Long-term corneal endothelial changes after intraocular lens implantation

Comparative long-term outcomes of vitrectomy combined with anterior chamber intraocular lens to intra-scleral haptic fixation of posterior chamber intraocular lens

PURPOSE

To evaluate the long-term clinical outcomes in patients with combined pars plana vitrectomy (PPV) with anterior chamber intraocular lens (ACIOL) to intrascleral haptic fixation (ISHF) using the Agarwal technique with fibrin glue to secure the scleral flap of a posterior chamber intraocular lens.

METHODS

Retrospective, consecutive, single-center, comparative case series. 83 eyes were studied. Patients with < 8 months of follow-up were excluded. Detailed pre-, intra-, and post-operative complications were analyzed using mixed model univariate analysis and t-test. Pre- and post-operative best corrected visual acuity (BCVA) was analyzed.

RESULTS

Twenty-five subjects met entry criteria. Mean age at time of surgery was 70.4 ± 17.7 years in the ACIOL group (n = 12) and 54.6 ± 21.1 years in the ISHF group (n = 13; p = 0.03). Mean follow-up was 38.2 months. Incidence of corneal decompensation was similar in the ACIOL and ISHF lens group (p = 0.93). There was no difference in the BCVA mean change or cystoid macular edema (CME) at the final visit between the groups (p = 0.47; p = 0.08), but there was a trend toward increased CME in the ACIOL group.

CONCLUSIONS

PPV with concomitant placement of either ACIOL or ISHF lens result in improvement in BCVA. Both procedures are well tolerated and result in favorable outcomes with long-term follow-up though varying patient populations do not allow precise comparison between the two groups.

Association between aqueous humor cytokines and postoperative corneal endothelial cell loss after Descemet stripping automated endothelial keratoplasty

This study measured the intraoperative anterior aqueous humor concentrations of various cytokines during corneal endothelial transplantation and searched for relationships between these concentrations and postoperative corneal endothelial cell (CEC) depletion. We recruited 30 consecutive patients who underwent corneal endothelial transplantation with Descemet’s stripping automated endothelial keratoplasty (DSAEK) at Tohoku University Hospital between February 2014 and July 2017. During surgery, we obtained aqueous humor samples and later measured the concentrations of 27 cytokines with a Multiplex Bead Assay (Bio-Plex Pro). We counted CECs 1, 6 and 12 months after surgery, and used Spearman’s rank correlation coefficient to identify relationships between CEC depletion and the concentrations of detected cytokines. The loss of CECs 1–6 months after surgery was significantly correlated with IL-7, IP-10, MIP-1a and MIP-1b concentrations (-0.67, -0.48, -0.39, and -0.45, respectively, all P <0.01). CEC loss 1–12 months after surgery was significantly correlated with IL-1b, IL-7, IP-10 and RANTES concentrations (-0.46, -0.52, -0.48, and -0.43, respectively). Multiple regression analysis showed that IL-7 concentration was significantly associated with CEC loss 1–6 months after surgery (b = -0.65, P < 0.01) and IP-10 concentration was associated with CEC loss 1–12 months after surgery (β = -0.38, P < 0.05). These results suggest that not only inflammatory cytokines but also IL-7, a cytokine related to lymphocytes, may be involved in the depletion of CECs after DSAEK, particularly depletion that occurs relatively early.

Corneal endothelial cell damage after scleral fixation of intraocular lens surgery

PURPOSE

To analyze corneal endothelial cell damage after scleral fixation of intraocular lens (SFIOL) surgery.

STUDY DESIGN

Retrospective study.

METHODS

Medical records of consecutive eyes undergoing SFIOL surgery performed by a single surgeon were reviewed between January 2011 and June 2019. The patients were classified into three groups according to surgical methods: Group I, re-fixating the existing intraocular lens (IOL) or fixating a new IOL in an aphakic eye; Group II, removing the existing IOL and fixating a new IOL; and Group III, phacoemulsification and fixating a new IOL simultaneously. Preoperative and postoperative specular microscopy (SM) status were compared. Changes in SM were compared among the three groups.

RESULTS

Ninety-four eyes were included. Thirty-four eyes in Group I, 39 in Group II, and 21 in Group III. The endothelial cell density (ECD) loss in Group I was 1.5%, less than the ECD loss of 14.3% (p < 0.001) in Group II and 15.4% (p = 0.005), in Group III. In no eye was there an ECD decrease to < 1000/mm² following the surgical procedure.

CONCLUSIONS

ECD loss was related to IOL removal or phacoemulsification rather than SFIOL surgery. SFIOL using the existing IOL should be considered preferential in eyes with low ECD and dislocated IOL.

Myopia, corneal endothelial cell density and morphology in a Japanese population-based cross-sectional study: the JPHC-NEXT Eye Study

This population-based cross-sectional study was performed to determine the mean corneal endothelial cell density (ECD), coefficient of variation (CV), and hexagonality (HEX), and their associations with myopia in Japanese adults living in Chikusei city. Of 7109 participants with available data, 5713 (2331 male and 3382 female) participants were eligible for analysis. After assessing the relationship between participant characteristics and spherical equivalent refraction (SER), the association of SER with the abnormal value of ECD (< 2000 cells/mm), CV (≥ 0.40), and HEX (≤ 50%) were determined using the logistic regression models adjusting for potential confounders (age, intraocular pressure, keratometric power, height, and antihypertensive drug use). In male participants, there was no statistically significant relationships between SER and endothelial parameters. In female participants, compared to emmetropia, SER ≤ − 6 D had significantly higher odds ratio (OR) of having the abnormal value of CV (OR = 2.07, 95% confidence interval [CI] 1.39–3.10) and HEX (OR = 2.04, 95% CI 1.29–3.23), adjusted for potential confounders, indicating that the high myopia was associated with the abnormal values of CV and HEX. Further adjustment for contact lenses wear partly attenuated these associations. Association between the SER and ECD was not detected.

