Couching of Intra-ocular lens in microphthalmic eyes with irido-fundal coloboma - Revisiting the historical technique

Couching of Intra-ocular lens in microphthalmic eyes with irido-fundal coloboma - Revisiting the historical technique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Couching of Intra-ocular lens in microphthalmic eyes with irido-fundal coloboma - Revisiting the historical technique Naresh Babu Kannan, Ananya Goswami, Muthukrishnan Vallinayagam, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3453663/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose : Cataract surgery in microphthalmic eyes is challenging due to anatomical restraints, hard bulky nucleus. This series aims to evaluate the safety and efficacy of couching of intraocular lens in irido-fundal coloboma with microphthalmos. Setting: Tertiary care centre in South India Design: Retrospective non-comparative study in eyes with irido-fundal coloboma, corneal diameter <7mm and brown cataract. Visual acuity less than 6/60 in other eye. Methods: Anterior chamber entry made, zonules broken and lens dislocated into the vitreous cavity in a controlled manner. Baseline Clinico-demographic details, corrected distance visual acuity (CDVA), Intra-ocular pressure (IOP), corneal diameter, axial length, lens status and post-surgery CDVA, IOP and complications recorded and followed up for atleast 6 months. Results: 15 eyes of 15 subjects were evaluated with a mean age 49.4 ±10.9 years. At baseline, mean IOP 14.5 ± 3.8 mmHg, mean axial length 19.3 ± 0.5 mm, mean corneal diameter was 6.5 ± 0.34 mm and CDVA 2 logMAR which improved to 1.5 logMAR at 3 months (p value 0.002). Transient spike in IOP in 33.3% subjects was medically managed with no significant difference in IOP (p > 0.05) at baseline (14.5 ± 3.8 mmHg), 3 months post-surgery (16±2.8 mmHg) and 6 months post-surgery (14.9 ± 2.5 mmHg). One patient underwent re-couching. No other major complications were noted. Conclusion: Couching of Intra-ocular lens is an effective and safe method in microphthalmic eyes with irido-fundal coloboma with an ambulatory gain of visual acuity in previously non-ambulatory subjects. Corneal measurements help in determining the subset of patients where couching offers viable option. Couching Microcornea Irido-fundal coloboma Surgical technique Figures Figure 1 Introduction Subjects with iridofundal coloboma develop cataract which is usually advanced compared with age-matched subjects with senile cataract.[ 1 ] In addition, they are often associated with microphthalmos (defined as axial length < 95th percentile adjusted for age). Anatomical restraints pose difficulty in cataract surgery through anterior approach (sclerocorneal tunnel, relatively shallow anterior chamber) as well as posterior approach (instrument manoeuvring) with high rate of corneal complications and surgical aphakia. [ 2 , 3 ] Couching is the only feasible approach to circumvent the afore-mentioned challenges posed in microphthalmic eyes with coloboma. There is no available literature regarding couching of intraocular lens in iridofundal coloboma with microphthalmos to the best of our knowledge. Methodology This is a retrospective study conducted at a tertiary care centre in South India and the study adhered to the tenets of the Declaration of Helsinki. Computer-based record search was done to identify all patients who had undergone couching from June 2021 to December 2022. The study included all patients presenting with iridofundal coloboma associated with microphthalmos and brown/mature cataract who underwent couching of the intraocular lens (done by single surgeon) and followed up for at least 6 months post-surgery. All subjects included in the study had coloboma involving disc and macula documented on ultrasonography (Fig. 1 a). Subjects with visual acuity > 6/60 in other eye, retinal/choroidal detachment on B scan ultrasonography, and uncontrolled Intraocular Pressure (IOP) were excluded from the study. Data recorded included age, gender, baseline visual acuity in both eyes, IOP, corneal diameter (white-to-white), axial length, lens status in both eyes, post-surgery visual outcome, post-operative IOP and complications. All patients were followed up for a duration of atleast 3 months to evaluate the change in outcome. Corrected Distance Visual Acuity (CDVA) was recorded in LogMAR scale, IOP measured using I-care tonometer, corneal diameter measured using IOL Master 700 and confirmed intraoperatively. Axial length was measured using ultrasonography away from the colobomatous area. Axial length measurement was done by locating the patient’s preferred fixation point and taking an average of the 10 most accurate axial length readings. Ultrasound B-scan was done to document posterior segment of both eyes in all patients. Surgical Procedure All subjects underwent surgery under strict asepsis using a uniform surgical technique done by single surgeon under peribulbar local anaesthesia. The perilimbal areas were tapped using blunt end of iris repositor to agitate and loosen the zonules. A side port entry was made into the Anterior Chamber (AC) and AC formed with Ophthalmic Viscosurgical Devices (OVD). A spatula was introduced into AC and zonules broken all around. Lens is then dislocated into the vitreous cavity in a controlled manner. AC is then washed and formed. At the end surgery, Ofloxacin 0.3% eye ointment was instilled into the conjunctival cul-de-sac. Post-operatively all patients were prescribed a topical combination therapy of antibiotics (Moxifloxacin 0.5%) and steroid (prednisolone acetate suspension 1%) in tapering doses for a period of 6 weeks. Postoperatively, CDVA and intraocular pressure (I-care) are measured at each follow up visit. Slit lamp examination was performed at each follow-up to look for corneal clarity, anterior chamber integrity and lens status. In addition, all patients underwent dilated fundus evaluation including evaluation of retinal periphery and documentation of b-scan ultrasonography (Fig. 1 b). Postoperative complications if detected was treated accordingly. Statistical analysis Data were analysed using SPSS (version 20.0, International Business Machines Corp.). Visual acuity was converted from Snellen letters to logarithm of minimum angle of resolution (logMAR) for analysis. Data normality was checked using histograms. Continuous and categorical variables were described using mean (+- standard deviation) or median (with range) and frequency (percentage) respectively. Comparison of variables was done using t test for parametric data and Wilcoxon signed rank test for nonparametric data. 2-tailed p value of less than 0.05 was considered statistically significant. Results In this study, 15 eyes of 15 subjects underwent couching of intraocular lens. The mean age of the study population was 49.4 ± 10.9 years (median 47 years; range 35–69 years). 