5 dioptre and 

associated pre existing ocular pathology should 

be discouraged to under go multifocal IOL 

implantation. Over and above any intraoperative 

complications remain relative contraindications 

for Multifocal IOL implantation. Common Zonal 

refractive multifocal IOL possesses five refractive 

zones. Each and every zone represents a separate 

optical surface in true sense against mesopic light 

conditions (Pupillary size of 4.5 to 5 mm). These 

multiple zones face light scattering leading to 

formation of surrounding unwanted images like 

concentric circles or shadows around a main 

image. Due to the presence of this peculiar 

optical configuration, such IOLs are expected to 

have compromised mesopic vision. The apodized 

diffractive optics has two sloping zones, the 

central 3.6 millimeters of the lens and remaining 

part of a 6 millimeter optic. Central 3.6 mm zone 

act as a diffractive zone and are apodized. 

Remaining zone is a refractive region. The 

combination of these two zones are critical to 

produce a full range of vision under all lighting 

conditions, both photopic, or light conditions,


123 

and mesopic, or low light conditions. However 

despite the fact that efficacy of Night vision is of 

excellent order in case of Apodized multifocal 

IOL implant which is at par with the 

performance of the monofocal IOL implants, a 

word of caution should be applied in case of 

occupational night drivers. Accurate Biometry 

and selection of appropriate method of IOL 

Power Calculation has immense role in ultimate 

outcome of any IOL implantation. However such 

variants in calculation have tremendous impact 

on outcome of latest generation multifocal IOL 

implantation. Various small errors are likely to 

result in a large error. Application of contact 

biometry, Use of inaccurate Keratometry and 

wrong formula selection are key factors to have 

unexpected post-operative refraction and 

ultimate dissatisfaction. Whenever possible, it is 

better to compare the pre-cataract refractive error 

with bilateral IOL calculations for consistency. 

Average of multiple, consistent measurements in 

IOL calculations and deletion of others readings 

are better options. One should avoid taking 

measurements immediately after corneal contact 

or use of drops that dry the ocular surface. 

Contact lens wear should be discontinued until 

stable (repeatable) corneal values are obtained. 

Standard immersion A - Scan ultra sound or 

Optical Biometry by IOL Master is recommended 

to avoid axial misalignment, corneal 

compressions, or tear bridge .In our view, 

precision in IOL power calculation is one of the 

most significant issues in final visual outcome in 

these cases. Needless to stress, customized A- 

constants, ACO, and standardized surgeon factor 

carries great value in accuracy of presumed post 

operative refraction. Lens position also carries 

great value in relation to the final post-op 

refraction. In a Myopic eye, a 0.1 mm error could 

change the post - op refraction by 0.10 where as 

in an Emmetropic eye, a 0.1 mm error could 

change the postop refraction by 0.150. In a 

Hyperopic eye, a 0.1 mm error could change the 

post op refraction by 0.250. Therefore, in a 

Hyperopic eye, 1 mm error could change the post 

op refraction by 2.500. We recommend use of a 

new generation IOL calculation formula like 

SRKlT, Holladay 2, or Haigis for better results. 

These IOLs have been proved to be compatible 

to YAG laser energy under normal energy need 

of less than 2.5 MJ for the management of 

expected Posterior capsular Opacification. We 

did not notice any shift in the central ring 

position following YAG capsulotomy in any of 

the group. Undoubtedly multifocal IOL implants 

are very useful tools to restore earliest availability 

of skilled and trained manpower after cataract 

surgery like in sports, administrators, 

educationist ,medical and IT professional as well 

as in armed forces and paramilitary setup due to 

least derangement of anatomical integrity of 

eyeball and very quick multirange and dynamic 

visual restoration and that too without 

jeopardizing the medical requirement. 

However final results are yet to be critically 

analyzed against all types of Cataract particularly 

in long term follow up. 

Scleral Fixated IOL as A Secondary Procedure—Our Experience 

Scleral fixated posterior chamber IOL is done 

to place the IOL in the normal anatomic 

position of human lens. Here the lens reduces 

the risk of bullous keratopathy, damage to angle 

structures, risk of pupillary block glaucoma is 

reduced, pseudophacodonesis is reduced, as it is 

closer to the rotational centre of the eye. The 

centrifugal forces acting on the lens is reduced 

and ocular contents are stabilized thus reducing 

the risk of iritis, CME and retinal detachment. It 

improves the optical properties of the lens. 

Since it was first introduced by parry in 1950’s it 

Dr. Srinivas Rao V.K, Dr. Shreesh Kumar .K 

(Presenting Author: Dr. Srinivas Rao V.K) 

has undergone various changes and a number of 

techniques to do the same. 


It is a retrospective study of 42 consecutive 

patients undergoing scleral fixated IOL. The case 

records of all these patients were reviewed. 

Patients with preexisting retinal pathology were 

excluded from the study. 

Preoperative Evaluation 

Before the surgery all patients had a base line 

examination of best corrected visual acuity, slit


lamp examination, applanation tonometry, 

fundus examination by indirect ophthalmoscopy, 

specular microscopy, keratometry, A-scan 

biometry. Basic routine blood examination and 

ECG were done. 

Surgical Technique 

All the patients underwent the procedure under 

lignocaine 2% in the peribulbar space. The 

procedure was Ab externo two point fixation 

with a sclero corneal tunnel. The only difference 

being the scleral flaps which were ‘L’ shaped at 

the limbus and the two points of fixation exactly 

180 0 apart and they were not sutured at the end of 

the surgery. 

Postoperative Protocol 

Post operatively the eyes were treated with 

topical steroid drops (predinosolone acetate) 6 

times a day for 6 weeks, topical antibiotics 

(ofloxacin) 6 times for 1 week, topical timolol 

maleate 0.5 twice daily for 2 weeks. Ketorolac 

tromethamine topical drops 4 times for 6 weeks. 

Where necessary oral aectazolamide was 

prescribed for 1 or 2 days. 

Results 

44 eyes of 42 patients who underwent SFIOL 

between January 2006-May 2008. 20 males and 22 

females (two of these underwent bilaterally). The 

follow up period was 6 weeks-120 weeks (30 

months). The average age of the patient was 60 

years, age ranging from 21-75 years. 

Of the 44 eyes for SFIOL 30 were right and the 

rest 14 eyes were left. The indication for SFIOL in 

the series, Aphakia with no PC support in 25 

eyes, Posterior capsule rupture with inadequate 

posterior capsule in 4 eyes and 4 eyes had 

ectopia lentis where a CTR or Cionni ring could 

not be used. 

The best corrected visual acuity was maintained 

as in pre op in 28 eyes, 3 eyes there was an 

improvement of 1 line in Snellens chart, 8 eyes 

lost 1 line due to cystoid macular oedema, 4 eyes 

lost 2 lines due to CME and uveitis with pigment 

deposition over the IOL. One eye had hand 

movement visual acuity after 2 weeks following 

retinal detachment. 

The common complication encountered was 

raised IOP which was noted in 20 eyes which was 

controlled medically. 12 eyes had CME which 

was managed with topical NSAIDS. 4 eyes had 

uveitis which was managed with aggressive 

topical steroids. In one eye with retinal 

detachment the patient refused surgery and was 

lost for further follow up. 

Discussion 

Scleral fixated IOL when done as a secondary 

procedure does give good results especially 

when the surgeon encounters complication 

during routine cataract surgery. As the surgeon 

could be well prepared and the surgery could be 

done as an elective one, allowing the eye to 

recover from the earlier complication. 

