Sutureless Glued Posterior Chamber IOL

On March 7, 2011. Prof. Amar Agarwal and his wife Sunita Agarwal gave an interesting lecture in Sofotel Al Hamra Hotel, Jeddah. The lecture was focusing on the new technique of IOL implantation in aphakic eyes with no enough capsular support – it is “Glued IOLs”. Dr. Amar is the director of Dr. Agarwal’s Group of Eye Hospitals and Eye Research Centre. Also, he is the author of several books.

Both Agarwals discussed various techniques to manage complications such as capsular rent, dropped nucleus, or dropped IOL. The three- piece foldable IOL haptics were pulled through sclerotomies and affixed with fibrin glue under the scleral flaps.

In cases with acapsular aphakia, we are using plenty of IOL implantation techniques e.g. Iris claw lens (Artisan Aphakia) which can be fixed anterior or posterior to the iris tissue, anterior chamber kelman style angle supported or Scleral sulcus sutured PC IOL. Each of the previous has its own pros and cons.

Fibrin glue has been used previously in various medical specialties as a hemostatic agent to arrest bleeding, seal tissues and as an adjunct to wound healing. The fibrin kit we used was ReliSeal (Reliance Life Sciences). It is available in a sealed pack that contains freeze-dried human fibrinogen (20 mg/0.5 mL), freeze-dried human thrombin (250 IU/0.5 mL), aprotinin solution (1,500 KIU in 0.5 mL), one ampoule of sterile water, four 21-gauge needles, two 20-gauge blunt application needles, and an applicator with two mixing chambers and one plunger guide.

The commercially available fibrin glue that we used is virus inactivated and is checked for viral antigen with polymerase chain reaction; hence, the chance of transmission of infection is low. But with tissue derivatives, there is always a theoretical possibility of transmission of viral infections; therefore, it is mandatory to get informed consent from the patient before the procedure. Although the use of fibrin glue in ophthalmology is considered off-label, it has been successfully used in the eye. Its various uses in the eye include repair of lacerated canaliculi to seal full thickness macular holes, cataract incisions, corneal perforations and traumatic lens capsule perforations. It has also been used for temporary closure of scleral flaps after trabeculectomy in eyes with hypotony, conjunctival fistula closure, conjunctival autografts and amniotic membrane transplantation.

In Agarwal’s case series, there was no danger of intraocular infection gaining entry through the tunnel, as the fibrin glue hermetically seals the flaps, leaving behind no possible entry route for microbes. Also, there was no glue-induced intraocular inflammation in any of our patients, and all eyes had clear media on the postoperative visits. Scleral indentation performed in the operated eyes showed no change in the axial positioning of the IOL. After 1 month of follow-up, they found no IOL decentration or any other complications in any of the operated eyes.

Dr. Alaa Danasoury (President of ISRS and Medical director of Magrabi Hospital Jeddah) was the coordinator of this elegant scientific session. There were plenty of hot questions directed from the audience at the end of the session.

 

Meibomian Gland Probing !

Looking at the meibomian glands during an exam for dry eye, most of us are surprised to find that 70% of patients with dry eye symptoms have signs of meibomian gland disease. Unfortunately, finding relief for these patients is much more difficult than identifying the cause.

First, let’s put a nail in the coffin of warm compresses. As a rule, patients don’t do them — at least not long enough to consider them a meaningful solution. Most will give a few tries, find temporary relief, and soon forget about them. Docs who recommend baby shampoo scrubs will find even faster attrition of compliance. Detergents like baby shampoo sting.

However effective these age-old treatments, they become irrelevant for most patients.

Another approach is surgical meibomian gland expression performed in the office. Using two cotton-tip applicators, the examiner can apply bimanual pressure to the glands of the lower lid, expressing the opaque, inspissated, staph-laden material. (Upper lids can be expressed also but it leads to greater patient discomfort.) If you’ve ever performed this lipid catharsis, you know from somewhat grotesque personal experience the sheer amount of “gunk” that can be painstakingly (and painfully) removed with proper technique. The masochistic patients who return periodically for this time-consuming procedure do seem to experience true and prolonged relief. Why else would they ask for this procedure again?

