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type: a meta-analysis. Hematol Oncol. 2015;33(3):113-124. 19. Pinnix CC, Dabaja BS, Milgrom SA, et al. Ultra-low-dose radiotherapy
for definitive management of ocular adnexal B-cell lymphoma. Head
5. Yahalom J, Illidge T, Specht L, et al. Modern radiation therapy Neck. 2017;39(6):1095-1100.
for extranodal lymphomas: field and dose guidelines from the
International Lymphoma Radiation Oncology Group. Int J Radiat 20. Parsons JT, Bova FJ, Mendenhall WM, Million RR, Fitzgerald CR.
Oncol Biol Phys. 2015;92(1):11-31. Response of the normal eye to high dose radiotherapy. Oncology
(Williston Park). 1996;10(6):837-847; discussion 847-838, 851-832.
6. Conconi A, Martinelli G, Thieblemont C, et al. Clinical activity of
rituximab in extranodal marginal zone B-cell lymphoma of MALT 21. Sachsman S, Flampouri S, Li Z, Lynch J, Mendenhall NP, Hoppe BS.
type. Blood. 2003;102(8):2741-2745. Proton therapy in the management of non-Hodgkin lymphoma. Leuk
Lymphoma. 2015;56(9):2608-2612.
7. Jeon YW, Yang HJ, Choi BO, et al. Comparison of Selection and Long-
term Clinical Outcomes Between Chemotherapy and Radiotherapy 22. Gillis CC, Chang EH, Al-Kharazi K, Pickles T. Secondary malignancy
as Primary Therapeutic Modality for Ocular Adnexal MALT following radiotherapy for thyroid eye disease. Rep Pract Oncol
Lymphoma. EClinicalMedicine. 2018;4-5:32-42. Radiother. 2016;21(3):156-161.

8. Rosenberg SA. Malignant Lymphomas: Etiology, Immunology, 23. Meng K, Lim MC, Poon MLM, Sundar G, Vellayappan B. Low-
Pathology, Treatment. 1982. dose ‘boom-boom’ radiotherapy for ocular lymphoma arising
from IgG4-related ophthalmic disease: Case report and literature
9. Pelloski CE, Wilder RB, Ha CS, Hess MA, Cabanillas FF, Cox JD. review. Eur J Ophthalmol. 2021 May 24:11206721211018372.
Clinical stage IEA-IIEA orbital lymphomas: outcomes in the era of doi: 10.1177/11206721211018372. Epub ahead of print. PMID:
modern staging and treatment. Radiother Oncol. 2001;59(2):145- 34030509.
151.
Corresponding Author:
10. Pfeffer MR, Rabin T, Tsvang L, Goffman J, Rosen N, Symon Z. Orbital
lymphoma: is it necessary to treat the entire orbit? Int J Radiat Oncol Dr. Balamurugan Vellayappan, MBBS, FRANZCR, MCI
Biol Phys. 2004;60(2):527-530. Department of Radiation Oncology
National University Hospital, National University of Singapore.
11. Stafford SL, Kozelsky TF, Garrity JA, et al. Orbital lymphoma:
radiotherapy outcome and complications. Radiother Oncol.
2001;59(2):139-144.

12. Lowry L, Smith P, Qian W, et al. Reduced dose radiotherapy for local
control in non-Hodgkin lymphoma: a randomised phase III trial.
Radiother Oncol. 2011;100(1):86-92.

13. Anderson RE, Standefer, J. C. Radiation injury in the immune system.
1983.

14. Ganem G, Lambin P, Socie G, et al. Potential role for low dose limited-
field radiation therapy (2 x 2 grays) in advanced low-grade non-
Hodgkin’s lymphomas. Hematol Oncol. 1994;12(1):1-8.

15. Haas RL, Poortmans P, de Jong D, et al. High response rates and
lasting remissions after low-dose involved field radiotherapy in
indolent lymphomas. J Clin Oncol. 2003;21(13):2474-2480.

16. Fasola CE, Jones JC, Huang DD, Le QT, Hoppe RT, Donaldson SS.
Low-dose radiation therapy (2 Gy x 2) in the treatment of orbital
lymphoma. Int J Radiat Oncol Biol Phys. 2013;86(5):930-935.

17. Yahalom J. Radiotherapy of follicular lymphoma: updated role and
new rules. Curr Treat Options Oncol. 2014;15(2):262-268.

18. Hoskin PJ, Kirkwood AA, Popova B, et al. 4 Gy versus 24 Gy
radiotherapy for patients with indolent lymphoma (FORT):
a randomised phase 3 non-inferiority trial. Lancet Oncol.
2014;15(4):457-463.

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Article Review

Intra-Lenticular Lens Aspiration in
Anteriorly Dislocated Lens in Paediatric
Eyes

[Sahay P, Maharana PK, Shaikh N, et al. Intra-lenticular lens aspiration in paediatric cases with anterior dislocation of
lens. Eye (Lond). 2019 Sep;33(9):1411-1417.]