[Optimization of phacoemulsification in complicated cataract with lens subluxation]

Purpose - to optimize the process of phacoemulsification in patients with cataract complicated by degree I-II lens subluxation by using the scaffold technique, and to determine the indications for its application.

MATERIAL AND METHODS

The patients were divided into two groups: group 1 - the main group - included 29 patients (29 eyes; 47.54%) who underwent cataract phacoemulsification with implantation of iris retractors and capsular ring using the scaffold technique. Group 2 - the comparison group - included 32 patients (32 eyes; 54.46%) who underwent cataract phacoemulsification with implantation of iris retractors and capsular ring using standard technique.

RESULTS

Patients' visual acuity improved up to 0.53 (0.35; 0.80) in group 1, and up to 0.50 (0.45; 0.80) in group 2 by the time of hospital discharge. At 6 months and 1 year follow-ups, visual functions were equal, in group 1 - 0.70 (0.65; 0.80), in group 2 - 0.70 (0.60; 0.90). The number of intraoperative complications decreased from 8.20% in standard phacoemulsification to 1.64% in scaffold technique. The latter reduces endothelial cell loss by 1.95% in comparison with traditional phacoemulsification over 1 year follow-up. With the scaffold technique, the number of intraoperative complications decreased from 15.63% in group 2 to 3.45% in group 1, the number of postoperative complications - from 43.75% to 31.04%, respectively.

CONCLUSION

The scaffold technique is indicated in pseudoexfoliation syndrome with weakness of zonular apparatus, degree I-II lens subluxation, in hard nucleus with absence of posterior cortical layer, in intumescent cataract, Morgagnian cataract to stabilize the posterior capsule and protect it from rupture.

Immune privilege in corneal transplantation

Corneal transplantation is the most successful solid organ transplantation performed in humans. The extraordinary success of orthotopic corneal allografts, in both humans and experimental animals, is related to the phenomenon of "immune privilege". Inflammation is self-regulated to preserve ocular functions because the eye has immune privilege. At present, three major mechanisms are considered to provide immune privilege in corneal transplantation: 1) anatomical, cellular, and molecular barriers in the cornea; 2) tolerance related to anterior chamber-associated immune deviation and regulatory T cells; and 3) an immunosuppressive intraocular microenvironment. This review describes the mechanisms of immune privilege that have been elucidated from animal models of ocular inflammation, especially those involving corneal transplantation, and its relevance for the clinic. An update on molecular, cellular, and neural interactions in local and systemic immune regulation is provided. Therapeutic strategies for restoring immune privilege are also discussed.

Long-term (≥10 years) results of corneal endothelial cell loss after cataract surgery

OBJECTIVE

To investigate the extent of long-term corneal endothelial loss after uneventful cataract surgery and the factors associated with decreases in corneal endothelial cell density (ECD).

DESIGN

Retrospective case series.

PARTICIPANTS

Patients who had undergone uncomplicated cataract surgery.

METHODS

This study comprised 81 eyes of 48 patients who had undergone cataract surgery >10 years previously by a single surgeon with the same intraocular lens and visited the outpatient clinic between January 2014 and February 2017. Long-term (≥10 years) changes in visual outcome and ECD after uncomplicated cataract surgery were evaluated. To analyze factors correlated with endothelial cell loss, preoperative biometric variables, including cataract grade, anterior chamber depth, axial length, and postoperative corneal edema, were evaluated.

RESULTS

The mean ± SD preoperative and long-term postoperative ECD was 2793 ± 351.09 and 2148 ± 478.38 cells/mm², respectively. The mean follow-up period was 11.08 ± 1.06 years and 10-year ECD loss rate was 20.62 ± 13.63%. Preoperative nuclear firmness was most statistically correlated with 10-year ECD loss (β-coefficient 0.394 [95% CI 3.402-9.448]; p < 0.001). The degree of postoperative corneal edema was also a significant predictive factor of 10-year ECD loss after cataract surgery (β-coefficient 0.378 [95% CI 2.854-8.358]; p = 0.002).

CONCLUSION

Preoperative nuclear firmness and postoperative corneal edema were predictors of long-term (≥10 years) endothelial cell loss and severe endothelial cell loss after cataract surgery. It is important to remember that eyes with increased nuclear firmness have a significantly higher risk of long-term enhanced ECL.

Effects of intracameral cefuroxime on corneal endothelial cell counts and its morphology after cataract surgery

Background

Endophthalmitis is one of the most important complications after cataract surgery and in case event can cause many symptoms, such as severe decrease in eyesight and/or even the loss of vision. Employing methods to reduce this problem is very important. The aim of this study was to evaluate the effect of intracameral cefuroxime after cataract surgery on corneal endothelial cell counts and its morphology.