In my own experience with this procedure, most patients experience discomfort for about 24 hours afterwards, with extensive pus production and stinging of the lids. This can be treated by the patient regularly irrigating the lids with eye wash for the first day and applying a topical antibiotic/steroid for 72 hours. It is worthwhile to clearly warn patients about this postoperative ordeal prior to the procedure.

A new device from Tear Science is designed to detect patients in whom meibomian gland expression might be most helpful and will soon be on the market. The company hopes to pair with it a device (not yet approved) that automates the process of gland expression. The gland expression device, which first heats then gently squeezes a patient’s tarsal plates in about a 12-minute procedure, already has been shown to provide symptomatic relief of meibomian gland disease for 10 to 18 months. I am eager to see how it performs after FDA approval.

How about meibomian gland probing, as taught by Steven Maskin, MD? The tiny wire probes available from Rhein Medical are used surgically to explore the meibomian glands. Many glands become “capped” externally with keratin or plugged internally with meibum. These glands often lead to acute chalazia or chronic tenderness and swelling. Simply opening these caps can restore flow and provide meaningful, symptomatic relief. This procedure too is painstaking for the surgeon and somewhat uncomfortable for the patient. However, it is the only way we currently have to get inside those blocked glands and restore flow. Its ultimate success, in my personal experience really depends on fully treating the underlying meibomian gland disease with all the tools in our arsenal

 

Limbal Relaxing Incision

 

“Cataract and Refractive highlights” is the theme of 2011.

In the next weekend, a big scientific event will be held in Dr Soliman Fakeeh Hospital Jeddah- which is arranged by the Ophthalmology department. The lectures will be held in the second building of DSFH (7th floor) which will be along wednesday and Thursday 25/26 May. We discussed with the symposium’s chairman (Dr Serene Jouhargy, FRCSC) some points on this big event:

Q: Why do you choose to focus on (Cataract) and (Refractive Surgery) this year?
A: The symposium this year is directed to general ophthalmologists who are commonly deal with anterior segment disorders. The program will include videos as well as discussions on the management of difficult cataract surgery cases, presentations and discussions on complicated refractive surgery cases and their management.

Q: What are the goals that you are aiming to deliver during this big event?
A: there are plenty of goals we are aiming to fix:
• Assess various treatment options and surgical interventions for cataract patients.
• Strengthen the cataract surgical techniques in the enhancement of cataract surgery outcomes utilizing emerging technology of Infinity OZIL IP.
• Identify and apply appropriate surgical techniques for complex situations in cataract surgery to avoid complication.
• To understand issues related to IOL calculations and ocular biometry.
• Identify evidence-based approaches to outline best practices for management of postoperative complications related to ophthalmic surgery.
• Diagnose and correct astigmatism with incisional and intraocular lens techniques.
• To review patient selection, surgical techniques, outcomes, and complications for Refractive surgery.
• To discuss considerations for, and possible contraindications to, refractive surgery in the setting of preexisting ocular and systemic disease.
• Choose the optimal method of treatment for keratoconus, including Intracorneal ring with and without collagen cross-linking.
• Identify different IOLs for the treatment of cataract and refractive error, and analyze their indications and complications.
• Develop an algorithm for diagnosis, prevention and treatment of refractive surgery complications.
• Reduce the incidence of patient dissatisfaction after refractive surgery and demonstrate ways to optimize visual outcomes and improve patient satisfaction.

Q: Can you give us an idea about the invited speakersin the meeting?
A:
Ozana Moraru, MD
Consultant ophthalmologist
Medical Director OCULUS Eye Clinic
Bucharest-Romania

Cristian Moraru, MD
Consultant ophthalmologist
Medical Director OCULUS Eye Clinic
Bucharest-Romania

Ali A. Al-Rajhi, MD, FRCOphth
Senior Academic Consultant
Anterior Segment/External Disease Division
Chairman, Saudi Board of Ophthalmology
King Khaled Eye Specialist Hospital-Riyadh

Osama Badeeb, MD, FRCSC, American board
Professor of Ophthalmology
Director of glaucoma unit
King Abdulaziz University Hospital, Jeddah