SFIOL is a safe procedurewhendoneasasecondary 

procedure with minimum but a significant risk 

of complications in a complicated case. 


DR. MEENAKSHI Y. DHAR: M.B.B.S. (’86), Moulana Azad Medical College, Delhi University, 

New Delhi; M.S. (’91), Guru Nanak Eye Centre, Maulana Azad Medical College, Delhi 

University, New Delhi. Presently, Professor, Consultant and Head of Ophthalmology Services, 

Amrita Institute of Medial Sciences, Amrita Lane, Ernakulam-682026, Kerala. Member of 

Editorial Board of Kerala Journal of Ophthalmology. 

Contact: 9388839080, E-mail: mdhar@aims.amrita.edu 

To Elucidate The Management of Lenses with Zonular 

Dehiscence and Lens Coloboma 

Absence or weakening of zonules is still a 

challenging situation in the quest for 

Dr. Meenakshi Dhar , Dr. Sujithra H 

(Presenting Author: Dr. Meenakshi Dhar) 

excellence for a phaco surgeon, who now seems 

to have perfected every aspect of the surgery


125 

with precision. It poses a challenge both in 

removal of cataract as well as the safe and secure 

placement of the intraocular lenses. The common 

causes of zonular dehiscence are trauma, 

pseudoexfoliation [which may be occult in some 

cases], Hypermaturity [Weak Zonules], 

hereditary like Marfan’s, Homocystinuria, 

Ehler’s Danlos etc. 

Prospective clinical study to manage zonular 

dialysis in patients with subluxation or coloboma 

using Capsular tension ring. 


30 eyes of 25 patients with varying degree of 

zonular loss were included in the study. 19 of 

these were detected preoperatively, while the rest 

were detected peroperatively. All underwent 

phacoemulsification with insertion of Capsular 

Tension Ring and posterior chamber lens 

placement in the bag . The operative outcome 

was measured in terms of peroperative 

complications, early postoperative complications, 

visual acuity attained. 3 patients with bilateral 

coloboma and cataract were included in the 

study. Careful preoperative evaluation i.e. Slit 

lamp examination, gonioscopy, dilated slit lamp 

examination and fundus examination were done. 

Phacoemulsification with foldable IOL was done 

for all patients. Small perfect and central rhexis, 

Gentle hydrodissection, Viscoelastic assisted 

cortical aspiration. I/A was done applying 

traction tangential to the bag. CTR was inserted 

after capsulorhexis by hand over hand technique. 

Results 

100% cases had a positive surgical outcome with 

none of the eyes having a CTR drop/lens 

drop/visual loss. The difficulties encountered 

were unstable bag, trypan blue entering posterior 

segment and difficult cortical wash with CTR. 

Post op vision Unaided BCVA 

6/6 1 3 

6/9 3 5 

6/12 5 4 

6/18 5 4 

6/24 3 1 

6/36 1 1 

6/60 1 1 

Finger counting 1 1 

Complications 

Zonular dehiscence 4 

Nucleus drop 0 

Rhexis may go out 2 

Vitreous prolapse 0 

IOL decentration 4 

IOL + CTR + Capsular Bag dislocation 0 

Postop contraction of capsular bag 3 

Uveitis 6 

IOP rise 3 

IOL tilt 3 

PCO 5 

IOL descent 1 

Discussion 

Compromised zonular integrity is a surgical 

challenge.Subluxation and dislocation of lens 

should be suspected when there is unequal A.C 

depth, edge of lens seen in the dilated pupil, 

phacodonesis, iridodonesis and poor dilatation. 

When the zonules are weak it is very difficult to 

perforate anterior capsule and rhexis may go out. 

Rhexis should be small perfect and central. 

Hydrodissection should be gentle, done at 

multiple sites, with small amount of fluid. 

Rhexis will be difficult, hydrodissection risky, 

phaco, cortical wash and IOL insertion difficult. 

CTR –provides capsular support during phaco 

and long term support for IOL. 

CTR with inadequate support may tilt/ 

dislocate/collapse IOL tilt, decentration/ 

subluxation, tear may extend PC rent present, 

unless if PCR converted into PCC Increased time 

for surgery to insert ring; lens fracture more 

difficult -Do CHOP. Modifications of CTR are 

cionni ring [>90 0 zonular loss], Capsular edge 

ring, Coloboma ring, Aniridia ring [for 

coloboma- introduce it after IOL implantation], 

Equator ring. 

Careful surgery done with astute precision can 

ensure a successful outcome in patients with 

varying degree of subluxation. Surgical outcomes 

have dramatically improved with CTR usage, 

allowing support for cataract removal and stable 

central in the bag PCIOL placement. We found 

that with careful meticulous surgery we could 

achieve good postoperative results in patients 

with loss of zonular support.


1. Sukru Baraktar, MD, Tugrul Altan, MD, et al. 

Capsular tension ring implantation after 

capsulorhexis in phacoemulsification of cataracts 

associated with pseudoexfoliation syndrome. 

Intraoperative complications and early postoperative 

findings. J Cataract Refract Surg. 2001; 27:1620-8. 

2. Howard V. Gimbel, MD; Ran Sun, MD. Clinical 

Applications of Capsular Tension Rings in Cataract 

Surgery. Ophthalmic Surgery and Laseres 2002;33. 

3. Mizuno H, Yamada J, et al. Capsular tension ring 

use in a patient with congenital coloboma of the 

lens. J Cataract Refract Surg. 2004 Feb;30 (2):503-6 

4. Gimbel HV, Sun R. Clinical applications of capsular 

tension rings in cataract surgery. Ophthalmic Surg 

Lasers. 2002;33:44-53. 

5. Groessl SA, Anderson CJ. Capsular tension ring in 

References 

a patient with Weill-Marchesani syndrome. J 


6. D'Eliseo D, Pastena B, et al Prevention of posterior 

capsule opacification using capsular tension ring for 

zonular defects in cataract surgery. Eur J 

Ophthalmol. 2003;13:151-4. 

7. Nishi O, Nishi K, Menapace R, Akura J. Capsular 

bending ring to prevent posterior capsule 

opacification: 2 year follow-up. J Cataract Refract 

Surg. 2001;27:1359-65. 

8. Waheed K, Eleftheriadis H, et al. Anterior capsular 

phimosis in eyes with a capsular tension ring. J 


9. Berk AT, Yaman A, et al. Ocular and systemic 

findings associated with optic disc colobomas. J 

Pediatr Ophthalmol Strabismus. 2003;40:272-8. 


DR. ASHOKKUMAR PRANJIVANDAS SHROFF: M.B.B.S. (’71); D.O. (’74) and M. S. (’75) 

from B.J. Medical College, Ahmedabad. Recipient of Dr. Ganatra Rotating Trophy for 

Ophthalmologist (1999-2000) by Gujarat State Medical Association for outstanding services. 

Presently, Chief Ophthalmic Surgeon, Shroff Eye Hospital, Navsari and Director, Spectrum Eye 

Laser Centre, Surat, Gujrat. 

E-mail: sehnavsari@yahoo.co.in 

Long Term Evaluation of Four Points Scleral Fixated IOLs in 

Marfan’s Syndrome 

Dr. Ashok P. Shroff, Dr. Kuldeep Kumar, Dr. Hardik Shroff, 

Dr. Dishita Shroff, Dr. V. D. Vaishnav 

(Presenting Author: Dr. Kuldeep Kumar) 

In cases of Marfan’s syndrome, patient’s vision 

is compromised due to pupillary area not being 

covered adequately because of decentred 

crystalline lens. For this, surgical intervention 

becomes necessary and good options were 

available. 1,2,3 However, phacoemulsification with 

capsular tension ring and lensectomy with scleral 

fixated IOLs were very popular. In This series, 

we have used our own designed 4 point scleral 

fixated IOL by using special but simple surgical 

technique and evaluated results for almost 7 

years. 