Introduction Anaesthesia- GA or peribulbar (depending on the age and
systemic condition)
Spontaneous anterior dislocation of the crystalline lens in paedi- Surgical steps
atric cases can lead to long-term complications such as corneal • Using a 23-gauge MVR blade, (Microvitreoretinal blade
decompensation and glaucoma.[1] Thus, it warrants an imme-
diate surgical intervention with comprehensive management Alcon Laboratories, Inc.) 2 side port entries are made
strategies. Most of these cases are associated with some systemic (0.9mm) at 2 o’clock and 10 o’clock positions.
abnormalities such as Marfan syndrome, Weill Marchesini syn- • While making the incision, the MVR blade is advanced
drome, Noonan syndrome, Homocystinuria that further com- further to create 2 linear capsulotomies at the equator of
plicate the management strategy in these cases.[1-4] the lens. [Figure 1.A and B]
Various techniques such as Intra-lenticular lens aspiration, • The visualization of the edge of capsulotomy margins is
lensectomy, and in the bag bimanual irrigation and aspiration enhanced by injecting trypan blue dye (Auroblue 0.6%,
have been described in the literature to surgically remove the Aurolab, India) at the capsulotomy opening, rather than
anteriorly dislocated lens.[1,2,5-8] In a recently published article by intracameral injection. [Figure 1.C] This aided in easy entry
Maharana et al. a modified technique of microscope-integrated of instruments during bimanual irrigation and aspiration,
optical coherence tomography (MiOCT) guided intra-lenticular thus preventing further inadvertent damage to the capsule.
lens aspiration (ILLA) for management of anteriorly dislocated Miosis is achieved by injecting pilocarpine beneath the lens.
lens in paediatric cases was described. The current article • The anterior chamber is formed by injecting a viscodisper-
summarizes its important findings and conclusions. sive ophthalmic viscoelastic device [OVD] (Viscoat, Alcon
Surgery Laboratories, Inc., Forth Worth, TX, USA) between the
corneal endothelium and anterior capsule of the dislocated
Preoperative Assessment lens. [Figure 1. D]
All such cases must undergo a detailed pre-op examination to • The use of MiOCT to localize micro-adhesions between
record the baseline CDVA (Corrected distant visual acuity), the corneal endothelium and the anterior lens capsule.
IOP (Intraocular pressure), anterior segment examination and [Figure 2]
associated systemic and ocular comorbidities. In this study, the • Hydrodissection and hydrodelineation in multiple quad-
authors observed glaucoma in two cases and corneo-lenticular rants to obtain multiple cleavage planes in the crystalline
touch causing corneal oedema in 10 cases at presentation. The lens. [Figure 1.E]
reported systemic associations resulting in ectopia lentis were • Lens aspiration using a bimanual irrigation aspiration
Homocystinuria (2/8) and Marfan syndrome (1/8). Ocular cannula within the capsular bag through the two
associations such as Microspherophakia (2/8), Buphthalmos capsulotomy openings with parameters set to meet the
(1/8), and Ectopia lentis et pupillae (1/8) were noted. needs of individual cases. [Figure 1.F] IOP/bottle height
Detection of glaucoma and corneal oedema allows for proper on lower side (30–40 mm of Hg) along with a moderately
pre-operative planning and prognostication. Identification high vacuum (300–350 mm of Hg) and a low aspiration rate
of associated systemic syndromes is vital for appropriate (24–28 cc/min) in most scenarios.
anaesthesia planning since all such cases had to undergo surgery • During the lens aspiration, the irrigation cannula can be
under general anaesthesia. maneuvered so as to aid in both stabilizing the bag and
Surgical Technique hydrating the lens matter to enhance followability for its
The major steps of surgery includes

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aspiration. ml) (Aurocort, Aurolab, India).
• After lens aspiration, a vitrectomy cutter is used to remove • Balanced salt solution or air is then used to form the

the capsular bag in cut IA mode. [Figure 1.G] anterior chamber following which the wound is closed by
• A limited anterior vitrectomy and a peripheral iridectomy performing stromal hydration with BSS. Wherever required,
a 10-0 monofilament interrupted suture is used for closing
is performed. Any suspicion of incomplete vitrectomy is the MVR entry. [Figure 1.H]
resolved by injecting 0.1ml of triamcinolone acetate (40mg/

Figure 1 : A. MVR blade advanced into lens capsule at equator making a linear capsulotomy at 10 ‘o’ clock position; B. similar incision and capsulotomy
at 2 ‘o’ clock position; C. Injection of trypan blue dye at the capsulotomy site; D. Viscoelastic injection separating micro-adhesions; E. Hydrodelineation
and hydrodissection in various quadrants; F. Lens aspiration using bimanual irrigation aspiration probe; G. Removal of anterior and posterior capsule
using vitrectomy cutter; H. Wounds sutured and AC formed with air.

