Secondary pigmentary glaucoma associated with piggyback intraocular lens implantation

Efficacy of a Secondary Trifocal Sulcus IOL in Providing Near and Intermediate Vision in Patients with Prior Myopic Laser Vision Correction and Cataract Surgery

Purpose

To evaluate the visual function of patients with a history of prior laser vision correction and cataract surgery with implantation of a monofocal primary IOL after subsequent implantation of a secondary sulcus trifocal intraocular lens (IOL).

Setting

One clinical practice in Haugesund, Norway.

Design

Prospective, single arm, non-interventional unmasked study.

Methods

Eligible subjects who had previous laser vision correction and cataract surgery involving implantation of a monofocal IOL in the capsular bag of one or both eyes were subsequently implanted with a secondary IOL in the sulcus. Postoperative uncorrected and best distance-corrected visual acuities (VAs) were measured at distance (4 m), intermediate (60 cm), and near (40 cm), along with low contrast visual acuity and the monocular distance corrected defocus curve.

Results

Twenty-five eyes were evaluated from 7 to 24 months after trifocal implantation. The mean monocular uncorrected VAs were 0.06, 0.21 and 0.10 logMAR at distance, intermediate and near, respectively. Uncorrected near VA was 0.2 logMAR or better in 80% of eyes (20/25). VA of 0.2 logMAR or better at all test distances was achieved in 15/25 eyes (60%) in the uncorrected state and 17/25 eyes (68%) when corrected for distance vision. Binocular uncorrected distance visual acuity was 0.1 logMAR or better in all subjects while binocular uncorrected near visual acuity was 0.1 logMAR or better in all but one subject. The defocus curve showed a range of functional vision from distance to 30 cm. No adverse events were identified.

Conclusion

The trifocal sulcus IOL provided excellent distance and near vision and a good range of functional vision, similar to results obtained when a primary trifocal IOL is implanted. It is a viable option to provide better intermediate and near vision to patients with a prior history of refractive surgery and a monofocal IOL implanted.

Refractive and Visual Outcomes After Implantation of a Secondary Sulcus Intraocular Lens with an Extended Depth of Focus

Purpose

To evaluate the range of vision, visual function, and quality of vision after implantation of a secondary extended depth of focus intraocular lens (EDOF IOL) implanted in the sulcus.

Setting

One clinical practice in Haugesund, Norway.

Design

Prospective single arm non-interventional study.

Methods

Eligible subjects presenting for surgery, or who had previous successful primary cataract or refractive lens exchange surgery in both eyes were subsequently implanted with the AddOn® secondary EDOF IOL in the sulcus. Manifest refraction and visual acuity at distance, intermediate and near were measured 3 months after surgery, along with the monocular defocus curve. Subjects also completed a visual function and a quality of vision questionnaire.

Results

The study included 32 eyes of 16 subjects. At 3 months postoperative, the mean refraction spherical equivalent (MRSE) was −0.16 ± 0.30 D, with a residual cylinder of 0.29 ± 0.27 D. The mean monocular uncorrected VA was 0.1 logMAR (20/25) or better at all test distances. The monocular defocus curves showed a depth of focus of 2.0 D. For every category except reading fine print, all but one subject (94%) had no difficulty or little difficulty with near tasks. Glare and halos were the most common visual disturbances, with no reports of starbursts. There was no evidence of any intralenticular opacification in any of the eyes, and no evidence of iris chafing/depigmentation.

Conclusion

This secondary EDOF IOL provided excellent distance and intermediate vision, and very good near vision to subjects. Subject reported near visual function was also very good and visual disturbances were limited. This lens appears to be a good option for patients who would like to improve their range of vision. Results appear as good or better than those reported for primary EDOF lenses.

Self-identified Black Race as a Risk Factor for Intraocular Pressure Elevation and Iritis Following Prophylactic Laser Peripheral Iridotomy

PRCIS

In primary angle closure suspects (PACS), self-identified Black race was a risk factor for intraocular pressure (IOP) elevation and iritis following laser peripheral iridotomy (LPI). Laser type was not associated with either immediate post-LPI IOP elevation or iritis in multivariate analysis.

PURPOSE

The aim was to determine the impact of laser type and patient characteristics on the incidence of IOP elevation and iritis after LPI in PACS.

MATERIALS AND METHODS

The electronic medical records of 1485 PACS (2407 eyes) who underwent either neodymium-doped yttrium-aluminum-garnet or sequential argon and neodymium-doped yttrium-aluminum-garnet LPI at the University of Pennsylvania between 2010 and 2018 were retrospectively reviewed. Average IOP within 30 days before LPI (baseline IOP), post-LPI IOP within 1 hour, laser type, laser energy, and the incidence of new iritis within 30 days following the procedure were collected. Multivariate logistic regression accounting for intereye correlation was used to assess factors associated with incidence of post-LPI IOP elevation and iritis, adjusted by age, sex, surgeon, and histories of autoimmune disease, diabetes, and hypertension.