Methods

In this study, 32 eyes of 30 patients underwent endothelial cell count and morphology assessment by ConfoScan III device before and 1 month after cataract surgery. All patients undertaken cataract surgery by one surgeon and by one method. Intracameral cefuroxime (1 mg/0.1 ml) was used as prophylaxis of postoperative endophthalmitis at the end of operation.

Results

In this study, the rate of corneal endothelial cell loss 1 month after cataract surgery was 8.4%, and the rate of endothelial cells polymegathism before and after cataract surgery did not differ statistically. During the follow-up period, there were no cases of endophthalmitis or other complications.

Conclusion

With regard to the importance of the intracameral cefuroxime in a reduction in the rate of endophthalmitis after cataract surgery and that harmful effects on the endothelial cells were not seen, this method can be considered as a suitable method for endophthalmitis prophylaxis.

[Complex treatment results in a congenital glaucoma patient (case report)]

Early diagnosis of congenital glaucoma allows surgery to be performed at the stage of reversible glaucomatous alterations of the optic disc and retina. In primary congenital glaucoma, the main reason for visual acuity reduction following surgical stabilization of the intraocular pressure are corneal changes. These include an increased corneal diameter, Haab's striae, areas of thickening and a greater posterior elevation. The resultant irregular astigmatism leads to amblyopia and a marked decrease in visual acuity. Active pleoptic treatment started from a very early age in children operated on for compensated congenital glaucoma provides them an opportunity to achieve high visual acuity and full rehabilitation.

Long-term follow-up of changes in corneal endothelium after primary and secondary intraocular lens implantations in children

BACKGROUND

To evaluate long-term changes in corneal endothelial cell count and morphology after congenital cataract extraction and intraocular lens implantation.

METHODS

Cataract extraction and posterior chamber intraocular lens (IOL) implantation was performed on 54 congenital cataract patients (83 eyes). The corneal endothelial cell density (ECD), coefficient of variation (CV), hexagonality, and central corneal thickness (CCT) were measured for a retrospective analysis of long-term changes in corneal endothelial characteristics.

RESULTS

The mean age at the time of IOL implantation was 5.00 (3.62) years [mean (SD)], and the mean follow-up period was 8.83 (1.49) years. In a comparison of the treated and normal eyes of patients who underwent unilateral surgery, the treated eyes showed a significantly greater CCT (p < 0.05), and there was no significant difference in ECD, CV, and hexagonality (p > 0.05). In addition, there was no statistically significant difference in the ECD and CCT between the primary and secondary IOL implantation groups.

CONCLUSIONS

Our results did not show any significant corneal endothelial cell loss in congenital cataract patients; however, their CCTs were increased.

Corneal endothelial function after phacoemulsification using the fluid-based system compared to conventional ultrasound technique

AIM

To quantitatively assess corneal endothelial changes after phacoemulsification with the fluid-based system compared to conventional ultrasound technique.

METHODS

This prospective, randomized clinical study included patients with cataract who were randomly assigned either to have phacoemulsification with the fluid-based system (30 eyes of 30 patients--Group 1) or with traditional ultrasound (30 eyes of 30 patients--Group 2). Patients who were available at each follow-up visit (25 eyes in both groups) were enrolled in the statistical analysis. Endothelial function was evaluated by measuring central corneal thickness, central endothelial cell density (ECD), mean cell size, and coefficient of variation in cell size preoperatively, 10 days, 1 and 3 months, and 1 year after surgery. Statistical analyses were performed using two-way repeated measure ANOVA.

RESULTS

An acute, reversible increase of central corneal thickness (CCT) was found 10 days after surgery, which was similar in both groups (P=0.35). ECD decreased, whereas mean cell size increased significantly immediately after surgery. However, the impairments were finished after 1 month. The alterations were similar in both groups (ECD: P=0.99; mean cell size: P=0.85). The coefficient of variation in cell size remained stable after surgery (P=0.08), and significant difference was not found between groups (P=0.99). The endothelial cell loss (ECL) was 6.5+/-8.4% in Group 1 and 6.5+/-11.7% in Group 2 (P=0.69).

CONCLUSIONS

Corneal endothelial changes were similar using the fluid-based system compared to the traditional ultrasound technique. The fluid-based method proved to be as safe as conventional ultrasound in cataract surgery.

Corneal endothelial cell change after phacoemulsification relative to the severity of diabetic retinopathy

PURPOSE

To investigate the differences in corneal endothelial cell morphology between diabetic patients who were divided by the degree of the severity of diabetic retinopathy and normal patients after phacoemulsification with intraocular lens (IOL) implantation.

SETTING

Department of Ophthalmology, College of Medicine, Pusan National University, Pusan, Korea.

METHODS

Before and 6 months after phacoemulsification, specular microscopy was used to evaluate the number and morphology of endothelial cells in patients with diabetic retinopathy. The patients were divided into 3 groups: group I (n=30 eyes), without diabetes; group II (n=30 eyes), diabetes with severe nonproliferative diabetic retinopathy; group III (n=30 eyes), diabetes with high-risk proliferative diabetic retinopathy (PDR).