12 subjects were males (80%) and 3 were females (20%). The demographic profile and clinical presentation of the study subjects is summarised below in Table 1 . Table 1 Demographic profile and clinical presentation of the study subjects S.no. Age (years) Gender Preop CDVA (logMAR) Intraocular Pressure (mmHg) Grade of cataract White to white (in mm) Axial length (in mm) Other eye status Other eye CDVA (logMAR) 1 46 F 2.0 8 Mature 6.8 20.1 Mature cataract 2 2 47 M 2.0 11 Mature 6.3 19.8 Closed funnel RD 2.5 3 43 M 2.0 14 Mature 6.4 20.2 Closed funnel RD 2.5 4 47 M 2.5 14 Brown 6.6 19.5 Phthisis bulbi NLP 5 45 M 1.9 18 Mature 6.5 19.6 Mature cataract 2.5 6 69 F 2.5 11 Brown 5.9 18.4 Subluxated lens 2.5 7 59 M 2.0 16 Mature 6.9 19.8 Phthisis bulbi 2.5 8 50 M 2.0 20 Brown 6.3 19.6 Phthisis bulbi 2.5 9 61 F 2.0 20 Brown 5.8 18.8 Phthisis bulbi 2.5 10 64 M 1.5 12 Brown 6.8 19.5 Phthisis bulbi NLP 11 50 M 2.0 20 Brown 6.7 19.4 Mature cataract 2.5 12 35 M 1.8 13 Brown 6.8 19.5 Phthisis bulbi 2.5 13 26 M 1.9 12 Brown 6.8 19.2 Phthisis bulbi NLP 14 58 M 2.5 15 Brown 6.7 18.8 Brown cataract 2 15 41 M 2.5 14 Brown 6.5 18.6 Phthisis bulbi NLP Preoperatively, B scan in all patients revealed coloboma involving disc and macula which was confirmed intraoperatively. The fellow eye had phthisis bulbi in 8 cases, old RD in 2 cases, mature cataract in 5 cases. The fellow eye in 5 cases had visual acuity reduced to absent perception of light. At baseline, median corrected distance visual acuity (CDVA) was 2 [range 1.5 to 2.5] logMAR (Snellen equivalent HMCF), mean IOP was 14.5 ± 3.8 mmHg, mean axial length was 19.3 ± 0.5 mm and mean corneal diameter was 6.5 ± 0.34 mm. At postoperative period of 3 months, there was an improvement in CDVA from baseline (median 2 [range 1.5 to 2.5]) to 1.5 [range 1.0 to 2.0] logMAR which was statistically significant (p value 0.002). The same CDVA was maintained at 6months. A transient rise in intraocular pressure (IOP) at 15 days post-surgery was noted in 5 patients. The mean IOP at 15 days, 3 months post-surgery and 6 months post-surgery were 19.5 ± 5.9mmHg, 16 ± 2.8mmHg and 14.9 ± 2.5 mmHg respectively. Mean change in IOP from pre-op to 15 days post-surgery was statistically significant (p = 0.001). Topical Anti-glaucoma medications (AGM) were initiated and IOP was well controlled on AGM (3 months post-surgery). There was no significant difference in IOP at baseline and at 3 and 6 months post-surgery (p > 0.05). The post-surgery CDVA and IOP are summarised in Table 2 . One patient had to undergo re-couching. No other major complications were noted. Table 2 Comparison of Pre and Post-surgery CDVA and IOP S.no. Pre-operative CDVA (logMAR) Post-operative 3months CDVA (logMAR) IOP Pre-operative (mmHg) IOP Post operative day 15 (mmHg) IOP Post operative 3months (mmHg) IOP Post operative 6months (mmHg) 1 2.0 1.5 8 10 11 12 2 2.0 1.8 11 18 16 18 3 2.0 2.0 14 26 20 18 4 2.5 2.0 14 15 14 12 5 1.9 1.1 18 18 12 13 6 2.5 1.9 11 19 18 12 7 2.0 1.0 16 16 14 14 8 2.0 2.0 20 22 18 20 9 2.0 1.5 20 10 15 12 10 1.5 1.3 12 28 19 16 11 2.0 1.3 20 18 15 14 12 1.8 1.1 13 30 21 16 13 1.9 1.8 12 28 18 15 14 2.5 2.0 15 17 13 18 15 2.5 1.5 14 18 16 14 Discussion Irido-fundal coloboma involving the macula is frequently associated with poor visual acuity and poor fixation along with nystagmus. They are often microphthalmic (the age adjusted axial diameter is < 95th percentile, < 18.5 mm in adult).[ 4 ] These eyes have been associated with early onset nuclear sclerosis as compared to age matched controls. The presence of microcornea (corneal diameter < 2 SD below normal population range or < 11 mm horizontally) [ 5 ], non-dilating pupils, absence of zonules, lens coloboma and other structural anomalies make cataract surgery more challenging with a corresponding rise in operative complications. (19.5% by Phylactou et al, 30.7% by Chaurasia et al.) [ 6 , 7 ] Cataract extraction in these eyes is difficult due to anatomical restraints in creating corneoscleral tunnel in Small Incision Cataract Surgery (SICS) or Extracapsular Cataract Extraction (ECCE).[ 2 ] There is risk of severe damage to corneal endothelium from the use of excessive ultrasound energy in relatively shallow anterior chamber during phacoemulsification.[ 2 ] Creating sclerotomies for performing pars plana lensectomy in microphthalmic eyes has additional risk of retinal dialysis due to anterior placement of sclerotomies and difficult surgical manoeuvring. In eyes with very severe microcornea (< 6.5mm), crowding of instrument is a major challenge.[ 3 ] The limited anterior chamber space combined with hard bulky nucleus poses a great challenge to the operating surgeon. The word “couching” derives from the French verb “coucher,” which means “to put to bed”. It is one of the oldest surgical procedures to be performed in history. The procedure was first described in “Sushruta Samhita” by Sushruta and later adopted by the Greeks, Romans as well as Egyptians, Arabs and Europeans.