The report found iris suture fixation of IOLs to be a safe and effective method of correcting aphakia. The report could not determine whether iris suture. Abstract Purpose To compare two surgical treatment options for acute corneal hydrops in keratoconus: Mini-DMEK versus predescemetal sutures. Morphological and physiological changes in the monkey visual system after short-term lid suture. Invest Ophthalmol ; LUIS RIVAS FOREX BROKER You can search the connection to whitelisting helps to bottom of the. It is designed use environment variables in your command. Privilege Alerts will extensive visual inspection.
Learn about institutional subscriptions. Table of contents 14 chapters Search within book Search. Macsai Pages Johnson, R. Doyle Stulting Pages Uttley, Stephen S. Lane Pages Suturing an Intraocular Lens Julie H. Tsai, Edward J. Holland Pages Corneal Suturing Techniques W. Barry Lee, Mark J. Mannis Pages Trauma Suturing Techniques Marian S. Macsai, Bruno Machado Fontes Pages Iris Reconstruction Steven P.
Dunn, Lori Stec Pages Packo, Sohail J. Hasan Pages Lumba, Anne L. Coleman Pages Strabismus Mark J. Greenwald Pages Majmudar Pages Hannush Pages Twelve of these 17 eyes either maintained or improved their vision from preoperative to postoperative BSCVA. Other significant preoperative ocular comorbidities in these 17 eyes included glaucoma, retinal detachment, trauma, vitreous hemorrhage, and ARMD. Postoperatively, patients in group 2 presented with the following new diagnoses: CME in 2 eyes 5.
Endothelial cell counts were not measured for group 2 because preoperative numbers could not be obtained. A total of 22 postoperative complications occurred in groups 1 and 2 combined. These included CME, glaucoma, bullous keratopathy, retinal detachment, uveitis, endothelial dystrophy, hemorrhages retinal and choroidal , HSV keratitis, and retinal scarring Table 3. Overall, there were no reported surgical complications associated with the sutured IOL in either group.
There was only one reported case of suture erosion in group 1. No subsequent problems, such as IOL dislocation or decentration, suture breakage, or endophthalmitis, occurred. In addition, no patients required repeated surgery.
Postoperative visual acuity groups 1 and 2 combined was improved in 73 of eyes Studies have reported various benefits and complications for each procedure. However, the decision of which IOL to place for each patient may introduce selection bias that could have affected study outcomes. For example, angle abnormalities and anterior synechia may have precluded ACIOL placement in some patients, and patients with limited iris tissue may not get an iris-sutured lens.
In the study described in this report, mean visual acuity improved in both groups. Visual acuity was followed for an average of Studies of the TS PCIOL, in particular, have shown that it is a safe procedure that can improve visual acuity, but it can present various complications.
The published complications include glaucoma, CME, retinal detachments, endophthalmitis, lens tilt or redislocation, and suture exposure or breakage. All of these complications have been reported at variable frequencies following placement of iris-sutured IOLs, and all except suture exposure or breakage have been documented with ACIOLs. Other compounding factors for interpreting the actual cause of the glaucoma include falsely low IOP measurements before PK from corneal edema and an increased occurrence of glaucoma in patients with PK.
This value is lower than the reported incidence of postoperative glaucoma following iris-sutured PCIOLs 6. In patients with bullous keratopathy or other corneal opacities, preoperative analysis of CME is not possible, and it may be present before the surgery, therefore artificially increasing the postoperative incidence of CME, and should be considered when evaluating these data. There was only 1 eye 1. The frequency of retinal detachments in this study is comparable to that in studies of iris-sutured PCIOL 0.
Risk factors for hemorrhage include older age, history of hypertension, peripheral vascular disease, aortic stenosis, emphysema, prior eye surgery, and need for excessive intraoperative manipulation. The patient had several risk factors for hemorrhage formation, including previous ocular trauma with hypema, older age, and prior ocular surgery. The study reported here did not have any cases of lens tilt or redislocation.
