Challenges of Pediatric Cataract Surgery in a Case of Seasonal Hyperacute Panuveitis (SHAPU)

A four-year-old female child diagnosed as a case of severe Seasonal Hyperacute Panuveitis (SHAPU) underwent lens-sparing core vitrectomy in her left eye with intravitreal antibiotic and steroid. Patient responded well to treatment and intraocular inflammation subsided. However, three months later, she developed vision impairing dense cataract which also made posterior segment assessment difficult. Lens aspiration with primary posterior capsulotomy and anterior vitrectomy with intraocular lens (IOL) implantation was performed. However, four weeks later, the patient developed occlusio pupillae with iris bombe. She did not respond to medical management so synechiolysis with surgical iridectomy was performed after which a normal depth anterior chamber was attained. Synechia and iris bombe were also relieved, and vision was regained.

OPTICAL NEUROPATHY: ANTIGLAUCOMATOUS TREATMENTS OFFERED BY THE UNIQUE HEALTH SYSTEM IN BRAZIL, AN ANALYSIS OF THE LAST DECADE

Introduction: Optical neuropathy with progressive loss of visual field, glaucoma represents the main cause of irreversible blindness. Objectives: To analyze the frequency of antiglaucomatous procedures performed by the Unified Health System (SUS), in the last 10 years, requiring hospitalization and outpatient care. Methods: This is a cross-sectional quantitative retrospective study, carried out through consultations and data analysis of antiglaucomatous procedures in the DATASUS system, between January 2010 and December 2019. Results: In Brazil, trabeculectomy was the most performed procedure in the last 10 years. Outpatient care had an average of 10,661 per year, on the other hand, the need for hospitalization increased by 70%. The second procedure that generated the most hospitalizations was the implantation of an anti-glaucomatous prosthesis, which doubled in the corresponding period. Cyclodialysis was the least used procedure in the 10 years of analysis, both on an outpatient and hospital basis, and is reserved for the final stages of glaucoma. Surgical iridectomy, used for acute treatment, showed a reduction, in 2019 it represented less than a third compared to 2010. As for outpatient procedures using lasers, such as phototrabeculoplasty and iridotomy, they showed significant growth. Conclusion: Trabeculectomy is considered the gold standard, justifying its greater frequency, both on an outpatient and hospital basis. Procedures using laser are expanding, trabeculoplasty as an alternative to primary therapy, and iridotomy for greater safety in acute treatment. As the population ages, glaucoma tends to be increasingly prevalent, contributing to the progressive increase in trabeculectomies.

Anterior 360° Synechiolysis in a Case of Late Iridocorneal Adhesions after 25-G Vitrectomy: Surgical and Physiopathogenetic Aspects

We describe the case of an 86-year-old patient, pseudophakic in both eyes and with high myopia, who had previously had a 25-G vitrectomy with 20% C3F8 used as a tamponade due to a total retinal detachment with choroidal hemorrhages and macular hole. At the postoperative 4-month follow-up, we found 360° iridocorneal synechiae with elevated intraocular pressure due to angle closure in all sectors, with an adherent retina and in the absence of choroidal hemorrhage/detachment and of corneal edema or endothelial damage. The patient was, therefore, hospitalized to receive 360° anterior synechiolysis with a single opening to the corneal limbus, like in paracentesis, with topical anesthesia. We have tried to study the possible causes of this case history. However, it should be recognized that the development of iridocorneal synechiae and the rise of intraocular pressure can be a possible complication of air/C3F8 vitrectomy, which cannot be managed with medical therapy. It will be essential to monitor the situation and to hospitalize the patient for surgical synechiolysis to restore the normal anatomy and physiology and to correct the ocular hypertension. During the vitrectomy, we will have to introduce in advance an adequate amount of viscoelastic material in the anterior chamber and to perform a preventive surgical iridectomy, even if the iridocorneal angle is open in all sectors.

Microincision, Aspiration Cutter-Assisted Multifocal Iris Biopsy for Melanoma

Purpose To describe a minimally invasive method to create multifocal full-thickness surgical iridectomy biopsies. Methods Seven patients suspected to have diffuse iris melanoma underwent multifocal surgical iridectomy biopsy through a single 1.0-mm clear corneal incision. A 25-G inked trocar was used to create one visible corneal portal, through which the anterior chamber was filled with sodium hyaluronate 1%. Then, a 25-G aspiration cutter probe was introduced through the corneal incision such that the aspiration portal was occluded by the iris biopsy sites. Then aspiration (600 mm Hg) cutting (300 cuts per minute) was used to create full- and partial-thickness surgical iridectomy biopsies at multiple locations. After each biopsy the probe was removed, and its contents aspirated into a separate 3-mL syringe (marked by clock hour location). The sodium hyaluronate 1% was removed and wound checked for leakage. Results Diagnostic specimens were obtained in all cases. Five were found to be diffuse iris melanomas and 2 were indeterminate iris melanocytic proliferations. No patients developed a secondary increase in intraocular pressure, hyphema, infection, cataract, or vision loss. No cases of intraocular tumor dissemination were observed. No patient complained of glare or monocular diplopia. Three of 7 corneal wounds were self-sealing. Conclusions Multifocal surgical iridectomy biopsy can be minimally invasive and effective allowing for partial- and full-thickness iris biopsy. Use of a 25-G aspiration cutting probe allowed for small incision surgery, rapid rehabilitation, and no significant complications.

Repeated pupillary capture and pigmentary glaucoma after implantation of reversed three-piece sulcus intraocular lens

A 58-year-old man underwent phacoemulsification, anterior vitrectomy, and areversed three-piece intraocular lens placement in the sulcus. He developed pseudophakic pupillaryblock with optic capture of the intraocular lens four months later and underwent intraocularlens repositioning combined with surgical iridectomy. After 18 months, he had elevated intraocularpressure that was thought to be secondary to complicated cataract surgery, and he wasprescribed topical glaucoma medications. He had poor adherence and follow-up attendance.After another six months, he presented to the Baylor College of Medicine, Houston, USA, withan intraocular pressure of 30 mmHg and advanced pigmentary glaucoma. The intraocular lensoptic was captured by the pupil after dilation. A trabeculectomy and intraocular lens exchangewas performed. Reversed intraocular lens in the sulcus may present as repeated intraocular lenspupillary capture and result in the development of pigmentary glaucoma.