PURPOSE:To analyze the clinical outcomes of pinhole pupilloplasty (PPP) in eyes with higher order aberrations (HOAs) due to scarred cornea. METHODS:In this prospective, interventional series, eyes with central or paracentral localized corneal opacity (partial or full thickness) with adjacent clear corneal zone with or without cataract were included. Phacoemulsification with posterior chamber intraocular lens (IOL) implantation was performed followed by PPP. HOAs were assessed with the Pentacam HR (Oculus Optikgeräte GmbH) and optimum pupil size was determined by placing the pinhole template and recording the pinhole size that enabled patients to see distinctly. Postoperative visual outcomes, patient satisfaction score, change in HOAs, and pupil size were documented. RESULTS:Overall, 25 eyes of 24 patients underwent the procedure. The mean size of the corneal scar was 4.5 ± 2.4 mm (2 to 12 mm) (linear [n = 5] and non-linear [n = 20]) and the mean depth was 462.4 ± 108.6 μm (range: 158 to 600 μm). PPP was combined with phacoemulsification and posterior chamber IOL in 23 eyes and with glued IOL in 2 eyes. Postoperatively, there was significant improvement in uncorrected (P < .001) and corrected (P < .001) distance visual acuity. There was significant reduction in pupil size (P < .001) and optimum pinhole (P = .071) size was attained for all eyes. There was no significant difference in the postoperative period for HOA root mean square values (P = .118) except one case that underwent corneal suture removal. No change in corneal topography (P = .249) was observed. A negative correlation was observed between reduction of pupil size and improvement in corrected distance visual acuity; however, it was not statistically significant (r = -0.136, P = .517). Seventy-five percent of the patients reported being highly satisfied (score 3) and 25% of the patients were satisfied (score 2) with the surgical outcomes. CONCLUSIONS:PPP leads to satisfactory visual outcomes and can be considered as an alternative in eyes with central or paracentral corneal scar with residual clear cornea.

PURPOSE:As the prevalence of high myopia increases around the world, the incidence of highly myopic cataract (HMC) would increase and present clinicians with unique management challenges. This modified Delphi consensus study aimed to establish practical recommendations for HMC diagnosis and treatment, addressing key controversies in preoperative evaluation, surgical considerations, and postoperative care. METHODS:An international panel of 30 cataract experts from 14 countries/territories participated in this two-round e-Delphi study. Consensus was defined as ≥ 75% agreement on 5-point Likert-scale statements covering disease characterization, preoperative evaluation, intraoperative precautions, and postoperative care. RESULTS:A formal consensus was reached by a broad majority of the panel (86.67%) to endorse HMC as a separate disease category, typically manifesting 10-20 years earlier than age-related cataracts. Key consensus included: use of combined IOL formula calculations (96.67% agreement), preference for hydrophobic acrylic intraocular lens (96.67%), and mandatory 3-month postoperative retinal exams (96.67%). Controversies persisted regarding immediate sequential bilateral surgery, prophylactic routine implantation of a capsular tension ring, and postoperative steroid regime. CONCLUSIONS:We present commonly agreed recommendations for the clinical management of HMC, which include tailored surgical approaches and vigilant postoperative monitoring to address this growing public health challenge.

PURPOSE:To report the graft detachment and rebubbling rate of pre-Descemet endothelial keratoplasty (PDEK) in patients with Fuch dystrophy and pseudophakic bullous keratopathy. METHODS:In this prospective interventional study of 131 eyes (131 patients), the main-outcome measures were visual acuity, graft detachment and rebubbling rate, pachymetry, and endothelial cell count (ECD) loss. RESULTS:The mean age of graft recipients was 64.5 ± 12.3 years(range 21-87 years); the mean donor age was 25.1 ± 8.7 years(range 10-70 years); and mean graft size was 7.5 ± 0.4 mm. Four eyes (3%) experienced partial graft detachment. Inferotemporal detachment was detected in 2 eyes, inferior in 1 eye, and central detachment in 1 eye. Two cases with graft detachment had no air bubble in the anterior chamber and 2 cases had less than 20% air in anterior chamber on the first postoperative day (POD). The graft detachment was detected on first POD in 2 cases, on second POD in 1 case and on third POD in 1 case. The mean ECD loss was 22.3%, whereas the ECD loss for eyes that underwent rebubbling was 24.8%. There was significant improvement in visual acuity (P < 0.001). Postoperative best-corrected visual acuity was not dependent on donor age, donor specular count, or PDEK graft size. There was no significant correlation between ECD loss and postoperative best-corrected visual acuity (P = 0.524). The mean preoperative central corneal thickness was 758 ± 152.1 μm, whereas the mean postoperative central corneal thickness was 541.3 ± 90.8 μm (P = 0.000). No incidence of graft failure or rejection was observed during 18 months of follow-up. CONCLUSIONS:PDEK offers satisfactory visual outcomes and has a favorable complication profile with lower rate of graft detachment and rebubbling rate of 3%.