Figure 2 : Micro-adhesions seen on MiOCT between the corneal The authors could achieve excellent outcomes in this series.
endothelium and anterior lens capsule. The technique was performed in 11 eyes of 8 patients under the
age of 16 years with anteriorly dislocated lens. Three of these
Postoperative Management and Follow-up patients presented with a bilateral anterior lens dislocation.
Post-operatively, the patients are prescribed topical moxifloxacin Median postoperative CDVA at 6-month was 1 logMAR unit
0.5% four times a day for 4 weeks, prednisolone phosphate 1% with a median IOP of 15 mm of Hg. The median central corneal
six times a day for one week followed by tapering over the next thickness and central macular thickness were 516 and 248 μm
four weeks, and homatropine bromide 2% four times a day for respectively. Postoperatively, visual rehabilitation was done
one week. in all cases with spectacle correction. There was no significant
complication in any of the patients who were operated on using
this procedure. One patient developed a dense adhesion between
the anterior capsule and endothelium, which was peeled off
using intravitreal forceps. Corneal oedema resolved in all eyes
within one week. Three eyes had persistently raised IOP, which
was controlled with medical management using anti-glaucoma
drugs. Central corneal Descemet scarring was noted in five eyes.

Advantages of ILLA over other Techniques of Removal of
Dislocated Lens

The authors have enumerated the following advantages
with ILLA

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• Minimal risk of intra-operative vitreous prolapse, iris fixation of IOL (SFIOL), Anterior chamber IOL (ACIOL),
damage, or posterior movement of lens matter. contact lens or spectacles can be done.
The authors have discussed the pros and cons of these methods
• Controlled lens aspiration without disturbing the vitreous in patients, especially from Indian perspective. In their series,
face. ACIOL was avoided taking into account the young age of
patients, the presence of corneal oedema, and the risk of pre-
• Since entire procedure is within the capsular bag, the risk of existing glaucoma. Most of their cases had systemic associations
vitreous prolapse due to its hydration is minimal. which are known to be associated with scleral thinning
precluding the use of SFIOL. Though contact lens rehabilitation
• In comparison to ICCE, there is no risk of vitreous prolapse, was discussed with the parents, their socio-economic status and
supra-choroidal haemorrhage, and significant post-surgery poor compliance remained a major concern. Hence all cases
astigmatism in ILLA since the whole procedure is done in a were rehabilitated with spectacles.
closed chamber with a one mm incision. Conclusion