RESULTS

Postoperative corneal endothelial cell density and hexagonality were significantly decreased and the coefficient of variation in cell size increased in all groups, in contrast to the preoperative state (P<.05). During the postoperative 6 months, the percentage of hexagonal cells showed a tendency to decrease progressively, and this was a significant difference between the 3 groups (P<.05). However, the patterns of change in endothelial cell density and the coefficient of variation in cell size were not different between the groups (P>.05). At the postoperative 6 months, the corneal endothelial cell density and the coefficient of variation in cell size of high-risk PDR patients were statistically changed compared with normal persons (P<.05). However, the percentage of hexagonal cell was not significantly difference between diabetic retinopathy patients and normal patients (P>.05).

CONCLUSIONS

Corneal endothelial cell density significantly decreased and the coefficient of variation in cell size significantly increased for high-risk PDR patients undergoing phacoemulsification, in contrast to normal persons at the postoperative 6 months.

Long-term endothelial changes after implantation of anterior chamber intraocular lenses in cataract surgery

PURPOSE

To determine and quantify corneal endothelial damage after primary or secondary implantation of anterior chamber intraocular lenses (AC IOLs).

SETTING

Eye Clinic, University of Trieste, Trieste, Italy.

METHODS

This retrospective study comprised 125 patients who had implantation of an AC IOL from January 1987 to December 1998. The mean follow-up was 5.2 years. The IOLs were the Domilens Chiron Vision Z (n = 52), the Iolab U85J (n = 38), and the AMO AC51B (n = 35). The Konan specular microscope was used to perform full morphometric analysis of the corneal endothelium. The values obtained were compared with those in fellow eyes, which were phakic or pseudophakic with a posterior chamber IOL (PC IOL). Two years later, 63 patients (mean follow-up 2.1 years) had another morphometric analysis and the values obtained were compared with those in the same eye at the previous examination. The Student t test for unpaired groups was used to compare the results at a 5% significance level.

RESULTS

The mean endothelial cell density (ECD) was significantly lower in eyes with primary or secondary AC IOL implantation than in unoperated phakic eyes (P<.01). Patients who had primary AC IOL implantation in 1 eye and PC IOL implantation in the fellow eye had a difference in ECD that was not statistically significant. The endothelial cell difference was significantly greater in aphakic patients who had a secondary AC IOL implantation (P<.05). The ECD ranged from 1015 to 2980 cells/mm(2). The endothelium in the various groups showed no significant changes in the coefficient of variation (CV) in cell size. The ECD and endothelial CV in the same eyes at the second examination were not significantly different from the values 2 years previously.

CONCLUSIONS

Anterior chamber IOL implantation did not appear to alter corneal endothelial function. Results indicate that the endothelial cell loss was related to surgical trauma rather than the presence of an IOL in the anterior chamber.

Corneal endothelial cell protection with a dispersive viscoelastic material and an irrigating solution during phacoemulsification: low-cost versus expensive combination

PURPOSE

To evaluate the protective effect on corneal endothelial cells of a low-cost and an expensive combination of a dispersive viscoelastic material and an irrigating solution during phacoemulsification.

SETTING

Department of Ophthalmology, University of Vienna, Vienna, Austria.

METHODS

This prospective randomized examiner- and patient-masked study comprised 90 eyes of 45 consecutive patients with age-related cataract in both eyes. For each patient, the first eye was randomly assigned to receive hydroxypropyl methylcellulose 2% (Ocucoat) and Ringer's solution (low-cost combination) or sodium chondroitin sulfate 4%-sodium hyaluronate 3% (Viscoat) and an enriched balanced salt solution (BSS Plus) (expensive combination) during phacoemulsification. The contralateral eye received the other treatment. Endothelial cell function was evaluated by measuring corneal thickness (CT) using partial coherence interferometry, morphology assessment, and endothelial cell counts.

RESULTS

The acute postoperative increase in CT was +9.8 microm in the low-cost group and +10.9 microm in the expensive group; the difference between groups was not significant. After 1 month, the CT still differed significantly from baseline in the low-cost group. Three months after surgery, the CT had returned to baseline values in both groups. There was no significant between-group difference in endothelial cell counts or morphology.

CONCLUSIONS

During phacoemulsification in a nonselected patient population, there was no difference in acute postoperative corneal edema and endothelial cell morphology after 3 months between a Viscoat and BSS Plus combination and an Ocucoat and Ringer's solution combination. Eyes receiving the expensive combination had marginally faster recovery of corneal swelling by 3 months. However, the cost of Viscoat and 500 mL BSS Plus is 5 times that of Ocucoat and Ringer's solution.

Risk factors for reduced corneal endothelial cell density before cataract surgery

PURPOSE

To assess the prevalence and risk factors for reduced endothelial cell density before cataract surgery.

SETTING

Ohtsuki Eye Clinic, Sendai, Japan.

METHODS

The records of 1304 eyes of 700 consecutive Japanese patients who had cataract surgery from 1995 through 2000 were retrospectively reviewed. The incidence of reduced endothelial cell density to less than 2000 cells/mm(2) was calculated, and potential risk factors for the reduced density were analyzed using logistic regression analysis.

RESULTS

The mean preoperative endothelial cell density was 2561.4 cells/mm(2) +/- 375.2 (SD). Reduced endothelial cell density was observed preoperatively in 123 eyes (9%) of 85 patients (12%). In these patients, factors responsible for the decrease were identified in 37 eyes (30%) of 28 (33%) patients. Logistic regression analysis revealed that corneal diseases (P =.003), angle-closure glaucoma (P =.004), pseudoexfoliation (P =.031), and a history of trauma (P <.001) were significantly associated with reduced endothelial cell density. Advanced nuclear cataract and chronic pulmonary disease were also significant risk factors (both P <.001). A subset quantitative comparison study showed that the mean endothelial cell densities in the subgroups of eyes with these risk factors were significantly less than those in a control group (P <.05, analysis of variance).