20 eyes of 15 patients were included in this study. 

11 patients were male while 4 were female. Out 

of 20 eyes, 12 were right eyes and 8 were left eyes. 

All patients had marked subluxation of 

crystalline lens and entire pupillary area was 

uncovered. Age varied from 5.5 years to 11 years 

(mean being 7.5 years). Pre-operative vision 

recording was not satisfactory in young children, 

while in 12 patients it varied from 6/60 to 6/24 

with aphakic glasses. Rest of the anterior 

segment, retina and IOP were normal. 

Procedure 

6 to 7 mm long corneoscleral tunnel was made at 

12 o’clock, 1.5 to 2 mm away from upper limbus. 

2 partially deep sclerotomy incisions at about 

2mm away from limbus, each on either side of 

limbus and 2mm long were made diagonally 

opposite to each other Two limbal stab wounds 

each at 10 and 2 o’clock position were made by 

15 o lancet knife. Two sclerotomies, one for pars 

plana infusion canula and one for PP lensectomy 

procedure were made as usual (Fig. 1). 

Crystalline lens was removed by vitreous cutter


127 

through pars plana (Fig. 2). 9-0 monofilament 

nylon suture was fashioned through the lumen 

of 24G 1.5 inch long hypodermic needle till it 

comes out from the other end. Similarly second 

24G 1.5 inch long hypodermic needle was 

prepared. Now tip of one needle was introduced 

into the eye through one end of the temporal 

scleral wound. It was allowed to pass behind the 

temporal iris through pupillary area, behind the 

nasal iris and then to push through the 

corresponding end of nasal scleral wound (Fig. 

3). Once the tip of the needle was protruded out, 

the part of the 9-0 suture which was with in the 

lumen was pulled out (Fig. 4) and the needle was 

withdrawn. Now first suture was seen going 

across the eye and coming out through both 

scleral wounds. (Fig. 5) Similarly second needle 

was fashioned through the sclerotomy wounds 

but at about 1.5 to 2 mm away from the first one 

(Fig. 6). Now two sutures were seen going 

through both scleral wounds and across the 

pupillary area (Fig. 7). Pointed triangular knife 

was entered into AC through CS tunnel. Then 

C.S. tunnel was enlarged using large 5.5 mm 

keratome knife. From pupillary area, both 

sutures were picked up with suture tying forceps 

and were brought out of the eye from CS tunnel. 

The sutures were kept long and cut in the middle. 

Now to understand better these sutures can be 

given names in following manner (Fig. 8) 

UNS = Upper Nasal Suture; LNS = Lower 

Nasal Suture; UTS = Upper Temporal Suture;, 

LTS = Lower Temporal Suture 

Now newly designed IOL with 2 eyelets on either 

haptic was brought in and was placed on the 

cornea. Then upper nasal suture (UNS) was 

fashioned through one eyelet on nasal haptic, 

then through second eyelet, then again through 

1st eyelet and then again through 2nd eyelet. The 

loose end of upper nasal suture was tied to the 

loose end of lower nasal suture with the help of 

tying forceps (Fig. 9). The lower nasal suture 

which was lying outside the nasal sclerotomy 

wound was gently pulled so that the knot would 

slip through CS tunnel, AC and nasal scleral 

wound (Fig. 10). (Now the upper nasal suture 

was seen going through the eyelets on nasal 

haptic, CS tunnel, AC, pupil and out of the eye 

on nasal side). Similarly upper temporal suture 

was fashioned through both the eyelets on 

temporal haptic and was tied with lower 

temporal suture and the knot was gently pulled 

out from temporal scleral wound (Fig. 10). Now, 

avoiding intermingling of the sutures, IOL was 

gently and carefully placed in AC through CS 

tunnel and with the help of hook through corneal 

stab wound, was dialed behind the iris. Then the 

nasal haptic was placed behind nasal iris and 

temporal haptic behind temporal iris. Both 

sutures on either side (in all 4 suture ends) were 

gently pulled and balanced so as to make the 

IOL horizontal and center in the pupillary area 

(Fig. 11). Nasal sutures were tied twice and were 

cut close to the knot and the knot was buried 

deep in the nasal scleral wound. Similarly 

temporal sutures were tied and cut and the knot 

was placed deep in the temporal scleral wound 

(so that no end of sutures were seen out side the 

wound and on the sclera – very imp). Additional 

P.P. vitrectomy was done if necessary. 

Conjunctiva was closed and the procedure was 

concluded (Fig. 12). 

Results 

We have observed that all patients were 

comfortable. All eyes were quiet. IOP was within 

normal range. IOLs were stable in position. 

Scleral incisions were well healed. There was no 

erosion of suture through sclera in any case. 

Trimming or removal of suture end or any other 

additional surgical procedure was not needed in 

any case. In initial postoperative period, few 

complications like Raised IOP, Corneal Edema 

and Cystoid Macular Edema (CME), were noted 

but they settled with conservative treatment. Best 

corrected visual acuity was recorded between 

6/6 to 6/18. Moreover cylinder was recorded 

between +0.50 D to -1.50 D only. 

Discussion 

As crystalline lens was decentred markedly, 

lensectomy by vitreous cutter through pars plana 

is a good method. IOL was used with two holes 

on either haptic, so that threading was easy, 

moreover knot would not slip. As there was 2 

point scleral contact on either side, all IOLs were 

found stable in horizontal position with 

acceptable refraction. As knots were well buried 

in the scleral wound, there was no extrusion of 

suture ends or any endophthalmits, which 

otherwise have been noted in few series. Knots 

were well buried in the scleral wounds, hence 

there was good amount of fibrosis around.


Monofilament nylon suture normally 

biodegrades over a period of time, hence for 

precautions, it was fashioned twice through 

the eyelets. Moreover some kind of fibrosis 

around the haptics develops, which 

provides fixation to the sclera. Therefore 

there was no dislocation of IOL. There were 

no intraocular knots and there was no 

chance of slipping of knots as they were 

threaded through holes. As movement of 

needle pass was obscured by iris and sclera 

at some points, intra operative bleeding can 

`1. Lewwas JS. Ab externo sulcus fixation. Ophthalmic 

Surg. 1991;22:692-5. 

2. Ruben Grigorian et al: A New Technique for Suture 

Fixation of PC IOL that Eliminates Intraocular 

Knots; Ophthalmology 2003;110;1349-56. 

References 

occur. However, vitrectomy 

even after fixing the lens can be 

done. Injury to ciliary body can 

lead to CME but is easily 

manageable. This design of IOL 

having two eyelets provided 

easy threading and in true 

sense 4 point fixation to the 

sclera. Intermingling of suture 

has to be avoided during 

insertion and positioning of 

IOL. This procedure with such 

a long follow up suggests that 

it is a quite safe, stable and 

result oriented. 

Imp. Points to remember 

o Both scleral incisions should be 

at equal distance from limbus and 

should be exactly diagonally 

opposite. 

o Distance between two sutures should be 

equal throughout. 

o Both these sutures should be away from 

centre of the cornea equally on either side. 

o Make sure that all sutures and haptics were 

away from infusion canula tip. Otherwise, on 

removal of infusion canula, the centration can 

be disturbed. 

o Make sure about centration and good 

horizontal position of IOL before tying the 

knots. 