• Use of bimanual irrigation aspiration instead of a vitrecto- The technique of ILLA described by Sahay et al. group appears
my cutter for lens matter aspiration avoids damage to the safe, effective, and easy to perform. It offers several advantages
anterior and posterior capsule, which can result in lens mat- when compared to previously described techniques. MiOCT
ter dropping into the vitreous cavity. assistance can be an added advantage in cases with poor visibility.
However, MiOCT is not essential, ILLA can be performed with
Advantages of our Modified Technique of ILLA over other simple cataract surgery instruments.
Techniques
References
Several other surgical techniques have been described to man-
age such cases. In a technique of in the bag lens aspiration de- 1. Vasavada AR, Praveen MR, Desai C. Management of bilateral
scribed by Vasavada et al, a vitrectomy cutter was used to severe anterior dislocation of a lens in a child with Marfan’s syndrome. J
the capsular adhesions with vitreous while removing the lens Cataract Refract Surg. 2003;29:609–13.
capsule with forceps.[1] In contrast to that in ILLA, by engaging
the anterior capsule followed by the posterior capsule with a vit- 2. Mukhopadhyaya U, Chakraborti C, Mondal A, Pattyanayak U,
rectomy cutter one can avoid traction or any disturbance in the Agarwal RK, Tripathi P. Spontaneous dislocation of a crystalline lens
vitreous face. to the anterior chamber with pupillary block glaucoma in Noonan
In the endo-capsular lens aspiration technique described by Syndrome: a case report. Pan Afr Med J. 2014;17:135.
Khokhar et al, a vitrectomy cutter was used for lens aspiration
in contrast to a bimanual irrigation aspiration probe used in 3. Ismail S, Khairy-Shamel ST, Hussein A, Shaharuddin B, Embong
our technique.[8] In cases of an anteriorly subluxated lens with Z, Ibrahim M. Spontaneous bilateral anterior lens dislocation in an
corneo-lenticular touch and compromised endothelium, this 8-year-old girl. J Pediatr Ophthalmol Strabismus. 2010;47:111–3.
may not be very safe and ideal and has a higher risk of capsular
damage. This can result in vitreous loss and lens matter drop, 4. Ram J, Gupta N. Bilateral spontaneous anterior dislocation of
which shadows the ultimate purpose of lens aspiration in the crystalline lens in an infant. Lancet. 2011;378:1501.
bag. Hence a bimanual irrigation aspiration probe would be safer
in cases with poor visibility due to corneal decompensation. 5. Sinha R, Sharma N, Vajpayee RB. Intralenticular bimanual irrigation:
Another unique feature of ILLA, in contrast to previous Aspiration for subluxated lens in Marfan’s syndrome. Journal of
techniques is injecting the dye into the capsulotomy opening. Cataract & Refractive Surgery. 2005 Jul 1;31(7):1283-6.
This makes the area of capsulotomy more apparent without
the risk of posterior migration of dye into the vitreous cavity. 6. Jovanović M. Bilateral spontaneous crystalline lens dislocation to the
Identification of entry points in the capsule becomes easy anterior chamber: a case report. Srp Arh Celok Lek. 2013;141:800–2.
because of the dye in these difficult cases wherein corneal
oedema is often present. 7. Kim YJ, Ha SJ. Intracapsular lens extraction for the treatment of
Advantage of MiOCT pupillary block glaucoma associated with anterior subluxation of the
crystalline lens. COP. 2013;4:257–64.
The authors have reported that in two of their cases, there was
very poor visibility, and MiOCT guided them in identifying the 8. Khokhar S, Aron N, Yadav N, Pillay G, Agarwal E. Modified technique
corneo-lenticular micro-adhesions and aided in releasing them of endocapsular lens aspiration for severely subluxated lenses. Eye.
completely. Thus, if available MiOCT appears to be useful in 2018;32:128–35.
complicated cases with corneal oedema.
Choice of Visual Rehabilitation after ILLA 9. Meredith TA, Maumenee AE. A review of one thousand cases of
intracapsular cataract extraction: I. Complications. Ophthalmic Surg.
Depending upon the patient’s age and, surgeons expertise any of 1979;10:32–41
the described methods for visual rehabilitation such as Scleral
10. Lam A, Seck CM, Faye M, Brassier PK, Cisse MB, Diagne M.
Spontaneous andbilateral anterior luxation of the lens in a 5-year-old
child. J Fr Ophtalmol. 1996;19:279–82.

11. Chung Jae Lim, Kim Sun Woong, Kim Ji Hyun, Kim Tae-im, Lee
Hyung Keun, Kim Eung Kweon. A Case of Weill-Marchesani
Syndrome with Inversion of Chromosome 15. Korean Journal of
Ophthalmology. 2007;21(4):255. doi: 10.3341/kjo.2007.21.4.255.

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Acknowledgement Corresponding Author:
I am extremely grateful to Dr. Prafulla Kumar Maharana
[corresponding author] and Dr. Pranita Sahay [first author] the
original authors of the article for their valuable inputs while
writing this manuscript.

Dr. Priyadarshini K, MD
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi.

Corresponding Author of the Article:

Dr. Prafulla Kumar Maharana, MD
Associate Professor, Dept. of Ophthalmology
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi.

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Book Review

Current Concepts in Refractive Surgery :
Comprehensive Guide for Decision Making
and Surgical Techniques

Publisher: Jaypee Brothers, New Delhi
Editors: Jeewan S Titiyal, Manpreet Kaur, Sridevi Nair

I thoroughly enjoyed reading this comprehensive book titled ‘Current Concepts in Refractive Surgery’, which is an up-to-date
reference guide covering all the relevant aspects of modern refractive surgery. The book is written in a uniform, easy-to-grasp format.
The text is lavishly interspersed with clear illustrations and high-quality color clinical photographs. The authors have incorporated
numerous tables and flowcharts to help organize the clinically relevant material.
The book is organized into eight sections. The first section provides an overview of the history and evolution of refractive surgery.
This follows on to the section on preoperative evaluation and screening, including the latest diagnostic modalities, patient counseling
and choosing the most suitable surgical technique. Next three sections focus on the different surgical approaches, namely, corneal
laser ablation-based procedures, SMILE and phakic IOL implantation. Layout of the chapters is well organized starting with a brief
background about the surgery, followed by patient selection, step-by-step detailing of the surgical technique and clinical outcomes.
The chapter on customized ablation explores the role of wavefront analysis and topography in tailoring corneal ablative treatment,
with a detailed analysis of the various treatment profiles. Complications associated with each surgical approach have been covered
in ample detail in separate chapters.
Retreatment after laser refractive surgery has been dealt with in a separate section, with clear directives on when to intervene, and
the factors that need to be weighed in while choosing the appropriate technique. The section on presbyopic correction provides
a comprehensive overview of existing and evolving surgical modalities, with special emphasis on patient selection as well as the
advantages and limitations of each technique.
The final section deals with refractive surgery in special scenarios, including post-keratoplasty patients, hyperopia, and pediatric
patients. The role of adjunctive corneal collagen crosslinking, corneal ring segment implantation and corneal incisional surgery
have also been addressed in this section.
I strongly believe that the book will cater to a wide range of readers including residents, general ophthalmologists, and experienced
refractive surgeons. I commend the exemplary efforts of the authors in compiling this book and recommend it to all those
interested in understanding and mastering the art and science of refractive surgery.