[ 8 ] Couching is an ancient technique typically performed on mature cataracts for ambulatory visual rehabilitation. The technique involves use of a thorn or needle, to pierce the eye at the limbus. The opaque lens is then dislocated from the central visual axis and pushed down into the vitreous cavity, producing an instantaneous improvement in vision. [ 8 , 9 ] However, couching has been relevant in history when management of complications were not feasible. Lately, they are being practiced and rightfully discredited in sub-saharan contries. [ 10 ] In all these studies, surgeries have been performed by non-ophthalmologists and traditional healers without proper sterile precautions and required post-operative management of complications. Kohli et al [ 2 ] recommended phacoemulsification for softer cataracts with corneal diameter more than 8 mm. M-SICS was preferred for smaller corneas with hard nuclear cataracts. Khokhar et al [ 11 ] described a modified technique of sclero‑corneal tunnel for phacoemulsification in coloboma and hard cataract. No IOL implantation in 3 out of 8 patients with corneal diameter < 7 mm. 4 of the 8 eyes (including 2 with microcornea) had significant corneal edema in the early postoperative period. In a study by Sahay et al [ 12 ], 29/39 (74.4%) cases who underwent cataract surgery had corneal diameter < 9.0 mm. IOL was not implanted in 30.8% cases and 2 cases had persistent corneal edema subsequently requiring endothelial keratoplasty. Khokhar S et al [ 13 ] in a retrospective study of 22 eyes reported favourable outcomes following phacoemulsification with IOL in patients with coloboma. However, only 6 eyes had severe microcornea out of which 3 were left aphakic. Postoperative corneal edema was noted in 18%. Chaurasia et al [ 6 ] reported outcomes of cataract surgery in 26 eyes with coloboma. 5 out of 26 eyes had coloboma involving disc and macula with microcornea and hard cataract. They were managed with ECCE/ICCE without IOL. 4 patients had posterior capsular rupture (PCR) due to radial extension of capsulorhexis while prolapsing the hard nucleus out of the capsular bag. None of the patients had severe microcornea. The corneoscleral approach in small cornea and hard cataracts are associated with complications mainly attributed to anatomical restraints. These microphthalmic eyes are fraught with untoward consequences including corneal edema, Descemet’s membrane detachment, PCR and surgical aphakia. Although cases of microcornea have been included in the above-mentioned studies, no specific emphasis has been made regarding management and outcome of severe microcornea with hard cataract through anterior approach. Posterior approach has been described by Sen et al [ 3 ] where they performed pars plana lensectomy in brown cataract with severe microcornea (mean corneal diameter 6.7+/-0.64 mm, range 4–8 mm) and chorio‑retinal coloboma. All eyes underwent pars plana vitrectomy (20G in 7 eyes and 23G in 23 eyes) with pars plana lensectomy and were left aphakic. There was gain of ambulatory vision in the post-operative period. However, there was crowding of instruments and closely placed sclerotomy ports due to small corneal diameter. They also reported difficulty due to displacement of the noncontact viewing system during manipulation and in viewing periphery of the fundus. There was also difficult access of the posterior pole during induction of posterior vitreous detachment. 2 eyes had iatrogenic breaks with localised retinal detachment (RD) above horizontal meridian and 1 eye developed RD on the first postoperative day with break in the intercalary membrane. All 3 cases were managed with endodrainage, endolaser and silicone oil tamponade. There is no mention of surgical challenges and outcomes in very severe microcornea (corneal diameter < 6.5mm). All the above studies point towards the fact that cornea‑related complications, intraoperative difficulties, posterior capsular dehiscence and the inability to implant an IOL appears to be higher in eyes with severe microcornea. Corneal diameter can be considered to be an important parameter and our series represent cases with severe grade of microcornea only, as phacoemulsification can be safely performed with IOL insertion in less severe grade of microcornea. The mean corneal diameter was 6.5 ± 0.34 mm in our study. We believe that corneal measurements can help in deciding a possibly safe approach for the represented subset of eyes, in which couching remains a viable option. Following couching, there was an ambulatory gain of visual acuity in previously non-ambulatory subjects enabling them to mobilise in a familiar environment. The visual gain was statistically significant (p 0.002) The existent case series on the management of brown cataracts in eyes with microcornea and coloboma remain focused on the outcomes in the early postoperative period but with little information on the long‑term outcome of cases which incurred complications and were left aphakic in their series. Apart from need for repeated couching in one subject, no other major complications were noted during the study period. Anteby et al. [ 14 ] reported that lens with intact capsule maintains the integrity of the vitreous with no traction on the retina. In addition, there is no literature suggesting increase in peripheral vitreous traction in colobomatous eyes. Conclusion Couching of Intra-ocular lens is an effective and safe method in microphthalmic eyes with irido-fundal coloboma. Corneal measurements can help in determining the subset of patients where couching offers viable option. There was an ambulatory gain of visual acuity in previously non-ambulatory subjects enabling them to mobilise in a familiar environment. The limitations being retrospective nature of the study and the small sample size, long term studies are required to be offer conclusive evidence. Declarations The manuscript is being submitted by me (corresponding author) on behalf of all the authors. Written informed consent was taken from the subjects and necessary Ethics committee approval sought The manuscript is original work of all authors. All authors made a significant contribution to this paper. This manuscript has not been submitted for publication and has not been published in any other journal. All authors have read and approved the final version of the manuscript. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare that no funds, grants, or other support were received during the preparation of this manuscript and have no relevant financial or non-financial interests to disclose. References Lingam G, Sen AC, Lingam V, Bhende M, Padhi TR, Xinyi S. Ocular coloboma—a comprehensive review for the clinician. Eye. 2021;35(8):2086–109. Kohli G, Shah C, Sen A, Joshi R, Sood D, Patidar N, Sen P, Sharma D, Jain T. Cataract surgery in eyes with associated coloboma: Predictors of outcome and safety of different surgical techniques. Indian Journal of Ophthalmology. 