PURPOSE:To present clinical outcomes of glued IOL scaffold for management of aphakia with Soemmering ring in eyes with microcornea. DESIGN:Prospective, Interventional series. SETTING:Private practice. METHODS:11 eyes of 6 patients (3 males, 3 females) with microcornea underwent glued IOL scaffold procedure for aphakia associated with Soemmering ring. All patients had undergone initial cataract surgery at age less than 10 years and were rendered aphakic. MAIN OUTCOME MEASURES:Uncorrected and best-corrected visual acuity (UCVA; BCVA), Specular count and IOL centration. RESULTS:The mean age group of the cases was 22.9±11years, the mean corneal diameter was 7.8±0.25mm, the mean axial length was 21.7±1.2mm and the mean extent of Soemmering ring was 5.2±2.4 (range 3-10) clock hours. The mean follow-up period was 31.6±16.8 months. The mean preoperative and postoperative UCVA was 1.64±0.15 LogMAR and 0.68±0.18 LogMAR respectively (p=0.003). The preoperative and postoperative specular count was 2463.4±451.3 cells/sq mm and 2264.5±459.4 cells/sq mm respectively. The mean percentage of endothelial cell loss was 8.3±4.8%. The mean haptic length trimmed was 1.3±0.17mm and all the haptics were well-placed in subscleral position. Negative correlation was observed between the corneal diameter and the extent of haptic length trim. The IOL was well-centred in all the cases and there was no incidence of slippage of soemmering material into the vitreous cavity. CONCLUSIONS:Satisfactory visual outcomes can be achieved in eyes with microcornea and aphakia with associated soemmering ring.

PRÉCIS:The study documents the ability of Elisar-Fast to successfully assess visual field in patients with glaucoma. PURPOSE:To compare 2 fast threshold strategies of visual field assessment: SITA-Fast (SF; Humphrey field analyser) and Elisar-Fast (EF; advanced vision analyser) in patients with glaucoma. METHODS:In this cross-sectional observational study, of total 192 subjects, 138 subjects (150 eyes, 80 glaucoma subjects [91 eyes] and 58 healthy controls [59 eyes]) were analysed and included. Each subject underwent 24-2 EF and SF in randomized order with a minimum time interval of 1 hour between tests. MAIN OUTCOME MEASURES:Mean test-time, pointwise and sectoral sensitivity, significance of values of mean sensitivity (MS) and global indices (mean deviation [MD] and pattern SD [PSD]) and their correlation. RESULTS:The mean test-time was 2.59±0.25 and 3.38±0.28 minutes ( P = 0.001) with SF and EF, respectively. Correlation coefficient for pointwise threshold values correlated strongly for both devices (range, 0.70-0.92). The intraclass correlation value of ≥0.8 was observed across all sectors, indicating good reliability. Bland-Altman plot denoted 95% of the data for MS values within limit of agreement. The intraclass correlation values for overall MS, MD, and PSD were 0.916, 0.913, and 0.872, respectively, indicating good reliability. High degree of correlation was observed for MD (r=0.912, P =0.00) and PSD values (r=0.732, P =0.00). Comparison of values indicated a difference of 1.09 dB for MD and 0.06 dB for PSD between both strategies. CONCLUSIONS:A high degree of correlation existed between the global indices and pointwise threshold values. The study documents the ability of EF to successfully assess visual field in patients with glaucoma.

Subluxation of lens is a challenging situation faced by surgeons, and the scenario becomes more complicated when there is an associated cataract, too. The degree of subluxation may vary, and depending on that, the surgical procedure to perform is chosen. Care has to be exercised while operating these cases as fragile zonules are often predisposed to further damage during the process of nuclear emulsification. Stability of the capsular bag is always a concern, and adequate measures should be adopted intraoperatively to minimize further damage and enhance bag stability with capsule stabilization and fixation devices.