RESULTS

The incidence of post-LPI IOP elevation and iritis were 9.3% (95% confidence interval: 8.1%-10.5%) and 2.6% (95% CI: 1.9%-3.2%), respectively. In multivariate analysis, self-identified Black race was a risk factor for both IOP elevation [odds ratio (OR): 2.08 compared with White; P=0.002] and iritis (OR: 5.07; P<0.001). Higher baseline IOP was associated with increased risk for post-LPI IOP elevation (OR: 1.19; P<0.001). Laser type and energy were not associated with either post-LPI IOP elevation or iritis (P>0.11 for all).

CONCLUSIONS

The incidence of immediate IOP elevation and iritis following prophylactic LPI was higher in Black patients independent of laser type and energy. Heightened vigilance and increased medication management before and after the procedure are suggested to help mitigate these risks.

Secondary Piggyback Intraocular Lens for Management of Residual Ametropia after Cataract Surgery

Purpose

To investigate the indications, clinical outcomes, and complications of secondary piggyback intraocular lens (IOL) implantation for correcting residual refractive error after cataract surgery.

Methods

In this prospective interventional case series, patients who had residual refractive error after cataract surgery and were candidates for secondary piggyback IOL implantation between June 2015 and September 2018 were included. All eyes underwent secondary IOL implantation with the piggyback technique in the ciliary sulcus. The types of IOLs included Sulcoflex and three-piece foldable acrylic lenses. Patients were followed-up for at least one year.

Results

Eleven patients were included. Seven patients had hyperopic ametropia, and four patients had residual myopia after cataract surgery. The preoperative mean of absolute residual refractive error was 7.20 ± 7.92, which reached 0.42 ± 1.26 postoperatively (P< 0.001). The postoperative spherical equivalent was within ±1 diopter of target refraction in all patients. The average preoperative uncorrected distance visual acuity was 1.13 ± 0.35 LogMAR, which significantly improved to 0.41 ± 0.24 LogMAR postoperatively (P = 0.008). There were no intra- or postoperative complications during the 22.4 ± 9.5 months of follow-up.

Conclusion

Secondary piggyback IOL implantation is an effective and safe technique for the correction of residual ametropia following cataract surgery. Three-piece IOLs can be safely placed as secondary piggyback IOLs in situations where specifically designed IOLs are not available.

Clinical and Surgical Outcome of a Supplementary Multifocal Intraocular Lens Implanted with a Bag-In-the-Lens Intraocular Lens: 5-Year Follow-Up

INTRODUCTION

To assess the postoperative outcome and patient-reported satisfaction, spectacle independence, and dysphotopsia after implantation with the mutifocal Rayner Sulcoflex supplementary intraocular lens (sIOL).

MATERIALS AND METHODS

We analyzed the outcome of all patients implanted with a multifocal sIOL between 2009 and 2011. In all cases, the sIOL was the Rayner Sulcoflex IOL (type 653F) and the primary IOL was a bag-in-the-lens (BIL) IOL. The data were obtained through a retrospective analysis of the patient records and by means of a questionnaire, 5 years after sIOL implantation.

RESULTS

This study included 31 eyes of 20 patients. In 13 eyes, the sIOL needed explantation (n = 13, 41.94%). Dysphotopsia is a frequent complaint (12/15 patients: 80.0%) after sIOL implantation. In 13 out of 31 eyes (41.94%), pigment deposits were found on the sIOL with variable clinical complaints. Five eyes required additional surgery because of clinically significant deposits.

DISCUSSION/CONCLUSION

Patients with a multifocal sIOL in combination with a BIL implantation have a higher incidence of dysphotopsia compared to previously published studies. Dysphotopsia was the main complaint and reason for explantation. We encountered a high incidence of pigmented IOL deposits. The sIOLs can be safely removed even years after implantation.

Outcomes of refractive error correction in pseudophakic patients using a sulcus piggyback intraocular lens

PURPOSE

The purpose of this study was to assess the results of a sulcus intraocular lens (Sulcoflex) for pseudophakic refractive errors following phacoemulsification cataract surgery.

METHODS

This retrospective clinical observational cohort study included consecutive eyes in which a Sulcoflex was implanted. Uncorrected distance visual acuity and corrected distance visual acuity as well as refractive outcomes were assessed. The minimum follow-up time required for inclusion was 3 months.

RESULTS

In total, 15 eyes (n = 15) were evaluated. The mean follow-up was 14 months (range: 3-18 months). The Sulcoflex aspheric (653L) was implanted in 13 eyes and the Sulcoflex toric (653T) in two eyes. The preoperative mean logMAR (Snellen) uncorrected distance visual acuity and corrected distance visual acuity were 0.88 (20/150) and 0.27 (20/40), respectively. The postoperative mean logMAR (Snellen) corrected distance visual acuity was 0.15 (20/30). The preoperative mean spherical equivalent was -0.22 ± 5.95 D and the postoperative mean spherical equivalent was -1.59 ± 1.45 D. There was a significant and strong correlation (r = 0.64, p < 0.001) between the attempted and the achieved spherical equivalent.

CONCLUSION

The Sulcoflex is a safe and viable option for patients with residual refractive error following cataract surgery.