CONCLUSIONS

Approximately 10% of patients had reduced endothelial cell density before cataract surgery; the reason for the reduction was unknown in two thirds. Advanced nuclear cataract and chronic pulmonary disease were significant risk factors for reduced density. Although the mechanisms are unknown, cataract surgeons should recognize that patients with these risk factors may have a poor endothelial reserve.

A comparative assessment of endothelium from pseudophakic and phakic donor corneas stored in organ culture

AIMS

To evaluate the endothelial quality of corneas obtained from pseudophakic donors and to compare the data with matched phakic controls.

METHODS

Corneas from eyes with posterior chamber intraocular lenses (PCIOLs) and corneas from phakic eyes (controls) were stored for 1-2 weeks in organ culture and then examined after staining with Alizarin red S. The corneas were divided into two groups according to the duration of storage. Endothelial cell density, the percentage of hexagonal cells, and the coefficient of variation (CV) were determined.

RESULTS

There was no statistically significant difference between the 14 PCIOL corneas and the 13 controls stored in organ culture for 7 days for any of the three parameters studied. The mean cell density was 2155 (SD 529) cells/mm(2) in the PCIOL corneas and 2118 (453) cells/mm(2) in the controls (p=0.85). The mean percentage of hexagonal cells was 52% (8%) and 58% (7%), respectively (p=0.06). The mean CV was 0.32 (0.18) in the pseudophakic corneas and 0.39 (0.18) in the controls (p=0.33). Moreover, there was no significant difference between the PCIOL corneas and the controls stored for up to 2 weeks.

CONCLUSIONS

The corneal endothelium from eyes with PCIOLs appears to be similar to that of phakic eyes after 1-2 weeks in organ culture. This finding suggests that corneas from pseudophakic eyes should not routinely be disqualified for transplantation. The use of at least some pseudophakic corneas may substantially increase the potential donor pool.

Effect of incision size and site on corneal endothelial changes in cataract surgery

PURPOSE

To compare endothelial damage induced by different cataract incision sites and sizes using specular microscopy.

SETTING

Department of Ophthalmology, Hospital of San Donà di Piave, Venice, Italy.

METHODS

Eighty-one eyes having phacoemulsification were randomly assigned to 1 of 3 groups of 27 eyes each: 3.5 mm clear corneal incision (CCI) with silicone foldable intraocular lens (IOL) implantation; 5.5 mm sutured CCI with poly(methyl methacrylate) (PMMA) IOL implantation; 5.5 mm scleral tunnel with PMMA IOL implantation. All incisions were centered at the 120-degree semimeridian; that is, they were superotemporal in right eyes and superonasal in left eyes. Noncontact specular microscopy was performed in the center and at the 12 o'clock position preoperatively as well as 1 week and 1, 3, and 12 months postoperatively. The endothelial cell density, mean cell area, cell size variation coefficient, percentage of hexagonality, and corneal thickness were considered.

RESULTS

Progressive endothelial cell loss and an increase in mean cell area occurred in all groups during the follow-up. The cell loss percentages relative to the endothelial center appeared similar among the groups and slightly although not significantly lower in the scleral tunnel group. The scleral tunnel group had a statistically significant lower cell loss percentage at the 12 o'clock position than the 2 CCI groups at all follow-ups.

CONCLUSIONS

The scleral tunnel group had less postoperative endothelial damage than the 2 CCI groups, with a statistically significant difference at the 12 o'clock position. This is probably because the scleral tunnel incision is placed more posteriorly and therefore induces less direct and indirect endothelial trauma.

Safety of posterior chamber phakic intraocular lenses for the correction of high myopia: anterior segment changes after posterior chamber phakic intraocular lens implantation

OBJECTIVE

To assess the safety of posterior chamber phakic intraocular lens (PCPIOL) implantation in patients with high myopia.

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

Twenty eyes of 10 patients were included.

INTERVENTION

Staar Collamer Implantable Contact Lens PCPIOLs were implanted for the correction of high myopia.

MAIN OUTCOME MEASURES

Intra- and postoperative complications were recorded. Specular microscopy, lens fluorophotometry, laser flare-meter, and ultrasound biomicroscopy were performed before surgery and at different stages of the follow-up period to evaluate endothelial cell density, crystalline lens transmittance, aqueous flare, and anatomic relations of the implanted lenses with the other structures of the anterior segment.

RESULTS

There were no intraoperative complications. One patient experienced pupillary entrapment by the lens in the immediate postoperative period, which was resolved without incident. Pigmentary dispersion or cataracts did not appear during the postoperative period. All the lenses remained correctly centered, and no patient reported night halos or glare. Anterior chamber depth showed a statistically significant reduction, between 9% and 12%. Central endothelial density was significantly decreased after surgery. The percentages of cell loss after 3, 6, 12, 18, and 24 months were 4.41%, 4.83%, 5.17%, 5.46%, and 6.57%, respectively. Aqueous flare increased by 49.19% in the first postoperative month in relation to preoperative values. Afterward, it decreased and then remained above preoperative values for the entire follow-up period (33.76% at month 3, 27.81% at month 6, 27.65% at month 12, 23.39% at month 18, and 27.27% at month 24). Crystalline lens transmittance decreased by 0.72% at month 3, by 1.44% at month 6, by 1.95% at month 12, by 2.25% at month 18, and by 2.24% at month 24. Finally, by ultrasound biomicroscopy it was observed that the PCPIOL and the crystalline lens were in contact on the peripheral level in 12 patients (60%) and in the center in another three patients (15%) during at least one checkup. In all the patients, contact between the PCPIOL and the posterior iris surface could be observed.

