June 2010




Advanced cataract surgery routinely performed

by Parag A. Majmudar, M.D.

Parag Majmudar, M.D. (far right), poses with several colleagues at the IIRSI meeting

Although I had known for some time that the state of cataract and refractive surgery in India was advanced, I really had no idea until I was able to witness firsthand the complexity of surgeries being performed on a routine basis. Prior to attending a conference organized by the Intraocular Implant and Refractive Society of India (IIRSI) and Amar Agarwal, M.D., Agar, India, I had the opportunity to visit one of Dr. Agarwal’s eye hospitals in Chennai, India. The eye center was where the first micro-phakonit cataract removed through a sub-1 mm incision was performed.

Drs. Amar and Athiya Agarwal, a husband and wife team of ophthalmologists, are the third generation of ophthalmologists in their family and have developed the “Dr. Agarwal’s Group of Eye Hospitals.” Although the majority of their centers are based in Chennai (formerly known as Madras) in the southern part of India, some of the centers stretch as far as Jaipur in the north and even to Mauritius, a small island off the coast of Madagascar. At the eye center, one of the advanced surgeries I witnessed was a novel method of scleral IOL fixation, without sutures, using biologic tissue adhesive. Appropriately nicknamed the “glued IOL,” Dr. Agarwal’s center has had more than two years of follow-up in over 350 cases with outstanding results. Dr. Agarwal developed this technique for cases where there isn’t any kind of capsular support for a lens implant. The technique is such that he can take a three-piece PMMA lens and use the haptics, externalize them, and tuck them into a little scleral pocket, which he makes. Then he uses tissue glue to secure the scleral flap down so there is adhesion of the flap. The alternative in the U.S. right now for that kind of situation is to either suture the lens to the scleral wall or suture it to the iris. Both of those depend on sutures, and if the suture erodes or breaks you could potentially have a dislocation of the IOL. In the “glued IOL” technique, I was struck by how stable the IOL is within the eye, as compared to the relative pseudophakodonesis seen after suture fixation either to the scleral wall or to the iris. I think there may be surgeons in the U.S. who are starting to do that procedure. I don’t think there are any regulatory issues; most surgeons are able to do it anytime but it’s a question of knowing about it and being familiar with it. It’s something that I would potentially try myself if I came across a situation where I had to fixate a lens and I didn’t have any other good way of doing it. Dr. Agarwal has modified a Bausch & Lomb (Rochester, N.Y.) phaco unit to have what’s called an air pump so that it actually prevents surge. As a result, he’s getting more stable anterior chambers. As I mentioned earlier, Dr. Agarwal is also performing micro-phakonit surgery where he’s basically using a 1-mm handpiece probe and a 700-micron incision. In the U.S., we’re typically using 2- to 3-mm incisions in most cataract surgeries.

In addition to my visit to Dr. Agarwal’s eye center, I also attended an international symposium titled Advanced Course in Cataract and Refractive Surgery in Agra. Amid the backdrop of the majestic Taj Mahal, the IIRSI in partnership with Jaypee Brothers Publishers (New Delhi, India) brought together renowned experts in the field of cataract and refractive surgery from across India as well as an internationally recognized faculty from the U.S., Mexico, Germany, Switzerland, and the United Kingdom. It was my distinct honor and privilege to have been invited to visit India to participate in this event.

A number of presentations at the conference described the experience of several surgeons using Dr. Agarwal’s glued IOL procedure. Among the other topics discussed at the meeting were optimizing outcomes in cataract surgery, management of small pupils and loose zonules, micro-incisional cataract surgery (MICS), as well as complicated and challenging cataract cases. Refractive surgery topics included an analysis of available femtosecond laser technology, advanced surface ablation, updates on anterior lamellar keratoplasty, and LASIK complications. In addition, surgical procedures including glued IOL, MICS with a 700-micron incision, and femtosecond assisted LASIK and Intacs (Addition Technology, Des Plaines, Ill.) were broadcast live via satellite from Chennai.

A personal highlight for me was a keynote lecture by Richard Packard, M.D., London, titled Phacoemulsification Through the Ages. Much of the content came directly from the personal experience of Dr. Packard, one of the original pioneers in phacoemulsification, and it was truly an honor to interact with one of the giants in ophthalmology.


Dr. Majumudar is associate professor of ophthalmology at Rush Medical Center, Chicago. He can be reached at 847-275-6174 or pamajmudar@yahoo.com.

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