Purpose: To determine optimal pinhole size (OPS) and establish a relationship with visual acuity (VA) and RMS (root mean square) values in cases with higher-order aberrations (HOAs) undergoing pinhole pupilloplasty (PPP). Setting: Private practice, India. Design: Prospective, interventional study. Methods: RMS value for 6-mm–diameter optical zone was determined by Scheimpflug imaging (Pentacam). Patients with RMS value >0.3 μm were included. Preoperatively, a hand-held pinhole gauge with varied apertures determined the OPS, and single-pass four-throw technique was used to perform pupilloplasty with Purkinje-1 reflex as a marker for centration. VA with OPS, correlation of RMS values with OPS and pupil size, and Strehl ratio were the main outcome measures. Results: 29 eyes with HOAs were analyzed; all patients chose 1.0 or 1.5 mm as OPS. The mean preoperative and postoperative pupil size was 3.25 ± 0.81 mm and 1.8 ± 0.54 mm ( P = .000), respectively. Postoperative mean pupil size when compared with OPS denoted that 14 eyes had a difference of <0.1 mm, 8 eyes ranged from 0.2 to 0.45 mm, and 7 eyes had ≥0.6 mm (range from 0.6 to 1.8 mm) difference from OPS. Eyes with higher RMS values needed smaller pupil gauge to achieve better VA. Preoperatively, vision with OPS correlated well with preoperative 6-mm RMS HOAs ( r = 0.728; P = .00). Postoperative UDVA correlated well with VA measured with OPS ( r = 0.847; P = .00). The preoperative and postoperative mean Strehl ratio was 0.109 ± 0.07 and 0.195 ± 0.11 ( P = .001), respectively. Conclusions: Higher RMS values required a smaller pupil to achieve optimum VA. PPP can help achieve pinhole size in accordance with patient's optimum pinhole requirement.

Refractive surprise post cataract surgery in previously operated eyes with laser-in-situ-keratomileusis (Lasik) is an established entity.Unsatisfactoryoutcomewithmixed astigmatism after placement of toric multifocal IOL necessitates explantation of the intraocular lens (IOL) followed by implantation of a monofocal IOL. Correction of irregular astigmatism and associated higher order aberrations (HOAs) is a challenging task in these select group of patients. The authors share their experience in performingPPP to nullify the effect of unwarranted visual outcomes in these patients. A 45-year-old patient with unsatisfactory visual outcomes was referred for further management. Patient presented with history of Lasik surgery performed before 15 years. Recently, the patient underwent cataract extraction with placement of a toric multifocal IOL in the bag and had a post-operative refractive surprise of +2.5 D Sph / −4.5 D Cyl @ 115 degrees with an unaided visual acuity of 20/200 and best-corrected acuity (BCVA) of 20/100. Under peribulbar anesthesia, IOL explantation was performed and a monofocal IOL was placed in the capsularbag. Additionally, PPP was performed to impart pinhole visual acuity and to override the associated cylindrical component. On post-operative day-3, the unaided visual acuity improved to 20/20 (Figure 1). Another case had history of Lasik 20 years back; had monofocal IOL implantation in the bag (5 years back) and had post-operative refraction of +2.0 D Sph/ −2.5 D Cyl @ 75 degrees and BCVA of 20/100. PPP was performed for this case and postoperatively, the uncorrected visual acuity improved to 20/40 on day-1. Estimation of corneal power and effective lens position are two important variables in IOL power calculation. Change in the optical profile of cornea and presence of astigmatismmay drastically affect the visual output due to errors in IOL power calculation. The situation is enhanced if a multifocal toric IOL is placed, as posterior corneal astigmatism and the pupil size also play an important role infinal visual outcomes. The most common modes of treatment for refractive surprise post-cataract surgery are IOL exchange, corneal refractive enhancement procedure and piggyback IOL placement. Cornea based refractive correction is not a viable option for patients with previous history of Lasik surgery especially after placement of a multifocal toric IOL. Therefore, for this case, IOL explantation with monofocal IOL placement and PPP was performed. PPP procedure imparts pinhole optics at the level of pupil and leads to considerable improvement in visual acuity in cases with HOAs. The authors have documented functional outcomes of PPP in cases with radial keratotomy (RK) and unstable vision. The desire of spectacle independence is strong in candidateswho undergoLasik at young age followed by premium IOL placement during cataract surgery. Post-operative refractive surprise with marked deterioration of vision leads to dissatisfied patient. Therefore, in these select group of patients where the options are limited, PPP can be performed, and optimum visual output can be restored. However, it is essential to state that posterior segment examination can be challenging following the procedure of PPP. Nevertheless, multimodal imaging devices can help