CONCLUSIONS

Posterior chamber phakic IOL implantation for the surgical correction of high myopia is a safe procedure with regard to immediate visual and refractive results. The short-term clinical benefit and lack of immediate surgical complications are impressive. However, the increase in flare, the endothelial cell loss, the decrease in crystalline lens transmittance, and the iris-PCPIOL and crystalline lens-PCPIOL contact are findings that suggest caution regarding the long-term safety of this lens implant.

Long-term follow-up of leiske closed-loop anterior chamber intraocular lenses

PURPOSE

To provide long-term follow-up on the rates of endothelial cell loss in eyes with retained closed-loop anterior chamber intraocular lenses (IOLs).

SETTING

Private practices, Chicago, Illinois, USA.

METHODS

In 1980 to 1982, 3 surgeons performed 587 intracapsular cataract extractions with implantation of Leiske closed-loop anterior chamber IOLs. During the prospective part of the study from 1991 to 1996, 59 patients with 83 eligible eyes were followed using specular microscopy and pachymetry. The mean follow-up of the prospective study was 41.9 months, or 12.9 years from the original cataract surgery.

RESULTS

No specific preoperative or postoperative factor except the behavior of the fellow eye (P =.022) predicted the rate of endothelial cell loss. During the prospective study, 6 patients required IOL exchange and corneal transplantation. The rate of corneal decompensation was heavily dependent on the initial measurement of endothelial cell density. Corneas with initial endothelial cell counts greater than 1000 cells/mm(2) had a decompensation rate of 1.5%, and corneas with counts of 500 cells/mm(2) or less had a decompensation rate of 57.1% (P <.01).

CONCLUSIONS

Clinical examination and serial measurements of endothelial cell density provide the most reliable methods for monitoring patients with closed-loop anterior chamber IOLs. Endothelial cell counts can predict the rate of corneal decompensation. Patients with endothelial cell counts greater than 1000 cells/mm(2) usually do not require an IOL exchange.

Endothelial study of iris-claw phakic lens: four year follow-up

PURPOSE

To study quantitative and morphometric endothelial changes in phakic eyes implanted with the Worst iris-claw lens to correct high myopia.

SETTING

Department of Ophthalmology, University Hospital "La Fe", Valencia, Spain.

MATERIAL AND METHODS

This retrospective study involved 111 phakic eyes (73 patients) implanted with the Worst iris-claw lens. Noncontact specular microscopy and computer-assisted analysis was performed preoperatively and 6 months and 1, 2, 3, and 4 years postoperatively.

RESULTS

The mean cell loss was 3.85% at 6 months, 6.59% at 1 year, 9.22% at 2 years, 11.68% at 3 years, and 13.42% at 4 years. At 2 years, the hexagonality and coefficient variation in cell size were close to the preoperative levels. No major complications were seen; early postoperative corneal touch required intraocular lens (IOL) removal in 1 case (0.9%). Four eyes (3.6%) needed a reoperation because of poor IOL fixation (2 eyes), traumatic subluxation of the IOL (1 eye), and miscalculation of the IOL power (1 eye).

CONCLUSIONS

Although there was a slight progressive cell loss after IOL implantation, the morphometric changes recovered and were close to the preoperative levels. This suggests that endothelial damage occurred primarily during the surgical procedure.

Effects of posterior chamber lens implantation on the endothelium of transplanted corneas

AIMS

The morphological changes of the corneal endothelium after posterior chamber lens implantation in the transplanted corneas were investigated.

METHODS

36 patients underwent extracapsular cataract extraction with posterior chamber lens implantation. Among these, penetrating keratoplasty had been performed in 18 patients before cataract surgery. The indications for penetrating keratoplasty in these cases included keratoconus, herpetic keratitis, and macula cornea. 18 cataract patients with normal corneas were also studied as controls. The central corneal endothelium in each subject was examined with a wide field specular microscope at a few days before and 3 months after cataract surgery.

RESULTS

Although the transplanted corneas showed lower endothelial cell densities, marked polymegethism, and pleomorphism in the baseline variables, the endothelial morphological changes in the transplanted corneas after posterior chamber lens implantation were comparable with those in the normal corneas. Also, there was no clinical evidence, especially, of corneal epithelial and/or endothelial rejections and corneal decompensation in all corneas.

CONCLUSION

Even though the transplanted corneas have a lower endothelial cell density and marked polymegethism, it is believed that cataract surgery does not induce corneal decompensation in cases where the peripheral recipient endothelium can be considered to have normal morphology.

Iris Claw Phakic Intraocular Lens for High Myopia

BACKGROUND

The implantation of a Worst-Fechner iris claw intraocular lens (IOL) is one of the surgical procedures used for the correction of high myopia. This technique reduces myopia with stable refractive results; however, its potential long-term risks have not been evaluated. We report results in 94 eyes with a minimum follow-up of 3 years.

