SOOSAN JACOB, MS, FCRS,DNB AMAR AGARWAL, MS, FRCS, FRCOpth; ATHIYA AGARWAL, MD, DO; AMAR AGARWAL, MS, FRCS, FRCOpth; ATHIYA AGARWAL, MD, DO; GAURAV PRAKASH, MD; DHIVYA A KUMAR, MD; GAURAV PRAKASH, MD; DHIVYA A KUMAR, MD; ARCHANA NAIR, MS; AKBAR SALEEM, MS DR. AGARWAL’S GROUP OF EYE HOSPITALS & EYE RESEARCH CENTRE, CHENNAI, INDIA CHENNAI, INDIA PROF. AMAR AGARWAL IS A PAID CONSULTANT TO ABOTT MEDICAL OPTICS AND BAUSCH & LOMB. NONE OF THE OTHER AUTHORS HAVE ANY FINANCIAL DISCLOSURES.

BACKGROUND : OPTIONS FOR CORRECTION OF APHAKIA IN THE ABSENCE OF ADEQUATE CAPSULAR SUPPORT ARE – ANTERIOR CHAMBER IOL, IRIS FIXATED IOL, SUTURED SCLERAL FIXATED IOL AND GLUED IOL BACKGROUND : OPTIONS FOR CORRECTION OF APHAKIA IN THE ABSENCE OF ADEQUATE CAPSULAR SUPPORT ARE – ANTERIOR CHAMBER IOL, IRIS FIXATED IOL, SUTURED SCLERAL FIXATED IOL AND GLUED IOL PURPOSE : TO EVALUATE THE VISUAL OUTCOME AND COMPLICATIONS OF EYES OPERATED WITH FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION IN EYES WITH DEFICIENT POSTERIOR CAPSULE AT ONE YEAR FOLLOW UP PURPOSE : TO EVALUATE THE VISUAL OUTCOME AND COMPLICATIONS OF EYES OPERATED WITH FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION IN EYES WITH DEFICIENT POSTERIOR CAPSULE AT ONE YEAR FOLLOW UP

FIBRIN GLUE ASSISTED SUTURELESS TRANS-SCLERAL HAPTIC FIXATED POSTERIOR CHAMBER IOL IMPLANTATION FIBRIN GLUE ASSISTED SUTURELESS TRANS-SCLERAL HAPTIC FIXATED POSTERIOR CHAMBER IOL IMPLANTATION RIGID PMMA IOL OR 3 PIECE FOLDABLE IOL RIGID PMMA IOL OR 3 PIECE FOLDABLE IOL EXPERIENCE OF >300 EYES (FIRST CASE: 2007), 11 PEER REVIEWED PUBLICATIONS EXPERIENCE OF >300 EYES (FIRST CASE: 2007), 11 PEER REVIEWED PUBLICATIONS INDICATIONS: INDICATIONS: IN THE BAG IOL/ SULCUS SUPPORT NOT POSSIBLE IN THE BAG IOL/ SULCUS SUPPORT NOT POSSIBLE >180º SUBLUXATION >180º SUBLUXATION APHAKIA APHAKIA GLUED IOL IS AN OFF LABEL USE OF IOLs AND FIBRIN GLUE AGARWAL A, KUMAR DA, JACOB S, ET AL. FIBRIN GLUE–ASSISTED SUTURELESS POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION IN EYES WITH DEFICIENT POSTERIOR CAPSULES. J CATARACT REFRACT SURG 2008; 34: 1433–1438 PRAKASH G, KUMAR DA, JACOB S ET AL. ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY–AIDED DIAGNOSIS AND PRIMARY POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION WITH FIBRIN GLUE IN TRAUMATIC PHACOCELE WITH SCLERAL PERFORATION. J CATARACT REFRACT SURG 2009; 35: 782–784 JACOB S, PRAKASH G, ASHOK KUMAR D, NAIR V, AGARWAL A, AGARWAL A. ANTERIOR SEGMENT TRANSPLANTATION WITH A NOVEL BIOSYNTHETIC GRAFT. EYE CONTACT LENS MAR;36(2):130-6.

