Surgical technique


Incision opened up to 3.8mm , Using
Monarch injector, Acrysof IOL MA 30 in
first 11 cases subsequently single piece
inserted first . The Hema IOL is inserted
with a holder folder is placed over it. Both
in the bag
Single suture 10/0 Nylon applied
Intraocular Implants using
Bagged Disc Hema with Acrysof
( Alcon) IOL in babies

9 month child
with gradual fall
in vision.
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Side port with
MVR blade,
supporting from the
opposite side
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Diamond knife tunnel
corneal incision .
Care to make a deep
tunnel .
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Rhexis
commenced with
sharp pointed
Utrata forceps
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies
Hydrodissection
with blunt
cannula
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Phaco with high
aspiration ,
occasional pulse
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Fragments aspirated
out carefully . Note
edge of rhexis
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Final fragments
aspirated out.
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Posterior rhexis
with the Utrata
forceps
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Posterior rhexis
completed
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Incision widened to
3.8 mm using a
keratome. Note
width of tunnel
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Acrysof lens
prepared for
injection insertion
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Loading lens in the
Monarch injector
cartridge
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Acrysof lens being
injected into the
posterior chamber
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Note Acrysof lens
going below the
rhexis , into the
bag. Care to be
taken that it does
not snag on the
edge of the
posterior rhexis
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Acrysof lens in
place
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Hema domed
IOL implant . 9.5
mm in diameter,
5.00 mm optics,
periphery very
thin . Note bevel
on edge to permit
easy insertion.
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Lens placed in the
folder to permit
easy holding . The
lens is folded on
itself like a roll in
the folder.
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Hema IOL inserted
into the chamber ,
note its rolled state
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Hema lens opening
up. Care must be
taken to insert the
rim under the iris
edge and under the
rhexis
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Lens is tyre ironed
under the rhexis
rim and gradually
worked into the
position. It goes in
surprisingly easily
due to the edge
bevel
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

Final edge is
slipped in
Intraocular Implants using Bagged Disc
Hema with Acrysof( Alcon) IOL in babies

It’s a very easy
procedure. Both
IOL’s are stable.
Thanks to the
beveled edge of the
IOL, insertion
under the rhexis is
easy.
Unilateral or
bilateral cataract
Children
16
Number
Unilateral
5
Percentage
Number
Bilateral
Percenta
ge
31.25%
11
68.75%
Age at Implantation
Age at
Implantation
2 months
Number
Males
Females
5
4
1
3 months
3
1
2
5 months
4
3
1
7 months
5
3
2
8 months
5
1
4
10 months
3
3
0
13 months
1
0
1
15 months
1
1
0
TOTAL
27
16
11
Age at Explantation of the Hema IOL
Age at Hema
Explantation
Number
%
18 months
3
11.1
22 months
4
14.8
25 months
6
22.2
28 months
14
51.9
Total
27
100
Residual ametropia after removal of Hema
IOL
Residual ametropia
No
%
+/- 0.50
3
4
6
0
3
5
4
1
3
1
1
9.7
12.9
19.4
00.0
9.7
16.1
12.9
3.2
9.7
3.2
3.2
+/- 1.00
+/- 1.50
+/- 2.00
+/- 2.50
+/- 3.00
+/- 3.50
+/- 4.00
+/- 4.50
- 5.50
- 7.00
Complications n =27
Complications
Number
Percentage
Corneal abrasion
2
7.4
Shallow A/C
9
33.3
Iritis
6
22.2
Hema IOL Pupil
capture
Raised IOP : Temporary
2
7.4
7
25.9
Raised IOP : Needed
Surgery
Hyphema
3
11.1
5
18.5
Criteria for selection of IOL



Under anesthesia, measure corneal curvature with
auto keratometer on table. Take axial length
reading with A- Scan , using SRK –T formula ,
calculate IOL power.
Extrapolate to age of two years based on reading (
a baby at 3 months , with an IOL power of 28 –30
D will be 23 D at 2 years).
Place the anticipated IOL power as Acrysof in
the bag first, place the residue as Hema over it.
Choice of Location
1.
2.
3.
Primary posterior chamber IOL's have been placed
in the bag and in the sulcus with good success.
Secondary posterior chamber IOL's may be placed
in the sulcus if the residual capsular leaflets offer
sufficient support for the IOL. Some dissection may
be necessary to recreate the sulcus in these cases.
Sutured posterior chamber IOL's have been used if
capsular support is inadequate, but the long-term
safety of these lenses is uncertain
Why No A/C IOL in a child
A/C IOL's are to be avoided at all costs because of
 intense postoperative inflammatory reaction,
 risk of angle fibrosis and glaucoma,
 corneal decomposition,
 changing dimensions of the angle in the growing
child.
If a secondary IOL is sought with no capsular
support, an PC IOL's should and must be
sutured in place.

Criteria for removal of IOL
When anticipated IOL refraction reaches –4.00 ,
remove IOL. Example. Baby placed IOL at 3
months of 31 D , 23.00D as Acrysof , + 6 D as
Hema ( under correcting by 20%). Will reach –
4.00 at age of 18 months when IOL removed.
 We use the rule of 4 as a variation of 4 dioptres
from emetropia rarely induces significant
amblyopia. *
* ( Isenberg S. Torczynski E:Mosby 2nd Ed 36-50 Eye in Infancy 1994 )

Summary



The Hema domed IOL gives a format which is easy
to insert, stable in the eye, very quiet in the eye &
induces no adhesions .
It is easy to insert via 3.4 mm incision and just as
easy to remove without cutting or splitting it.
The concept of multiple IOL with phased removal is
a concept which is feasible thus giving the best hope
for controlling deprivation amblyopia in infants
.