Residual Iris Retraction Syndrome After Artificial Iris Implantation

PURPOSE

To evaluate the effect of an artificial iris implant on the remnant iris.

DESIGN

Interventional case series.

METHODS

Setting: Single center.

PATIENT POPULATION

Forty-two consecutive patients.

OBSERVATION PROCEDURES

Morphologic evaluation over 24 ± 14 months.

MAIN OUTCOME MEASURES

Remnant pupillary aperture, iris color, visual acuity, intraocular pressure, and endothelial cell count.

RESULTS

In 7 of 42 cases (16.7%), the residual iris aperture dilated from 36.6 ± 15.4 mm² preoperatively to 61.1 ± 12.5 mm² 1 year postoperatively (66.9% increase). In 5 of 7 affected eyes the artificial iris had been implanted into the ciliary sulcus; in 2 eyes it had been sutured to the sclera. Four of the 7 patients presented with remarkable complications: 2 eyes needed glaucoma shunt surgeries owing to pigment dispersion; 1 suffered from recurrent bleedings; and in 1 case artificial iris explantation was performed owing to chronic inflammation. Anterior chamber depth and angle, endothelial cell count, and visual acuity did not change in this cohort. Changes in color were not observed in the remnant iris.

CONCLUSIONS

The implantation of an artificial iris prosthesis can lead to a residual iris retraction syndrome. It is likely that residual iris is trapped in the fissure between the artificial iris and the anterior chamber angle, preventing further pupil constriction. Another possibility could be a constriction or atrophy of the residual iris. A scleral-sutured implant and an implantation in the capsular bag were both found to prevent the iris retraction. The study group number is inadequate to allow statistical comparison of these different implantation methods. As the use of artificial irises increases, we may expect more patients with iris retraction syndrome in the future.

Advanced pigment dispersion glaucoma secondary to phakic intraocular collamer lens implant

Purpose

We report a case of pigment dispersion glaucoma secondary to uncomplicated phakic intraocular collamer lens (ICL) (Visian ICL™, Staar Inc., Monrovia, CA) implant that resulted in advanced visual field loss.

Observations

A 50-year-old man presented for routine follow-up status post bilateral phakic intraocular collamer lens (ICL) placement 8 years earlier. He was incidentally found to have a decline in visual acuity from an anterior subcapsular cataract and elevated intraocular pressure (IOP) in the left eye. There were signs of pigment dispersion and no evidence of angle closure. Diffuse optic nerve thinning was consistent with advanced glaucomatous visual field defects. Pigment dispersion was also present in the patient's right eye, but without elevated IOP or visual field defects. The patient was treated with topical glaucoma medications and the phakic ICL in the left eye was removed concurrently with cataract surgery to prevent further visual field loss.

Conclusions and importance

Pigment dispersion glaucoma is a serious adverse outcome after phakic ICL implantation and regular post-operative monitoring may prevent advanced visual field loss.

Angle-Closure Glaucoma after Piggyback Intraocular Lens Implantation

Purpose

To report a case of angle closure glaucoma after piggyback intraocular lens implantation and its treatment.

Methods

The authors present the case of a 75-year-old woman who was seen in the emergency department with angle closure glaucoma. Two years before she had undergone piggyback intraocular lens (IOL) implantation in order to correct a refractive error after cataract surgery. Ultrasound biomicroscopy revealed a closed angle with synechiae in 360° as well as the presence of two IOLs: one in the capsular bag and the other in the ciliary sulcus. Extraction of the anterior IOL was precluded due to the poor endothelial count. Peripheral iridotomy and trabeculectomy were ineffective to lower the intraocular pressure (IOP); the authors decided to implant with an Ahmed valve and to place the valve's tube between the two IOLs to protect the endothelium.

Results

After Ahmed valve implantation, IOP maintains stable around 10–12 mmHg without medical treatment.

Conclusions

Ahmed valve implantation is a good option in angle closure glaucoma due to piggyback. The placement of the valve's tube between the two IOLs is a good option to protect corneal endothelium.

Supplementary IOLs: Monofocal and Multifocal, Their Applications and Limitations

Supplemental intraocular lenses (IOLs) have been developed to replace IOLs designed for in-the-bag placement being used as "piggy-back" IOLs in the sulcus due to unacceptable complications. The new IOLs have unique platform designs to avoid these complications. As a result, a new nomenclature is needed to describe the 4 scenarios when supplemental IOL use is now indicated.

Refractive outcomes in nanophthalmic eyes after phacoemulsification and implantation of a high-refractive-power foldable intraocular lens

PURPOSE

To evaluate the refractive and postoperative outcomes of a high-power foldable intraocular lens (IOL) in nanophthalmic eyes.

SETTING

Six ophthalmic surgical centers in Canada.

DESIGN

Retrospective case series.