RETROSPECTIVE CASE SERIES, IRB APPROVED, INFORMED CONSENT TAKEN RETROSPECTIVE CASE SERIES, IRB APPROVED, INFORMED CONSENT TAKEN DECEMBER 2007 TO MAY 2008: 59 EYES (OF 56 PATIENTS ) DECEMBER 2007 TO MAY 2008: 59 EYES (OF 56 PATIENTS ) ALL UNDERWENT FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION WITH TRANS-SCLERAL HAPTIC FIXATION ALL UNDERWENT FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION WITH TRANS-SCLERAL HAPTIC FIXATION FOLLOW UP: 1, 3, 6, 12 MONTHS FOLLOW UP: 1, 3, 6, 12 MONTHS STATISTICAL ANALYSIS: SPSS VERSION 16.1(SPSS INC, USA). STATISTICAL ANALYSIS: SPSS VERSION 16.1(SPSS INC, USA). DIFFERENCES CONSIDERED STATISTICALLY SIGNIFICANT AT P<0.05. WILCOXON SIGNED RANK TEST USED DIFFERENCES CONSIDERED STATISTICALLY SIGNIFICANT AT P<0.05. WILCOXON SIGNED RANK TEST USED ANALYSIS AT ONE YEAR OF: ANALYSIS AT ONE YEAR OF: POSTOPERATIVE BEST CORRECTED VISUAL ACUITY (BCVA) POSTOPERATIVE BEST CORRECTED VISUAL ACUITY (BCVA) UNCORRECTED VISUAL ACUITY (UCVA) UNCORRECTED VISUAL ACUITY (UCVA) SPECULAR COUNT SPECULAR COUNT INTRA OCULAR PRESSURE (IOP) INTRA OCULAR PRESSURE (IOP) CELLULAR REACTION (SUN CLASSIFICATION) CELLULAR REACTION (SUN CLASSIFICATION) CENTRAL MACULAR THICKNESS (CMT) CENTRAL MACULAR THICKNESS (CMT) INTRAOPERATIVE COMPLICATIONS INTRAOPERATIVE COMPLICATIONS POSTOPERATIVE COMPLICATIONS POSTOPERATIVE COMPLICATIONS IOL TILT IOL TILT IOL CENTERATION IOL CENTERATION

INFUSION CANNULA INSERTED INFUSION CANNULA INSERTED TWO LAMELLAR SCLERAL FLAPS 180 DEGREES APART WERE MADE TWO LAMELLAR SCLERAL FLAPS 180 DEGREES APART WERE MADE SCLEROTOMY WAS MADE UNDER EACH FLAP 1 MM FROM THE LIMBUS SCLEROTOMY WAS MADE UNDER EACH FLAP 1 MM FROM THE LIMBUS THE IOL HAPTIC WAS GRASPED WITH 23 G MST FORCEPS AND EXTERIORIZED UNDER THE FLAP THE IOL HAPTIC WAS GRASPED WITH 23 G MST FORCEPS AND EXTERIORIZED UNDER THE FLAP BOTH HAPTIC TIPS WERE TUCKED INTO SCLERAL TUNNELS AT THE EDGE OF THE FLAPS BOTH HAPTIC TIPS WERE TUCKED INTO SCLERAL TUNNELS AT THE EDGE OF THE FLAPS FIBRIN GLUE WAS USED TO SEAL THE FLAP FIBRIN GLUE WAS USED TO SEAL THE FLAP SCLERAL FLAPSIOL INTRODUCEDHAPTIC GRASPED WITH 23 G MST FORCEPS OPPOSITE HAPTIC SIMILARLY EXTERIORIZED HAPTIC EXTERIORIZEDTUNNEL AT EDGE OF FLAP MADE WITH 26 G NEEDLE HAPTIC TUCKED INTO SCLERAL TUNNEL FIBRIN GLUE APPLIEDFLAPS SEALED ABC DEF GHI

