Cataract - III Free Papers - aioseducation

ContentsContentsCATARACT - IIIVisual Outcome Following Cataract Surgery in Various Levels of Hospitalsand Camps in Shimla District- A Longitudinal Follow Up Study................ 261Dr. Ramlal SharmaN-Butyl-2-Cyanoacrylate Glue: An Effective Wound Sealant in Clear CornealCataract Surgery............................................................................................... 268Dr. Shwetambari Singh, Dr. Dipali Satani R, Dr. Amit Patel PComparative Study of Secondary SFIOL and Primary ACIOL Implantation... -............................................................................................................................ 270Dr. Suraj P Bhagde, Dr. Suvarna BhagdeImplantation of IOL in Ringer Lactate without using Visco-Elastic Substancein Small Incision Cataract Surgery ................................................................ 274Dr. Pranay Singh, Dr. B K Jain, Dr. Suraj Bhagde, Dr. Ravinder Gandhi, Dr. AjayPrakashNSAID without Mydriatic — A Better Choice in Postoperative SICS.......... 278Dr. Jaishri Murli Manoher, Dr. Anita Chahar, Dr. Anju Kochar, Dr. Kalpana Jain (Daga),Dr. Rimaljeet KaurEvaluation of the Outcomes of Cataract Surgeries Performed by ResidentDoctors............................................................................................................... 280Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Amit Patel, Dr. Dipali Satani RCorneal Endothelial Damage after Manual Small Incision Cataract Surgeryof Very Hard Cataracts..................................................................................... 283Dr. Ashish Bacchav, Dr. Sandhya Reddy K, Dr. Venkat Rami Reddy Tetali,Dr. Yashodhan Satalkar, Dr. Ramakrishnan RTips and Tricks of Repositioning a Decentred Intraocular lens.................. 284Dr. Jagdish C ShahClinical Study of Visual Outcome and Complications after VariousTechniques of Secondary Intraocular Lens Implantation in Aphakia........ 288Dr. Jyoti Shetty, Dr. Janvi JhamnaniOutcomes of Iris Fixated IOL........................................................................... 292Dr. Tamilarasi S, Dr. Haripriya AravindAcinetobacter Baumannii Endophthalmitis in Post Cataract Extraction andIOL Implantation Surgery ............................................................................... 295Dr. Shalabh SinhaIntracameral Cefuroxime-An effective Prophylaxis for Post Cataract SurgeryEndophthalmitis................................................................................................ 300Dr. Subhash Prasad, Dr. Suryakant Jha

Cataract Free Paperscomplications occurred in 11 patients. Therefore 47 (9.81%) of all 479 patientshad some form of a complication which was managed suitably.The Best Corrected Visual Acuity was recorded at least 6 weeks followingcataract surgery with full correction. Post-operatively visual outcome wasgood in 77.2 % in the 80 years age group.The association of the visual outcome was analyzed in relation to place ofsurgery and it was seen that the best results for good visual outcome aftersurgery were obtained in medical college (IGMC) with 80.7 % of the patientsachieving a vision greater than or equal to 6/18. The corresponding percentagein District hospital was 78.6 %, in RH was 79.9 % and in CAMP was 68.0 %. Thep value was >0.50 which was statistically insignificant.Table 3: Visual outcome following cataract surgeryVisual acuity Category IGMC DH RH CAMP TOTAL>6/18 GOOD 113 110 111 34 78.46%6/18-3/60 LOW VISION 17 25 18 13 15.57%

69th AIOC Proceedings, Ahmedabad 2011N-Butyl-2-Cyanoacrylate Glue: An EffectiveWound Sealant in Clear Corneal CataractSurgeryDr. Shwetambari Singh, Dr. Dipali Satani R, Dr. Amit Patel PTo determine the feasibility and side effect profile of N-Butyl-2-Cyanoacrylateglue as an adjunct wound sealant after clear corneal cataract surgery.Over the past several years, the trend of sutureless clear corneal incisions forphacoemulsification is increasing among the cataract surgeons. The potentialbenefits of this approach over the scleral tunnel incision include better surgicalexposure, less patient discomfort, less risk of conjunctival bleeding, quickersurgical time and better aesthetic appearance after surgery. However, thereare studies suggesting that sutureless clear corneal wounds may be associatedwith an increased risk of acute postoperative endophthalmitis. There is concernthat with intraocular pressure fluctuations clear corneal incisions possiblyallows influx of extraocular fluid containing surface bacteria. Studies haveshown that cyanoacrylate glue as a wound adhesive will provide watertightmechanical barrier. This tissue adhesive will prevent the influx of extraocularsurface fluid through clear corneal incisions despite variations of intraocularpressure or manual pressure. The purpose of our study was to assess theintraoperative applicability, clinical course and side effect profile on N-Butyl-2-cyanoacrylate glue as a barrier device for clear corneal cataract surgery.268MATERIALS AND METHODSThirty patients undergoing phacoemulsification surgery for senile cataractwere included in the study. Written consent was obtained from all the patients.Peribulbar anesthesia was used in all patients. A 2.8 mm clear corneal uniplanartemporal incision with tunnel length of approximately 2.0mm was made witha 2.8mm stainless steel disposable blade. Phacoemulsification and corticalcleanup were completed in standard fashion. A foldable intraocular lens wasinserted into the capsular bag in all eyes without enlargement of the wound.At the conclusion of each case, all wounds were hydrated with balance saltsolution and checked for leakage by gentle pressure with a cellulose spongeon the lip of the wound. Whether or not a leak was present, the edges of thewound were dried with fresh microsponges. A trimmed microsponge soakedwith 1 to 2 drops of N-Butyl-2-cyanoacrylate was applied in a smooth singlelayer along the entire length of the wound. This was allowed to dry for 15 to30 seconds. All wounds were rechecked with a cellulose sponge for leakageafter glue application. If any leakage was noted, the area was redried and glueapplication was repeated. Patch was given to every patient.