Dr. Rupal Shah
Group Medical Director, Centre for Sight

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CM-T FLEX Scleral Fixated Intraocular Lens

Madhangopalan[1], MS, DNB, FICO, FMRF, MRCS, M. Nivean[2], MBBS, MS, FMRF, Pratheeba Devi[3], MBBS, DO, DNB,
Archana N[4], MBBS, MS
1. VR Surgeon, JB Eye Hospital, Salem.
2. Academic Director, M N Eye Hospital.
3. Chief Cataract Clinic & Occuloplaty Surgeon, M N Eye Hospital.
4. VR Fellow, M N Eye Hospital.

Abstract: We present the CM-T Flex intraocular lens (IOL) that simplifies complex scleral fixated intraocular lens
(SFIOL) surgery. Established techniques for sutureless fixation of SFIOL use 3-piece IOLs and anchor the haptics to
the sclera after exteriorizing them. This requires a certain degree of haptic manipulation, which entails a learning
curve. By its unique design, the CM-T Flex IOL simplifies the process of SFIOL fixation by limiting the process to
simply exteriorizing and releasing the haptic. The CM-T Flex IOL was used in a 45 year old patient with surgical
aphakia. Improvement in visual acuity was recorded with no complications at 15 months.

Introduction Case Report
Ophthalmologists performing cataract surgery are often con-
fronted with complications and placement of an intraocular A 45-year old male presented with surgical aphakia and retained
lenses (IOL) in these eyes with compromised capsular support nuclear remnants. He had complicated cataract surgery 1 week
is a challenge.[1] Scleral fixated IOL (SFIOL) are so designed ago at another center. After complete ocular exam and obtaining
that the haptics have provisions for suturing or tucking into the an informed written consent, SFIOL surgery with CM-T Flex
sclera for additional stability.[2] In order to avoid haptic manipu- IOL was planned.
lation extra-ocularly, the innovative CM-T Flex IOL was devel- After local anesthesia by peribulbar block, peritomies were
oped. The special T shaped haptics allows for a simple pull and made 180 degree apart at m3 and 9 ‘o’ clock meridian. Scleral
release technique that is sufficient to anchor the haptics to the flaps of 3.5 x 3.5 mm were made using a crescent blade for
sclera without the need for additional procedures.[3,4] partial thickness. The scleral flaps were hinged on the limbus.
Care was taken to have even thickness. Button-holing and flap
FRONT SIDE avulsion was carefully prevented. Full thickness sclerotomies
Material Hydrophilic 26% Water were created at the centre of the scleral bed under the flaps with
Refractive Index 1.460 23-gauge needles to exteriorize the haptics. Using regular 23-
Optic Diameter 6.00MM gauge 3 port pars plana vitrectomy with the standard ports in
Overall Diamter 13.75MM infero-temporal, superotemporal and superonasal quadrants,
Angulation 10 vitrectomy and nuclear fragment removal was completed. The
A. Constant 118.0 retina was thoroughly checked for breaks.
The CM-T Flex SFIOL of +20.00 D was then placed. This fold-
The design of CM-T Flex IOL able lens was introduced into the eye through corneal incision.
CM-T Flex IOL has a total length of 13.50 mm. It is a hydrophilic The haptic that first entered the eye was guided behind the iris
foldable lens. An A constant of 118 is used. The refractive index as it was injected. Once behind the iris plane, it was held at the
of the material is 1.460. The IOL has a T shaped haptic that is centre of the T shaped haptic with the PraNiv T Flex intraoc-
connected to the 6 mm circular optic by means of semi-circular ular forceps (Appasamy Associates, Pondicherry, India) which
connecting arms. A 10° angulation between the optic and semi- was introduced into the eye through the sclerotomy under the
circular arms of the haptic prevents iris-IOL touch. scleral flap on the left of the surgeon. This is a unique forceps
with shorter teeth that prevents cutting of the soft hydrophilic
lens. The PraNiv forceps is brought out of the eye thereby ex-
teriorizing the leading haptic. Since the material is hydrophilic,
the haptic is bendable and passes through the sclera easily. Once
outside, it quickly springs back to its natural shape and anchors
itself to the sclera. The trailing haptic, meanwhile, rests on the
iris after exiting the injector. Using a side port, the Nishi grasp-
ing forceps (Appasamy Associates, Pondicherry, India) is used
to exteriorize the trailing haptic using the handshake technique
through the other sclerotomy under the scleral bed at 9 ‘o’ clock