Mohamed Hantera, PhD, FRCS (Glasg), MBA
Consultant Ophthalmologist
Medical Director
Batal Eye Center, Jeddah
Editor of Middle East Ophthalmology Management Journal (MEOMJ)

Yasir Almazroui, MD, FRCSC
Consultant Ophthalmologist
Oculoplastic surgery
Armed Forces Hospital- Alhada

Saeed A. Alghamdi, MBChB, FRCSC
Consultant Ophthalmologist
Cornea and External Diseases, Uveitis and Refractive Surgery
King Abdulaziz Medical City – Jeddah

Islam M. Hamdi, FRCS (Glasg), Ph.D.
Assistant Professor of Ophthalmology
Ain Shams University, Egypt
Head, Cornea and Refractive Surgery Unit
Magrabi Center, Jeddah

Ihab Elhawary, FRCS (Glasg)
Consultant Ophthalmologist
Chief, Cataract and Glaucoma Unit
Magrabi Eye Center- Jeddah

Ohood Owaydha, MD
Consultant Ophthalmologist
Glaucoma Department
CME Department Director
Jeddah Eye Hospital

Sultan Al Kahtani, MD, FRCS (Ed)
Consultant Ophthalmologist
Jeddah Eye Hospital

Dr. Soliman Fakeeh Hospital
Serene Jouhargy, MBChB, FRCSC
Symposium chairman
Consultant ophthalmologist
Cornea, Uveitis and Refractive Surgery
Ophthalmology department Director-DSFH

Hisham Hosny, MD, FRCS (Ed)
Assistant Professor of Ophthalmology
Cairo University, Egypt
Consultant Ophthalmologist-DSFH

Khaled Shalaby,MD
Assistant Professor of Ophthalmology
Al-Azhar University, Egypt
Vitreoretinal Surgery-DSFH

Ahmed Eldib, MD
Professor of Ophthalmology
Zagazig University, Egypt
Pediatric and Strabismus Surgery-DSFH

Q: what are the topics that you are going to discuss during the lectures?
A: The lectures will be along two days – starting at 9.00 AM and finishes 4.30 PM

Wednesday, May 25, 2011
8:00 AM Registration
9:00 AM Opening Remarks

Session # 1 The Art & Practice of Cataract Surgery
Moderator: Dr. Serene Jouhargy

9:05 AM Settings and techniques with Infiniti OZil IP
Dr. Cristian Moraru
9:25 AM Phacoemulsification on 1,8 mm incision with
with Infiniti Ozil Torsional
Dr. Ozana Moraru
9:45 AM Managing hard nuclei with Infiniti OZil IP
Dr. Cristian Moraru
10:05 AM Phacoemulsification in difficult cases
Dr. Ali Alrajhi
10:25 AM Questions/Answers
10:25 AM Break

Session # 2 Preventing catastrophic events
Moderator: Dr. Saeed Aghamdi

10:55 AM Avoiding complications in most difficult
cataract cases
Dr.Ozana Moraru
11:15 AM Update on Prevention of Endophthalmitis
Dr. Hisham Hosny
11:35 AM Management of posterior capsule break
Dr. Khaled Shalby
11:55 AM Phacoemulsification with zonular weakness
Dr. Ihab Elhawary
12:15 PM Questions/Answers
12:25 PM Prayer/Lunch Break

Session # 3 Cataract Management
Moderator: Dr. Ahmed Aldib

1:30 PM IOL power calculation
(selection and ocular biometry)
Dr. Ihab Elhawary
1:50 PM Pearls and how to manage soft and
hard cataracts
Dr. Ozana Moraru
2:10 PM Uveitic Cataract
Dr. Saeed Alghamdi
2:30 PM Limbal relaxing incision
Dr. Serene Jouhargy
2:50 PM Questions/Answers
3:00 PM Break

Session # 4 Cataract complication
Moderator: Dr. Osama Badeeb

3:20 PM Evidence based post cataract
CME management
Dr. Khaled Shalaby
3:40 PM Update on management of Endophthalmitis
Dr. Sultan Al Kahtani
4:00PM End stage of Endophthalmitis
Dr. Yasir Almazroui
4:20 PM Questions/Answers
4:30 PM Adjourn