COMMUNITY OF PRACTICE ON INCLUSIVE ENTREPRENEURSHIPregard to clarity and precision. The aim was to make the wording clear andcomprehensible. Further changes will be described in more detail below.2.5.1 Greater comparability of the perception of survey groupsBecause the different survey groups have different perceptions and areas ofinfluence, the statements of all interviewees cannot be treated equally. Forinstance, entrepreneurs cannot usually asses the political and strategicframework of start-up support in their region. As users of the offers they areinterested mainly in the functioning of structures and can at best confirmretrospectively at which point they see problems.At the same time in previous versions, many questions were asked only toindividual actors, although the views of other groups would have been possibleand interesting. Especially because the comparison of perceptions - as mentionedbefore - has been gaining more importance in the previous studies, the tool hasbeen revised accordingly. The aim was to look at the different aspects of settingup support structures from as many angles as possible.2.5.2 Thematic block: Entrepreneurship educationEntrepreneurship education is an essential element of entrepreneurship support.Self-employment should be treated as an obvious alternative to dependentemployment within education and vocational training. It is necessary to train andpractice entrepreneurial thinking and acting.In previous studies, however, many problems with this thematic block emerged.Generally statements about interviewees‘ experience during school andvocational training were of no value for the current situation as theseexperiences dated back too far in time. The majority of interviewees could notjudge the current situation in schools, universities, or other educationalinstitutions because they did not have sufficient insight into the present state ofthings.In order to fully understand this topic it would necessary to have a survey groupthat deals with entrepreneurship education only. This group should consist ofdecision-makers, people in charge of educational institutions as well as scholars,students and trainees. Although the results of such an enquiry would be veryinteresting, it would mean a complete abandonment of the research design of theCOPIE analysis tools, making the investigation much more complex.In the present, fourth version of the analysis tool, the sub-category"entrepreneurship education" has been deleted. In order to not completely blankout the issue two statements on the treatment of the topic in schools anduniversities have been added to the thematic block ―awareness andsensitization‖. Since none of the interviewees has direct influence on the designof frameworks in this area, all given estimates are those of outsiders. Thus,Page 12 of 23

Cataract Free PapersTable 5: Post-operative BCVAPost-operative BCVA SFIOL group ACIOL group< 6/60 1 (5%) 1 (5%)6/60 to 6/36 3 (15%) 3 (15%)6/24 to 6/18 11 (55%) 6 (30%)6/12 to 6/6 5 (25%) 10 (50%)Mean LogMAR 0.516 + 0.263 0.439 + 0.305Using paired t-test, there was significant difference between pre-operativeand post-operative BCVA in SFIOL group (p-value – 0.0031).Using unpaired t-test, there was no statistical difference between postoperativeBCVA of ACIOL and SFIOL groups (p value – 0.3941) though themean LogMAR value of ACIOL group is smaller than SFIOL group indicatingthat mean post-operative BCVA of ACIOL group is better than SFIOL group.The inter-group comparison of intra- as well as post-operative complicationswas not statistically significant for any parameter.DISCUSSIONThe decision of primary vs secondary ACIOL or SFIOL implantation is trickyand often difficult to make. The advantages of SFIOL over ACIOL are: withSFIOL, there is less corneal endothelial damage, reduced aniseikonia if thecontralateral eye is phakic as the IOL is in the posterior chamber, and canbe done in presence of iris abnormalities such as large-sectoral iridectomy orin shallow anterior chambers due to PAS or other causes. The disadvantagesare: it demands higher surgical skill, more surgical time and patience,and is associated with posterior segment complications such as vitreoushaemorrhage and retinal detachment; ciliary body complications such asciliary detachment, suprachoroidal haemorrhage, ciliary shock and hypotony.Late erosion of scleral sutures associated with lens tilt and dislocations havealso been reported. The advantages of ACIOL over SFIOL are: the technique issimpler, takes less time but runs the risk of corneal decompensation, pupillarycapture of IOL, pupil block glaucoma, UGH syndrome.Yolanda et al studied 46 cases of primary ACIOL and 36 cases of primarySFIOL and observed that 71.7% eyes with ACIOL had BCVA of 20/40 orbetter while 47.2% eyes with SFIOL had BCVA of 20/40 or better. Althoughboth the number of eyes with complications and the total number ofcomplications were higher in the SFIOL group, the differences in early andlate complications were not statistically significant. However, Everekliogluet al studied 73 cases of secondary ACIOL and 51 cases of secondary SFIOLand found that although both the number of eyes with complications and thetotal number of complications were higher in the SFIOL group, the differences273