A 75-year-old man with an ocular history of 8-cut radial keratotomy (RK) in both eyes presented for cataract surgery evaluation. He was previously correctable in spectacles in years prior despite his irregular corneas to 20/25 in the right eye and 20/30 in the left eye. He recently noticed a change in his overall visual function with significant nighttime glare and difficulty reading despite spectacle correction. Of note, he was unable to tolerate contact lenses and was resistant to refitting despite additional encouragement. Cataract surgery was delayed for many years, given he was correctable in spectacles and the concern of uncovering a highly aberrated cornea after removing his cataracts (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202308000-00021/figure1/v/2023-07-21T030437Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202308000-00021/figure2/v/2023-07-21T030437Z/r/image-tiff). Of note, the patient was interested in returning to the spectacle independence he enjoyed in the past. Ocular examination revealed a corrected distance visual acuity (CDVA) of 20/30 in the right eye and 20/60 in the left eye, with a manifest refraction of +4.50 -0.50 × 177 in the right eye and +5.75 -1.75 × 14 in the left eye. Glare testing was 20/50 in the right eye and 20/100 in the left eye, with retinal acuity meter testing of 20/25 in each eye. Pupils, confrontation visual fields, and intraocular pressures were normal. Pertinent slitlamp examination revealed corneal findings of 8-cut RK with nasal-gaping arcuate incisions in both eyes and lens findings of 2+ nuclear sclerosis with 2+ cortical changes in the right eye and 3+ nuclear sclerosis with 3+ cortical changes in the left eye. Cup-to-disc ratios of the optic nerves measured 0.5 with temporal sloping in the right eye and 0.6 with temporal sloping in the left eye. The dilated fundus examination was unremarkable. What intraocular lens (IOL) options would you offer this patient and how would you counsel regarding realistic expectations? What additional diagnostic testing would be helpful in your assessment? How would you calculate the IOLs?

Pre-descemet’s endothelial keratoplasty (PDEK) is the latest iteration in the pool of various endothelial keratoplasty procedures that an ophthalmologist can perform. The PDEK graft essentially involves the donor endothelium with pre-descemet’s layer (Dua’s layer) that provides a splinting effect to the donor graft.

PURPOSE:To describe Reverse four-throw (RFT) technique for pupilloplasty.METHODS:The technique involves making a single pass through the anterior chamber that helps achieve a posteriorly directed suture knot. A single arm 9-0 polypropylene suture attached to long arm needle engages the iris defects with the tip of the needle piercing the iris tissue from the posterior surface and emerging from the anterior aspect. The suture end is passed from the loop with four throws taken consecutively in the same direction that create a self-sealing and self-retaining lock like single-pass four-throw technique but with the difference that the knot slides on the posterior surface of the iris tissue.RESULTS:The technique was performed in 9 eyes and the suture-loop easily slided along the posterior surface of iris tissue. The iris defect was well approximated in all the cases and the suture knot or suture tail was not visible in the anterior chamber. Anterior segment optical coherence tomography depicted smooth iris configuration with no suture extrusion in the anterior chamber.CONCLUSIONS:The RFT technique provides an effective measure to seal the iris defect with the absence of knot in AC.

Purpose: The aim of this study was to analyze the outcomes of pre-Descemet endothelial keratoplasty (PDEK) for failed therapeutic penetrating keratoplasty. Methods: This was a retrospective, interventional study that involved 12 eyes of 12 patients with failed therapeutic penetrating keratoplasty that underwent PDEK. All cases had a minimum follow-up of 12 months. The main outcome measures were best-corrected visual acuity, graft clarity, endothelial cell density loss, and graft survival. Corneal clarity was graded on a scale from 0 to 4, where grade 4 denoted an absolutely clear cornea and grade 0 denoted a totally opaque cornea. Three cases underwent PDEK, 6 cases PDEK with phacoemulsification, and 3 cases underwent PDEK with pupilloplasty. Results: The mean follow-up period for all cases was 18.5 ± 4.9 months. The mean preoperative and postoperative best-corrected visual acuity (in Snellen decimal equivalent) was 0.02 ± 0.01 and 0.54 ± 0.17, respectively, at the last follow-up. Postoperatively, corneal clarity grade 4 was present in 9 eyes, grade 3 in 2 eyes, and grade 2 in 1 eye. Mild subepithelial haze was noted in 2 eyes. The percentage of endothelial cell density loss was 28.2% ± 10.6%. No correlation was observed between the postoperative graft clarity and preoperative specular count (r = −0.021, P = 0.512). Rebubbling was performed for 1 eye that developed partial graft detachment in the first postoperative week. One patient had an episode of rejection that was managed with systemic and topical steroids. Conclusions: In patients with failed therapeutic penetrating keratoplasty, PDEK can be a useful alternative for visual rehabilitation as it demonstrates favorable visual outcomes with a good graft survival rate.