3. Quanhang Han et al:, Combined suture in needle 

and scleral tunnel technique for scleral fixation of 

IOL: J Cat Ref. Surgery 2007;33;1362-5. 

4. Shroff A. P.; Scleral Fixation of Suturable IOLs as 

Primary Procedure; AIOC Proceedings 2001:149-51. 

A Study of The Comparison of Spherical Equivalent by IOL 

Master and A Scan Method 

Dr. Ashish Gangwar, Dr. Shivkumar Chandrashekharn, 

Dr. R. Ramakrishanan, Dr. Arijit Mitra 

(Presenting Author: Dr. Shivkumar Chandrashekharn) 

Cataract extraction and artificial intraocular 

lens (IOL) implantation is one of the most 

frequent and successful ophthalmic surgical 

procedures carried out today 1 but phacoemulsification 

and foldable intraocular lens (IOL) 

implantation has led to improved success rates 

and faster visual rehabilitation in patients 

undergoing cataract surgery. 2


129 

One of the remaining problems, however, is 

accurate calculation of IOL power, in order to 

obtain the desired postoperative refraction. 

Accurate and precise biometry is one of the key 

factors in obtaining a good refractive outcome 

after cataract surgery. Ultrasound biometry still 

has an important role to play in this regard. But 

the advent of the IOL Master, which uses partial 

coherence interferometry technology, has mostly 

eliminated operator error, and proven to be a 

boon for biometric assessment. 

The data required for accurate intraocular lens 

calculations include axial length, corneal 

curvature and anterior chamber depth. These 

data are integrated in calculation formulas. The 

most commonly used is the SRK II formula. 1 

A-scan ultrasonography uses the echo delay time 

to measure intraocular distances. It has a 

longitudinal resolution of 200ùm and an 

accuracy of 100ùm -120ùm in measuring axial 

lengths. 3,4 In ultrasound biometry or A SCAN, 

measurements of axial length can be obtained 

either by an applanation or an immersion 

technique. 5 When considering the SRK II 

formula: P =(A+C) - 2.5AL - 0.9K it is obvious 

that axial length is the biggest source of error in 

IOL power calculations. 6 An error of only 1.0 mm 

in axial length will result in a post-operative 

refractive error of three dioptres. Immersion 

scans are more precise because there is no corneal 

indentation but the applanation method suffers 

from the disadvantage of corneal indentation 

during measurement. But recently, optical 

biometry techniques offer new possibilities. The 

technology of an instrument like the IOL Master 

is based on laser interferometry with partial 

coherent light, often termed as partial coherence 

interferometry (PCI). 

A dual beam of infrared light (780 nm) of short 

coherence length (160ùm) with different optical 

lengths is emitted by a laser diode source. The 

eye to be measured and the photodetector are 

situated at each leg of the interferometer. Both 

partial beams are reflected at the corneal surface 

and the retina (RPE). Interference occurs if the 

path difference between the beams is smaller 

than the coherence length. The interference signal 

received by the photodetector is measured 

dependent on the position of the interferometer 

mirror, which could be measured precisely. This 

measurement gives the optical length between 

the corneal surface and retina. 


A retrospective study was done for two month 

from 17 March-17 May 2008 at ARAVIND EYE 

HOSPITAL., TIRUNELVELI. Two hundred 

postoperative (one month post op) patients of 

Cataract were selected for the study in which 

foldable lens were inserted in the capsular bag 

after phacoemulsification. Out of 200, 100 

patients were randomly selected for evaluation 

of refractive outcome by IOL MASTER and rest 

of the patients (100) were selected for refractory 

acessment by A SCAN method. 

Results 

A SCAN ultrasound measures the distance 

between the anterior surface of the cornea and 

the internal limiting membrane, whereas the IOL 

Master measures the distance between the 

anterior corneal surface and the pigment 

epithelium. Measurements using the ultrasonic 

contact technique cause additionally an 

applanation of the eye. In our study, we got a 

mean difference of 0.24 mm in axial length by 

using both methods. 

The spherical equivalents of patients by both 

methods are given in following Table no. 1. 

Table-1: Spherical equivalents by IOL master 

and A scan method 

By A Scan Sph. By IOL 

Method Equ. Master 

3% 0 +2 D 2% 

3 -2 D 

3% 0 +1.75 D 2% 

3 -1.75 D 

4% 0 +1.5 D 3% 

4 -1.5 D 

6% 0 +1.25 D 5% 

6 -1.25 D 

14% 0 +1.0 D 8% 

14 -1.0 D 

14% 2 +0.75 D 10% 

12 -0.75 D 

12% 2 +0.50 D 13% 

10 -0.50 D 

13% 7 +0.375 D 15% 

6 -0.375 D 

15% 8 +0.25 D 19% 

7 - 0.25 D 

16% O D 23%


Using the data obtained by the IOL Master, there 

was an excellent refractive outcome. 23% of 

patients had a spherical equivalent of 0 D, most 

of them were with in range of < ±1.5 D and the 

overall refractive outcome was in the range of 

±2D (Fig-1). 

Refractive outcome by using the US biometry 

shows that and the overall refractive outcome 

was in the range of ±2 D. But In 10% of cases, the 

refractive outcome was ≥1.5 D (Fig-2). 

In the following table no-2 we compared the 

refractive outcome achieved by A scan 

ultrasound versus IOL MASTER. For each 

biometric technique, the percentages of patients 

with refractive errors less than 0.5D, 1D, 1.5D, 

2.0D, 2.5D etc. are shown. In 80% of patients 

tested with the IOL Master, we obtained a 

refractive result of less than 1 D of the spherical 

target and the same result in only 70% of patients 

tested with the standard A SCAN US 

measurements. 

Table-2 

Sp EQ


131 

1. Verhulst e.,Vrijghem j.c.. Accuracy of intraocular 

lens power calculations using the Zeiss IOL 

master. -A prospective study. Bull. Soc. Belge 

ophtalmol 2001;281:61-5. 

2. Ms Rajan, I keilhorn and Ja bell. Partial coherence 

laser interferometry vs conventional ultrasound 

biometry in intraocular lens power calculations. Eye 

2002;16:552–6. 

3. Oslen t. The accuracy of ultrasonic determination 

of axial length in pseudophakic eyes. Acta 

ophthalmol (copenh) 1990;67:141–4. 

4. Bamber jc, Tristam m. Diagnostic ultrasound. In: 

webb s(ed). The physics of medical imaging. 

Philadelphia: Adam Hilger 1988:319–88. 

5. Binkhorst RD. The accuracy of ultrasonic 

measurements of the axial length of the eye. 

Ophthal surg 1981;12:363-5. 

6. Olsen T. - sources of error in intraocular lens power 

calculation. J cat refract surg 1992;18:125-9. 

7. Baumgartner A et al. Measurements of the posterior 

structures of the human eye in vivo by partial 

References 

coherence interferometry using diffractive optics. 

Proc SPIE 1997;2981:85–91. 

8. Findl O et al. High precision biometry of 

Pseudophakic eyes using partial coherence 

interferometry. J Cataract Refract Surg. 1998;24: 

1087–93. 

9. Kiss B, Findl O, Menapace R, et al. Refractive 

outcome of cataract surgery using partial coherence 

interferometry and ultrasound biometry: clinical 

feasibility study of a commercial prototype II. J 

Cataract Refract Surg 2002;28:230–4. 

10. Findl O, Drexler W, Menapace R, et al. Improved 

prediction of intraocular lens power using partial 

coherence interferometry. J Cataract Refract Surg. 

2001;27:861-7. 