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meridian. As before, once exteriorized, the haptic immediately At 1st post operative day, visual acuity (VA) was 6/18 with an
opens out and anchors itself to the sclera stabilizing the IOL. intraocular pressure (IOP) of 8 mm Hg. The IOL was well
At conclusion, the posterior segment was rechecked. The partial centered with no optic capture or IOL tilt. The patient was
thickness scleral flaps were closed with fibrin glue and the regu- followed up at 1st week, 1st month and 3rd month when the VA
lar 3-port 23 gauge sclerotomies were self sealed. was 6/12, 6/9 and 6/9 respectively. IOP increased to 18 mm Hg
Discussion by 1 month and maintained at that level until the last follow-up
at 15 months.
Different IOLs help clinicians in management of surgical By 15 months, best-corrected visual acuity was 6/6 with no hap-
aphakia.[5,6] Amongst the various options, surgeons prefer the tic exposure, well covered scleral flaps, clear cornea, no pupil-
SFIOLs. Gabor Schariothwas the one who innovated and pop- lary capture or inflammation and a well centered IOL. The IOP
ularized the technique of sutureless fixation by tucking haptics was 16 mm Hg and there was no macular edema (as document-
into the sclera.[7] Later, Agarwal and colleagues introduced a flap ed on optical coherence tomography) or retinal lesions on clin-
and glue technique to enhance the stability.[8] The Yamane tech- ical exam.
nique is a recent addition to the surgeons armamentarium where References
the haptics are flanged and pushed back to rest intra-sclerally.[9]
Each of the above mentioned methods have use in different 1. Por YM, Lavin MJ. Techniques of intraocular lens suspesion in the
scenarios. Many surgeons have adopted one or more of these abscnce of capsular/2onular support. Surv Ophthalmol 2005:50(5429-
techniques and have achieved success with them. The common 462.
denominator that connects all these techniques is the use of
a 3 piece IOL that has prolene haptics. The haptics have to be 2. Madanagopalan V, Sen P. Baskaran P. Scleral Fixated Intraocular
carefully handled and manipulated gently to achieve the desired Lenses. TNOAJ Ophthalmic Sci Res. 201866)237-243.
final anatomic position to poide for IOL stability. That requires
finesse and mastery, which comes only with years of experience. 3. Machivanan N. Nivean PD. Aysha Pa. P Arthi M, Madanagopalan
A slight misjudgment on the surgeon’s part can lead to haptic VG. Innovative intraocular lens design to manage surgical aphakia in
bending and breakage, which then necessitates redoing the an eye with a filtering bleb. J Cataract Refract Surg. 2020:46(11:1564-
entire surgery. The learning curve is quite steep with increased 1567.
surgical time as a result of complex maneuvers.
The CM-T Flex IOL specifically addresses these concerns.[3,4] 4. Madanagopalan V G. Madhivanan Nivean Selvam V Panneer A
It makes haptic handling easier. Stability of the IOL is not de- Novel Sutureless Scleral-Fixated Lens That Eliminates Ea Ocar Haptic
pendent on complex manouvers after haptic exteriorization. Manipulation: The CM-T Flex Lens. Ophthalmic Surg Lasers Imaging
Instead, this IOL provides for a simple grasp, pull and release Retina 202o5111648-650.
technique which simplifies the complexities involved in SFIOL
surgery. The IOL has a U shaped haptic design that allows for 5. Luk ASW, Young AL, Cheng LL. Long term outcome of scleral-fixated
use in eyes of varying white to white diameters. The hydrophil- intraocular lens implantation. Br J Ophthalmol. 201397(10)1308
ic design helps in easy maneuvering and offers more pliability 1311.
when passing through the sclera.
To conclude, the unique design of CM-T Flex IOL helps to 6. Baykara M, Ozcetin H. Yilmaz S. Timuçin OB. Posterior iris fixation
simplify the complex procedure of fixing an IOL to the sclera of the iris-claw intraocular lens implantation through a scleral tunnel
by use of sutures or varied haptic manipulation techniques. incision. Am J Ophthalmol. 2007144 4)586-591.
Long term follow-up in this patient has shown no IOL related
complications like inflammation, IOP changes or macular 7. Gabor SGB. Pavlidis MM. Sutureless intrascleral posterior chamber
edema. IOL exposure or tilt was also absent. intraocular lens fixation. J Cataract Refract Surg. 2007:33(11):1851-
1854.

8. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S.
Fibrin glue-assisted Sutureless posterior chamber intraocular Lens
implantation in eyes with deficient posterior capsules. J Cataract
Relfract Surg 20o08 349)1433-1438.