METHODS

Consecutive charts of nanophthalmic patients having cataract extraction and insertion of the CT Xtreme D IOL were reviewed. Demographic and clinical data were collected, including age, sex, axial length (AL), minimum keratometry (K) value and maximum K value, corneal white-to-white (WTW), anterior chamber depth, lens thickness (LT), and complications. The following preoperative and operative data were collected: uncorrected distant visual acuity (UDVA), corrected distant visual acuity (CDVA), sphere, cylinder, and spherical equivalence (SE). The primary outcome measure was change in SE. The secondary outcome measures were changes in UDVA and CDVA.

RESULTS

A total of 21 eyes from 13 patients with a mean follow-up time of 9.6 ± 8.5 months were studied. Mean preoperative data were: age (51.4 ± 15.2 years), AL (16.63 ± 0.68 mm), minimum K value (46.20 ± 2.26 D), maximum K value (47.55 ± 2.34 D), anterior chamber depth (2.60 ± 0.49 mm), WTW (11.08 ± 1.38 mm), LT (4.70 ± 0.97 mm), and IOL power implanted (+49.9 ± 3.3 diopters [D]). SE improved from +16.11 ± 3.26 D preoperatively to +2.00 ± 2.37 D postoperatively (P < .0001). UDVA improved from 1.47 ± 0.30 logMAR preoperatively to 0.74 ± 0.43 logMAR postoperatively (P = .016). CDVA did not change significantly. Five eyes (23.8%) had serious postoperative complications. Of these eyes, 2 had malignant glaucoma, 2 had vitreous hemorrhages, and 1 eye had a vitreous hemorrhage with retinal detachment resulting in visual acuity of no light perception.

CONCLUSION

Implanting foldable high-power IOLs in a series of nanophthalmic eyes yielded significant improvement in UDVA and SE. Cataract surgery in these eyes carries increased risk.

FINANCIAL DISCLOSURE

Iqbal Ike K. Ahmed is a consultant to Carl Zeiss Meditec AG. No other author has a financial or proprietary interest in any material or method mentioned.

Analysis of the Optical Quality of Spherical and Aspheric Intraocular Lenses in Simulated Nanophthalmic Eyes

PURPOSE

To analyze the optical performance of different implant strategies in simulated nanophthalmic eyes.

METHODS

An optical design software was used. Analysis included eye models that required 30.00, 45.00, and 60.00 diopters (D) intraocular lenses (IOLs) to achieve emmetropia. Spherical and aspheric IOLs were designed. They were tested either with a single implant setting S or by splitting the power into two lenses. Setting P1 had an even split of the power between the lenses and setting P2 had an uneven power split with one-third of the power in the anterior lens and two-thirds in the posterior IOL. The area under the modulation transfer function (MTF) curve was calculated and spherical aberration was recorded in each setting.

RESULTS

Setting S had the worst optical performance in the spherical group and the best performance in the aspheric group. A statistically significant difference was found between setting S and the piggyback options (settings P1 and P2) in all analyzed variables for the spherical and aspheric groups for the 45.00 and 60.00 D IOL requirement. No statistically significant difference was found between the piggyback settings.

CONCLUSIONS

Single aspheric IOLs had better optical performance than piggybacking lower-power aspheric IOLs. In the spherical lenses group, the results were the opposite, with the piggyback options having higher optical quality than the single IOL. MTF shows that single aspheric lenses provide the highest contrast sensitivity among all of the analyzed settings.

Stability and safety of MA50 intraocular lens placed in the sulcus

PURPOSE

To describe the safety and stability of sulcus placement of the MA50 intraocular lens (IOL).

PATIENTS AND METHODS

Consecutive patients with MA50 IOLs placed in the sulcus at the University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA, from 1997 to 2012 were identified. Inclusion criteria included patients with over 4 weeks of follow-up data. AEL was compared with incidence of IOL decentration using at two-tailed Student's t-test.

RESULTS

Fifty eyes of 49 patients meeting the inclusion criteria were identified. Four weeks post-operatively, the average best-corrected visual acuity was 20/30. IOL decentration occurred in 14% of patients; patients with decentered IOLs had a significantly longer average AEL (25.37 mm) than patients whose IOL remained centered (23.94 mm, P=0.017). Other complications included uveitis-glaucoma-hyphema syndrome (12%), iritis (8%), and glaucoma (6%). There were no cases of pigment dispersion syndrome or need for lens exchange. Twelve eyes (24%) had intra-operative optic capture by the anterior capsule, none of which had post-operative decentration.

CONCLUSION

The MA50 IOL is a reasonable, stable option for placement in the sulcus, with a low-risk profile; however, in eyes with longer AEL and presumably larger anterior segment, surgeons should consider placing an IOL with longer haptic distance than the MA50 to maintain centration. Optic capture of the MA50 IOL by the anterior capsule should be considered for longer eyes, as it is protective against decentration.

Corrective Techniques and Future Directions for Treatment of Residual Refractive Error Following Cataract Surgery

Postoperative residual refractive error following cataract surgery is not an uncommon occurrence for a large proportion of modern-day patients. Residual refractive errors can be broadly classified into 3 main categories: myopic, hyperopic, and astigmatic. The degree to which a residual refractive error adversely affects a patient is dependent on the magnitude of the error, as well as the specific type of intraocular lens the patient possesses. There are a variety of strategies for resolving residual refractive errors that must be individualized for each specific patient scenario. In this review, the authors discuss contemporary methods for rectification of residual refractive error, along with their respective indications/contraindications, and efficacies.