Thursday, May 26, 2011
8:00 AM Registration

Session # 5 Refractive surgery decision
Moderator: Dr. Serene Jouhargy

09:00 AM Which is the best refractive surgery
technique for my paient?
Dr. Cristian Moraru
09:20 AM Contraindication to Refractive surgery
Dr. Saeed Alghamdi
09:40 AM Refractive surgery and glaucoma
controversy and management
Dr. Ohood Owaydha
10:00 AM The effect of Refractive surgery on
early glaucoma detection
Dr. Osama Badeeb
10:20AM Questions/Answers
10:30 AM Break

Session # 6 Keratoconus management
Moderator: Dr. Ohood Owaydha

10:50 AM Collagen Cross Linking
Dr. Ahmed Aldib
11:10 AM Improving Intra-corneal Ring
Segments practice
Dr. Islam Hamdi
11:30 AM Myoring – science fiction versus
science faction
Dr. Mohamed Hantera
11:50 AM Myoring versus INTACTS in management
of keratoconus
Dr. Ali Alrajhi
12:10 AM Phacoemulsification on eyes with
corneal graft – things to be considered
Dr.Ozana Moraru
12:20 AM Questions/Answers
12:30 PM Lunch/ Prayer Break

Session # 7 Focus on Premium IOLs
Moderator: Dr. Yasir Almazroui

1:25 PM Phakic IOL – Artisan myopia and toric
lenses
Dr.Cristian Moraru
1:45 PM Enhancing and maintaining the
accommodative power of Crystalens
Dr. Islam Hamdi
2:05 PM Our experience with accomodative
IOLs – Crystalens
Dr. Ozana Moraru
2:25 PM Acrysoft Toric IOLs – tips and tricks
Dr.Cristian Moraru
2:45 PM Questions/Answers
2:55 PM Break

Session # 8 Refractive Complication
Moderator: Dr. Khaled Shalaby

3:15 PM Refractive nightmare
Dr. Hisham Hosny
3:35 PM Ten reasons for patient dissatisfaction
in refractive surgery practice
Dr. Mohamed Hantera
3:55 PM Management of corneal rings side effects
Dr. Islam Hamdi
4:15 PM Questions/Answers
4:25 PM Closing Ceremony (Speaker Recognition)
4:30 PM Adjourn

Q: What would you say at the end of this interview?
A: Special thanks for the time and effor for the team members who helped me to prepare for this event:

Dr. Hossam Ghoneim
Dr. Abdelhameed Agha
Ms. Bassant Hamad
Dr. Amira Zin
Dr. Sherif Tehemar
Ms. Nadine Wehbe
Ms. Maya Ghandoor
Ms. Fatma Shebl
Mr. Ahmed Abdelrahman
Dr. Azza Abdulaziz
Dr. Tamadur Abdelkarim
Ms. Myrna Aldy
Mr. Mohamed Rashad
Mr. Ezzat Zaki
Mr. Sayed Soliman
Ms. Hatoun Farsi
Mr. Maxwell Seegrado

 

17 CME hours for the International Ophthalmology Symposium in Soliman Fakeeh next week

 

Dry Eye is not only tear film deficiency !

In Crown Plaza, Jamjom pharma invited Dr. Osama Ibrahim (Professor Ophthalmology in Alexandria University, Cheif Cornea & Refractive surgery in Roayah Alex Vision Correction Center ) to give a lecture on Dry Eye. Dr Osama mentioned that “Dry eye is the commonest cause of red eye seen in the clinics”. The tear film now is cosidered as a corneal layer – Dr Ibrahim mentioned. Moreover, he classified the dry eye into 3 main categories: aquous decifiency, lipid deficiency and mucous deficiency.

“Schirmer test is still in use in ophthalmology clinics – putting in mind that it can be falsly negative” & “the Inability to differentiate unstable tear film from delayed tear clearance can aggrevate the dry eye complaints of the patients” – Dr Ibrahim said.

Dr. Osama instructed the young ophthalmologists to not over come the evaluation of the hydrodynamic forces i.e. Blinking – which is reduced post -LASIK surgery beside the compositional component of the tear film.