11. Drexler W et al. Partial coherence interferometry: a 

Novel approach to biometry in cataract surgery. Am 

J Ophthalmol 1998;126:524–34. 

12. Findl O et al. Improved prediction of intraocular 

lens power using partial coherence interferometry. 

J Cataract Refract Surg 2001;27:861–7. 


DR. SURESH K PANDEY: M.B.B.S. (’96), Rani Durgawati University, Jabalpur, M.P.; M.S. 

(’98), PGIMER, Chandigarh. Anterior Segement Fellowship (2000), Medical University of 

South Carolina, Charleston, SC, USA. Recipient of Achivement Award, AAO. Author of more 

than 100 peer-reviewed publication and editor of 12 textbook in Ophthalmology. Presently, 

Director, Suvi Eye Institute and Research Centre, Kota, Rajasthan. 

E-mail: suesh.pandey@gmail.com 

Prospective Evaluation of Viscomydriasis Using Healon-5® and 

Flexible Iris Hooks for Phaco Surgery in Patients on Tamsulosin 

Hydrochloride 

Intraoperative Floppy Iris Syndrome or IFIS 

was first described in 2005 by Chang and 

Campbell, as a clinical triad observed during 

cataract surgery, that includes fluttering and 

billowing of the iris stroma, propensity for iris 

prolapse, and progressive intraoperative 

constriction of the pupil. IFIS increases the risk of 

serious complications during cataract surgery 

and makes the surgery much more difficult for 

the surgeon. It was first reported in association 

with the use of tamsulosin, which is an alpha 1- 

adrenergic receptor ( 1AR) antagonist used in the 

treatment of benign prostatic hypertrophy. Since 

then, many cataract surgeons from all over the 

Dr. Suresh K. Pandey, Dr. Vidushi Sharma 


world have reviewed their own patients taking 

this drug and found the same association during 

cataract surgery. 


Clinical Signs of IFIS 

Characteristically, the pupil dilates poorly in 

response to the routine preoperative mydriatics, 

or starts to constrict soon after the first incision; 

the iris tends to prolapse despite wellconstructed 

incisions, and the iris stroma flutters 

excessively in response to normal intraocular 

fluid currents during surgery. All routine 

attempts to dilate the pupil are usually ineffective


and the pupil progressively constricts further, 

making the surgery more and more difficult. We 

have seen that in Indian patients, the tendency to 

prolapse is seen markedly, while the billowing 

and flutter are not as marked probably because 

of the thicker irides seen in our country. 

Etiopathogenesis of IFIS 

While the exact cause for this syndrome is still 

not clear, it has been postulated that the 

1AR antagonists cause relaxation of the iris 

dilator muscle and cause disuse atrophy of this 

muscle in the long-term. It has been estimated 

that up to 2% of cataract surgery patients may be 

taking tamsulosin as cataract and BPH often coexist 

in the same elderly population. In a postal 

survey of UK cataract surgeons, 53% surgeons 

had encountered the syndrome either 

retrospectively or prospectively in male and 

female patients on tamsulosin as well as other 

alpha-receptor antagonists. Although 68% of 

consultants had patients discontinue taking 

tamsulosin preoperatively, they reported no 

consistent benefit from this step. In a similar 

online survey of members of the American 

Society of Cataract and Refractive Surgery, 95% 

believed that tamsulosin makes cataract surgery 

more difficult and 77% believed it increases the 

risks of surgery. Commonly reported 

complications of IFIS were significant iris trauma 

and posterior capsule rupture. 

Systemic medications associated with IFIS 

Tamsulosin is a selective alpha-1A receptor 

subtype antagonist, while other non-specific 

1receptor antagonists, including terazosin, 

doxazosin, and alfuzosin, have also been linked 

to IFIS; however, their relationship to the 

syndrome is not as definitive. Similarly, an antipsychotic 

drug, risperidone has also been 

implicated to cause IFIS. 

Prospective evaluation of viscomydriasis using 

Healon-5® and flexible iris hooks: 

We prospectively evaluated the use of Healon- 

5® and flexible iris hooks during phacoemulsification 

surgery in male patients taking Tamsulosin 

Hydrochloride for treatment of benign 

prostatic hyperplasia (BPH) that predisposed 

them to IFIS. All male patients undergoing 

cataract surgery at our centre over the last two 

years were enquired about the use of tamsulosin. 

Patients on tamsulosin underwent bilateral 

phacoemulsification surgery and the two eyes 

were randomized to two groups; 

Group A: use of sodium hyaluronate 2.3%, 

(Healon-5®) to achieve intraoperative dilatation 

of small pupil and 

Group B: use of flexible iris hooks to expand the 

pupil (in the fellow eye). 

Results 

In our study, out of a total of 600 male patients 

undergoing cataract surgery during this time, 12 

patients (2%) had history of systemic intake of 

Tamsulosin. Nine of these patients were on 

Urimax, 2 were using Dynapres, while one 

patient was using Veltam. The mean age was 

67±5.2 years. The average duration of tamsulosin 

intake was 10±4.4 months. The cases of IFIS were 

classified as follows: 

a. Mild: Pupillary dilation of 6-7 mm at the 

commencement of surgery, and showing 

mild fluttering and tendency to prolapse into 

the incisions 

b. Moderate: Cases with pupillary dilation of 5- 

6 mm at the commencement of surgery and 

showing all other features of IFIS 

c. Severe: Pupillary dilation of less than 5 mm 

at the commencement of surgery and 

showing repeated iris prolapse out of the 

incisions and iris fluttering even in response 

to low flow parameters. 

In Group A, viscomydriasis achieved by injection 

of Healon-5® provided satisfactory pupillary 

dilatation to commence the surgery in all cases 

and make a good capsulorhexis. However, a 

tendency of progressive constriction of the pupil 

was noted during nuclear emulsification and 

irrigation/aspiration, even with low flow 

settings, which necessitated repeated injection of 

the Healon-5®. Posterior capsule rupture 

occurred during chopping of a dense cataract 

using high vacuum and high flow rate in one eye. 

The flexible iris hooks maintained a satisfactory 

pupil size throughout the procedure. There was 

no intraoperative complication in any eye where 

these hooks were used for mechanical 

enlargement of pupil. However, these cases had 

to be performed under block and the planned


133 

surgical time increased due to the extra step of 

inserting the hooks. Also, sometimes the 

retractors came off during globe movement, and 

had to be reapplied. The two eyes tended to 

behave similarly with regard to the severity of 

IFIS, though one case had very severe IFIS in one 

eye and mild IFIS in the other eye. 

Postoperatively, these patients in both groups 

were noted to have small, iris pigment epithelial 

defects on retro-illumination, at the site of iris 

prolapse, which were not clinically significant. 

Discussion 

Results of this pilot study suggest that 

performing phacoemulsification in IFIS cases 

using Healon 5® is more dependent upon fluidic 

parameters, surgical technique as well as 

surgeon's experience. While Healon 5® does 

achieve good pupillary dilation in cases not 

dilating with drops, there is a tendency of 

progressive pupillary constriction and the need 

for repeated replenishment of Healon 5®. The 

repeated replenishment of Healon 5 substantially 

increases the cost of surgery, specially in dense 

and hard cataracts, where the surgical time is 

increased and high flow and vacuum settings 

may become necessary. Slow motion phaco helps 

to retain Healon 5 in the anterior chamber and 

also helps in minimizing iris prolapse and flutter. 

A bottle height of 60- 70 mm, flow rates of 20- 26 

cc/min and vacuum of 150 mm Hg or lower, 

have been recommended. However, these 

settings are often inadequate for the hard, dense 

cataracts seen in our population, specially in 

these elderly patients with co-existing BPH. 