Ultrasound biomicroscopy in chronic pseudophakic ocular inflammation associated with misplaced intraocular lens haptics

PURPOSE

To evaluate the usefulness of ultrasound biomicroscopy in confirming intraocular lens haptic-induced ocular irritation and in the management of these patients.

DESIGN

A retrospective review of patient data.

METHODS

Twenty pseudophakic patients who underwent ultrasound biomicroscopy examination between May 2009 and February 2011 to confirm the clinical suspicion of misplacement of intraocular lens haptics were reviewed. Ophthalmic findings at the time of presentation and at each follow-up visit, and management of each patient, were recorded.

RESULTS

Intraocular lens haptic misplacement was confirmed by ultrasound biomicroscopy in all suspected cases. In 75% of the eyes 1 haptic was embedded in the iris; it extended into the ciliary body process in 35% and into the pars plana in 10%. Focal iris thinning/atrophy was detected by ultrasound biomicroscopy in 15% of cases and focal angle closure in 25%. Intraocular lens exchange was performed in 40% of patients. The remaining 60% were kept under observation, with the addition of topical steroids and/or cycloplegics in eyes that demonstrated anterior chamber inflammation and intraocular pressure-lowering medications in eyes with persistent elevated intraocular pressure or glaucoma.

CONCLUSIONS

Ultrasound biomicroscopy appears to be a valuable tool in confirming the presence of haptic-induced ocular irritation and in assisting the management of these patients.

Late-onset secondary pigmentary glaucoma following foldable intraocular lenses implantation in the ciliary sulcus: a long-term follow-up study

Background

To review the long-term outcomes of eyes with secondary pigmentary glaucoma associated with the implantation of foldable intraocular lenses (IOL) in the ciliary sulcus.

Methods

The study retrospectively reviewed a series of cases who developed secondary pigmentary glaucoma after cataract operations. Data were collected from cases that were referred between 2002 and 2011.

Results

Ten eyes of 10 patients who developed secondary pigmentary glaucoma after foldable IOLs implantation in the sulcus were included in this study.

Intraocular pressure (IOP) elevation was present in 2 eyes (20%) within the first 2 weeks following the initial cataract operation. The onset of glaucoma was delayed in the other 8 eyes (80%); the average onset time in these eyes was 21.9 ± 17.1 months after the initial cataract operation. Six eyes (60%) received surgical treatment because of large fluctuations and poor control of IOPs. Only 3 eyes (30%) achieved final visual acuities better than 20/40.

Conclusion

Secondary pigmentary glaucoma accompanying the implantation of a foldable IOL in the ciliary sulcus may present as acute IOP elevation during the early postoperative period or, more commonly, late onset of IOP elevation accompanied by advanced glaucomatous optic nerve damage. Despite treatment, the visual prognosis for these patients can be poor. Placing a foldable IOL in the ciliary sulcus could pose a threat to the vision of the patients and long-term follow-up of IOP in these patients is necessary.

Pathologic comparison of asymmetric or sulcus fixation of 3-piece intraocular lenses with square versus round anterior optic edges

OBJECTIVE

To evaluate the pathologic findings of 3-piece intraocular lenses (IOLs) with asymmetric or sulcus fixation in pseudophakic cadaver eyes, comparing IOLs with square or round edges on the anterior optic surface.

DESIGN

Comparative case series with pathology.

PARTICIPANTS

A total of 661 pseudophakic cadaver eyes, obtained from eye banks within the United States, implanted with different IOLs.

METHODS

Anterior segment scanning of whole eyes with a high-frequency ultrasound system or high-resolution anterior segment magnetic resonance imaging followed by gross examination. Selected eyes were processed for complete histopathologic analysis.

MAIN OUTCOME MEASURES

Findings from imaging, gross, and histopathologic evaluation that could be related to out-of-the-bag fixation of the lenses.

RESULTS

Of 661 pseudophakic cadaver eyes obtained, 13 had 3-piece hydrophobic acrylic IOLs with anterior and posterior square optic edges, and 14 had 3-piece lenses with anterior round edges (13 silicone lenses and 1 hydrophobic acrylic lens) without symmetric in-the-bag fixation. These 27 selected eyes were processed for complete histopathologic analysis. Gross findings in both groups were composed of IOL decentration and tilt, pigmentary dispersion within the anterior segment and on the IOL surface, and iris transillumination defects. Histopathology of the 14 eyes with 3-piece IOLs with round anterior optic edges showed mild focal disruption of the iris pigmented layer and loop protrusion/erosion in the ciliary sulcus. Additional changes observed in the 13 eyes with square anterior optic edge IOLs included iris changes, such as vacuolization, disruption and loss of the pigmented epithelial layers, iris thinning and atrophy, synechiae, and pigmentary dispersion within the trabecular meshwork. One eye also exhibited initial signs of optic nerve disc cupping.