69th AIOC Proceedings, Ahmedabad 2011P value was significant at 6 hr and 24 hr(p value 0.05 and so the difference wasnot significant.IOL position Ringer’s group Visco groupBag 47 49Bag in sulcus 3 1The preoperative mean endothelial cell count in visco group was 2361.08and postoperative mean count was 2217.52, loss was 143.56 cells (6.08%).Preoperative mean endothelial cell count in ringer group was 2355.4 and postoperative mean count 2144.72, loss was 210.68 cells (8.9%). Though the cell losswas more in ringers group but this difference was not significant (p value0.055).DISCUSSIONA number of studies have shown that all viscoelastic substances are capableof increasing IOP in the early postoperative period (Liesegang 1990; Goa andBenfield 1994).PD Sharma et al.1 has reported significantly higher IOP on day 1, 2, and 7 inSICS and maximum on day one as compared to mean preoperative IOP.In our study IOP in visco group was maximum at 6 hr and gradually becamenormal at 48 hr same results were in ringer lactate group with lesser spikes ofIOP.Sanjay M Shah et al. 2 have reported maximum number of ant. chamber cellsafter cataract surgery on day one.276

Cataract Free PapersIn our study we got same results. Number of anterior chamber cell on day onewere more then day two, but cell in visco group at 24hr 1.56(SD±1.47) and at48hr 1.08 (SD±1.03) were significantly more than ringer lactate group 24hr 1.48(SD±0.81) and at 48 hr 0.72 (SD±0.729).Thomas R. et al 3 have reported implantation of IOL in the bag by Blumenthaltechnique is easy and safe.In our study number of IOL in bag was less in ringer group than visco groupthat was not significant. There was no complication during IOL implantationin each group.Ronnie George et al. 4 have reported 4.21% endothelial cell loss in SICS usingvisco in NS grade 3 or less.Gogate et al 5 have reported 6.5% endothelial cell loss in SICS using visco.Wright et al 6 have reported that the mean central and superior endothelial celllosses at 12 months after surgery were 20% and 25% respectively after cataractsurgery using the ACM without viscoelastic.Krishan PS Malik et al 7 have reported endothelial cell loss in blumenthaltechnique is 5.5% in three months.In our study we have reported 6.08% endothelial cell loss in visco group and8.9% endothelial cell loss in ringer lactate group. Results are comparable.Average time was less in ringer lactate because there was no need to washvisco after IOL implantation in ringer lactate group.Only a small modification in one step of small incision cataract surgery cansignificantly control spikes of IOP with significantly lesser post operativereaction. Implantation of IOL in the bag under a continuous irrigation ofRinger Lactate is safe, accurate and less time consuming method without anysignificant extra loss of endothelial cells.REFERENCES1. Sharma PD, Madhavi MR. A comparative study of postoperative intraocularpressure changes in small incision vs conventional extra capsular cataract surgery.Eye (London). 2010;24:608-12. Epub 2009 Jul 24.2. Sanjay M Shah, David J Spalton. Changes in anterior chamber flare and cellsfollowing cataract surgery. Britishjournal of Ophthalmology 1994;78:91-4.3. Thomas R, Kuriakose T, GeorgeR. Towards achieving small-incision cataractsurgery 99.8% of time. Indian J Ophthalmol 2000;48:145-51.(s)4. Ronnie George et al. Comparison of Endothelial Cell Loss and Surgically InducedAstigmatism following Conventional Extra capsular Cataract Surgery, ManualSmall-Incision Surgery and Phacoemulsification Ophthalmic Epidemiology,2005;12:293–7.277

69th AIOC Proceedings, Ahmedabad 20115. Gogate et al. Comparison of endothelial cell loss after cataract surgery:Phacoemulsification versus manual small-incision cataract surgery: six-weekresults of a randomized control trial. J Cataract Refract surgery 2010;36:247-53.6. Mark Wright, Hector Chawla , Alistair Adams. Results of small incision extracapsular cataract surgery using the anterior chamber maintainer withoutviscoelastic. Br J Ophthalmology 1999;83:71-5.7. Krishan PS Malik, Ruchi Goel. Nucleus management with Blumenthal technique:Anterior chamber maintainer. Indian J Ophthalmology 2009;57:123-5.NSAID without Mydriatic — A Better Choice inPostoperative SICSDr. Jaishri Murli Manoher, Dr. Anita Chahar, Dr. Anju Kochar,Dr. Kalpana Jain (Daga), Dr. Rimaljeet Kaurlarge backlog of cataract blindness exist in the developing world , andA cataract is still the most common cause of avoidable blindness. 1 Manualsmall incision cataract surgery (SICS) has emerged as a popular and costeffective technique in last ten years in India. 2 The post operative treatmentregime usually is antibiotic and steroid drop locally in eye with mydriatic orcycloplegic drop in night time. This post operative treatment continues for along time and may be associated with complications.The aim of this study is to compare the efficacy of steroid versus NSAID dropwithout mydriatic associated with minimal complications. 3,4278MATERIALS AND METHODSIn this study, 510 cases of cataract selected from August 2009 to December2009 were randomly divided into two groups. The age of the patient rangesfrom 50 to 70 years. All patients were having a variety of maturity of cataract–the nuclear sclerosis ranging from grade I to hypermature cataract. All thesecases were operated as SICS with PCIOL were implanted. The patient whohad complicated cataract, traumatic cataract, poorly dilating pupil, advanceglaucoma with cataract and extensive pseudoexfoliation syndrome wereexcluded from this study.In both groups the preoperative treatment was same but the post operativetreatment was different. In group I patient were given Gatifloxacin withKetorolac eye drop locally 2 hourly 6 times a day, while in group II Gatifloxacinwith Dexamethasone eye drop five times a day and mydriatic tropicamide wasprescribed in the night time up to one month . For all the patients the followup was done at 1st, 3rd, 7th, 15th and 30th post operative day.

