QuizWise 4

1. Pupillary dilatation can be achieved by which of the following –  
   1. Iris hooks 
   2. B- Hex ring 
   3. Malyugin ring 
   4. All of the above 
2. Which of the following  does not  cause late subluxation of in the bag IOL  – 
   1. Zonular dehiscence 
   2. Hypermetropia 
   3. Contraction of capsular bag 
   4. Trauma 
   5. Pseudoexfoliation 

3. The following are the risk factors for pseudoexfoliation syndrome except – 
   1. Age 
   2. Exposure to UV lights 
   3. Southern latitudes 
   4. Higher altitudes 

4. Identify the ring :
   
   1. Modified Morcher ring
   2. Ahmed capsular tension ring 
   3. Hendersons ring 
   4. Cionni ring 

5. The surgical options for the treatment of IOL- bag complex subluxation include 
   1. IOL explantation with pars plana vitrectomy, leaving the eye aphakic 
   2. IOL explantation with pars plana vitrectomy, secondary IOL implantation 
   3. Repositioning the dislocated IOL and fixing it to sclera 
   4. All of the above 

1. Answer – 4 : All of the above 

There is a wide range of options to manage the small pupil, including pharmacological treatment, mechanical stretching or dilation with iris hooks or pupil expanders. As a rule, all pupil expanders should be used with the anterior chamber filled with OVD to protect the corneal endothelium. One of the most popular pupil expander is the Malyugin ring. 

Reference – Grzybowski A, Kanclerz P. Methods for achieving adequate pupil size in cataract surgery. Current opinion in ophthalmology. 2020 Jan 1;31(1):33-42. doi: 10.1097/ICU.0000000000000634.

2.  Answer – 2 : Hypermetropia 

Zonular dehiscence often develops slowly over a long postoperative period because surgeons rarely report intraoperative phacodonesis. Zonules become more friable as patients age, especially in eyes with pseudoexfoliation. 

Contraction of the capsular  bag may be present to some degree after cataract surgery. It happens as early as three months following phacoemulsification, but in the presence of solid zonule support does not lead to significant IOL displacement. When capsular shrinkage is extreme, it is called “capsular contraction syndrome.” Such contraction results in additional stress on the potentially weakened zonules. 

Preoperative or surgical trauma might be a cause of luxation

Reference – Ascaso FJ, Huerva V, Grzybowski A. Epidemiology, etiology, and prevention of late IOL-capsular bag complex dislocation: review of the literature. Journal of ophthalmology. 2015;2015. https://doi.org/10.1155/2015/805706

3. Answer – 3 : Southern latitude 

Pseudoexfoliation syndrome occurs in all areas of the world. Researchers have been able to identify pseudoexfoliation as the cause of more than 50 percent of the cases of open-angle glaucoma in Scandinavian countries. In addition, some studies report a higher prevalence among women than men. Another major risk factor is age, as pseudoexfoliation syndrome rarely occurs in individuals under the age of 50. Other risk factors associated with this disorder include living at higher altitudes or in northern latitudes, and disproportionately high exposure to ultraviolet light.

Reference – Plateroti P, Plateroti AM, Abdolrahimzadeh S, Scuderi G. Pseudoexfoliation syndrome and pseudoexfoliation glaucoma: a review of the literature with updates on surgical management. Journal of ophthalmology. 2015;2015. doi: 10.1155/2015/370371

4. Answer – 3 : Hendersons Ring 

Henderson capsule tension ring (HCTR, Morcher), is an open C-shaped loop made of polymethylmethacrylate. It has 8 equally spaced indentations of 0.15 mm to improve the ease of removing nuclear and cortical material while maintaining equal expansion of the capsular bag.

Reference – Henderson BA, Kim JY. Modified capsular tension ring for cortical removal after implantation. Journal of Cataract & Refractive Surgery. 2007 Oct 1;33(10):1688-90 https://doi.org/10.1016/j.jcrs.2007.05.041

5. Answer – 4 : All of the above

Various surgical interventions in the management of subluxated in-the-bag IOLs have been introduced such as repositioning the dislocated IOL and fixating it to the sclera, or externalizing and exchanging the IOL. 

Reference – Gunenc U, Kocak N, Ozturk AT, Arikan G. Surgical management of spontaneous in-the-bag intraocular lens and capsular tension ring complex dislocation. Indian journal of ophthalmology. 2014 Aug;62(8):876. doi: 10.4103/0301-4738.116451