Title Secondary posterior chamber IOL (PC IOL) Implantation-made simple Author(s) Dr zia u Mazhry FRCS, FCPS Abstract Objective: 1. To classify Indications and to discuss surgical planning for secondary PC IOL implantation 2. To elaborate variations of surgical procedure required to manage different situations encountered in secondary PC IOL implantation. Synopsis: Secondary PC IOL implantation in aphakics is an established procedure. Variation of surgical procedure are required to manage different situations. The status of posterior capsule may vary from intact to partially deficient or totally absent. Similarly the technique has to be varied from simple implantation to synechiolysis to anterior vitrectomy combined with single or double haptic trans-scleral fixation of PC IOL.This course will present simplified approach to manage secondary IOL implantation. Presentation Instruction Course Subspecialty ophthalmology,Cataract Education Level advance Course Format lecture Target Audience general Course Length 60 minutes Program english

1. Secondary posterior chamber IOL (PC IOL) Implantation-made simple Dr. Zia.ul.Mazhry FRCS(Edin), FRCS(Glasgow), FCPS(Pak), CICOphth- (UK) Life Member OSP Pakistan Member Executive council OSP LHR (Pak) Member American Academy of Ophthalmology Assistant Professor Central Park Medical College Lahore Pakistan Consultant Eye Surgeon & Head of Department WAPDA Teaching Hospital Lahore Pakistan We do not have any financial interest in this presentation

2. The Speaker Dr. Zia.ul.Mazhry FRCS(Edin), FRCS(Glasgow), FCPS(Pak), CICOphth- (UK) Life Member OSP Pakistan Member Executive council OSP LHR (Pak) Member American Academy of Ophthalmology Assistant Professor Central Park Medical College Lahore Pakistan Consultant Eye Surgeon & Head of Department WAPDA Teaching Hospital Lahore Pakistan The Course Secondary posterior chamber IOL (PC IOL) Implantation-made simple Part 1 Background and classification Part 2 Clinical and surgical skills Part 3 To review and interact Introduction

3. General Issues in Learning and Teaching “Learning without thought is labor lost. Thought without learning is intellectual death” Confucius

4. Objective: To demonstrate the safe and effective use of techniques for Secondary posterior chamber IOL implantation while avoiding the pitfalls, and to explore the alternative of scleral fixation of PC IOL in eyes with partial or total absence of posterior Capsule. To classify Indications and to discuss surgical planning for secondary PC IOL implantation To elaborate variations of surgical procedure required to manage different situations encountered in secondary PC IOL implantation.

5. Upon completion of this course, the ophthalmologist should be able to: Plan a surgical intervention when faced with uniocular or binocular aphakia needing a secondary PC IOL Implant. Classify and describe the different clinical presentations and appropriate surgical technique for secondary PC IOL Implantation Identify and manage the most frequent intraoperative and post operative complications encountered in secondary PC IOL Implantation .

6. Synopsis: Secondary PC IOL implantation in aphakics is an established procedure. Variation of surgical procedure are required to manage different situations. The status of posterior capsule may vary from intact to partially deficient or totally absent. Similarly the technique has to be varied from simple implantation to synechiolysis to anterior vitrectomy combined with single or double haptic trans-scleral fixation of PC IOL. This course will present simplified approach to manage secondary IOL implantation.

7. Course overview Objectives Synopsis Historical Review Background Classification Criteria Classification Preoperative Considerations Intraoperative Considerations Surgical Techniques Post Operative Management Video Review FAQs Secondary IOL Pearls Summary Conclusion

9. Secondary posterior chamber IOL (PC IOL) Implantation-made simple Part 1 Background & Classification

10. Evolution of cataract Surgery

14. Shearing 1976 (J Loop)

15. Sinskie

16. Simcoe (C Loop)

17. Kartz

18. Intra Bag IOLs

19. Foldable IOL

20. Phaco-Ersatz

22. Relevence 270,000 cataract procedures were performed in UK National health service in 2008.1 The reported incidence of PC rupture and zonular dehiscence is 1.92% and 0.46% respectively. 2 Both of these complications have the potential to prevent primary lens insertion and aphakia Secondary lens implant is now the standard for managing aphakia.3 However there is a wide variation in the choice of lenses for secondary lens implant.