2021;69(4):937. Pars plana vitrectomy with phacofragmentation for hyperdense cataracts in eyes with severe microcornea and chorio retinal coloboma: A novel approach Alok C Sen, Gaurav M Kohli, Ashish Mitra, Shubhi Tripathi, Sachin B Shetty, Sonal Gupta1 Duke-Elder S. Coloboma choroid. In: System of ophthalmology. St Louis: CV Mosby Company; 1961. p. 489. Batra DV, Paul SD. Microcornea with myopia. Br J Ophthalmol 1967;51:57–60. Chaurasia S, Ramappa M, Sangwan VS. Cataract surgery in eyes with congenital iridolenticular choroidal coloboma. British Journal of Ophthalmology. 2012;96(1):138–40. Phylactou M, Matarazzo F, Day AC, Hussain B, Maurino V. Cataract surgery in eyes with congenital ocular coloboma. Graefes Arch Clin Exp Ophthalmol. 2020;258:2753–9. Leffler CT, Klebanov A, Samara WA, Grzybowski A. The history of cataract surgery: from couching to phacoemulsification. Annals of Translational Medicine. 2020;8(22). Roy PN, Mehra KS, Deshpande PJ. Cataract surgery performed before 800 BC. British Journal of Ophthalmology. 1975;59(3):171-. Mahmoud AO. Traditional operative couching of the lens is not a safe alternative procedure for cataract surgery in Northern Nigeria. Sahel Medical Journal. 2005;8(2):30. Khokhar S, Gupta S, Tewari R, Agarwal R. Scleral tunnel phacoemulsification: Approach for eyes with severe microcornea. Indian J Ophthalmol 2018;64:320 2. Sahay P, Maharana P, Mandal S, Sinha R, Agarwal T, Sharma N, et al. Cataract surgery outcomes in eyes with chorioretinalcoloboma. J Cataract Refract Surg 2019;45:630 8 Khokhar S, Gupta S, Kusumesh R, Kumar G. Outcomes of phacoemulsification in eyes with congenital choroidal coloboma. Graefe's Archive for Clinical and Experimental Ophthalmology. 2013;251:2489–90. Anteby I, Isaac M, BenEzra D. Hereditary subluxated lenses: visual performances and long-term follow-up after surgery. Ophthalmology. 2003;110(7):1344–8. Supplementary Video Video is not available with this version. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Dec, 2023 Reviews received at journal 01 Dec, 2023 Reviews received at journal 11 Nov, 2023 Reviewers agreed at journal 26 Oct, 2023 Reviewers agreed at journal 22 Oct, 2023 Reviewers invited by journal 22 Oct, 2023 Editor assigned by journal 17 Oct, 2023 Submission checks completed at journal 17 Oct, 2023 First submitted to journal 16 Oct, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3453663","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":240739328,"identity":"605b524a-a634-430b-9440-0faf9028c125","order_by":0,"name":"Naresh Babu Kannan","email":"","orcid":"","institution":"Aravind Eye Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Naresh","middleName":"Babu","lastName":"Kannan","suffix":""},{"id":240739329,"identity":"e6ab13b4-2adb-4cc8-9bd3-5125783bc640","order_by":1,"name":"Ananya Goswami","email":"","orcid":"","institution":"Aravind Eye Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ananya","middleName":"","lastName":"Goswami","suffix":""},{"id":240739331,"identity":"1874a8f4-ca76-4ebf-8461-c46dc97a4552","order_by":2,"name":"Muthukrishnan Vallinayagam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYBACgwNsDAwJDAfk5JmZDz4ACvDwEavF2LC9LdkApIWNKC0MDAcSG86cMZMAMQlqkZx2LO3Dgz93GBtnpKVVfs2xk2FjYH746AY+LbPTDs9IbHvGzC6RfOy27LZkoMPYjI1z8GpJb2ZIbDjMxgi05bbkNmagFh42aXxa+KWBWhL+HOZhuJFjViy5rZ4YLWmHGRLYDkswAL3P+HHbYcJa2KTTkhkS2w4bgAJZmnHbcR42ZgJ+AWoxZvzx53D9fGBUfvy5rdqen7354WN8WlAAMw+YJFY5CDD+IEX1KBgFo2AUjBgAAAHKSp8qTaXfAAAAAElFTkSuQmCC","orcid":"","institution":"Aravind Eye Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Muthukrishnan","middleName":"","lastName":"Vallinayagam","suffix":""},{"id":240739333,"identity":"fde6e06d-9bc6-4b8f-86cd-2a79eb5413ba","order_by":3,"name":"Avik Dey Sarkar","email":"","orcid":"","institution":"Aravind Eye Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Avik","middleName":"Dey","lastName":"Sarkar","suffix":""}],"badges":[],"createdAt":"2023-10-16 16:29:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3453663/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3453663/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44935261,"identity":"5ceb5bc5-df88-4a39-a8ef-2f0c87f69324","added_by":"auto","created_at":"2023-10-19 16:41:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":246892,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea \u003c/strong\u003ePre-surgery B-scan ultrasonography showing coloboma involving disc and macula\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb\u003c/strong\u003e Post-surgery B-scan ultrasonography showing coloboma involving disc and macula and lens positioned over coloboma\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-3453663/v1/08e6ffe55226cc7e46d2ce5c.png"},{"id":44936180,"identity":"34073b71-a193-448c-8e72-74b8214a3e17","added_by":"auto","created_at":"2023-10-19 16:49:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":506465,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3453663/v1/aa7c9f26-e108-4897-ab2d-5382e6d6797c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Couching of Intra-ocular lens in microphthalmic eyes with irido-fundal coloboma - Revisiting the historical technique","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSubjects with iridofundal coloboma develop cataract which is usually advanced compared with age-matched subjects with senile cataract.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] In addition, they are often associated with microphthalmos (defined as axial length\u0026thinsp;\u0026lt;\u0026thinsp;95th percentile adjusted for age).\u003c/p\u003e \u003cp\u003eAnatomical restraints pose difficulty in cataract surgery through anterior approach (sclerocorneal tunnel, relatively shallow anterior chamber) as well as posterior approach (instrument manoeuvring) with high rate of corneal complications and surgical aphakia. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eCouching is the only feasible approach to circumvent the afore-mentioned challenges posed in microphthalmic eyes with coloboma. There is no available literature regarding couching of intraocular lens in iridofundal coloboma with microphthalmos to the best of our knowledge.