With revised techniques, the rate of suture breakage decreased to 0 to 2. On the basis of these results, the use of a scleral flap with knot rotation method seems to provide the lowest incidence of suture exposure or breakage in TS PCIOL. Furthermore, preventing suture erosion may decrease the risk of endophthalmitis by limiting open communication and the ability of bacteria to track through the suture path into the eye.
Cases of endophthalmitis are more commonly reported with suture exposure and occurred more frequently with earlier techniques. Prompt surgical intervention should be performed for cases of exposed sutures to prevent endophthalmitis. Previously published data report an incidence of There was only one case of bullous keratopathy 2. Although limited by its noncomparative retrospective design, this case series provides evidence that TS PCIOL insertion with or without PK can be performed with minimal postoperative complications.
This technique appears to be a satisfactory method of visual rehabilitation. The technique of transscleral PCIOL insertion via the ab externo method with a thick scleral flap and knot rotation offers a low complication profile and should be considered as a viable option for secondary IOL. Ultimately, individual patient factors and surgeon preference and expertise should guide the decision as to which secondary IOL is most appropriate for each patient.
Author Contributions: Design of the study V. N ; Management, analysis, and interpretation of data J. Dr Nottage and colleagues present a retrospective consecutive case series of the safety and visual outcomes of transscleral sutured posterior chamber PC IOLs performed by a single surgeon over a 4 year period. They studied 2 groups. The first group consisted of 69 eyes that underwent secondary scleral-sutured PC IOL insertion after complicated cataract surgery, trauma, or ectopia lentis.
The second group consisted of 38 eyes that underwent secondary scleral-sutured PC IOL insertion at the time of penetrating keratoplasty. In all cases, the haptics were secured to the scleral wall under a scleral flap by using polypropylene suture tied directly to the haptic.
The mean follow-up in both groups was limited to approximately 14 months. Complications of corneal edema 3 eyes , glaucoma escalation 4 eyes , and cystoid macular edema 4 eyes were relatively minor. Complications were also relatively minor. The findings of the author should not be unexpected. As recently as , an American Academy of Ophthalmology sponsored report by Wagoner and colleagues 1 reviewed 13 published articles and found similar visual acuity results and complication rates as reported today by Dr.
Wagoner concluded that, in the absence of capsular support, scleral-sutured PC IOLs are safe and effective in adults. They also concluded that there was insufficient evidence to demonstrate the superiority of scleral-sutured PC IOLs over open loop anterior chamber IOLs. Although the authors conclude the safety of scleral-sutured PC IOLs, a new concern has been raised about the long-term safety of using polypropylene as the suture material to fixate the IOL haptic to the scleral wall.
The suture just degrades and fails. The fact that polypropylene suture might degrade enough to break over time is not completely unexpected. AOS member, Dr. Robert Drews, in his Binkhorst Medal Lecture in , 3 predicted that polypropylene sutures may fail after a period of time in the eye. His scanning electron micrographs of polypropylene suture removed from iris-fixated IOLs showed surface cracking and flaking. Ed Holland and coworkers 4 showed that when haptics are sewn in the ciliary sulcus, a fibrous membrane will form around the haptic and that this scar tissue could fixate the IOL even if the suture fails.
It is unknown how long this scar tissue can fixate an IOL without suture support. The rationale for selecting polypropylene suture for this task cannot be found in the literature. But is polypropylene just a longer fuse than ? I do not know. As a suture material, it is used in cardiac and vascular surgery and in the eye it has been used in strabismus surgery.
Although the suture is not approved for use in ophthalmic surgery, in the few cases I have used it, it seems to works well. However, before you begin cutting your Gor-Tex rain coats into thin strips, the currently available Gor-Tex suture is larger than we are used to equivalent in size to polypropylene , the current vascular needles are acceptable, but not ideal.
The main disadvantage is the larger size of the knot which requires a concerted effort to rotate it into the sclera. I have no financial interest. It is interesting that we have emphasized throughout this meeting the importance of long-term follow-up, but in this case I would like to just point out my concerns about short-term follow-up. I have been doing secondary sutured posterior chamber lenses either as an IOL exchange at the time of keratoplasty and in the early s in patients who were aphakic and who might have been wearing spectacles or who reached an age or dementia when they could no longer handle contact lenses.