CONCLUSIONS

In this series, pathologic findings were more severe in eyes implanted with 3-piece IOLs with square anterior optic edges, suggesting that IOLs with round anterior edges are more suitable for sulcus fixation.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Pathologic assessment of complications with asymmetric or sulcus fixation of square-edged hydrophobic acrylic intraocular lenses

OBJECTIVE

One-piece hydrophobic acrylic intraocular lenses (IOLs) are not indicated for sulcus fixation because of complications, such as uveitis-glaucoma-hyphema syndrome. Similar complications may also be observed with 3-piece lenses that have a square optic edge on the anterior surface. The objective of this study was to provide pathologic evidence of complications related to out-of-the-bag fixation of 1- or 3-piece hydrophobic acrylic IOLs with anterior and posterior square optic edges.

DESIGN

Comparative case series with pathology.

PARTICIPANTS

A total of 661 pseudophakic cadaver eyes obtained from eye banks within the United States, implanted with different IOLs.

METHODS

Anterior segment scanning of whole eyes with a high-frequency ultrasound system or high-resolution anterior segment magnetic resonance imaging, followed by gross examination. Selected eyes were processed for complete histopathologic analysis; some of them were explanted before histopathology to allow for direct light microscopic evaluation of the lenses.

MAIN OUTCOME MEASURES

Findings from imaging, gross, and histopathologic evaluation that could be related to out-of-the-bag fixation of the lenses.

RESULTS

A total of 256 eyes were implanted with hydrophobic acrylic IOLs with anterior and posterior square optic edges; 18 of them exhibiting asymmetric or sulcus IOL fixation (six 1-piece and twelve 3-piece IOLs) underwent complete histopathologic evaluation and were compared with the contralateral eyes with symmetric in-the-bag IOL implantation. Pathologic findings were composed of IOL decentration and tilt, pigmentary dispersion within the anterior segment and on the IOL surface, iris transillumination defects, iris changes including vacuolization/disruption/loss of the pigmented layer, iris thinning, and iris atrophy, as well as synechiae and loop erosion in the case of 3-piece lenses. Findings were more significant in comparison with the control contralateral eyes and were particularly evident in relation to the sulcus-fixated haptic in the case of 1-piece lenses. The majority of the eyes with 3-piece lenses showed signs of complicated surgery.

CONCLUSIONS

This study provides pathologic correlation of complications that were clinically reported in the peer-reviewed literature in relation to sulcus fixation of 1-piece hydrophobic acrylic IOLs. The eyes with 3-piece lenses generally exhibited evidence of complicated surgery; therefore, all pathologic findings in those cases may not be strictly attributed to the out-of-the-bag fixation.

Unilateral sulcus implantation of the crystalens HD

PURPOSE

To evaluate the results after unilateral sulcus implantation of the Crystalens HD (Bausch & Lomb) accommodative intraocular lens (IOL).

METHODS

This retrospective interventional case series comprised six eyes from three patients who underwent cataract surgery and bilateral Crystalens HD accommodative IOL implantation. The Crystalens HD was implanted in the bag in one eye (non-sulcus group) and, due to posterior capsule rupture, the lens was positioned in the ciliary sulcus in the fellow eye (sulcus group).

RESULTS

Mean patient age was 66.3 ± 4.9 years (range: 60 to 72 years). Mean follow-up was 14.3 ± 3.2 months (range: 12 to 18 months) for the non-sulcus group and 14 ± 2 months (range: 12 to 16 months) for the sulcus group. Uncorrected distance visual acuity improved from 20/100 to 20/33 in the non-sulcus group and from 20/63 to 20/32 in the sulcus group during last follow-up. Corrected distance visual acuity improved from 20/35 to 20/20 in the non-sulcus group and from 20/27 to 20/23 in the sulcus group. Regarding near vision, all eyes in the sulcus group and 66.7% of eyes in the non-sulcus group achieved J1-J2 (Birkhauser reading chart). None of the eyes had any intra- (except posterior capsule rupture in the sulcus cases) or postoperative complications.

CONCLUSIONS

Based on this small series, ciliary sulcus implantation of the Crystalens HD seems to be associated with no significant morbidity and provides satisfactory visual acuity outcomes.

Black-on-clear piggyback technique for a black occlusive intraocular device in intractable diplopia

Black occlusive intraocular devices have been used successfully for intractable binocular diplopia. We describe a novel technique of implanting both a black occlusive device and a clear poly(methyl methacrylate) intraocular lens (IOL) in the capsular bag during phacoemulsification surgery. If the need should arise at a later date, this approach will allow safer and easier explantation of the black occlusive device, avoiding the need for IOL exchange.

Pigment dispersion syndrome associated with intraocular lens implantation: a new surgical technique

Aims

We report the case of a myopic patient who, after intraocular lens transplant in the posterior chamber, suffered elevated intraocular pressure due to pigment dispersion, with recurrent episodes of blurred vision. The patient was treated with a new surgical technique that can avoid potential iridolenticular contact.

Methods

Complete ophthalmologic examination and optical coherence tomography (OCT) of the anterior segment were performed.