23. Aphakia Aphakia with Full Capsular Support Aphakia with Partial/Absent Capsular Support Complicated by: Dislocated/subluxated Nuclear fragments Pseudophacos

24. Options for correcting Aphakia: Epikeratophakia Angle supported IOLs Iris supported IOLs Scleral supported IOLs Capsule supported IOLs

25. Aphakia with Full Capsular Support Pupil Mobile/Fixed Regular/Irregular Constricted /Dilated Iris Tissue Intact/Missing Synechiae Anterior Posterior Visual Axis Clear/Opaque

26. Aphakia with Partial/ Absent Capsular Support Posterior Capsule Deficient Central round rent Central linear rent Peripheral Rent Absent Anterior Vitreous Prolapsed Vitrectomized Further Complicated Sublux/Dis-Pseudophacos Dislocated Nuclear Fragmant Dispersed Cortical Matter

27. Classification Simple Secondary PC IOL (Sec- PC IOL): Sulcus Dissection/Synechiolysis and PC IOL implantation (SD &PC IOL) Intra shelf PC IOL implantation (IS PC IOL) with anterior vitrectomy

28. Classification Single Haptic Sclera Fixation (SHSF PC IOL) Double haptic scleral fixation (DHSF PC IOL). Retrieval & Fixation of dislocated IOL (R&SF PC IOL)

30. Secondary posterior chamber IOL (PC IOL) Implantation-made simple Assistant Professor Central Park Medical College Lahore Consultant Eye Surgeon & Head of Department WAPDA Teaching Hospital Lahore Part- 2 Clinical & Surgical Skills Dr. Zia.ul.Mazhry FRCS(Edin), FRCS(Glasgow), FCPS(Pak), CICOphth- (UK) Life Member OSP Member American Academy of Ophthalmology Executive Member OSP Lahore Branch

31. Over twenty-four hundred years ago, Confucius declared: What I hear, I forget. What I see, I remember. What I do, I understand.

32. Preoperative Considerations Status of zonula-capsule complex Intact clear Intact opaque Central rent Peripheral rent Pupil Mobile reactive Fixed constricted Fixed dilated irregular IridocapsularAdhisions Anterior Vitreous Prolapsed in AC Vitrectomized Visual Potential BCVA Corneal status Retinal status Investigate FFAOCTBscan

33. Preoperative Considerations Instruction Course Secondary PC IOL Implantation - made simple

34. Preoperative Considerations Instruction Course Secondary PC IOL Implantation - made simple

35. Preoperative Considerations Instruction Course Secondary PC IOL Implantation - made simple

36. Preop Planning Instruction Course Secondary PC IOL Implantation - made simple

37. Preop Planning Instruction Course Secondary PC IOL Implantation - made simple

38. Preop Planning Instruction Course Secondary PC IOL Implantation - made simple

39. Preop Planning Instruction Course Secondary PC IOL Implantation - made simple

40. The Materials The Instruments Routine Cataract Set Kuglon’s Hook 27-30G hypodermic needles The IOL PMMA Single Piece Preferably Eyelets on the haptics 13.5-14.0 mm overall 6.00-7.00 mm optic Foldable Acrylic Single piece Min 13.00 mm overall Optic 6.00 -6.5 mm The Sutures Polypropylene (Prolene) 10/0 Double arm straight needle Nylon 9/0, 10/0 If Prolene not available

41. Aphakia with Full Capsular SupportClinical Situation:1 Sec- PC IOL eyes with intact posterior capsule and no anterior or posterior synechiae along with clear visual axis

42. Aphakia with Full Capsular SupportClinical Situation:2 SD &PC IOL in eyes with intact posterior capsule but with anterior or posterior synechiae and clear/opaque visual axis

43. Aphakia with Partial/ Absent Capsular SupportClinical Situation:3 IS PC IOL in eyes with central rent in posterior capsule or densely opaque visual axis

44. Aphakia with Partial/ Absent Capsular Support IS PC IOL in eyes with Periph- rent in posterior capsule extending less than 90 degrees Instruction Course Secondary PC IOL Implantation - made simple

45. Aphakia with Partial/ Absent Capsular SupportClinical Situation:4 SHSF PC IOL in eyes with partially deficient posterior capsule with peripheral rent extending for less than 180

47. AbExterno Surgical Tech-27G Needle &10/0 Nylon Suture

48. AbExterno Surgical Technique 10/0 Prolene Straight Needle and PMMA SP IOL PMMA SP IOL with eye lets and two 10/0 Prolene Double armed suture

49. Surgical TechniquePre-Tied IOL Fixation PMMA SP IOL with eye lets and 10/0 Prolene Double armed suture

52. “The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.”