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e This is a retrospective study conducted at a tertiary care centre in South India and the study adhered to the tenets of the Declaration of Helsinki. Computer-based record search was done to identify all patients who had undergone couching from June 2021 to December 2022. The study included all patients presenting with iridofundal coloboma associated with microphthalmos and brown/mature cataract who underwent couching of the intraocular lens (done by single surgeon) and followed up for at least 6 months post-surgery. All subjects included in the study had coloboma involving disc and macula documented on ultrasonography (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). Subjects with visual acuity\u0026thinsp;\u0026gt;\u0026thinsp;6/60 in other eye, retinal/choroidal detachment on B scan ultrasonography, and uncontrolled Intraocular Pressure (IOP) were excluded from the study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData recorded included age, gender, baseline visual acuity in both eyes, IOP, corneal diameter (white-to-white), axial length, lens status in both eyes, post-surgery visual outcome, post-operative IOP and complications. All patients were followed up for a duration of atleast 3 months to evaluate the change in outcome.\u003c/p\u003e \u003cp\u003eCorrected Distance Visual Acuity (CDVA) was recorded in LogMAR scale, IOP measured using I-care tonometer, corneal diameter measured using IOL Master 700 and confirmed intraoperatively. Axial length was measured using ultrasonography away from the colobomatous area. Axial length measurement was done by locating the patient\u0026rsquo;s preferred fixation point and taking an average of the 10 most accurate axial length readings. Ultrasound B-scan was done to document posterior segment of both eyes in all patients.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedure\u003c/h2\u003e \u003cp\u003eAll subjects underwent surgery under strict asepsis using a uniform surgical technique done by single surgeon under peribulbar local anaesthesia. The perilimbal areas were tapped using blunt end of iris repositor to agitate and loosen the zonules. A side port entry was made into the Anterior Chamber (AC) and AC formed with Ophthalmic Viscosurgical Devices (OVD). A spatula was introduced into AC and zonules broken all around. Lens is then dislocated into the vitreous cavity in a controlled manner. AC is then washed and formed. At the end surgery, Ofloxacin 0.3% eye ointment was instilled into the conjunctival cul-de-sac. Post-operatively all patients were prescribed a topical combination therapy of antibiotics (Moxifloxacin 0.5%) and steroid (prednisolone acetate suspension 1%) in tapering doses for a period of 6 weeks.\u003c/p\u003e \u003cp\u003ePostoperatively, CDVA and intraocular pressure (I-care) are measured at each follow up visit. Slit lamp examination was performed at each follow-up to look for corneal clarity, anterior chamber integrity and lens status. In addition, all patients underwent dilated fundus evaluation including evaluation of retinal periphery and documentation of b-scan ultrasonography (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Postoperative complications if detected was treated accordingly.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analysed using SPSS (version 20.0, International Business Machines Corp.). Visual acuity was converted from Snellen letters to logarithm of minimum angle of resolution (logMAR) for analysis. Data normality was checked using histograms. Continuous and categorical variables were described using mean (+- standard deviation) or median (with range) and frequency (percentage) respectively. Comparison of variables was done using t test for parametric data and Wilcoxon signed rank test for nonparametric data. 2-tailed p value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, 15 eyes of 15 subjects underwent couching of intraocular lens. The mean age of the study population was 49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 years (median 47 years; range 35\u0026ndash;69 years). 12 subjects were males (80%) and 3 were females (20%). The demographic profile and clinical presentation of the study subjects is summarised below in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic profile and clinical presentation of the study subjects\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS.no.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePreop CDVA (logMAR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntraocular Pressure (mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade of cataract\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWhite to white (in mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAxial length (in mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOther eye status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOther eye CDVA (logMAR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMature cataract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClosed funnel RD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClosed funnel RD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNLP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMature cataract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSubluxated lens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNLP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMature cataract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNLP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBrown cataract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNLP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePreoperatively, B scan in all patients revealed coloboma involving disc and macula which was confirmed intraoperatively.\u003c/p\u003e \u003cp\u003eThe fellow eye had phthisis bulbi in 8 cases, old RD in 2 cases, mature cataract in 5 cases. The fellow eye in 5 cases had visual acuity reduced to absent perception of light.