I have been concerned about short-term visual rehabilitation and microscopic hemorrhages that are associated with sutured posterior chamber lenses. I have observed delayed visual improvement, although I have not looked at it statistically. Publications on the subject tend not to report short-term visual acuity and whether there might be a higher incidence of cystoid macular edema CME or a higher incidence of microscopic hemorrhaging into the vitreous at the time of the procedure.
I question what your experience might be in this regard. Further, in we had a fellow from Wake Forest University, Dr. Jerry Ford, who had adopted the technique that John Reed popularized of not using scleral flaps. I initially started using the technique of burying the polypropylene Prolene sutures under scleral flaps and noted that over time the scleral flap tends to thin, disappear, or erode with a tendency towards exposure of the knot.
I think the exposure and erosion rate is less, but I would appreciate your comments on this technique and on the short-term visual rehabilitation. I want to start off by saying thank you very much for the incredible bibliography you are going to give me related to your paper. All those cases that you reviewed will be a perfect starting point for another study. Now this is a retrospective comparison study and the controls are difficult to design. In pharmacology we are faced with this problem all the time.
When it comes to cataract surgery our techniques change, our equipment changes, the drugs used in the eyes and the body changes, and the indication for surgery changes. We are operating on a much younger and healthier population that takes fewer medications.
Retrospective comparisons are by their very nature fraught with hazards. I wonder if you have any clues as to why your retrospective comparisons might be better than those to which we are accustomed. No conflict. Just to comment on some of the surgical techniques and some of the concerns that has been raised.
First, we chose the time frame because we had one of the medical students go back and look at our available results. I have been doing this surgical technique for about 25 years and we have moved several times. It was just a problem of being able to get all patient records or to get back those patients who probably were lost to follow-up.
When we looked at the total number it was nearly 1, and it just seemed to be a nightmare in trying to assemble all the information. Secondly, my technique has been fairly consistent and we still follow patients. Our patients who still come back once a year had the same technique done over 25 years ago. I have not observed among my patients any of the concerns about Prolene, I know that these problems have been reported before and we always look out for that possibility.
We tell the patients that it is possible that the Prolene might fail and we may have to go back and re-suture it. Nothing lasts forever, but surprisingly in the last 25 years we have not had a single patient with this problem, except for one who was in an auto accident and had the airbag blowup in his face. He actually noticed loss of vision a week later and one of the sutures had broken. We-sutured it, but that this was the only one that I can remember over so many years.
Initially we used Prolene when we were trying to determine the right suture to use for corneal transplants. Surgeons started with nylon and then went to double nylon, then nylon, then nylon, and then and 10 Prolene. I still have at least 10 patients with Prolene sutures. I chose to use this material primarily in patients who were mentally challenged because it was difficult to remove their sutures. I still follow them and some have been followed for 18—19 years after surgery.
The Prolene looks as good today as it did 18 years ago. I have two questions. Did you ever consider using Mersilene as opposed to Prolene? When the procedure was done open sky why did you not chose to use the CZ7obd Alcon Laboratories, Inc. Was it used in some of the patients and not in others and were the results compared? No financial disclosures. I consider these to be some of the most technically difficult cases to repair when the lenses become dislocated.
Based on my experience, I believe that we should seriously consider why these patients developed cataracts in the first place. If there is any history of possible eye trauma, I would advise using a technique other than sutured posterior chamber IOLs. Some patients with traumatic cataracts tend to have recurrent trauma and trauma has been one of the most frequent causes for dislocation of sutured posterior chamber IOLs. Another cause of IOL dislocation in this setting is abnormal sclera, such as in patients with Marfan syndrome.
They are also are not good candidates for this technique. Thank you. First, I would like to thank Dr. Nirankari and Dr. I know Dr. Nirankari answered many of the questions. In summary, the decision for using this set of patients was based on the availability of their medical records. We believed that we had the best ability to evaluate all the different data points from this subset of patients from through The arbitrarily picked dates translated into an average follow-up of 14 months.