Cataract Free PapersPeribulbar anesthesia was used in all patients.SICS was carried out with frown incision, tunnel size depending upon thenucleus grading ranging from 5-8 mm, capsulorhexis/ capsulotomy wasperformed and nucleus delivery with viscoexpression method and PMMAlens was implanted after cortical wash. Phaco were performed with threeports with clear corneal tunnel of 2.8 mm incision. All standard steps of phacowere carried out and foldable lens was implanted. All important intraoperativeevents were noted in each case.Post operative all study patients were evaluated on Day 1, 1 Week, 3 Weeksand 6 Weeks follow up. On all visits Vision, Tension, Slit lamp examination forcorneal edema, cells / flare and placement of IOL were evaluated.. After sixweeks of surgery refraction was carried out.RESULTS60 eyes of 60 patients with mean age of 58 years with 40 SICS and 20 phacoeswere performed by 2nd and 3rd year residents respectively.Intraoperative complicationsIntraoperative complications of SICS were posterior capsular rent withvitreous loss in 6(15%), premature entry with iris prolapsed 5(12.5%),Descemets detachment in 3(7.5%), shallow groove with perforation of scleralflap 2(5%). In phaco group posterior capsular rent (PCR) with vitreous losswas encountered in 1(5%), wound leak with suture needed: 1(5%), iris trauma1(5%), difficulty in chopping 2(10%) were noted. In both the groups no majorcomplications like nucleus drop, retinal detachment, hemorrhagic choroidals,and endophthalmitis were notedPost Operative ComplicationsSICSPhacoCorneal Edema 6 (15 %) 2 (10 %)Cells( Grade II 16-25 per field) 5(12.5%) 1(5%)Residual lens matter not in visual axis 8 (20 %) 2 (10 %)Elevated IOP 3 (7.5 %) 1 (5 %)Rates of all other minor complications is more in SICS group. Intraocularlenses were implanted in all study patients. 30 (75%) were in the bag, 6 insulcus (15%), 2 partially in bag (5%) and 2 (5%) ACIOLs in SICS Group. In phacogroup 19 (95%) were in the bag and 1 (5%) was in sulcus.The final mean BCVA in SICS Group is 0.29 + 0.15 and in phaco +0.2+0.13 onLog MAR equivalent scale. Mean astigmatism in SICS group is 1.3D + 0.8D and0.6D+ 0.6 in phaco group.281

Cataract Free PapersCorneal Endothelial Damage after ManualSmall Incision Cataract Surgery of Very HardCataractsDr. Ashish Bacchav, Dr. Sandhya Reddy K, Dr. Venkat Rami ReddyTetali, Dr. Yashodhan Satalkar, Dr. Ramakrishnan RCataract is the leading cause of blindness worldwide. The majority ofthese cases are in developing countries. With advances in microsurgicaltechniques, manual small-incision technique has become increasinglypopular. Manual Small Incision cataract surgery is valuable in communitybased cataract surgery programmes. Hard and brunescent cataracts aretough as they may cause endothelial damage. We evaluate corneal endothelialchanges after manual small incision cataract surgery.To evaluate the endothelial damage by clinical specular microscopy aftermanual small incision cataract surgery in very hard brunescent cataracts.MATERIALS AND METHODSIn this prospective, randomized study, 100 patients with age-related and veryhard brunescent cataracts underwent manual small incision cataract surgery.Preoperative complete ophthalmological evaluation was done. Manual SICSwas done by the same surgeon. All cases underwent a detailed pre-operativeevaluation including vision, refraction, slit-lamp examination, applanationtonometry and dilated fundus examination. Keratometry (AppasamyKeratometer, AppasamyAssociates, Chennai, India) was performed byan independent observer. Central endothelial cell counts were measuredpre- and 1 month postoperatively using the TOPCON SP3000P, non contactspecular microscope. Cell density was recorded as the number of cells persquare millimeter. 1 month postoperatively, a complete ophthalmologicalexamination and endothelial specular microscopy was done. Endothelialcell loss, pleomorphism, polymegathism and corneal thickness were studied.Parameters evaluated in this study were central corneal thickness (inmicrometers), endothelial cell density (cells per square millimeter), percentageof hexagonal cells, and the coefficient of variation before and after surgery.Changes in each item after surgery were compared by t test.RESULTSMean age was 71.09 years. Out of the total 100 patients 62 were males andfemales 38. Pre-operatively Cell density was 2505.5, CV 38.41, Hexagonality48.94 and Thickness 513.82. 1 month Postoperatively Cell density 2454.36,CV 36.847, Hexagonality 47.79 and Thickness 522.69. The percentage loss ofendothelial cells was 2.04%283