METHODS

We studied 94 eyes of 62 patients with myopia > or = -7.00 diopters (D) who underwent Worst-Fechner IOL implantation. Lens decentration, permeability of the blood-aqueous barrier by iris angiography, and changes in corneal endothelial density were analyzed.

RESULTS

Mean follow-up time was 48.9 months (range 36 to 72 mo). Three years after surgery, 58 eyes (61%) had an uncorrected visual acuity > or = 20/40, and 77 eyes (82%) gained two or more lines of spectacle-corrected visual acuity with respect to the preoperative value; 75 eyes (79%) were within +/- 1.00 D of emmetropia and 46 eyes (48%) were within +/- 0.50 D of emmetropia. The mean endothelial cell loss was 17.9% at 5 years after surgery, while the percentage of hexagonality and the coefficient of cell variation tended toward preoperative levels. No vision threatening complications were seen.

CONCLUSIONS

The implantation of a Worst-Fechner iris claw phakic IOL reduced high myopia with a stable refractive outcome. Endothelial cell damage was within acceptable limits. The absence of major complications makes this procedure an acceptable method for correcting high myopia.

Long term changes in human corneal endothelium following toxic endothelial cell destruction: a specular microscopic and fluorophotometric study

AIMS

To investigate the long term relation between corneal thickness, endothelial morphometric variables, and endothelial permeability in patients with endothelial cell counts under 900 cells/mm2 as a result of endothelial cell destruction after cataract surgery.

METHODS

Eighteen patients developed the so called toxic endothelial cell destruction (TECD) syndrome following routine cataract surgery because of the intracameral injection of a toxic detergent residue. Ten patients with a mean (SEM) initial cell loss of 72% (2%) were followed for 4 years. Data were obtained at 6 months and 4 years postoperatively and compared between TECD eyes and contralateral control eyes.

RESULTS

Mean (SEM) endothelial cell density of the TECD eyes increased from 642 (41) cells/mm2 to 849 (50) cells/mm2 at 4 years postoperatively (p = 0.005). There was no difference in coefficient of variation or percentage hexagonals between 6 months and 4 years postoperatively. Mean (SD) corneal thickness of the TECD eyes and control eyes was similar, 0.51 (0.02) mm and 0.49 (0.01) mm, respectively (p = 0.65). Mean (SD) endothelial permeability was also similar for TECD eyes and control eyes (4.3 (0.9) x 10(-4) cm/min and 4.4 (0.6) x 10(-4) cm/min, respectively (p = 0.57). There was no correlation between endothelial cell density, coefficient of variation, or percentage of hexagonal cells and endothelial permeability in the TECD eyes. In three patients a permanent corneal decompensation occurred.

CONCLUSIONS

Four years after TECD corneal endothelial wound healing is stable and the barrier function has been restored.

Fluorophotometry in phakic eyes with anterior chamber intraocular lens implantation to correct myopia

In this longitudinal study, we implanted 16 angle-fixated anterior chamber intra-ocular lenses in phakic eyes of 13 patients to correct high myopia. Using fluorophotometry, we discovered a statistically significant decrease (P < .01) in lens transmittance. Blood-aqueous barrier permeability tended to remain increased six months after surgery.

Intraocular lens exchange for anterior chamber intraocular lens-induced corneal endothelial damage

BACKGROUND

Anterior chamber and iris-plane intraocular lenses (IOLs) have been implicated in causing corneal endothelial damage and progression to pseudophakic bullous keratopathy.

METHODS

The authors performed IOL exchanges on 102 eyes with signs of early corneal decompensation or progressive endothelial cell loss associated with these anterior chamber or iris-plane IOLs. Replacement IOLs were posterior chamber lenses sutured to the iris (87 eyes), sutured to the sclera (3 eyes), or placed in the ciliary sulcus (12 eyes).

RESULTS

Seventy-two eyes (71%) had the same or improved vision after a mean follow-up period of 18.6 months (range, 6 to 60 months). Only 24 eyes (23.5%) progressed to corneal decompensation. Of the eyes that decompensated, 75% had preoperative endothelial cell counts of 500 cells/mm2 or less (P < 0.0001), and 83% had preoperative signs of early corneal decompensation (P < 0.001). Biomicroscopic signs of early corneal decompensation seen preoperatively in 50 eyes resolved in 17 eyes (34%) and remained unchanged in 12 eyes (24%) at the last postoperative follow-up visit.

CONCLUSION

Removal of anterior chamber and iris-plane intraocular lenses in eyes showing signs of endothelial damage may prevent progression to pseudophakic bullous keratopathy if performed before a critical degree of endothelial cell loss or dysfunction has developed.

Retinal detachment after cataract surgery. Surgical results

The authors studied the results obtained by the Retina Associates in 376 eyes of 361 patients operated on for retinal detachment associated with aphakia or pseudophakia with a postoperative follow-up of at least 6 months. All eyes underwent scleral buckling. The series included 103 eyes with aphakia, 17 eyes with iris-fixated intraocular lens, 111 eyes with anterior chamber (AC) IOL, and 145 eyes with posterior chamber (PC) IOL. The overall success rate for retinal detachment was 93%, without significant difference among the different groups. The aphakia and PC IOL groups had significantly higher prevalence (63% and 60%, respectively) of visual acuity equal to or better than 20/40 compared with the AC IOL group (33%). The prevalence of postoperative corneal edema in the AC IOL group was significantly higher than in the aphakia and PC IOL groups. Preoperative vitreous hemorrhage, large retinal breaks, posterior retinal breaks, total retinal detachment, proliferative vitreoretinopathy, and the need for performing a closed vitrectomy were significant factors in predicting ultimate failure.