A 66-year-old patient underwent surgery for congenital cataract in both eyes in her first year of life without implantation of an intraocular lens (IOL). In 1994, at the age of 39 years, both eyes received secondary Kelman multiflex-style angle-fixated anterior chamber IOLs (AC IOLs). The surgeries were followed by retinal detachments in both eyes, in the left eye in the same year and in the right eye 4 years later, which were successfully repaired. The patient presented with a decompensated cornea with epithelial and stromal edema in the left eye. The AC IOL axis was oriented from 5- to 8-o'clock position with the haptic contacting the cornea. The distal portion of the inferior-nasal haptic was deeply buried and entrapped in a broad iridocorneal synechia extending between 6- and 8-o'clock positions. The synechia also caused adjacent pupillary distortion and pigment leaf eversion (Figure 1JOURNAL/jcrs/04.03/02158034-202205000-00021/figure1/v/2022-04-22T173532Z/r/image-tiff). The AC IOL in the right eye was well positioned, and the cornea was clear with an endothelial cell count (ECC) of 2160 cells/mm2 and central corneal thickness (CCT) of 650 μm. No ECC was obtainable in the left eye, and CCT was 775 μm (Figure 2JOURNAL/jcrs/04.03/02158034-202205000-00021/figure2/v/2022-04-22T173532Z/r/image-tiff). Visual acuity was 0.8 corrected in the right eye and hand motion in the left eye. Both eyes were normotonic. On optical coherence tomography (OCT) imaging, a broad iridocorneal synechia was visible with a canal corresponding to the deeply buried haptic end of the AC IOL (Figure 3JOURNAL/jcrs/04.03/02158034-202205000-00021/figure3/v/2022-04-22T173532Z/r/image-tiff). Abundant condensed cortical material (Soemmerring's ring) was found behind the iris and above the ciliary body. What would be your surgical options to rehabilitate the patient's left eye considering corneal decompensation caused by haptic contact of an angle-fixated AC IOL and capture of 1 haptic within an iridocorneal synechia extending along 2 clock hours?

Background:Disinsertion of iris leads to debilitating sequelae like diplopia and glare. Hence, iridodialysis repair is essential to optimize the visual quality. Iris base repair often leads to corectopia that necessitates an additional procedure to optimize the pupil shape and size. Twofold technique helps to achieve both the aspects.Purpose:To highlight the technique of twofold iridodialysis repair.Synopsis:The video highlights the method of twofold iridodialysis repair, wherein nonappositional repair is followed by single-pass four-throw (SFT) pupilloplasty that allows adequate closure of varied degrees of iridodialysis along with centration of eccentric pupil.Highlights:The twofold technique is a combination of nonappositional iris repair and SFT procedure. It can be clinically applied in all cases of iridodialysis with varied degrees of severity.Online Video Link:https://youtu.be/OncBdz2UIBY.

Background: Silicon oil is an important adjunct for achieving internal tamponade in the treatment of retinal detachment. Silicone oil tamponade often leads to narrowing of the angle and development of adhesions between the iris and anterior chamber angle structures, with consequential elevation of the intraocular pressure. The video showcases the management of these challenging scenarios. Purpose: To highlight the management of early synechial closures due to silicon oil tamponade. Synopsis: The video highlights the management of early synechial closure following silicon oil tamponade. Surgical pupilloplasty has been demonstrated to break the peripheral anterior synechias on intraoperative gonioscopy as well as on anterior segment optical coherence tomography (AS-OCT). Performing pupilloplasty in the early phase of development of peripheral anterior synechias (PAS) helps to break the existing synechias and prevent angle closure and sequential deterioration of vision. Highlights: Surgical pupilloplasty helps to relieve the post silicon oil-induced secondary angle closure glaucoma by breaking the peripheral anterior synechias and significantly opening the anterior chamber angles. Online Video Link: https://youtu.be/xe2NGlhPBF4