69th AIOC Proceedings, Ahmedabad 2011DISCUSSIONManual small-incision technique is gaining popularity as quick, relativelyinexpensive technique for large-scale cataract management in the developingworld. One of the concerns has been the endothelial cell loss followingsurgery. Manual small-incision technique has been thought to be associatedwith increased endothelial cell loss due to surgical maneuvers in the anteriorchamber. Our results document minimal endothelial cell loss followingSICS. The mean endothelial cell loss was 51.14 cells. The percentage loss ofendothelial cells was 2.04%. This is due to better surgical technique and nucleusmanagement using adequate viscosurgical devices like sodium hyaluronate.A large proportion of India’s cataract blind reside in rural India withoutuniform access to ophthalmic care. Techniques with no associated increasein postoperative morbidity that promote early visual rehabilitation witha reduced need for additional postoperative visits would improve patientcompliance and improve cataract surgical results in the country.In our series of patients the endothelial cell loss after manual small incisioncataract surgery was 51.14 cells. Better surgical technique and nucleusmanagement result in better postoperative outcome and less endothelial cellloss.REFERENCES1. Rao SK, Ranjan Sen P, Fogla R, et al. Corneal endothelial cell density andmorphology in normal Indian eyes. Cornea. 2000;19:820–3.2. Hayashi K. Calculating endothelial cell loss. J Cataract Refract Surg. 1997;23:6.Tips and Tricks of Repositioning a DecentredIntraocular lensDr. Jagdish C ShahCataract surgery has rapidly progressed from extra capsular cataractsurgery (ECCE) to manual small incision cataract surgery (MSICS) tophacoemulsification (PE) to micro incision cataract surgery (MICS) withphacoemulsification. Also rapid progress in intraocular lens design andmaterial has made modern cataract surgery safe. The expectations of peopleof achieving complete visual recovery have increased tremendously. Astechniques for cataract surgery have evolved, spontaneous intraocular lens(IOL) dislocation has decreased overall.However, the complications are known to occur and one of the most disturbingcomplication is ‘Decentration of implanted intraocular lens (IOL) ‘. This284

Cataract Free Paperscomplication causes severe anxiety to the patients once he is aware about itapart from loss of vision. The surgeon also has to manage such a situationskilfully.The attempt is made to show how a difficult situation can be best corrected bysimple manoeuvring.MATERIALS AND METHODSThe case study done here is a case of 80 year old female patient complained ofmark loss of vision in her right eye with a short history of 10 to12 days.There was no history of trauma in otherwise a normal patient.She had undergone phacoemulsification (PE) 10 years ago by the author with 3piece foldable intraocular lens.She had been seen regularly once in 2 yearsand had no significant loss of visual acuitythroughout.On slit lamp, undilated right eye showedmarked displacement of IOL towards laterallywith medial edge of the IOL optics coincidingwith the edge of the undilated pupil.The right eye was dilated and the pupil wasapprox. 10 mm in size. The optics was seenGraphical representation of laterally displacedIOL with Figure 1 also showing intact CCC edge.Figure 1: Graphical presentationof displaced IOL laterallyThe repositioning of the intraocular lens was done under topical anaesthesiasitting temporally. The first tip was to introduce ‘anterior chamber maintainer’after the first of three stab incisions (Figure 2).Next step is the Trick as shown in Figure 3Graphical presentation of the ‘Trick ‘ to reposition the IOL (Figure 3).Pupil was constricted and iol position restored to full recovery of visual acuity(Figure 4).DISCUSSIONManagement of dislocated intraocular implants is always a challenging task.Possible pre-disposing factors are many like trauma, in-the –bag or out-of the–bag displacement, faulty capsulorrhexis, zonular dehiscence, sulcus fixatedIOL, pseudoexfoliation, entanglement of the heptics in posterior iris surface,broken or poor design of IOLs and capsular fibrosis. In the above case, though285

69th AIOC Proceedings, Ahmedabad 2011there were apparently no cause could be found to result such a displacementof IOL laterally.Commonly IOLdecentrationresults into‘sunset ors u n r i s es y n d r o m e‘where in IOLgets displacedeither inferiorlyor superiorly.Figure 2This conditionresults into dramatic symptoms of glare,diplopia and loss of vision.In the present case, the author only hadcarried out the primary surgery whichwas uneventful. She was seen to have thelateral displacement of the IOL with intactposterior capsule (in fact with minimumposterior capsular thickening) and had Figure 3no aetiopathology to ascertain for suddendisplacement ofthe IOL. The onlyattrbuting factorcould be fibrosisof the capsular bagand shorteningof the equatorialdiameter of the bag.Also possibly the3 piece design of Figure 4Anterior chamber maintainer.Figure 5286