Results

Contact between the pigmentary epithelium and the iris with an intraocular lens was revealed by utrasound biomicroscopy and OCT. In this case, Nd:YAG laser iridotomy and laser iridoplasty were not effective for iridolenticular separation and control of the pigment dispersion. We propose a new technique: stitches on the surface of the iris to obtain good iridolenticular separation and good intraocular pressure control.

Conclusion

Stitches on the iris surface should be considered as optional therapy in pigmentary glaucoma secondary to intraocular lens implantation. This surgical technique can avoid potential iridolenticular contacts more definitively.

Refractive surgery after corneal transplant

PURPOSE OF REVIEW

Ametropia and astigmatism following successful penetrating keratoplasty can seriously impact a patient's quality of vision. Similar limitations can result following anterior lamellar keratoplasty (ALK) and Descemet's stripping endothelial keratoplasty (DSEK). These patients often suffer from aniseikonia and can be intolerant of spectacles and contact lenses. Refractive surgery can correct both ametropia and astigmatism following corneal transplantation and improve a patient's final visual outcome. The same methods used to correct naturally occurring refractive errors are being used with increasing success in patients who have undergone corneal transplants.

RECENT FINDINGS

Many refractive options are available to treat ametropia following penetrating keratoplasty. Incisional keratotomies have been employed to treat high amounts of astigmatism. Photorefractive keratectomy (PRK) and laser in-situ keratomileusis (LASIK) are also used to treat myopia, hyperopia and astigmatism. LASIK has been shown to have an overall better outcome compared to PRK; however, the use of mitomycin-C with PRK has improved results. Phakic and pseudophakic piggyback intraocular lenses are also being used to treat high degrees of ametropia and astigmatism; however, the long-term results are somewhat limited.

SUMMARY

Refractive surgery can improve the final visual outcome of patients who have undergone successful corneal transplantation. Currently available modalities provide many options for patients who are intolerant of spectacles and contact lenses. Continued advances and research will enable surgeons to optimize visual quality in postkeratoplasty patients.

Pigment dispersion with elevation of intraocular pressure after bilateral phacoemulsification with implantation of acrylic intra-ocular lenses

The purpose is to report a case and management of secondary Pigment Dispersion (PD) with severe elevation of the Intraocular Pressure (IOP) after bilateral uncomplicated phacoemulsification with implantation "within the capsular bag" of hydrophobic acrylic intra-ocular lenses (HAIOLs). The patient, a 68-year-old Hispanic male, developed severe anterior segment PD in both eyes after uncomplicated bilateral cataract surgery with implantation within-the-capsular-bag of HAIOLs one week apart. This PD was accompanied by severe elevation of the IOPs in both eyes. After filtering surgery in the worse affected eye, and medical therapy for both, the IOPs stabilized and the patient retained good distance and near uncorrected visual acuity (UCVA). HAIOLs implantation may lead to PD and IOP elevation, even when correctly placed within the capsular bag. A separation of at least two weeks between surgeries would have prevented the occurrence of this rare complication in both eyes at the same time.

Complications of sulcus placement of single-piece acrylic intraocular lenses: recommendations for backup IOL implantation following posterior capsule rupture

PURPOSE

To describe complications arising from sulcus placement of single-piece acrylic (SPA) intraocular lenses (IOLs), evaluate IOL options for eyes that lack adequate capsule support, and examine the appropriateness of various IOL designs for sulcus placement.

SETTING

University and private anterior segment surgery practices.

METHODS

Patients referred for complications of SPA IOLs in the ciliary sulcus from 2006 and 2008 were identified. Demographic information, examination findings, and complications of the initial surgery were recorded. Details of surgical interventions and the most recent corrected distance visual acuity (CDVA) were noted. A thorough review of the literature was undertaken to analyze options for IOL placement.

RESULTS

Complications of sulcus SPA IOLs included pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage, and cystoid macular edema. Two patients in the series of 30 patients experienced 1 complication; 8 experienced 2 complications; 13 experienced 3 complications; 4 experienced 4 complications; and 2 experienced 5 complications. Twenty-eight eyes (93%) required surgical intervention; IOL exchange was performed in 25 (83%). Postoperatively, the mean CDVA improved, with most eyes attaining 20/20.

CONCLUSIONS

Intraocular lenses designed solely for the capsular bag should not be placed in the ciliary sulcus. Backup IOLs in appropriate powers, sizes, and designs should be available for every cataract procedure. The development, investigation, and supply of IOLs specifically designed for placement in eyes that lack adequate capsule support represent clinically important endeavors for ophthalmology and the ophthalmic industry.