The flexible iris hooks are helpful for mechanical 

pupil enlargement and for protection of the pupil 

margin in IFIS syndrome. While the cost of iris 

retractors or iris hooks is supposed to be 

significantly high in the western literature, the 

indigenously manufactured iris hooks are very 

cost effective and some of them can even be resterilized. 

They are suited for the entire spectrum 

of phacoemulsification techniques, using any 

settings for flow and vacuum. However, these 

cases need to be performed under block and the 

surgical time is increased due to the extra step of 

applying the iris hooks and sometimes 

reapplying them during the procedure. The 

increased surgical time is somewhat offset by the 

ability to use normal fluidic parameters, which 

makes the phacoemulsification faster. 

Management of IFIS 

The management of this condition begins by 

anticipating the syndrome preoperatively by 

taking a careful history of drug use in all cataract 

surgery patients. If the pupil does not dilate 

preoperatively, atropine may be used, but is 

usually not very effective. It is important for 

surgeons to pay attention to achieve a proper 

wound construction, excessive hydrodissection 

and excessive injection of viscoelastic injection 

should be avoided. 

Flexible Iris Retractors 

It is better to anticipate the problem and place iris 

retractors at the outset, and this is one of the best 

methods for managing this condition. Multiple 

sphincterotomies and pupillary stretching is not 

only ineffective, it may actually increase the 

propensity for iris prolapse and fluttering by 

decreasing the iris tone further. This 

distinguishes IFIS from other causes of small 

pupil, where pupillary stretching is effective as 

the pupillary margins are fibrotic unlike the 

floppy, atonic iris seen in IFIS. 

Viscoadaptive Viscoelastic- sodium hyaluronate 

2.3%, (Healon-5®): The use of viscoelastics like 

Healon-5®) has also been shown to be effective 

in dilating the pupil, though it needs to be 

replenished constantly. Slow motion phaco is 

certainly a help in minimizing intraocular fluid 

currents. The use of intracameral phenylephrine or 

epinephrine is useful in many cases, to dilate the pupil 

though iris prolapse still remains a challenge. 

To conclude, IFIS is being increasingly 

recognized with the use of many kind of systemic 

medications used to manage BPH. Recently, antipsychotic 

drugs (e.g. risperidone) have also been 

implicated to cause IFIS. While these 

complications were observed by surgeons even 

before the discovery of this syndrome, now we 

can anticipate the problem by taking a careful 

medical history of using tamsulosin 

hydrochloride and other medications in all 

elderly patients and be prepared for managing 

patients identified to be at risk for having IFIS.


1. Chang DF, Campbell JR. "Intraoperative floppy iris 

syndrome associated with tamsulosin. J Cataract 

Refract Surg. 2005;31:664-73. 

2. Pandey SK, Milverton EJ. The Prospective use of 

Perfect Pupil Injectable for Cataract surgery in 

patients on Flomax. Presented at American 

Academy of Ophthalmology. Chicago, IL, USA, 

November 2005. 

3. Schwinn DA, Afshari NA. "alpha(1)-Adrenergic 

receptor antagonists and the iris: new mechanistic 

insights into floppy iris syndrome. Surv Ophthalmol. 

2006;51:501-12. 

4. Parssinen O, Leppanen E, Keski-Rahkonen P, 

Mauriala T, Dugue B, Lehtonen M. "Influence of 

tamsulosin on the iris and its implications for 

cataract surgery. Invest Ophthalmol Vis Sci. 

2006;47:3766-71. 

References 

5. Cheung CM, Awan MA, Sandramouli S. 

"Prevalence and clinical findings of tamsulosinassociated 

intraoperative floppy-iris syndrome. J 


6. Chang DF, Braga-Mele R, Mamalis N, Masket S, 

Miller KM, Nichamin LD, Packard RB, Packer M; 

ASCRS Cataract Clinical Committee. Clinical 

experience with intraoperative floppy-iris 

syndrome. Results of the 2008 ASCRS member 

survey. J Cataract Refract Surg. 2008;34:1201-9. 

7. Chadha V, Borooah S, Tey A, et al. Floppy Iris 

Behaviour During Cataract Surgery: Associations 

and Variations. Br J Ophthalmol. 2007;91:40-2. 

8. Oshika T, Ohashi Y, Inamura M, et al. Incidence of 

intraoperative floppy iris syndrome in patients on 

either systemic or topical alpha (1)-adrenoceptor 

antagonist. Am. J. Ophthalmol 2007;143:150-1. 


DR. ASHOKKUMAR PRANJIVANDAS SHROFF: M.B.B.S. (’71); D.O. (’74) and M. S. (’75) 

from B.J. Medical College, Ahmedabad. Recipient of Dr. Ganatra Rotating Trophy for 

Ophthalmologist (1999-2000) by Gujarat State Medical Association for outstanding services. 

Presently, Chief Ophthalmic Surgeon, Shroff Eye Hospital, Navsari and Director, Spectrum Eye 

Laser Centre, Surat, Gujrat. 

E-mail: sehnavsari@yahoo.co.in 

IOL Exchange in High Residual Refractive Error in Pediatric 

Psuedophakia 

Dr. Ashok P. Shroff, Dr. Kuldeep Kumar, Dr. Hardik Shroff, 

Dr. Dishita Shroff, Dr. V. D. Vaishnav 


Few years before, precise formula for IOL 

power calculation was not available for 

pediatric cataracts. Hence, there were erratic 

refractive landings after surgery. Now these 

children have grown up and their parents are 

concerned about glasses. However, as they are 

still very young, additional use of contact lenses 

and Lasik procedure are not advisable. Even 

Piggy back IOLs are not advisable due to 

anatomical and financial limitations. Therefore in 

this study, we have opted for exchange of IOL 

with appropriate diopter and evaluated the 

results. 


12 eyes of 6 children between the age of 10 to 16 

years (mean age 13.6 years) whose refraction had 

remained unchanged for a while, were selected. 

Both eyes were equal in no. as 6 cases were 

bilateral. When they were operated, their age was 


135 

and optics of IOL. Synechiae, if any were 

carefully separated. Then with the help of dialer, 

IOL was carefully, skillfully rotated clockwise so 

that it would become free and then gently 

brought into the anterior chamber and placed 

vertically so that it could be delivered outside 

safely with the help of tying forceps or lens 

holding forceps. Then epithelial cells and debris 

from the equator and posterior capsule were 

thoroughly removed by using polish mode. Now 

the new one piece non foldable IOL was placed in 

the sulcus, and the procedure was concluded 

after adequate closure of wounds and 

conjunctiva. 

Results 

In all patients postoperative period was 

comfortable. There was mild corneal Edema in 7 

eyes and IOP rise in 3 eyes which resolved with 

conservative treatment in 7 days to one month. 

Patients were followed up for 19 to 38 months 

(mean 31 months). 

Visual Results 

Vision 

No. of Eyes 

6/6 3 (25.00%) 

6/9 7 (58.33%) 

6/12 2 (16.67%) 

Residual refractive error for distance was between 

+0.75 D to -1.25 D of spherical equivalent. 

Discussion 

High residual refractive error, following previous 

cataract surgery in children though stable, is a 

matter of concern. Once refractive error is 

stabilized then better solutions can be offered to 

such grown up children. Contact lens is a good 

option but the younger age and their 

acceptability is an issue. Lasik and Piggy back 

IOLs can not be advised for obvious reasons. The 

better option is exchange of IOL and this method 

is in use with very good results in other 

situations. Therefore, we have considered this 

option in such children. Though it is a surgical 

procedure and may be little difficult and time 

consuming, but possible. In this series, we have 

seen very good anatomical and visual outcome 

with few treatable complications. Cases have 

been followed up for sufficient time to establish 

this procedure being safe. 