69th AIOC Proceedings, Ahmedabad 2011All patients underwent a detailed ocular examination including slit lampexamination, gonioscopy, IOP recording, fundus examination. History ofprevious surgery or trauma leading to aphakia and the time duration tillthe secondary IOL implantation was noted. Parameters analyzed includedmaintenance of preoperative best spectacle corrected visual acuity (BSCVA),intra operative and post operative complications.RESULTSOur study included eyes of 27 patients. Mean age of patient with secondary SFIOL was 32.44 years. Mean age of patients with secondary PC IOL was 34.11years. Mean age of patients with secondary AC IOL was 65.33 years. Agedistribution was statisticallysimilar in SF IOL and PC IOLgroup but not in AC IOL groupas the later was deliberatelynot attempted in pediatric agegroup. Mean interval betweenprimary surgery/trauma andsecondary IOL implantationsurgery was 4.148 years.Capsular complications duringsenile cataract extraction(55.56%) was the most commonindication for secondary IOL followed by traumatic cataract extraction withcorneal tear repair (33.33%) and congenital cataract extraction (11.11 %).Post operative BSCVA improved or remained same in 70.37% of patients anddeclined in 29.62% of patients after secondary IOL implantation.Post operative BSCVA in the SFIOL group was better in 44.4% eyes, remainedsame in 33. 3% eyes but decreased in 22.2% eyes. In the PCIOL implantationgroup, post operative BSCVA was better in 77.8% and declined in 22.2% eyes.In the ACIOL group, the BSCVA was better in 22.2% eyes. No change was seenin 33.3% eyes and decreased in 44.4% eyes. The improvement in BSCVA in thePCIOL was statistically significant with p

Cataract Free PapersAt the end of 8 weeks, increase in IOP was more in ACIOL group with astatistical significance of (p=0.004**)ComplicationsPost operative complications were more in ACIOL group and least in thePCIOL group.DISCUSSIONSecondary IOL implantation is an excellent method for apahkic rehabilitationwhen contact lens and spectacle are not tolerated. With development of newertypes of intraocular lenses, viscoelastic substances and improved microsurgical technique, secondary IOL implantation can be performed routinelyin appropriately selected patients.In our study, careful selection of patients for various techniques of secondaryintraocular lens implantation was done. The mean time interval between theprimary surgery and secondary IOL implantation was 4.148 years which wasstatistically similar in all 3 groups.The most important measure of outcome of any ocular surgery is visual acuity.In our study, 70.3% of patients had improved or maintained BSCVA. SecondarySF IOL and Secondary PC IOLgroup maintained or showedimprovement in 77.8% of eyes.However, in secondary ACIOL group, post operativeonly 55.6% of eyes maintainedor improved visual acuity.The maintenance of BSCVA,post operatively, was low inthe secondary AC IOL groupwhen compared to othergroups due to post operative complications like corneal edema, secondaryglaucoma and uveitis affecting the final visual outcome.The most common complication encountered after secondary IOL implantationsurgery were uveitis, raised IOP and corneal edema. Whereas CME, sutureerosion and epiretinal membrane were less common. Uveitis was more insecondary AC IOL group (44.44%) followed by secondary PCIOL group (33.33%)and least with the secondary SF IOL group (11.11%). The probable cause couldbe more manipulation during the surgery.Elevated IOP was another common complication encountered with secondaryimplantation surgery. Its incidence was maximum in secondary AC IOL group(55%) followed by secondary SFIOL group (33 %) and least in secondary PC IOL291

Cataract Free PapersPre operative evaluation included recording of patients demographics,preoperative BCVA, slit lamp examination to evaluate the state of cornea,anterior chamber depth, status of iris, presence of vitreous in AC, Evaluationof remnant capsular support , IOP, Fundus evaluation , USG if needed.The technique of iris fixation is as follows. At the desired site of iris fixation,a 9-0 prolene suture is passed through the peripheral cornea, anterior surfaceof the iris and through posterior surface of the iris and retrieved through theperipheral cornea. This creates a loop behind the iris which is hooked using aKuglens hook and brought out through the main tunnel. The leading haptic isthen looped into the suture and lens is introduced into the posterior chamber,at this time the distal end of the suture is tightened simultaneously so that theloop does not escape out of the haptic.Once the haptic is in place, both the suture ends are brought out through thecommon side port using a kuglens hook and the knots are tied . While placingthe knots watch for the optic movement to ensure that the haptic is looped.Suture end trimmed short and left to rest over the anterior surface of the iris.Since there is capsular support left inferiorly the trailing haptic is placed in theposterior chamber and then iris fixation is done with haptic insitu. The knotsare tied similarly after ensuring that the haptic is engaged in the suturePatients were followed up at one day, one month and at three months. Visualacuity and complications were noted in the postoperative period. Eyes wereexamined for pigment dispersion, prolonged iritis, IOL centration, elevatedIOP and CME.RESULTSThe age range of our patients was between 13-85 years with maximum numberof patients ranging between 51-60 years. Among the patients included I thisstudy 54 were females and 26 were males. Iris fixation was done in right eye in46 patients and 34 in left eye. Indication of iris fixation in this study includes,complicated cataracts in 4 eyes which included brown, mature, HMC one eachwith severe PXF and phacodonesis and one was IMC with coloboma, 9 eyeshad traumatic cataracts, 5 eyes had congenital zonular weakness, in 19 eyesit was done as a result of decenterd IOLs (either one/ two haptic), 12 eyes hadaphakia due to lensectomy/ lens matter aspiration done for congenital cataractin the past. Majority of the patients belonged to the group of aphakia due tocomplicated cataract surgery.Further analyzing this indication revealed, The diagnosis to be Immaturecataract in 16 cases , Mature cataract in 5 cases ,hard nuclear cataract in 4 cases,4 Hyper mature cataract and 2 lens induced cataracts. The complication notedin these 31 cases were 12 cases of large PCR in which sulcus placement of293