9 Yamane S, Sato S, Maruyama linou M, Kadonosono K. Flanged
Intrascleral Intraocular Lens Fixation with Double-Needle Technigue.
Ophthalrmology. 2017:124(8):1136-1142.

Corresponding Author:

DOS Times - Volume 28, Number 1, January-February 2022 Dr. V.G. Madhanagopalan, MS, DNB, FICO, FMRF, MRCS
VR Surgeon, JB Eye Hospital, Salem.
108

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Visual Outcomes and Optical Quality After
Implantation of Multifocal Intraocular Lens

N. V. Arulmozhi Varman, DO, MS, Aadithreya Varman, MS, M. B. Dinesh, MS, DNB, Fellow Phaco- Refractive
Uma Eye Clinic, Chennai.

Introduction All cases were uneventful with implantation of IOL in the bag.
Routine post-operative medication orders were given. Parame-
The technology of the multifocal intraocular lenses (IOLs) is ters evaluated were uncorrected visual acuity for distance and
advancing as the objectives of the cataract surgery are becom- near immediate post operatively, on the first to third day post
ing more adoptive. Nowadays, patients have more expectations operatively, after 1 week, 1 month, 3 to 6 months.
about their vision and desire spectacle independence after cat- 18 eyes of 9 patients received MultiDiff IOL bilaterally and the
aract surgery. In addition, they do not expect any complication remaining 35 eyes were uniocular implantation of MultiDiff
or unsatisfactory result. IOL.
In this context, the multifocal IOLs were developed to en- Results
hance outcomes of cataract surgery improving near vision The overall outcomes of MultiDiff IOL are presented below
by dividing light in different focuses, which changes the vi- Preoperatively, all patients had a full ophthalmologic examina-
sion physiology because of the light dispersion that hap- tion including uncorrected distance visual acuity (UDVA) and
pens when it enters into the eye. As a result, visual symp- corrected distance visual acuity DVA, uncorrected near visul
toms such as halos, glare, and lower contrast sensitivity acuity measured in snellens visual acuty chart, slit lamp evalu-
may occur. ation, fundoscopy, intraocular pressure assessment (IOP; Gold-
With the objective of getting a more physiological division of man Applanation tonometry) endothelial cell density, corneal
light and, in this way, to optimize the spectacle independence topography, aberration measurement, and contrast sensitivity
and also provide better vision quality and less visual symptoms (CS) evaluation under photopic (85 cd/m2) conditions.
for the patient, recent researches aim to enhance the optical
design of the multifocal IOLs. Although it is still a developing Keratometry Values
technology, the available multifocal IOLs are often able to re-
store visual function and allow spectacle independence after Axial Lengths
the surgery with great levels of patient satisfaction.
The purpose of this study was to assess visual outcomes and
patient satisfaction after implanting MultiDiff IOL in patients
and provide referential clinical data for future cataract surgery.
Materials and Methods

This study comprised 55 eyes of cataract patients ranging in
age of above 55 years, who were recruited within 6 months.
Inclusion criteria were patients above the age 55 with cataract
operated upon by a single surgeon with no intraoperative
complications. Exclusion criteria were patients with Posterior
segment pathology, coexisting glaucoma, any other ocular
pathology capable of interfering with quality of vision.
The MultiDiff sterile UV-absorbing Hydrophilic foldable single
piece posterior chamber lens is an optical implant for the
replacement of human crystalline lens in the visual correction
of aphakia. These lenses have two point supporting haptics for
easy centration and aspherical surface on posterior side and
Refractive-Diffractive surface on anterior side.
Biometry was accurately calculated by a single experienced op-
tometrist with good signal strengths with the Zeiss IOL Master
500 or Zeiss IOL Master 700. All cases were operated by a single
surgeon under topical anesthesia.

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Results Distance Vision Uncorrected Near Vision Uncorrected
Post OP Day
6/6 6/9 6/12 N6 N8
1 Week 39/55 12/55 4/55 46/55 9/55
(70.9%) (21.8%) (7.3%) (83.6%) (16.3%)
1 Month 42/55 9/55 4/55 51/55 4/55
(76.3%) (16.3%) (7.4%) (92.7%) (7.3%)
3 Months to 6 Months 42/55 9/55 4/55 51/55 4/55
(76.3%) (16.3%) (7.4%) (92.7%) (7.3%)
Table-2
At the end of 1 month Table-3