54. Intra Operative Considerations Proper IOL Positioning Abexterno Suture Passage 1.00 mm behind the limbus Thorough Anterior Vitrectomy Choose a proper IOL 13-14.00 mm overall, 6-6.5mm Optic Minimize Intraoperative Bleeding Measured enteries Use smaller gauge thin needles Screen for dispirin use and bleeding disorders Instruction Course Secondary PC IOL Implantation - made simple

55. Intra Operative Considerations Hypotony Closed Chamber Technique Keep Globe Tense Minimize surgical time Suture Exposure Use self sealing tunnel Burry the knots properly Instruction Course Secondary PC IOL Implantation - made simple

56. Postoperative Care Remove the sutures in time but warn the patient if fixation suture knot is exposed Monitor Glaucoma uveitis Instruction Course Secondary PC IOL Implantation - made simple

57. Youth and Age Nought cared this body for wind or weatherWhen Youth and I lived in't together. Samuel Taylor Coleridge

58. Secondary posterior chamber IOL (PC IOL) Implantation-made simple Part 3 Course Review & Interactive Dr. Zia.ul.Mazhry FRCS(Edin), FRCS(Glasgow), FCPS(Pak), CICOphth- (UK) Life Member OSP Member Executive council OSP LHR Member American Academy of Ophthalmology Assistant Professor Central Park Medical College Lahore Consultant Eye Surgeon & Head of Department WAPDA Teaching Hospital Lahore Instruction course Secondary PC IOL Implantation-made simple

59. Memory Levels(Dale) 10% of what is read 20% of what is heard 30% of what is seen 50% of what is heard and seen 70% of what is said and written 90% of what is said as it is done

60. Video Review Instruction course Secondary PC IOL Implantation-made simple

61. Video Review Instruction course Secondary PC IOL Implantation-made simple

62. "Who dares to teach must never cease to learn." - John Cotton Dana Instruction course Secondary PC IOL Implantation-made simple

63. Surgical Plan? Instruction Course Secondary PC IOL Implantation - made simple Decent red IOL Prolapsed Vitreous

64. What I did PC IOL was arranged for exchange Anterior Vitrectomy through the rent A little dialing of IOL got it well centered and remained so postoperatively Instruction Course Secondary PC IOL Implantation - made simple

65. Instruction Course Secondary PC IOL Implantation - made simple Post traumatic surgical Aphakia referred for 2nd IOL Capsular remnants Vitreous Deficient Iris

66. Instruction Course Secondary PC IOL Implantation - made simple DHSF PC IOL with anterior core vitrectomy 2 months postop

67. MCQ-1 Following are the indication for secondary IOL Implantation except: Subluxated Crystalline lens Aphakia with Intact Capsule Aphakia with No Capsular support Dislocated or subluxated PC IOL Aphakia with Central Rent in Posterior Capsule Aphakia with partial capsular support Instruction course Secondary PC IOL Implantation-made simple

68. MCQ-1 Following are the indication for secondary IOL Implantation except: Subluxated Crystalline lens Aphakia with Intact Capsule Aphakia with No Capsular support Dislocated or subluxated PC IOL Aphakia with Central Rent in Posterior Capsule Aphakia with partial capsular support Instruction course Secondary PC IOL Implantation-made simple

69. MCQ-2 2- Anterior Core Vitrectomy is mandatory for following surgical Procedure: Trabeculectomy Phacoemulsification ECCE with PC IOL Scleral Fixation of PC IOL Secondary IOL Implantation on Intact Posterior Capsule Refractive Surgery Instruction course Secondary PC IOL Implantation-made simple

70. MCQ-2 Anterior Core Vitrectomy is mandatory for following surgical Procedure: Trabeculectomy Phacoemulsification ECCE with PC IOL Scleral Fixation of PC IOL Secondary IOL Implantation on Intact Posterior Capsule Refractive Surgery Instruction course Secondary PC IOL Implantation-made simple

71. MCQ-3 Ideal site for IOL implantation in order of preference is: A C Angle, Ciliary Sulcus, Pupil. Ciliary Sulcus, A C Angle, Iris. Ciliary Sulcus, Capsular Bag, A C Angle. Capsular Bag, Ciliary Sulcus, A C Angle. A C Angle, Capsular Bag, Ciliary Sulcus. Iris, Ciliary Sulcus, A C Angle. Instruction course Secondary PC IOL Implantation-made simple

72. MCQ-3 Ideal site for IOL implantation in order of preference is: A C Angle, Ciliary Sulcus, Pupil. Ciliary Sulcus, A C Angle, Iris. Ciliary Sulcus, Capsular Bag, A C Angle. Capsular Bag, Ciliary Sulcus, A C Angle. A C Angle, Capsular Bag, Ciliary Sulcus. Iris, Ciliary Sulcus, A C Angle. Instruction course Secondary PC IOL Implantation-made simple

73. MCQ-4 Recommended site for scleral fixation sutue placement lies: 2.00mm behind the limbus At pars plana 1.00mm behind limbus 0.5 mm behind limbus 3.00 mm behind limbus Instruction course Secondary PC IOL Implantation-made simple