12 eyes of 6 patients, who had high residual 

refractive errors following pediatric cataract 

surgery with IOL when they were very young 

and no definite IOL power calculation formula 

was available, were treated with IOL exchange 

with good anatomical and visual outcome. 


DR. CHITRA RAMAMURTHY: M.B.B.S. from Patna Medical College, Bihar; P.G. at Joseph 

Eye Hospital, Trichy. Presently, Consultant at Eye Foundation at R.S.Puram in Coimbatore; 

Thirumurthy Nethralaya at Avanashi Road, Tirupur; Lasik Centre (India) at Coimbatore and 

Nethra Jyothi Trust. 

Address: The Eye Foundation, 582, D.B. Road, R.S. Puram, Coimbatore-641 002, Tamilnadu 

Comparison of Visual Outcome of Refractive and Diffractive 

Multifocal IOLs 

Dr. Chitra R., Dr. Ramamurthy D., Dr. Shreesha Kumar, Dr. Subha 

(Presenting Author: Dr. Chitra R) 

Refractive cataract surgery has revolutionized 

the quality of vision and escalated the expectations 

of the patients at large. To this end, the 

multifocal IOLs largely dominate the scene. The 

goal of a multifocal IOL is based on the principles 

of simultaneous vision with one image in focus 

and the second image defocused and ignored. 

The types of multifocal IOLs available are refractive, 

diffractive or a combination of both. Emmetropia 

or a slight hypermetropia is aimed at post 

operatively. TheRezoom IOL is the refractive IOL 

of foldable acrylic material an optic edge design 

with 5 zones of which 1, 3 and 5 are distant dominant 

and 2 and 4 are near dominant. The Tecnis 

multifocal are silicon diffractive IOLs with the 

anterior surface refractive and posterior diffractive.



The efficacy of the Refractive Rezoom MF IOLs 

(Group I) and diffractive Tecnis MF IOLs (Group 

II) are being compared in this study. 

There were 80 eyes of 53 patients in Group I and 

57 eyes of 37 patients in Group II. The study was 

conducted during the period July 06 – April 07 

with a 6 month follow up. All the patients 

underwent temporal near limbal 

phacoemulsification with multifocal IOL 

implantation uneventfully. 

Preoperatively in Group I, 12.5 % had a BCVA of 

6/6, 30% 6/9 and 57.5% < 6/9. In Group II, 7 % 

had a BCVA 6/6, 21% 6/9 and 71.9 % of < 6/9. 

Assessment of near vision in Group I indicated 

66.25 % with a BCVA of N/6, 22.5% N/8 and 

11.25 % < N/8. In Group II, 47.4 % had a BCVA 

of N/6, 36.8 % N/8 and 15.8 % < N/8. 

Results 

Postoperatively, in Group I, 97.5 % had a BCVA 

of 6/6 with 2.5 % improving upto 6/9, with a 

posterior pole evaluation indicating dull foveal 

reflexes. In Group II, 94.7 % had a BCVA of 6/6 

with 5.3 % improving upto 6/9. But in both 

groups, BCVA of N/6 was achieved in 100% of 

the patients. Subjective visual satisfaction was 

further assessed for distance, intermediate and 

near vision. It was found that the intermediate 

vision fared better followed by near and the 

distance in the Rezoom Group I. For Tecnis 

Group II, intermediate vision fared best followed 

by distance and then near. 

Visual tasks were again objectively assessed in 

different ranges of vision. 95% of them had no 

difficulty in near vision in Group I and 96.5 % in 

Group II. 88.75 % had no difficulty in distance 

vision and 89.48% in Group II. Glare was noticed 

in 5% in Group I and 3.5 % in Group II. Posterior 

capsular opacification was noted in 1.25 % in 

Group I against 5% in Group II. The dependence 

on spectacle wear was on the constant basis in 

3.75% in Group I, and 1.75 % in Group II. 

The low contrast was better in Group II in the 

unilateral implants and in Group I in the bilateral 

implants. 

Finally on assessing the overall quality of life 97.5 

% were happy in Group I and 98.24 % in Group 

II but only 85% in Group I and 87.71 % in Group 

II were willing to recommend the same IOL to 

the other members of the family. 

Discussion 

The results have been favorable and equivocal in 

this study encouraging the inclusion of 

multifocal IOL implants of these categories in the 

cataract surgery armamentarium. 


DR. SHIVKUMAR CHANDRASHEKHARAN: M.S. (’93), M.S.University, Baroda; Fellow, 

Aravind Eye Care System. Presently faculty in Aravind Eye Hospital, 

Address: Aravind Eye Hospital & PGI, Triunelveli-627001, Tamilnadu; 

E-mail: aravind@tvl.aravind.org. 

IOL Master Optical Biometry Vs Conventional Ultrasound 

Biometry in Intraocular Lens Power Calculations in High Myopic 

Eyes 

Dr. Shivkumar Chandra Shekharan, Dr. Neelam Pawar, Dr. Devendra Maheshwari, 

Dr. R Ramakrishnan 

(Presenting Author: Dr. Neelam Pawar) 

The accurate calculation of intraocular lens 

(IOL) power is essential for attaining the 

desired refractive outcomes after cataract 

surgery. The most important factor affecting the 

accuracy of biometry is the axial length. 1 The 

overall accuracy depends on 3 factors: 

preoperative biometric data (axial length AL), 

anterior chamber depth (ACD), lens thickness,


137 

and keratometric index (K), IOL power 

calculation formulas, IOL power quality control 

by the manufacturer. Studies based on 

preoperative and postoperative ultrasound 

biometry show that 54% of errors in predicted 

refraction after IOL implantation can be 

attributed to AL measurement errors, 8% to 

corneal power measurement errors, 38% to 

incorrect estimation of postoperative ACD. 2,3,6 

Partial Coherence Interferometry (PCI) by IOL 

Master is a fast, noncontact method to calculate 

lens implant power for cataract surgery. It has 

been reported as a potentially more accurate 

method than ultrasound biometry. The AL when 

measured by applanation A-scan ultrasound, 

because of the indentation of the globe and offaxis 

measurement of the AL by the transducer, 

causes erroneous AL detection and an undesired 

postoperative refractive outcome. The AL 

measurement will be inaccurately shorter with 

corneal indentation in highly myopic . 


In a prospective randomised clinical study, 50 

high myopic patients undergoing 

phacoemulsification cataract surgery were 

randomised to undergo biometry by either IOL 

Master (25 patients) or the ultrasound (25 

patients) between October 2007 and January 2008 

at Aravind Eye Hospital Tirunelveli. 

Inclusion Criteria were: 1) Eyes with significant 

cataract and suitable for phacoemulsification and 

primary implantation of posterior chamber 

intraocular lens. 2) Spherical equivalent ≥ -6 D 

and or Axial Length ≥ 26.0 mm. 3) Patient 

coming for scheduled visits . 

Exclusion Criteria: (1) Presence of retinal 

detachment, proliferative diabetic retinopathy, 

(2) Previous intraocular or corneal surgery 

(including refractive surgery), (3) Corneal 

opacities or irregularities: previous scarring, 

dystrophy, ectasia, (4) Corneal astigmatism 

greater than 2 dioptres, (5) Inability to achieve 

secure ‘in-the-bag’ placement of the IOL (i.e. due 

to posterior capsule rupture, vitreous loss, weak 

zonules, zonular rupture). 