4/55 eyes which had a UCDVA At the end of 3 to 6 months At the end of 1 month At the end of 3 to 6 months
of 6/12 and 4/55 eyes had a
UCNVA of N8 improved to 4/55 eyes which had a UCDVA 9/55 eyes which had a UCDVA of 9/55 eyes which had a UCDVA
+0.50 DS/+0.50 DC x 180=6/6 of 6/12 and 4/55 eyes had a 6/9 and UCNVA of N6 improved of 6/9 and UCNVA of N6
N6 UCNVA of N8 improved to to improved to
+0.50 DS=6/6 N6 (2 eyes)=6/6 +0.50 DS/+0.50 DC x 180=6/6 +0.25 DS/+0.50 DC x 180=6/6 +0.25 DS/+0.50 DC x 180=6/6
N6 N6 N6 (3 eyes) N6 (3 eyes)
+0.50 DS/+0.50 DC x 90=6/6 +0.50 DS=6/6 N6 (2 eyes)=6/6 +0.25 DS/-0.50 DC x 90=6/6 N6 +0.25 DS/-0.50 DC x 90=6/6
N6 N6 (4 eyes) N6 (4 eyes)
+0.50 DS/+0.50 DC x 90=6/6
N6 -0.50 DS/-0.25 DC x 180=6/6 N6 -0.50 DS/-0.25 DC x 180=6/6
(2 eyes) N6 (2 eyes)

Binocular Vision in all Patients at the end of 1 month and beyond was
6/6 n6

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During all follow-ups, the patients were given Visual Function suggest that the Multifocal IOL is a good option to compensate
Questionnaire. All answers were documented and evaluated in for cataract.
all visits. Declaration of patient consent
Financial support and sponsorship The authors certify that they have obtained all appropriate pa-
Nil. tient consent forms. In the form, the patient has given her con-
Conflicts of interest sent for her images and other clinical information to be reported
There are no conflicts of interest. in the journal. The patient understands that name and initials
Conclusion will not be published, and due efforts will be made to conceal
The outstanding predictability, stability, and optical quality identity, but anonymity cannot be guaranteed.

Visual Function Questionnaire

1. At the present time, would you say your eyesight using both eyes is excellent, good, fair or poor?
2. How much difficulty do you have reading ordinary print in newspapers?
3. How much difficulty do you have reading the small print in a telephone book, on a medicine bottle?
4. How much difficulty do you have doing work or hobbies that require you to see well up close, such as cooking, sewing, fixing

things around the house, or using hand tools?
5. Because of your eyesight, how much difficulty do have doing things like shaving, styling your hair, or putting on makeup?
6. How much difficulty do you have reading street signs or the names of stores?
7. Because of your eyesight, how much difficulty do have going down steps, stairs, or curbs in dim light or at night?
8. Because of your eyesight, how much difficulty do have going out to see movies, plays, or sports events?

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9. Are you currently driving?
a. IF NO: Have you never driven car or have you given up driving?
b. IF YOU GAVE UP DRIVING: Was that mainly because of your eyesight, mainly for some other reasons, or because of both your

eyesight and other reasons?
c. IF CURRENTLY DRIVING: How much difficulty do you have driving during the daytime in familiar places?
d. How much difficulty do you have driving at night?
10. Are you limited in how long you can work or do other activities because of your vision?
11. How would you rate your eyesight now, on a scale of from 0 to 10, where zero means the worst possible eyesight, as bad or worse
than being blind, and 4 means the best possible eyesight?

References acuity outcomes with SA60D3, N60D3, and ZM900 multifocal IOL
implantation after phacoemulsification. J Cataract Refract Surg
1. Cochener B, Lafuma A, Khoshnood B, Courouve L, Berdeaux G. 2010;26:177–182.
Comparison of outcomes with multifocal intraocular lenses: A
meta-analysis. Clin Ophthalmol. 2011;5:45–56. [PMC free article] 5. de Vries NE, Webers CA, Touwslager WR, Bauer NJ, de Brabander J,
[PubMed] [Google Scholar] Berendschot TT, et al. Dissatisfaction after implantation of multifocal
intraocular lenses. J Cataract Refract Surg 2011;37:859-65.
2. Soda M, Yaguchi S. Effect of decentration on the optical performance
in multifocal intraocular lenses. Ophthalmologica. 2012;227:197– 6. Yang HC, Chung SK, Baek NH: Decentration, tilt, and near vision
204. [PubMed] [Google Scholar] of the Array multifocal intraocular lens. J Cataract Refract Surg
2000;26:586–589.
3. Pieh S, Weghaupt H, Skorpik C. Contrast sensitivity and glare
disability with diffractive and refractive multifocal intraocular lenses. 7. Yukiko K, Toshikatsu N, Shigeo Y, Tadahiko K, Masanobu K: The
J Cataract Refract Surg 1998;24:659-62. retinal image of three multifocal intraocular lenses through an eye
model. J JpnOphthalmol Soc 1994;98:1091–1096.
4. Ngo C, Singh M, Sng C, Loon SC, Chan YH, Thean L: Visual

Corresponding Author: Corresponding Author:

Dr. Aadithreya Varman, MS Dr. Dinesh MS, DNB, Fellow Phaco- Refractive
Uma Eye Clinic, Chennai. Uma Eye Clinic, Chennai.

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