\u003c/p\u003e \u003cp\u003eAt baseline, median corrected distance visual acuity (CDVA) was 2 [range 1.5 to 2.5] logMAR (Snellen equivalent HMCF), mean IOP was 14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 mmHg, mean axial length was 19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 mm and mean corneal diameter was 6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34 mm.\u003c/p\u003e \u003cp\u003eAt postoperative period of 3 months, there was an improvement in CDVA from baseline (median 2 [range 1.5 to 2.5]) to 1.5 [range 1.0 to 2.0] logMAR which was statistically significant (p value 0.002). The same CDVA was maintained at 6months.\u003c/p\u003e \u003cp\u003eA transient rise in intraocular pressure (IOP) at 15 days post-surgery was noted in 5 patients. The mean IOP at 15 days, 3 months post-surgery and 6 months post-surgery were 19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9mmHg, 16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8mmHg and 14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 mmHg respectively. Mean change in IOP from pre-op to 15 days post-surgery was statistically significant (p\u0026thinsp;=\u0026thinsp;0.001). Topical Anti-glaucoma medications (AGM) were initiated and IOP was well controlled on AGM (3 months post-surgery). There was no significant difference in IOP at baseline and at 3 and 6 months post-surgery (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The post-surgery CDVA and IOP are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eOne patient had to undergo re-couching. No other major complications were noted.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Pre and Post-surgery CDVA and IOP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS.no.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-operative CDVA (logMAR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-operative 3months CDVA (logMAR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIOP Pre-operative (mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIOP Post operative day 15 (mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIOP Post operative 3months (mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIOP Post operative 6months (mmHg)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIrido-fundal coloboma involving the macula is frequently associated with poor visual acuity and poor fixation along with nystagmus. They are often microphthalmic (the age adjusted axial diameter is \u0026lt;\u0026thinsp;95th percentile, \u0026lt;\u0026thinsp;18.5 mm in adult).[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] These eyes have been associated with early onset nuclear sclerosis as compared to age matched controls.\u003c/p\u003e \u003cp\u003eThe presence of microcornea (corneal diameter\u0026thinsp;\u0026lt;\u0026thinsp;2 SD below normal population range or \u0026lt;\u0026thinsp;11 mm horizontally) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], non-dilating pupils, absence of zonules, lens coloboma and other structural anomalies make cataract surgery more challenging with a corresponding rise in operative complications. (19.5% by Phylactou et al, 30.7% by Chaurasia et al.) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eCataract extraction in these eyes is difficult due to anatomical restraints in creating corneoscleral tunnel in Small Incision Cataract Surgery (SICS) or Extracapsular Cataract Extraction (ECCE).[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] There is risk of severe damage to corneal endothelium from the use of excessive ultrasound energy in relatively shallow anterior chamber during phacoemulsification.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Creating sclerotomies for performing pars plana lensectomy in microphthalmic eyes has additional risk of retinal dialysis due to anterior placement of sclerotomies and difficult surgical manoeuvring. In eyes with very severe microcornea (\u0026lt;\u0026thinsp;6.5mm), crowding of instrument is a major challenge.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The limited anterior chamber space combined with hard bulky nucleus poses a great challenge to the operating surgeon.\u003c/p\u003e \u003cp\u003eThe word \u0026ldquo;couching\u0026rdquo; derives from the French verb \u0026ldquo;coucher,\u0026rdquo; which means \u0026ldquo;to put to bed\u0026rdquo;. It is one of the oldest surgical procedures to be performed in history. The procedure was first described in \u0026ldquo;Sushruta Samhita\u0026rdquo; by Sushruta and later adopted by the Greeks, Romans as well as Egyptians, Arabs and Europeans.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eCouching is an ancient technique typically performed on mature cataracts for ambulatory visual rehabilitation. The technique involves use of a thorn or needle, to pierce the eye at the limbus. The opaque lens is then dislocated from the central visual axis and pushed down into the vitreous cavity, producing an instantaneous improvement in vision. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, couching has been relevant in history when management of complications were not feasible. Lately, they are being practiced and rightfully discredited in sub-saharan contries. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In all these studies, surgeries have been performed by non-ophthalmologists and traditional healers without proper sterile precautions and required post-operative management of complications.\u003c/p\u003e \u003cp\u003eKohli et al [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] recommended phacoemulsification for softer cataracts with corneal diameter more than 8 mm. M-SICS was preferred for smaller corneas with hard nuclear cataracts. Khokhar et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] described a modified technique of sclero‑corneal tunnel for phacoemulsification in coloboma and hard cataract. No IOL implantation in 3 out of 8 patients with corneal diameter\u0026thinsp;\u0026lt;\u0026thinsp;7 mm. 4 of the 8 eyes (including 2 with microcornea) had significant corneal edema in the early postoperative period.