Preoperatively, Snellen visual acuity was 

assessed and all patients underwent a noncycloplegic 

refraction, keratometry measurement 

and axial length measurement. Patient 

underwent dilated indirect ophthalmoscopy and 

USG B scan was done in patients where media 

opacity was dense obscuring fundus 

visualization. IOL MasterGroup (25 eyes) had 

AL and K measurements with the IOLMaster. 

Only data with a signal-to-noise (SNR) value 

higher than 2.1 were recorded. Ultrasound group 

(25 eyes) had AL measurements by applanation 

ultrasound (Sonomed,) and K measurements by 

Bausch and Lomb keratometer. AL 

measurements were performed by one 

experienced ophthalmic personnel. The 

intraocular lens power was based on the SRK/T 

formula. All patients underwent uncomplicated 

cataract surgery by phacoemulsification with in 

the bag IOL implantation through a temporal 

clear corneal incision. The IOLs used in the study 

were the 3-piece AcrySof (MA30BA, MA60BM, 

MA60MA), 1-piece AcrySof (SA60AT, SN60AT), 

and aspherical 1-piece AcrySof (SN60WF) and 

Aurofoldable (Aurolab, Madurai) . A standard 

postoperative topical antibiotic and antiinflammatory 

regime was administered . Patients 

were examined at the following intervals: 1 day 

after surgery,1week after surgery, 4-5 weeks after 

surgery. The primary outcome measure of the 

study was post operative spherical 

equivalent.The actual postoperative spherical 

equivalent (SE) was recorded 4 weeks after 

surgery. 

Results 

50 patients (20 females and 30 males), were 

included in this study, of whom 25 patients 

underwent optical biometry and 25 patients had 

biometry by applanation ultrasound . The mean 

age of patients was 65.6 (SD 6.85) years (range of 

43–72years). The preoperative mean axial length 

was 27.76 ±2.11 mm in the optical group (range of 

26.10-33.80 mm) and 26.84 ± 1.27 mm in the 

ultrasound group (range of 26.00-32.25 mm) 

(P


Table 1 

SE ≤ ±0.5D ≤ ±0.75 D ≤±1D ≤±2 ≤ ±3D 

PCI 40% 60% 68% 100% 

US 16% 28% 44% 92% 100% 

Discussion 

Accurate IOL calculation is crucial in modern 

phacoemulsification surgery. Applanation 

Ascan Ultrasonic instruments measure the 

distance from the corneal vertex to the internal 

limiting membrane (ILM )along optical axis for 

axial lenth measurement. The IOL master utilizes 

a non contact technique for axial length 

measurements based on partial coherence 

interferometry and measures the distance 

between the anterior corneal surface and the 

retinal pigment epithelium(RPE). Due to the 

thickness of the cell layer, the resulting 

differences of the measured axial length are 

between 150 - 350 µm. It has greater accuracy 

than ultrasound biometry because it measures 

the ocular AL along the visual axis, as the patient 

fixates at the measurement beam, whereas 

during ultrasound biometry a misalignment 

between the measured axis and the visual axis 

may occur. The error in measurement is 

theoretically more obvious in highly myopic 

eyes, which have a long AL and low scleral 

rigidity. The AL measurement will be 

inaccurately shorter with corneal indentation in 

highly myopic. Posterior pole staphylomas in 

eyes with an extremely long AL can also lead to 

errors in A-scan AL measurement. 11 IOL master 

in posterior pole staphyloma gives better results 

because of the more precise localization of the 

fovea. 

Several ultrasound biometry studies have 

1. Eleftheriadis H. IOLMaster biometry: refractive 

results of 100 consecutive cases. Br J Ophthalmol 

2003;87:960-3. 

2. Watson A, Armstrong R. Contact or immersion 

technique for axial length measurement? Aust N Z J 

Ophthalmol 1999;27:49-51. 

3. Connors R, III, Boseman P, III, Olson RJ. Accuracy 

and reproducibility of biometry using partial 

coherence interferometry. J Cataract Refract Surg 

2002;28:235-8. 

4. Rajan MS, Keilhorn I, Bell JA. Partial coherence laser 

interferometry vs. conventional ultrasound 

biometry in intraocular lens power calculations. Eye 

References 

examined the accuracy of various IOL power 

calculation formulas in eyes with a long AL. 6-10 

The SRK II formula has proved to be inaccurate 

for IOL power calculation in myopic patients. 6-10 

Third-generation formulas in eyes with long AL 

yield disparate results. 6,7,10 In a study by Hoffer, 6 

the IOL power calculated using the SRK/T, 

Hoffer Q, and Holladay 1 formulas predicted 

comparable refractive outcomes in 89 eyes with 

an AL longer than 24.5 mm. The MAE calculated 

using these 3 formulas ranged from 0.41 to 0.45 

D. 6 In a study of long eyes, Sanders et al. 7 found 

that the SRK/T and Holladay formulas 

performed equally well. Tsang et al. 10 report that 

the Hoffer Q formula provided the best predicted 

results in 125 Chinese eyes with high axial 

myopia. Wang et al reported the use of 

IOLMaster data with the SRK/T formula yielded 

the most precise refractive outcome (MAE 0.52 

D) in eyes with an AL between 25.0 mm and 28.0 

mm, and the precision of this refractive outcome 

was comparable to that obtained using the Haigis 

formula. However, the advent of the IOL Master 

has not rendered ultrasonic biometry obsolete as 

a significant number of eyes, approximately 

8–10%, still require ultrasound biometry, which 

is still essential in every ophthalmic practice. 3,4 In 

our small series of 25 patients we find that post 

operative spherical equivalent was ≤ ± 1D in 68% 

of patients in IOL Master group compared to 44% 

in US group. 

We may conclude that IOL measurements 

performed with the Zeiss IOL Master, using 

partial coherence interferometry, yielded 

significantly better IOL power prediction and 

therefore refractive outcome in cataract surgery 

than US biometry in high myopic eyes . 

2002;16:552-6. 

5. Findl O. Biometry and intraocular lens power 

calculation. CurrOpin Ophthalmol 2005; 16:61–64 

6. Hoffer KJ. The HofferQformula: a comparison of 

theoretical and regression formulas. J Cataract 

Refract Surg. 1993;19:700–12; errata 1994;20:677. 

7. Sanders DR, Retzlaff JA, Kraff MC, et al. 

Comparison of the SRK/T formula and other 

theoretical and regression formulas. J Cataract 

Refract Surg 1990;16:341–6. 

8. Olsen T, Corydon L, Gimbel H. Intraocular lens 

power calculation with an improved anterior 

chamber depth prediction algorithm. J Cataract


139 

Refract Surg 1995;21:313–9. 

9. Brandser R, Haaskjold E, Drolsum L. Accuracy of 

IOL calculation in cataract surgery. Acta Ophthalmol 

Scand 1997;75:162–5. 

10. Tsang CSL, Chong GSL, Yiu EPF, Ho CK. 

Intraocular lens power calculation formulas in 

Chinese with high axial myopia. J Cataract Refract 

Surg 2003;29:1358–64. 

11. Zaldivar R, Shultz MC, Davidorf JM, Holladay JT. 

Intraocular lens power calculations in patients with 

extreme myopia. J Cataract Refract Surg. 2000; 

26:668–74. 

12. Jia-Kang Wang ,Chao-Yu HuIntraocular lens power 

calculation using the IOLMaster and various 

formulas in eyes with long axial length. J Cataract 

Refract Surg 2008;34:262–7.

cataract session - iv - All India Ophthalmological Society

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