74. MCQ-4 Recommended site for scleral fixation sutue placement lies: 2.00mm behind the limbus At pars plana 1.00mm behind limbus 0.5 mm behind limbus 3.00 mm behind limbus Instruction course Secondary PC IOL Implantation-made simple

75. Secondary PC IOL Pearls Pre Op- assessment is crucial Dilated ant seg and VR exam Chalk out a clear Plan Be ready for intraoperative modification of the plan Remnants of the Posterior Capsular support need to be utilized to the maximum Instruction course Secondary PC IOL Implantation-made simple

76. Secondar PC IOL PearlsAphakia with Partial/ AbsentCapsular Support Scleral Fixation Pearls Where to fix 1.00 mm behind the limbus Avoid 3 and 9 o’clock positions for scleral sutures due to the presence of ciliary artery and nerve. How to choose an IOL having eyelets on haptics large optic 6.0mm or 7mm and 13.0 to 14mm haptic span What is the ideal suture 10/0 Prolene Instruction course Secondary PC IOL Implantation-made simple

77. Secondar PC IOL PearlsAphakia with Partial/ AbsentCapsular Support Scleral Fixation Pearls Fixation suture be always be burried underneath partial thickness scleral flaps Deep Anterior vitrectomy is mandatory. Recommended suture pssage is from outside in Ab Externo Method Instruction course Secondary PC IOL Implantation-made simple

78. To Summarize Instruction course Secondary PC IOL Implantation-made simple

79. To Summarize Instruction course Secondary PC IOL Implantation-made simple

80. The Message The status of posterior capsule may vary from : intact to partially deficient or totally absent. Thus the technique has to be varied from : simple implantation to synechiolysis to anterior vitrectomy combined with single or double haptic trans-scleral fixation of PC IOL. Instruction course Secondary PC IOL Implantation-made simple

81. Q&A Instruction course Secondary PC IOL Implantation-made simple

82. Conclusion Secondary PC IOL implantation is an effective and safe technique for visual rehabilitation of aphakic patients. One should be ready and well versed with the variations of surgical technique required while carrying out such procedures. Instruction course Secondary PC IOL Implantation-made simple

83. Literature Review 2003 AAO Report: IOL Implantation in the Absence of Capsular Support Open-loop AC IOLs Scleral-sutured PC IOLs Iris-sutured PC IOLs all are safe and effective in correcting aphakia in eyes without capsular support

84. Literature Review 2005 ASCRS-ESCRS Report: AC-IOL and Sutured PC-IOL in eyes with poor capsular support Findings suggest no significant differences in outcome exist between AC-IOL and sutured PC-IOL in the absence of capsular support KE Donaldson, JJ Gorscak, DL Budenz,WJ Feuer, MS Benz, RK Forster. JCRS 2005, 31:5,904-909.

85. References Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL American Academy of Ophthalmology. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology. 2003 Apr; 110(40:840-59 Zheng G, Chen Y, Wang L, Chen G, Zhang X. The choice of methods of intraocular lens implantation in traumatic cataract in the absence of capsular and zonular support. Zhonghua Yan Ke Za Zhi. 1998 Sep; 34(5): 327-9 Dick HB, Augustin AJ. Lens implant selection with absence of capsular support. Curr Opin Ophthalmol. 2001 Feb; 12(1): 47-57 Hannush SB. Sutured posterior chamber intraocular lenses: indications and procedure. Curr Opin Ophthalmol. 2000 Aug; 11(4): 233-40 Bellamy JP, Queguiner F, Salame N, Montard M. Secondary intraocular lens implantation: methods and complications. J Fr Ophthalmol. 2000 Jan:23(1):73-80 Krause L, Bechrakis NE, Heimann H, Salditt S, Foerster MH. Implantation of scleral fixated sutured posterior chamber lenses: a retrospective analysis of 119 cases. Int Ophthalmol. 2008 Apr 10. Everklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open loop anterior chamber and scleral fixated posterior chamber intraocular lenses. J Cataract Refract Surg. 2003 Feb; 29(2): 301-8 McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic surg. 1976 summer; 7(2): 98-103 Instruction course Secondary PC IOL Implantation-made simple

86. Acknowledgements Instruction course Secondary PC IOL Implantation-made simple My teachers Prof- Wasif M Kadri, Dr Tariq Saeed, Prof Mohammad Tayyib, Prof Samina Jahangir, Prof Nadeem Riaz, Prof Hamid Mehmood, Dr Z A Qazi My Colleagues Dr Saqib Siddiq, Dr Mohammad Aamir for graphics My Superiors Mr Afzaal Sheikh DGMS WAPDA Medical Services for providing digital video capturing system to eye opd and Operation room at WAPDA Hospital Lahore

87. One and a half decade with scleral fixated IOLs Thank you for your attention