We believe that scleral flaps are still necessary to protect the polypropylene Prolene suture and to prevent endophthalmitis. We are still using Prolene sutures because Dr. Nirankari has not had any complications with breaks or erosion of the material. The Prolene results in a slightly larger knot that could cause more erosion underneath the scleral flap. This is a consideration when selecting what type of suture to use. I am interested to determine what happens with the long-term results and complications of the Gor-Tex suture if that becomes a more frequently used technique.
Just like any other retrospective study, ours has a lower rate of validity. Our study was based on one surgical technique that did not change during the entire duration of the study. We cannot guarantee that other variables did not sway the data one way or the other.
About 50 patients were excluded from the study due to insufficient data. These patients could have altered the final outcome of the study. We did evaluate the short-term follow-up for the visual acuity and determined that it was not significantly different from the final postoperative visual acuity, which I presented in the data of the study.
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According to BS British Standards Institution "Specification for test charts for determining distance visual acuity" the minimum illumination for externally illuminated charts should be lx , however this very important parameter is frequently ignored by physicians, making many test results invalid. Thus the optotype can only be recognized if the person viewing it can discriminate a spatial pattern separated by a visual angle of 1 minute of arc.
In the most familiar acuity test, a Snellen chart is placed at a standard distance, twenty feet in the US. At this distance, the symbols on the line representing "normal" acuity subtend an angle of five minutes of arc, and the thickness of the lines and of the spaces between the lines subtends one minute of arc. The chart is at a distance of twenty feet, but a person with normal acuity could be expected to read these letters at a distance of forty feet.
In an even rougher way, this person could be said to have "half" the normal acuity. Acuity charts are used during many kinds of vision examinations, such as "refracting" the eye to determine the best eyeglass prescription. During such examinations, acuity ratios are never mentioned. A legally blind person is one who cannot read the E "even with the best possible glasses.
The fact that the number of letters increases while the size decreases introduces two variables, rather than just one. Some people may simply or unconsciously memorize the Snellen chart before being tested by it, or between tests of one eye and the other, to give the impression that their vision is good. Several studies indicate that the crowding together of letters makes them inherently more difficult to read. Another issue is that there are fairly large and uneven jumps in acuity level between the rows.
To address these concerns, more modern charts have been designed that have the same number of letters on each row and use a geometric progression to determine the size of each row of letters. Snellen was director of an eye clinic at Utrecht. In he introduced… … Medical dictionary. Snellen chart — the commonest chart used for testing sharpness of distant vision see visual acuity.
It consists of rows of capital letters, called test types, the letters of each row becoming smaller down the chart. The large letter at the top is of such a… … The new mediacal dictionary. Snellen chart etc. Snellen test type — block letters used in testing visual acuity, so designed that the whole letter subtends, at the appropriate distance, a visual angle usually of 5 minutes, and each component part subtends an angle of 1 minute.
See also Snellen chart, under chart … Medical dictionary. DescriptionThe traditional Snellen chart… … Wikipedia. Snellen was director of an eye clinic at Utrecht. In he introduced… … Medical dictionary. Acuity test, visual — This test measures how well you see at various distances. Snellen's chart — The familiar eye chart used to measure how well you see at various distances.
Snellen s chart is imprinted with block letters that line by line decrease in size, corresponding to the distance at which that line of letters is normally visible. The … Medical dictionary. Snellen visual acuity. Visual acuity VA is acuteness or clearness of vision, which is dependent on the sharpness of the retinal… … Wikipedia Visual acuity — The clarity or clearness of the vision, a measure of how well a person sees.
The eye chart itself the usual one is called Snellen s chart is imprinted with block letters that line by line decrease in size, corresponding to the… … Medical dictionary visual acuity — sharpness of vision: the degree to which a person is able to distinguish and resolve fine detail.
Acuity of… … The new mediacal dictionary Test, visual acuity — This test measures how well you see at various distances. In he introduced… … Medical dictionary Acuity test, visual — This test measures how well you see at various distances.
The eye chart itself the usual one is called Snellen s chart is imprinted with block letters that line by line decrease in size, corresponding to the… … Medical dictionary Snellen's chart — The familiar eye chart used to measure how well you see at various distances.
Snellen s investing suture care cad/usd investing in goldGoing through a Snellen eye chart by Vicki Chan MD
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