Scleral flaps 180 º apartLeading haptic graspedHaptic exteriorizedTrailing haptic grasped Both haptics exteriorizedScleral tunnel at flap edgeHaptic tucked into tunnelBoth haptics tucked Fibrin glue appliedFlap sealedOpposite flap sealedPost-op day 1: 20/30 A B CD EFGH IJKL

23 FEMALE/ 33 MALE 23 FEMALE/ 33 MALE MEAN AGE = 50.63±18.75 YRS MEAN AGE = 50.63±18.75 YRS PRIMARY PROCEDURE = 69.4% PRIMARY PROCEDURE = 69.4% SECONDARY PROCEDURE = 30.5% SECONDARY PROCEDURE = 30.5% INDICATIONS: INDICATIONS: INTRAOPERATIVE POSTERIOR CAPSULAR RUPTURE WITH ABSENT SULCUS SUPPORT (37.2%) INTRAOPERATIVE POSTERIOR CAPSULAR RUPTURE WITH ABSENT SULCUS SUPPORT (37.2%) APHAKIA (33.8%) APHAKIA (33.8%) SUBLUXATED CATARACT (28.8%) SUBLUXATED CATARACT (28.8%)

MEAN IOP (1 YR POST-OP) = 14.17±3.5mmHg MEAN IOP (1 YR POST-OP) = 14.17±3.5mmHg GRADE II AC CELLULAR REACTION ON DAY 1 GRADE II AC CELLULAR REACTION ON DAY 1 POST-OP PERIOD (RESOLVING WITHIN 48 HRS OF MEDICAL MANAGEMENT) = 3/59 EYES MEAN CMT (1 YEAR POST OP ON STRATUS OCT) = MEAN CMT (1 YEAR POST OP ON STRATUS OCT) = 190.8±5.9MICRONS 190.8±5.9MICRONS IRIDODONESIS = 16.9% IRIDODONESIS = 16.9% CLINICAL PSEUDOPHACODONESIS = 0 CLINICAL PSEUDOPHACODONESIS = 0 ENDOPHTHALMITIS = 0 ENDOPHTHALMITIS = 0 MEAN POST OP SPECULAR COUNT = MEAN POST OP SPECULAR COUNT = 2197 ± 318.7CELLS /MM2. PERCENTAGE LOSS OF ENDOTHELIAL CELLS PERCENTAGE LOSS OF ENDOTHELIAL CELLS (PREOP TO ONE YEAR POST OP) = 5.33±3.5% SCATTER PLOTSCATTER PLOTSCATTER PLOTSCATTER PLOT

ULTRASOUND BIOMICROSCOPY USED ULTRASOUND BIOMICROSCOPY USED LINE WAS DRAWN ALONG LIMBUS AS PLANE OF REFERENCE LINE WAS DRAWN ALONG LIMBUS AS PLANE OF REFERENCE SECOND LINEWAS DRAWN ALONG LONG AXIS OF IOL OPTIC SECOND LINEWAS DRAWN ALONG LONG AXIS OF IOL OPTIC OPTIC WAS CONSIDERED NOT TILTED WHEN REFERENCE LINE ALONG LIMBUS AND IOL OPTIC WERE PARALLEL OPTIC WAS CONSIDERED NOT TILTED WHEN REFERENCE LINE ALONG LIMBUS AND IOL OPTIC WERE PARALLEL ACCORDING TO EQUATION OF STRAIGHT LINE, Y = MX + C, SLOPE OF LINE THROUGH LIMBUS AND IOL WAS DETERMINED ACCORDING TO EQUATION OF STRAIGHT LINE, Y = MX + C, SLOPE OF LINE THROUGH LIMBUS AND IOL WAS DETERMINED SLOPES WERE CALCULATED AS M = (Y2-Y1)/(X2-X1) WHERE (X1, Y1) & (X2, Y2) ARE ANY TWO POINTS ON THE 2 LINES. IF TWO STRAIGHT LINES ARE PARALLEL, THERE SLOPES WILL BE EQUAL; OR THE RATIO WILL BE 1. RATIO BETWEEN SLOPE OF LINE 1 & LINE 2 WAS CALCULATED ABSOLUTE MEAN SLOPE OF LINE (L1) THROUGH LIMBUS = ± 0.09 ABSOLUTE MEAN SLOPE OF LINE (L1) THROUGH LIMBUS = ± 0.09 ABSOLUTE MEAN SLOPE OF LINE (L2) THROUGH IOL OPTIC = ± 0.1 ABSOLUTE MEAN SLOPE OF LINE (L2) THROUGH IOL OPTIC = ± 0.1 MEAN RATIO OF SLOPE = 1.04 ± 0.28 MEAN RATIO OF SLOPE = 1.04 ± 0.28 MEAN DISTANCE B/W IRIS AND IOL = 0.92 ± 0.27MM IN OCT MEAN DISTANCE B/W IRIS AND IOL = 0.92 ± 0.27MM IN OCT