\u003c/p\u003e \u003cp\u003eIn a study by Sahay et al [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], 29/39 (74.4%) cases who underwent cataract surgery had corneal diameter\u0026thinsp;\u0026lt;\u0026thinsp;9.0 mm. IOL was not implanted in 30.8% cases and 2 cases had persistent corneal edema subsequently requiring endothelial keratoplasty. Khokhar S et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] in a retrospective study of 22 eyes reported favourable outcomes following phacoemulsification with IOL in patients with coloboma. However, only 6 eyes had severe microcornea out of which 3 were left aphakic. Postoperative corneal edema was noted in 18%.\u003c/p\u003e \u003cp\u003eChaurasia et al [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] reported outcomes of cataract surgery in 26 eyes with coloboma. 5 out of 26 eyes had coloboma involving disc and macula with microcornea and hard cataract. They were managed with ECCE/ICCE without IOL. 4 patients had posterior capsular rupture (PCR) due to radial extension of capsulorhexis while prolapsing the hard nucleus out of the capsular bag. None of the patients had severe microcornea.\u003c/p\u003e \u003cp\u003eThe corneoscleral approach in small cornea and hard cataracts are associated with complications mainly attributed to anatomical restraints. These microphthalmic eyes are fraught with untoward consequences including corneal edema, Descemet\u0026rsquo;s membrane detachment, PCR and surgical aphakia. Although cases of microcornea have been included in the above-mentioned studies, no specific emphasis has been made regarding management and outcome of severe microcornea with hard cataract through anterior approach.\u003c/p\u003e \u003cp\u003ePosterior approach has been described by Sen et al [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] where they performed pars plana lensectomy in brown cataract with severe microcornea (mean corneal diameter 6.7+/-0.64 mm, range 4\u0026ndash;8 mm) and chorio‑retinal coloboma. All eyes underwent pars plana vitrectomy (20G in 7 eyes and 23G in 23 eyes) with pars plana lensectomy and were left aphakic. There was gain of ambulatory vision in the post-operative period. However, there was crowding of instruments and closely placed sclerotomy ports due to small corneal diameter. They also reported difficulty due to displacement of the noncontact viewing system during manipulation and in viewing periphery of the fundus. There was also difficult access of the posterior pole during induction of posterior vitreous detachment. 2 eyes had iatrogenic breaks with localised retinal detachment (RD) above horizontal meridian and 1 eye developed RD on the first postoperative day with break in the intercalary membrane. All 3 cases were managed with endodrainage, endolaser and silicone oil tamponade. There is no mention of surgical challenges and outcomes in very severe microcornea (corneal diameter\u0026thinsp;\u0026lt;\u0026thinsp;6.5mm).\u003c/p\u003e \u003cp\u003eAll the above studies point towards the fact that cornea‑related complications, intraoperative difficulties, posterior capsular dehiscence and the inability to implant an IOL appears to be higher in eyes with severe microcornea. Corneal diameter can be considered to be an important parameter and our series represent cases with severe grade of microcornea only, as phacoemulsification can be safely performed with IOL insertion in less severe grade of microcornea.\u003c/p\u003e \u003cp\u003eThe mean corneal diameter was 6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34 mm in our study. We believe that corneal measurements can help in deciding a possibly safe approach for the represented subset of eyes, in which couching remains a viable option. Following couching, there was an ambulatory gain of visual acuity in previously non-ambulatory subjects enabling them to mobilise in a familiar environment. The visual gain was statistically significant (p 0.002)\u003c/p\u003e \u003cp\u003eThe existent case series on the management of brown cataracts in eyes with microcornea and coloboma remain focused on the outcomes in the early postoperative period but with little information on the long‑term outcome of cases which incurred complications and were left aphakic in their series. Apart from need for repeated couching in one subject, no other major complications were noted during the study period.\u003c/p\u003e \u003cp\u003eAnteby et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] reported that lens with intact capsule maintains the integrity of the vitreous with no traction on the retina. In addition, there is no literature suggesting increase in peripheral vitreous traction in colobomatous eyes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCouching of Intra-ocular lens is an effective and safe method in microphthalmic eyes with irido-fundal coloboma. Corneal measurements can help in determining the subset of patients where couching offers viable option. There was an ambulatory gain of visual acuity in previously non-ambulatory subjects enabling them to mobilise in a familiar environment. The limitations being retrospective nature of the study and the small sample size, long term studies are required to be offer conclusive evidence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n\u003cli\u003eThe manuscript is being submitted by me (corresponding author) on behalf of all the authors.\u003c/li\u003e\n\u003cli\u003eWritten informed consent was taken from the subjects and necessary Ethics committee approval sought\u003c/li\u003e\n\u003cli\u003eThe manuscript is original work of all authors.\u003c/li\u003e\n\u003cli\u003eAll authors made a significant contribution to this paper.\u003c/li\u003e\n\u003cli\u003eThis manuscript has not been submitted for publication and has not been published in any other journal.\u003c/li\u003e\n\u003cli\u003eAll authors have read and approved the final version of the manuscript.\u003c/li\u003e\n\u003cli\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/li\u003e\n\u003cli\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript and have no relevant financial or non-financial interests to disclose.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLingam G, Sen AC, Lingam V, Bhende M, Padhi TR, Xinyi S. Ocular coloboma\u0026mdash;a comprehensive review for the clinician. Eye. 2021;35(8):2086\u0026ndash;109.\u003c/li\u003e\n\u003cli\u003eKohli G, Shah C, Sen A, Joshi R, Sood D, Patidar N, Sen P, Sharma D, Jain T. Cataract surgery in eyes with associated coloboma: Predictors of outcome and safety of different surgical techniques. Indian Journal of Ophthalmology. 