69th AIOC Proceedings, Ahmedabad 2011PCIOL was not possible, 11 were zonular dialysis, 2 were whole bag removal,6 were co-existent PCR with Zonular dialysisIntraoperatively in 40 cases one haptic and rest 40 two haptics were fixeddepending on the requirement. IOL used was 3 piece PMMA in 75 cases andin 3 cases acrylic 3 piece and 2 acrylic single piece was used. 98.75 % of caseshad no complications , only one patient had iris bleed which seeped into thevitreous cavity.All patients had well centered IOL. Postoperatively, persistent iritis was seenin 3 patients who responded to topical steroids. Two patients were found tohave increased IOP and patients were put on anti-glaucoma medications andIOP was well controlled. Two patients developed CME ,which resolved butpatients had a BCVA of 6/24 and 6/36 respectively.No patients had corneal decompensation or suture slippage or IOLdecentration. Postoperative BCVA of better than 6/18 is noted in 87.5% of eyes.Postoperative poor visual recovery (6/24 and less) noted in ten eyes. Causesof poor vision includes Temporal pallor (1 eye), CME which resolved (2 eyes),ARMD (2 eyes), AION (1 eye), R-C coloboma(2 eyes), Anisometropic amblyopia(1 eye), Diabetic maculopathy(1eye).DISCUSSIONLiterature search conducted revealed that many of the studies were in thesetting of concurrent PKP, thus resulting in a major confounding factorin evaluating the visual outcome and complications. Out of the 8 articles 5were in conjunction with PK, Post-op complications are all greater whenIOL implantation is combined with PK as opposed to without. With respectto reports of sutured IOL s in the literature, iris fixated PCIOL s are in theminority. Until recently, most of these reports of IFIOL are with concurrent PK.We did a literature search and found only two similar studies of IFIOL to ourknowledge. One was by Condon et al, in which he reviewed retrospectively48 eyes in which iris fixation of foldable acrylic IOL was done with two yearsfollow up. BCVA of >6/24 was seen in 89.1% of patients. Complications notedwere 2 cases of IOL dislocation and 3 cases of prolonged uveitis and pigmentdispersion and 1 case of increased IOP. NO new case of CME was noted.Another study by Stuzman et al reported 12 cases of iris fixation IOL, but thedraw back of the study is no follow up and insufficient data on follow up.In Our study, Postoperative BCVA of > 6/18 in 87.5% eyes. No IOL dislocationor decentration and no suture slippage was seen. Though it needs an intact irisdiaphragm and Technically demanding especially when there is absolutely nosupport it has many advantages, Reduced risk of corneal endothelial damageand secondary glaucoma when compared to ACIOL ,Decreased possibilities294

Cataract Free Paperssay “they could emerge as a bigger threat.”[1] The illness can cause severepneumonia and infections of the urinary tract, bloodstream and other partsof the body.Acinetobacter sp. are gram-negative bacteria that are commonly present insoil and water as free living saprophytes and are also isolated as commensalsfrom the skin, throat and various secretions of healthy people. A. baumanniiforms opportunistic infections. There have been many reports of A. baumanniiinfections among American soldiers wounded in Iraq, earning it the nickname“Iraqibacter”. Multi-drug resistant Acinetobacter baumannii is abbreviated asMDRAB.Acinetobacter baumannii is the most relevant human pathogen within theAcinetobacter genus. Most A. baumannii isolates are multiresistant, containingin their genome small, isolated islands of alien (meaning transmittedgenetically from other organisms) DNA and other cytological and geneticmaterial; this has led to more virulence. Acinetobacter have no flagellum; thename is Greek for “motionless”.Acinetobacter baumannii – is a multidrug resistant organism in criticallyinjured hospitalized patients and is the most important acinetobacter species.Although this organism appears to have a predilection for the most vulnerablepatients, community-acquired A. baumannii infection is an increasing causefor concern. The increase in A. baumannii infections has paralleled thealarming development of resistance it has demonstrated. The persistence ofthis organism in healthcare facilities, its inherent hardiness and its resistanceto antibiotics results in it being a formidable emerging pathogen.Other Reports of Acinetobacter species involvement in the eye1. Acinetobacter calcoaceticus endophthalmitis was reported by Gopal et al(SN, Chennai) following cataract extraction + IOL implantation. The IOL+ Capsular Bag explantation with PP BMV was done, high sensitivity tociprofloxacin was found. Am J Ophthalmol. 2000;129:388-90.2. Endophthalmitis caused by Acinetobacter calcoaceticus. A profile. GopalL et al reported the clinical and microbiological profile of endophthalmitiscaused by Acinetobacter calcoaceticus. Of the 20 cases studied, 10 werecases of postoperative endophthalmitis, 3 were posttraumatic, 6 wereendogenous and one was bleb-related endophthalmitis Cases withpostoperative endophthalmitis had better anatomical outcome. Indian JOphthalmol. 2003;51:335-40.3. Gupta at al reported spectrum and profile of post cataract surgeryendophthalmitis in north India. One patient had cultured Acinetobacterspecies. IJO 2003;51:139-45.297