There are plenty of therapeutic options are directed toward dry eye other than prescribing lubricants e.g. topical non preserved steroids, systemic tetracyclin, autoserum eyedrops, amniotic membrane transplantation …etc

In the second half of the scientific activity, Dr Osama described the new era in the refractive surgery “Use of Femtosecond Laser” and explained its role in refractive surgery as well as corneal procedures e.g. Intracorneal ring tunnel creation and Keratoplasty.

He focused on a new evolving technology from Carl Zeiss Meditec “FLEX and SMILE” were no ablation (i.e. no excimer laser) is required any more. The above video explain the FLEX technique, which aims for creating a stromal lenticular fashioned by the femtosecond laser which can be extracted easily under 80 microns flap. He operated nearby 500 eyes till now with both techniques (FLEX and SMILE) with promising results. Such techniques are able to correct up to -17.00 myopia i.e. higher levels of myopic correction in comparison to conventional FemtoLASIK.

Plenty of ophthalmologist attended the meeting e.g. Dr Amal Al Zebedi, Dr Islam Hamdi , Dr Mohamed Ramzy, Dr Mohamed Al Meslemany, Dr Mohamed Abdulbaset ….etc

 

Can we acheive better than 20/20 after LASIK?

Sent from Moustafa AlMoustafa, Bussiness develepoment Amico.

As great outcomes promote the field of laser vision correction and drive the reputations of surgeons, laser centers, and their networks of referring clinicians. For anyone who wants to improve results, here are some steps to consider:

1. Patient selection: The selection of good candidates for surgery remains critical to success. Eye care specialists should perform a careful preoperative examination to ensure that patients have no lenticular or macular pathology that
might prevent them from achieving a visual acuity of 20/20 or better. If the patient is otherwise a good candidate
for vision correction, physicians should also consider the status of the ocular surface. Dry eye has been
associated with poor outcomes and regression of refractive effect after LASIK. Delaying surgery for a few weeks in order to treat any preexisting ocular surface disease can go a long way toward improving outcomes.

2. Preoperative measurements: Achieving optimal results demands a commitment to excellence in every detail, including the preoperative refractions. During both the manifest and wavefront refractions, the patient should have a healthy tear film, fixate properly, and not accommodate. The manifest refraction can be made more efficient and more accurate by
using the refraction obtained with an aberrometer, such as the WaveScan (Abbott Medical Optics Inc.), as a starting
point. I have found that, when the manifest cylinder does not match the wavefront (not an uncommon occurrence) the patient will often see better when presented with the aberrometry-derived cylindrical correction.Historically, eye care specialists have tended to provide patients with the least amount of cylinder they will tolerate in a manifest refraction.That may be a sound strategy for prescribing spectacles or contact lenses, but it is not precise enough for corneal laser correction.

3. Surgical Technology:
Technological advances such as femtosecond lasers for the creation of the LASIK flap, Fourier based wavefront analysis, variable spot scanning, iris registration, and customized ablation play a major role in improving outcomes. Perhaps the most significant of these is customized ablation. Compared with conventional treatments, wavefront-guided customized ablations
have been shown to significantly improve patients’ contrast sensitivity, reduce glare and halos, and even improve functional night
vision. In night-driving simulations, the mean ability to detect and identify road hazards improved after wavefront-guided surgery compared to preoperatively. On the other hand, approximately 40% of patients who had conventional surgery had a significant decrease in their ability to detect or identify road hazards compared to preoperatively. In contrast, fewer than 3% of those undergoing wavefront-guided surgery experienced significant losses on this measure compared to preoperatively.

4. Postoperative Managment: Aggressive lubrication of the ocular surface with artificial tears and the eye care specialist’s attention to any signs or symptoms of dry eye are key during the postoperative period. Even mild dry eye can reduce visual results from LASIK at this stage. Simply treating the ocular surface can actually reduce patients’ need for an enhancement.
The most important thing any surgeon can do to improve outcomes is to track them. Recording outcomes consistently and then using those data to personalize nomograms and assess the effect of new technology are the best way to ensure continued improvement.

 

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