Ten-year follow-up of a ciliary sulcus-fixated silicone phakic posterior chamber intraocular lens

Prototype posterior chamber phakic IOL - 35 year follow up

Purpose

To present a case involving a rarely seen prototype posterior chamber phakic IOL (PC-pIOL) in a highly myopic patient with bilateral cataract.

Observations

A 64-year-old male presented to our clinic with poor vision in both eyes. Clinical examination revealed bilateral mature cataract, phacodonesis as well as a PC-pIOL implanted 35 years ago to address his high myopia. The visual acuity (VA) was 20/200 in the right eye and no light perception in the left eye. PC-pIOL extraction as well as 23G pars plana vitrectomy (PPV) and fragmentation surgery was scheduled for the right eye. The left eye was treated conservatively. Successful extraction of the PC-pIOL was performed while it was easy to remove. It was a bow-tie shaped lens with a collar-stud-like button in the middle which extended anteriorly into the anterior chamber through the pupil. PPV with lens fragmentation was successful and the patient was left aphakic in order to avoid the placement of a zero diopter IOL. Final best corrected VA was 20/25 one month post-surgery.

Conclusions and importance

Removal of this rarely seen pIOL was performed without difficulty while excellent VA was achieved. Aphakia following complete vitrectomy represented a viable option in this case. Furthermore, we highlight the clinical manifestations associated with this IOL more than three decades after implantation.

Reasons for explantation of phakic intraocular lenses and associated perioperative complications: cross-sectional explant registry analysis

Background

We discuss the safety, since their introduction, of phakic intraocular lenses (pIOLs) to correct refractive errors in healthy eyes. We investigated the reasons for pIOL explantation and the associated perioperative complications.

Methods

This retrospective, cross-sectional study included 69 pIOLs, explanted at a single tertiary center between July 2005 and March 2020: 34 angle-supported (G1), 28 iris-fixated (G2) and seven posterior chamber (G3) pIOLs. Case data including the reason for explantation was taken from the patient records. Intra- and postoperative complications were evaluated for an association with the pIOL.

Results

The mean duration in the eye was 10.4 (0.2–28) years. Cataractogenesis and subsequent surgery that required pIOL explantation was the reason in 42% of all cases. In 22%, cataract in combination with endothelial damage prompted explantation, with 26, 18 and 14% for G1, G2 and G3 respectively. The second most common reasons were corneal damage alone in the angle-supported group (26%), IOL subluxation in the iris-fixated group (18%), and photopic disturbance in the posterior chamber group (29%). In 68% of all explantations, the surgical course was unremarkable, while in the remaining cases perioperative complications were associated with the lens in 45.7%.

Conclusion

Overall, the need for cataract surgery was the most common reason for pIOL explantation. Corneal complications were more frequent in the angle-supported pIOLs and their removal was associated with higher rates of complication compared to the other groups.

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.

Three-year stability of an angle-supported foldable hydrophobic acrylic phakic intraocular lens evaluated by Scheimpflug photography

PURPOSE

To examine the postoperative positional stability of a new angle-supported, hydrophobic acrylic phakic intraocular lens (pIOL).

SETTING

Department of Ophthalmology, Goethe-University, Frankfurt am Main, Germany.

METHODS

In this prospective nonrandomized clinical trial, eyes with moderate to high myopia had implantation of an angle-supported pIOL (AcrySof Cachet). Scheimpflug imaging was performed preoperatively and postoperatively at 1, 3, 6 to 12, and 24 to 36 months. The main outcome measures were the distance between the corneal endothelium and the IOL and between the IOL and the crystalline lens. The overall significance threshold was P = .05.

RESULTS

Twenty-one of the 26 eyes (26 patients) evaluated were included in the statistical analysis. Analysis of variance showed no statistically significant differences in absolute endothelium-IOL or IOL-crystalline lens measurements at any postoperative visit. The mean endothelium-IOL distance was 2.05 mm +/- 0.25 (SD) at 1 month and 2.15 +/- 0.29 mm at 24 to 36 months and the mean IOL-crystalline distance, 0.92 +/- 0.23 mm and 0.86 +/- 0.22 mm, respectively. A 1-way t test showed a small but significant difference compared with zero in the overall change in the endothelium-IOL distance (mean 0.08 +/- 0.16 mm) and thus in the overall calculated anterior chamber depth (mean 0.07 +/- 0.08 mm); the difference was not significant for the IOL-crystalline lens change (mean -0.05 +/- 0.13 mm).

CONCLUSION

The angle-supported foldable hydrophobic pIOL maintained adequate central clearance distances to the corneal endothelium and the natural crystalline lens over 3 years.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Cataract surgery with implantation of an artificial lens

BACKGROUND

Cataract surgery, the most frequently performed operative procedure worldwide, typically concludes with the implantation of an artificial intraocular lens (IOL) to correct aphakia (absence of the crystalline lens).