Specular microscopic observation of normal human corneal epithelium

The authors analyzed the specular microscopic appearance of normal corneal epithelium, with particular regard to four cell patterns previously identified in pathologic corneas. Corneal epithelia of 75 normal eyes were examined by specular microscopy using a special compound contact lens. There were no elongated or extra large cells, whereas 44.0% and 35.7% of the corneas showed central epithelial nuclei and irregular patterns, respectively. The mean epithelial cell area and corresponding mean coefficient of variation (CV) for each of the corneas were 595.6 +/- 98.8 microns 2 and 30.3 +/- 15.3%, respectively. The values for the endothelium were 325.7 +/- 48.4 microns 2 and 33.6 +/- 6.3%, respectively. Although there was a significant Pearson correlation (r = 0.50, P less than 0.01) between mean endothelial cell area and age, none existed (r = 0.19, P greater than 0.05) between mean epithelial cell area and age, even though there was a relationship (r = 0.35, P less than 0.01) between the mean cell areas themselves. There were no significant relationships among the CV of the epithelium, that of the endothelium, and age. This study presents a powerful new technique and baseline data by which to assess normal corneal epithelium and any aberration.

Intraocular dapiprazole for the reversal of mydriasis after extracapsular cataract extraction with intraocular lens implantation. Part II: Comparison with acetylcholine

Intraocular dapiprazole for reversing mydriasis during extracapsular cataract extraction with intraocular lens (IOL) implantation has been compared to intraocular acetylcholine. Ninety patients were enrolled in a double-blind study and divided into three groups of 30 eyes; each group received balanced salt solution (control), 0.25% dapiprazole, or 1% acetylcholine. Pupillary diameter recordings were performed immediately before and a few minutes after drug injection, and two, four and eight hours after surgery. Goldmann tonometry was performed the day before and 6 and 24 hours after surgery. Contact endothelial cell count was performed before and one and four months after surgery. The results indicated a slower starting but longer lasting effect with dapiprazole than with acetylcholine and a significant reduction of the postoperative intraoperative pressure rise with both drugs. No significant difference in reduction in the endothelial cell count was seen between dapiprazole and acetylcholine groups and the control group.

Long-term endothelial cell loss and breakdown of the blood-aqueous barrier in cataract surgery

Progressive endothelial cell loss and endothelial cell loss induced at the time of surgery occurs in all eyes with rigid anterior chamber intraocular lenses (IOLs). Eyes with surgical tuck or late ovaling of the pupil following surgery have greater yearly rates of cell loss than eyes that have no complications. This progressive loss may be related to chronic uveitis from iris chafing by the implant or to direct mechanical damage to the corneal endothelium. We have demonstrated that fluorophotometry shows chronic damage to the blood-aqueous barrier in all eyes with rigid anterior chamber IOLs, but this does not correlate with the degree of endothelial cell loss. Our results suggest there is damage to the blood-aqueous barrier and to the corneal endothelium, but the damage to the latter influences progressive endothelial cell loss.

Specular microscopy at Southampton Eye Hospital

There is nothing significantly new in the technique of specular microscopy. The equipment has improved and the methods of cell counting have been automated using computer technology. This paper gives an account of how the old practice is still being used effectively in assessing the endothelial cell population, their shape and shape variability.

Natural history of cystoid macular edema in pseudophakic bullous keratopathy

A retrospective review of 25 consecutive patients having penetrating keratoplasty (PKP) with the preoperative diagnoses of pseudophakic bullous keratopathy (PBK) and cystoid macular edema (CME) was undertaken to analyze the natural history of preoperative CME following keratoplasty. Follow-up ranged from 13 to 54 months with a mean of 27 months. All patients had intraocular lens exchanges with 24 receiving posterior chamber lenses; 23 had lenses sutured to the posterior iris. Sixteen patients (64%) recovered a visual acuity of 20/40 or better. The average time for visual recovery to 20/40 was nine months with a range of two to 45 months. Eighteen (72%) had resolution of angiographic CME. Three patients previously diagnosed as having chronic CME recovered visual acuity of 20/40 or better. Cases of PBK with CME may have an excellent visual prognosis if the IOL is managed properly at the time of PKP.

Long-term changes of the corneal endothelium following intracapsular cataract extraction with implantation of open-loop anterior chamber lenses

The central corneal endothelium of a consecutive group of 158 patients with senile cataract was examined before intracapsular cataract extraction with implantation of an open-loop anterior chamber lens and 6, 12 and 48 months after surgery. Corneal endothelial morphometry was performed using an automated digital image analysis system. After 6 months of follow-up, there was an average loss of 10.8% in central corneal endothelial cell density, which increased to 14.8% after 12 months and 18.8% after 48 months. The early post-operative endothelial cell loss was correlated significantly with a decrease of cell pattern stability and polymegathism (P less than 0.0001). There was also a significant correlation between the continuous post-operative cell loss and the simultaneous changes of pattern stability and polymegathism and the age at the time of surgery (P less than 0.05).