DECENTRATION OF THE GEOMETRIC CENTER OF THE IOL OPTIC (a1) WITH RESPECT TO LIMBUS (a) WAS DETERMINED AS r (MM) MILD DECENTERATION DETECTED IN AN EYE IN EARLY POST OPERATIVE PERIOD SERIAL DIGITAL SLIT LAMP IMAGES OF THE EYE WITH FULL PUPILLARY DILATATION WERE TAKEN TO ASSESS IOLCENTERATION SERIAL DIGITAL SLIT LAMP IMAGES OF THE EYE WITH FULL PUPILLARY DILATATION WERE TAKEN TO ASSESS IOLCENTERATION IMAGE PROCESSING WITH MATLAB VERSION 7.1 (MATHWORKS, INC) WAS DONE TO QUANTIFY DECENTERATION IMAGE PROCESSING WITH MATLAB VERSION 7.1 (MATHWORKS, INC) WAS DONE TO QUANTIFY DECENTERATION GEOMETRIC CENTRE OF THE LIMBUS (a) AND THE IOL OPTIC (a1) WAS DEDUCTED AFTER COMPLETE PUPILLARY DILATATION GEOMETRIC CENTRE OF THE LIMBUS (a) AND THE IOL OPTIC (a1) WAS DEDUCTED AFTER COMPLETE PUPILLARY DILATATION DISTANCE (r) BETWEEN THE TWO GEOMETRIC POINTS WERE CALCULATED IN MM ON EACH VISIT DISTANCE (r) BETWEEN THE TWO GEOMETRIC POINTS WERE CALCULATED IN MM ON EACH VISIT AMOUNT OF DECENTRATION OF THE GEOMETRIC CENTER OF THE IOL OPTIC WITH RESPECT TO THE X-AXIS AND Y-AXIS OF A 2-DIMENSIONAL CARTESIAN SYSTEM (THE CORONAL PLANE) WAS DETERMINED AMOUNT OF DECENTRATION OF THE GEOMETRIC CENTER OF THE IOL OPTIC WITH RESPECT TO THE X-AXIS AND Y-AXIS OF A 2-DIMENSIONAL CARTESIAN SYSTEM (THE CORONAL PLANE) WAS DETERMINED AT LAST FOLLOW UP : MEAN r = 0.08±0.19MM MEAN r = 0.08±0.19MM MEAN X AND Y SHIFT = 0.08±0.19MM AND 0.01±0.05MM MEAN X AND Y SHIFT = 0.08±0.19MM AND 0.01±0.05MMRESPECTIVELY.

ONE YEAR RESULTS OF FIBRIN GLUE ASSISTED POSTERIOR CHAMBER IOL IMPLANTATION SUGGEST GOOD VISUAL OUTCOME WITH MINIMAL COMPLICATIONS IN EYES WITH DEFICIENT CAPSULAR SUPPORT