METHOD

Selective literature review including current regulations, guidelines and recommendations for cataract surgery.

RESULTS

The main symptom of cataract is loss of visual acuity, which usually progresses slowly. It can arise in one eye or both. There is a basic distinction between congenital and acquired cataracts. The probability of developing a cataract rises with age because of biochemical aging processes. The development of a cataract becomes highly likely from the sixth decade of life onward.

CONCLUSIONS

As no effective medications for cataract are available at present, its current standard treatment is the removal of the clouded lens. In industrialized countries, this is usually done with ultrasound (phacoemulsification), followed by the implantation of an IOL.

Cataractous Changes due to Posterior Chamber Flattening with a Posterior Chamber Phakic Intraocular Lens Secondary to the Administration of Pilocarpine

OBJECTIVE

To present the first reported case of cataract formation as a consequence of instillation of pilocarpine in an eye with a posterior chamber phakic intraocular lens (IOL).

DESIGN

Interventional case report.

INTERVENTION

A 46-year-old man received a hyperopic implantable collamer lens (ICL) bilaterally.

MAIN OUTCOME MEASURES

Determination of best-corrected visual acuity (BCVA); contrast sensitivity testing with and without glare; and intraocular pressure (IOP), specular endothelial cell, and slit-lamp examinations were performed serially. In addition, the distance between the ICL and crystalline lens was measured with optical coherence tomography.

RESULTS

Both eyes underwent uneventful ICL implantation for the correction of a manifest spherical equivalent of +7 diopters (D) in the right eye and +7.1 D in the left eye. The left eye was followed for 2 years without developing complications. The right eye, however, showed on the first postoperative day a fleckenlike opacification on the anterior pole of the crystalline lens after instillation on the operative day of 2% pilocarpine in an attempt to accelerate recovery from unwanted pupil dilation causing patient complaints of glare disability after surgery. Optical coherence tomography demonstrated complete contact of the ICL with the natural lens 24 hours postoperatively. Serial IOP measurements were always within the normal limits. The instillation of 1% cyclopentolate resulted in an increase in the ICL vault that measured 132 mum 24 hours later. Three days after the completion of a 3-day course of topical 1% cyclopentolate, the opacification was less dense and demarcated, and a 124-mum vault was measured. Three months postoperatively, the cataract was associated with a 3-line loss of BCVA and considerable degradation of the contrast sensitivity, especially at higher spatial frequencies and with a glare source, and corneal endothelial cell changes were within normal limits. One year after ICL implantation, the right eye had to undergo phacoemulsification and IOL implantation, which were uneventful.

CONCLUSIONS

Posterior chamber flattening with resulting crystalline lens opacification can occur immediately after the instillation of pilocarpine in an eye with a hyperopic ICL. Therefore, caution should be taken with the administration of cholinergic agonists such as pilocarpine in patients with phakic IOLs, at least if they are hyperopic ICLs.

Intraokularlinsen zur Korrektur von Refraktionsfehlern

In this overview, the current status of intraocular lens surgery to correct refractive error is reviewed. The interventions are divided into additive surgery with intraocular lens implantation without extraction of the crystalline lens (phakic intraocular lens, PIOL) or removal of the crystalline lens with implantation of an IOL (refractive lens exchange, RLE). Phakic IOLs are constructed as angle-supported or iris-fixated anterior chamber lenses and posterior chamber lenses which are fixated in the ciliary sulcus. The implantation of phakic IOLs has been demonstrated to be an effective, safe, predictable and stable procedure to correct higher refractive errors. Complications are rare and differ for the three types of PIOL; for posterior chamber lenses these are mainly cataract formation and pigment dispersion. RLE is preferable in cases of high ametropia in which the natural lens has lost its accommodative effect. The main complications for myopic RLA include retinal detachment, while hyperopic refractive lens exchange may be associated with surgical problems in the narrower anterior eye segment.

Intraokularlinsen zur Korrektur von Refraktionsfehlern

In this overview, the current status of intraocular lens surgery to correct refractive error is reviewed. The interventions are divided into additive surgery with intraocular lens implantation without extraction of the crystalline lens (phakic intraocular lens, PIOL) or the removal of the crystalline lens with implantation of an IOL (refractive lens exchange, RLE). Phakic IOLs are constructed as angle-supported or iris-fixated anterior chamber lenses and posterior chamber lenses that are fixated in the ciliary sulcus. The implantation of phakic IOLs has been demonstrated to be an effective, safe, predictable and stable procedure to correct higher refractive errors. Complications are rare and differ for the three types of PIOL; for anterior chamber lenses these are mainly pupil ovalization and endothelial cell loss.