Novel observations and potential applications using digital infrared iris imaging

Digital infrared iris photography using a modified digital camera system was performed on approximately 300 subjects seen during routine clinical care and research at one facility. Because this image database offered an opportunity to gain new insight into the potential utility of infrared iris imaging, it was surveyed for unique image patterns. Then, a selection of photographs was compiled that would illustrate the spectrum of this imaging experience. Potentially informative image patterns were observed in subjects with cataracts, diabetic retinopathy, Posner-Schlossman syndrome, iridociliary cysts, long anterior lens zonules, nevi, oculocutaneous albinism, pigment dispersion syndrome, pseudophakia, suspected vascular anomaly, and trauma. Image patterns were often unanticipated regardless of preexisting information and suggest that infrared iris imaging may have numerous potential clinical and research applications, some of which may still not be recognized. These observations suggest further development and study of this technology.

Refraktive Langzeitergebnisse nach Huckepackimplantation

BACKGROUND

Piggyback lens implantation is an alternative to exchange of the original intraocular lens (IOL) to treat high anisometropia in pseudophakic eyes. We present our results.

PATIENTS AND METHOD

A second IOL (piggyback) was implanted in 27 patients from 2000 to 2006. Nineteen patients were clinically investigated late postoperatively, and data for the other eight patients were evaluated from the patients' files.

RESULTS

The patients were 65+/-9 years old. Follow-up time was 38+/-25 months. The mean preoperative spherical equivalent (SE) in the myopic eyes was -7.86+/-3.82 D and in the hyperopic eyes was 1.64+/-0.74 D. After surgery, the mean SE in the myopic eyes was -1.77+/-1.82 D and in the hyperopic eyes was -0.09+/-0.51 D. Postoperative anisometropia was reduced from 4.64+/-3.3 D. to 0.9+/-0.82 D.

CONCLUSION

Piggyback lens implantation is a safe and effective surgical procedure and is less traumatic than exchange of the original IOL.

Pigmentary dispersion syndrome with a secondary piggyback 3-piece hydrophobic acrylic lens

We describe a case of pigmentary dispersion syndrome resulting from secondary piggyback implantation of a 3-piece hydrophobic acrylic squared-edged intraocular lens (IOL) in the ciliary sulcus. The intraocular pressure remained elevated despite pharmacological treatment, with a heavily pigmented trabecular meshwork. The piggyback IOL was subsequently explanted and replaced by a silicone IOL with smooth round edges. Examination of the explanted IOL under light and scanning electron microscopy showed clusters of pigment epithelial cells located around the periphery of the anterior optic surface.

Primary piggyback implantation of 3 intraocular lenses in nanophthalmos

We present a patient with bilateral nanophthalmos who had uneventful cataract extraction in the right eye with primary implantation of 3 intraocular lenses (IOLs) of 2 different materials: a 30 diopter (D) acrylic IOL and a 9 D silicone IOL in the capsular bag and a 30 D silicone IOL in the ciliary sulcus. Subsequently, cataract extraction was done in the left eye with bag-sulcus implantation of two 30 D silicone IOLs. The use of 3 IOLs in 1 eye was necessary because the highest available power of acrylic and silicone IOLs at our institution was 30 D. The only short-term complications were temporary corneal edema and partial displacement of the sulcus IOL anterior to the iris in the right eye and bilateral posterior capsule opacification. The late complication of interlenticular opacification was not present 1 year after piggyback IOL implantation.

Bilateral ciliary sulcus implantation of secondary piggyback multifocal intraocular lenses

Ciliary sulcus implantation of secondary multifocal intraocular lenses (IOLs) is an uncommon procedure. We describe a young pseudophakic patient with monofocal IOLs who achieved a high level of satisfaction following bilateral implantation of multifocal IOLs. They were used successfully to correct a residual refractive error for distance vision and to provide spectacle-independence for near vision. Postoperative symptoms such as glare were not problematic.

Scheimpflug measurement of intraocular lens position after piggyback implantation of foldable intraocular lenses in eyes with high hyperopia

PURPOSE

To investigate the position of 3-piece foldable intraocular lenses (IOLs) after piggyback implantation for high hyperopia.

SETTING

University Eye Hospital, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.

METHODS

Eight eyes of 5 highly hyperopic patients had phacoemulsification and implantation of 2 foldable IOLs. In 3 eyes, both IOLs were implanted in the capsular bag. In 5 eyes, 1 IOL was placed in the capsular bag and the second IOL in the ciliary sulcus. Intraocular lens optic tilt and decentration, combined thickness of both IOLs, and anterior chamber depth (ACD) were measured postoperatively over a period of 18 months using Scheimpflug photography.

RESULTS

All eyes with both IOLs in the capsular bag showed interpseudophakic opacification, with a mean increase in combined IOL thickness of 0.4 mm, a decrease in ACD of 0.3 mm, and a corresponding hyperopic shift of 4.00 diopters. Eyes in which the anterior IOL was placed in the ciliary sulcus showed no changes in refraction or combined IOL thickness. In these eyes, the anterior IOL had a higher mean decentration (0.49 mm +/- 0.20 [SD] after 12 months) than the posterior IOL (0.21 +/- 0.13 mm after 12 months).

CONCLUSIONS

Piggyback IOL implantation with placement of 2 foldable IOLs in the capsular bag can be followed by a hyperopic shift that may be caused in part by displacement of the IOLs. Placement of the anterior IOL in the ciliary sulcus can lead to higher decentration of this IOL.