2021;69(4):937.\u003c/li\u003e\n\u003cli\u003ePars plana vitrectomy with phacofragmentation for hyperdense cataracts in eyes with severe microcornea and chorio retinal coloboma: A novel approach Alok C Sen, Gaurav M Kohli, Ashish Mitra, Shubhi Tripathi, Sachin B Shetty, Sonal Gupta1\u003c/li\u003e\n\u003cli\u003eDuke-Elder S. Coloboma choroid. In: System of ophthalmology. St Louis: CV Mosby Company; 1961. p.\u0026nbsp;489.\u003c/li\u003e\n\u003cli\u003eBatra DV, Paul SD. Microcornea with myopia. Br J Ophthalmol 1967;51:57\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eChaurasia S, Ramappa M, Sangwan VS. Cataract surgery in eyes with congenital iridolenticular choroidal coloboma. British Journal of Ophthalmology. 2012;96(1):138\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003ePhylactou M, Matarazzo F, Day AC, Hussain B, Maurino V. Cataract surgery in eyes with congenital ocular coloboma. Graefes Arch Clin Exp Ophthalmol. 2020;258:2753\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eLeffler CT, Klebanov A, Samara WA, Grzybowski A. The history of cataract surgery: from couching to phacoemulsification. Annals of Translational Medicine. 2020;8(22).\u003c/li\u003e\n\u003cli\u003eRoy PN, Mehra KS, Deshpande PJ. Cataract surgery performed before 800 BC. British Journal of Ophthalmology. 1975;59(3):171-.\u003c/li\u003e\n\u003cli\u003eMahmoud AO. Traditional operative couching of the lens is not a safe alternative procedure for cataract surgery in Northern Nigeria. Sahel Medical Journal. 2005;8(2):30.\u003c/li\u003e\n\u003cli\u003eKhokhar S, Gupta S, Tewari R, Agarwal R. Scleral tunnel phacoemulsification: Approach for eyes with severe microcornea. Indian J Ophthalmol 2018;64:320 2.\u003c/li\u003e\n\u003cli\u003eSahay P, Maharana P, Mandal S, Sinha R, Agarwal T, Sharma N, et al. Cataract surgery outcomes in eyes with chorioretinalcoloboma. J Cataract Refract Surg 2019;45:630 8\u003c/li\u003e\n\u003cli\u003eKhokhar S, Gupta S, Kusumesh R, Kumar G. Outcomes of phacoemulsification in eyes with congenital choroidal coloboma. Graefe's Archive for Clinical and Experimental Ophthalmology. 2013;251:2489\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eAnteby I, Isaac M, BenEzra D. Hereditary subluxated lenses: visual performances and long-term follow-up after surgery. Ophthalmology. 2003;110(7):1344\u0026ndash;8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Supplementary Video","content":"\u003cp\u003eVideo is not available with this version.\u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Couching, Microcornea, Irido-fundal coloboma, Surgical technique","lastPublishedDoi":"10.21203/rs.3.rs-3453663/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3453663/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: Cataract surgery in microphthalmic eyes is challenging due to anatomical restraints, hard bulky nucleus. This series aims to evaluate the safety and efficacy of couching of intraocular lens in irido-fundal coloboma with microphthalmos.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting: \u003c/strong\u003eTertiary care centre in South India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign: \u003c/strong\u003eRetrospective non-comparative study in eyes with irido-fundal coloboma, corneal diameter \u0026lt;7mm and brown cataract. Visual acuity less than 6/60 in other eye.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eAnterior chamber entry made, zonules broken and lens dislocated into the vitreous cavity in a controlled manner. Baseline Clinico-demographic details, corrected distance visual acuity (CDVA), Intra-ocular pressure (IOP), corneal diameter, axial length, lens status and post-surgery CDVA, IOP and complications recorded and followed up for atleast 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e15 eyes of 15 subjects were evaluated with a mean age 49.4 ±10.9 years. At baseline, mean IOP 14.5 ± 3.8 mmHg, mean axial length 19.3 ± 0.5 mm, mean corneal diameter was 6.5 ± 0.34 mm and CDVA 2 logMAR which improved to 1.5 logMAR at 3 months (p value 0.002). Transient spike in IOP in 33.3% subjects was medically managed with no significant difference in IOP (p \u0026gt; 0.05) at baseline (14.5 ± 3.8 mmHg), 3 months post-surgery (16±2.8 mmHg) and 6 months post-surgery (14.9 ± 2.5 mmHg). One patient underwent re-couching. No other major complications were noted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eCouching of Intra-ocular lens is an effective and safe method in microphthalmic eyes with irido-fundal coloboma with an ambulatory gain of visual acuity in previously non-ambulatory subjects. Corneal measurements help in determining the subset of patients where couching offers viable option.\u003c/p\u003e","manuscriptTitle":"Couching of Intra-ocular lens in microphthalmic eyes with irido-fundal coloboma - Revisiting the historical technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-19 16:41:38","doi":"10.21203/rs.3.rs-3453663/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-12-01T17:58:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-12-01T11:11:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-11T11:02:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1857bf97-6d7f-476b-b080-d2b913e73a24","date":"2023-10-27T02:27:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3ff303c5-11bd-49ac-8cbe-27780db27684","date":"2023-10-23T01:52:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-22T19:33:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-17T09:38:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-10-17T09:10:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Ophthalmology","date":"2023-10-16T16:19:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0a95922c-d033-4411-a1bb-9336301b4a3d","owner":[],"postedDate":"October 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-11T11:18:53+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-19 16:41:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3453663","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3453663","identity":"rs-3453663","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}