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Drake, in your case I would first create the scleral flaps and a scleral tunnel. Then fix an AC maintainer. Make the 20 g sclerotomies 1 mm from the limbus. Check the white to white. This could be large eye in which case go for a vertical glued IOL if possible. Explanted the entire existing IOL bag complex and implant a three piece non foldable IOL as they are 13.5 mm. Foldables a 13 mm. You could do the eating of the rings etc but sometimes they are tough and can fall down so explanation of the entire bag is better. All the best and keep me updated how the case went. Amar agarwal

My patient's 3 piece Iol is encased in a large sommering's ring and subluxed severely inferiorly. He has no vitreous and is s/p RD repair with a buckle. Should I try and eat away sommering's ring with the vitrector to get to the haptics or will I just make a mess and wish I would have taken the whole thing out in one piece? I have done a couple glued already. Should be easier with the hand shake technique.

Prof Agarwal - The sclerotomy created with a 20 gauge needle or MVR blade is very small and typically much smaller than the sclerotomy created by a punch during trabeculectomy. Therefore, by suturing the scleral flap tightly there is no aqueous leakage underneath the flap, no bleb formation, and therefore no risk of late bleb-associated endophthalmitis. In the absence of aqueous flow and without application of mitomycin C as in a standard trabeculectomy, fibrosis occurs underneath the scleral flap, thereby encasing the haptic in scar tissue. I agree that fibrin glue would accelerate the process and is a faster technique; however, in the United States sutures are cheaper. I've only performed three of these cases, none have resulted in a bleb over the scleral flaps. I again applaud you for popularizing this creative technique. I predict it will replace traditional scleral fixation of PCIOLs as well as iris-fixation of PCIOLs. Respectfully, H. George Tanaka, MD

R Rahim, The glued IOL technique can be done with any three piece foldable or three piece non foldable IOL. Advantage is that the haptics cannot break in such cases. it can also be done using a single piece non foldable IOL. only thing in such IOL's one should be careful as the optic haptic junction can break. The technique cannot be done in a single piece foldable IOL as we need something firm in the haptic to tuck which is not there in such IOL's. If a subluxated single piece foldable IOL is there we explant it and replace and glue in a three piece IOL. Other types of IOLs like three piece we just fix the same IOL back with the glued IOL technique rather than explanting the IOL. Amar Agarwal

any proceedural variations regarding foldable\single piece lens in the same situation, r.rahim

reembasheer and Kouros- do contact for baxter the Indian contacts given below. They might get for you or help you get your country's contact for the glue. BAXTER DETAILS ARE AS FOLLOWS AREA MANAGER: Mr Thangamalai Baxter( INDIA) Pvt. Ltd. 17A, Sambasivam street, T-Nagar, Chennai-600017 Tel: +91 44 2815 8061/62/63 Fax: +91 44 4212 1662 Mobile: 91 900 301 6656 Email: thangam_malai@yahoo.co.in DEALER OF BAXTER: Mr Ramakrishnan Mobile: 91 9841003876 Office: 044 22350667 SALES EXCECUTIVE: Mr Dominic Mobile: 91 9444216322 Amar Agarwal

reembasheer and Kouros- The fibrin glue can be got from reliance life sciences reliseal. The cell no in India is + 91 9898030029. One can also get from baxter international. The trade name is tiessel. Do check in your country or in the baxter website. Amar Agarwal

ghtanaka - The fibrin glue is necessary as if you suture the flap you have effectively created a trabeculectomy opening. Also there is a connection from inside to outside whereas the glue firmly seals all. The opening if there can lead to an endophthalmitis later in life even if the patient develops conjunctivitis. The glue also helps firmly fix the haptic in place so that the haptic is stuck between two layers of sclera. Amar Agarwal

beej_eyemd- for a secondary IOL implantation one need not change the power of the PC IOL as you are implanting the IOL in the same area where the normal IOL is placed. If one wants they can reduce the power by 1/2 D also, as in some cases you might implant the IOl in such a way that it might be slightly anterior than a normal PC IOL. Amar Agarwal Amar Agarwal

O Makhzoum- The glued IOL technique will work with any three piece foldable or non foldable IOL. it will not work with a single piece foldable IOL as we need some firm haptic to tuck and glue. In a single piece foldable IOL the haptic is too pliable and so cannot be used. Amar agarwal

Dr.Suter, The IOL haptic is tucked intrasclerally and the fibrin glue applied. See to it that enough haptic is externalised so make the sclerotomy 1 mm from the limbus. Use a 13.5 mm or 13 mm IOL if the white to white length of the eye is big. Amar Agarwal

excellent Dr.Agarwal,any idea from wich company in Greece can we supply fibrin glue?

This is great technique. However it may not work with other types of IOLs. Do you have any suggestions to deal with subluxated IOL like the superflex Rayner lens for example?

I like this idea but can any one tell me how I can get fibrin glue in Egypt?

Is the fibrin glue really necessary? I know it saves time, but why not just suture the scleral flaps down with 10-0 nylon suture and close the conjunctiva with Vicryl wing sutures?

how do you correct IOL power if this is to be done as a secondary IOL implantation?

The IOL haptic is firmly in place in the scleral tunnel, no chance of unwinding or slipping out.

What stops the haptics from unwinding out of their new tunnels allowing lens drop?