Cataract Free PapersAcinetobacter cacoaceticus, Pseudomonas aeruginosa and Proteusmirabilis. Enterobacter aerogenes and Streptococcus pneumoniae wereisolated. Garg SP, Kalra VK, Verma L. Indian J Ophthalmol 1991;39:59-61.14. Sankaridurg et al demonstrated that 57.1% of the new, unopened contactlens cleaning solutions available in the Indian market had bacterialcontamination with organisms such as Pseudomonas sp, Enterobacterand Acinetobacter species. Gram negative bacteria and contact lensinduced acute red eye. Indian J Ophthalmol 1996;44:29-32.15. Purulent material collected surgically from the orbit cultured in orbitalabscess patients cultured Staphylococcus aureus, two each Pseudomonasaeruginosa, Proteus mirabilis, Acinetobacter species and one eachβ-haemolytic Streptococci, Citrobacter frundi and Enterobacter. Suneethaet al Orbital abscess: Management and outcome. Indian J Ophthalmol2000;48:129.16. Bacteria constitute the major causative agents of chronic dacryocystitisand include Streptococcus pneumoniae, Staphylococcus aureus,Staphylococcus epidermidis, Pseudomonas aeruginosa, Escherichia coli,Klebsiella, and Acinetobacter. Muralidhar S, Sulthana CM. Rhodotorulacausing chronic Dacryocystitis: A case report. Indian J Ophthalmol1995;43:196-8.17. A total of 648 corneoscleral rims from donor corneal buttons were cultured.Coagulase-negative staphylococci isolates were the most commonbacteria isolated. Next in frequency were Pseudomonas aeruginosa andAcinetobacter calcoaceticus respectively. Streptococcus species at 84.6%and Acinetobacter calcoaceticus at 81.8% also showed a high incidenceof gentamicin resistance. Gopinathan et al Donor corneoscleral rimcontamination by gentamicin-resistant organisms. Indian J Ophthalmol1994;42:71-4.18. Mathews et al reported a patient who had clinical signs of allergicconjunctivitis who was eventually found to have culture provenAcinetobacter calcoaceticus ar Lwoffi causing preseptal cellulitis.Preseptal cellulitis caused by Acinetobacter lwoffi. Indian J Ophthalmol2005;53:213-4.New Test for indentification of Acinetobacterf-real-t PCR test – new test for bacterial endophthalmitis, staphylococci,streptococcus, pseudomonas, acinetobacter, hemophilus, propionibacterium,corynebacteria – test completed in 90 minutes. Goldschmidt et al. Br JOphthalmol. 2009;93:1089-95.299

Cataract Free PapersSurgeons (ESCRS) prospective multicentric study on use of 1mg ofcefuroxime intracamerally has shown it quite effective in the prophylaxis ofendophthalmitis after cataract surgery. Encouraged by the reports of ESCRSwe also wanted to see whether intracameral cefuroxime would be effectivein our set of patients, who are majority from middle socio economic status,do not have very good hygiene,and reside in different climatic conditions. Weconducted retrospective study on cefuroxime instilled in capsular bag at theend of phacoemulsification .MATERIALS AND METHODSThis was a non randomized retrospective study done between January 2009and March 2010. Total 2000 patients of senile cataract who underwent clearcorneal phacoemulsification by single surgeon (SP) were included in the study.All patients received prophylactic measures to reduce the bacterial flora ofconjunctiva pre-operatively like antibiotics Moxifloxacin six times a dayfor two days, Providine Iodine 5% cleaning of the periorbital region,topicalprovidone-Iodine 5% on the conjunctiva, properly draping the periorbitalregion and eyelashes and post operative use of Moxifloxacin 0.5% eye dropsfour times a day. 1000 Patients from January 2009 to August 2009 wereselected as control group as they did not receive intracameral Cefuroxime.1000 Patients operated between September 2009 to March 2010 were instilledfreshly prepared Cefuroxime 1 mg in 0.1 ml in the capsular bag at the endof Phacoemulsification.The patients with a history of hypersensitivity tocephalosporins were excluded from the study. All patients were followed onday one, one week,two weeks and four weeks or in case of any problem. Followup examination included measuring visual acuity,slit lamp examination andophthalmoscopy.RESULTSOut of 1000 patients in group one, who did not receive intracameral cefuroxime,585 patients were female and 415 were male. Age ranged from 52 years to 85years (average age 65.5 years).Cefuroxime group had 525 female and 475 malewith the age range of 53 years to 84 years (average 66.8 years). While none of thepatients in group who received Cefuroxime developed endophthalmitis, five(0.5%) patients in group one without Cefuroxime developed endophthalmitis.One patients each reported on day 1, 3, 10 and two patients on day 7. Visualacuity ranged from finger count close to face to 6/60. All those patients aftervitreous aspiration, received freshly prepared intarvitreal vancomycin 1mg in0.1ml and ceftazidime 2.25 mg in 0.1 ml same day. All patients received oralciprofoxacin 750 mg twice a day for seven days, moxiloxacin and tobramycineye drops one hourly, topical prednisolone and atropine eye drops, oralprednisolone 1mg per kg body weight from next day of intravitreal injection.301