Phacofragmentation with perfluorocarbon liquid and anterior chamber or scleral-fixated intraocular lens implantation for the management of luxated crystalline lenses

PARS PLANA VITRECTOMY WITH ANTERIOR CHAMBER VERSUS GORE-TEX SUTURED POSTERIOR CHAMBER INTRAOCULAR LENS PLACEMENT: Long-Term Outcomes

PURPOSE

To compare clinical outcomes of combined pars plana vitrectomy (PPV) with anterior chamber intraocular lens (ACIOL) placement versus scleral fixation of a posterior chamber intraocular lens (PCIOL) using Gore-Tex suture.

METHODS

Retrospective, interventional case series of eyes undergoing combined PPV and IOL placement for retained lens material, aphakia, or dislocated IOL. Eyes with history of amblyopia, corneal opacity, retinal, or optic nerve disease were excluded. Outcome measures were change in visual acuity and occurrence of postoperative complications with minimum follow-up of 1 year.

RESULTS

Sixty-three eyes of 60 patients were identified. Thirty-three eyes underwent combined PPV and ACIOL placement and 30 eyes underwent combined PPV and scleral fixation of a PCIOL using Gore-Tex suture. Mean follow-up was 502 ± 165 days (median 450, range 365-1,095 days). In the ACIOL group, mean visual acuity improved from 20/914 preoperatively to 20/50 postoperatively (P < 0.001). In the scleral-fixated PCIOL group, mean visual acuity improved from 20/677 preoperatively to 20/46 postoperatively (P < 0.001). No difference in visual acuity was noted between groups at 1-year (P = 0.91) or final follow-up (P = 0.62). Regarding postoperative complications, eyes undergoing ACIOL placement had a significantly higher rate of transient corneal edema (30.3 vs. 6.7%, P = 0.02) compared with eyes undergoing scleral fixation of a PCIOL.

CONCLUSION

Combined PPV with ACIOL placement or scleral fixation of a PCIOL with Gore-Tex suture were well tolerated. The techniques resulted in similar visual outcomes at minimum follow-up of 1 year.

Managing dislocated hard lens nuclei: 23-gauge vitrectomy and lens extraction via a corneoscleral limbal incision versus 23-gauge vitrectomy and phacofragmentation

PURPOSE

To compare 23-gauge vitrectomy and lens extraction via a corneoscleral limbal incision (CSLI) with 23-gauge vitrectomy and phacofragmentation to treat dislocation of hard lens nuclei.

SETTING

Ningbo Eye Hospital, Zhejiang, China.

DESIGN

Retrospective case series.

METHODS

The study included consecutive patients with complete posterior dislocation of a hard nucleus (grade ≥ IV) into the vitreous cavity. All patients received 23-gauge 3-channel vitrectomy. Some patients also had phacofragmentation and others had lens extraction through a CSLI.

RESULTS

The CSLI group comprised 21 eyes of 21 patients and the phacofragmentation group, 22 eyes of 22 patients. The median follow-up was 10.8 months (range 6 to 24 months) and 11.3 months (range 5 to 18 months), respectively. Demographic characteristics, reason for lens dislocation, preoperative corrected distance visual acuity (CDVA), preoperative intraocular pressure (IOP), lens nucleus grade, and comorbidities were similar between groups. The CSLI group had a shorter mean surgical time than the phacofragmentation group (42.5 ± 7.2 minutes versus 68.2 ± 16.5 minutes); less frequent use of perfluorocarbon liquid, octafluoropropane, or air tamponade; lower incidence of retinal tears (9.5% versus 31.8%); and better CDVA but worse astigmatism 1 day and 1 week postoperatively (P < .05). The postoperative IOP did not differ between groups. Corneal edema and recurrent retinal detachment were less common in the CSLI group than in the phacofragmentation group.

CONCLUSION

The 23-gauge vitrectomy with lens extraction through a CSLI might have advantages over 23-gauge vitrectomy with phacofragmentation for management of dislocated hard lens nuclei.

Scleral-Fixated Intraocular Lenses: Past and Present

Intraocular lenses (IOLs) can have inadequate support for placement in the capsular bag as a result of ocular trauma, metabolic or inherited conditions such as Marfan's syndrome or pseudoexfoliation, or complicated cataract surgery. Surgical options for patients with inadequate capsular support include alternative placement in the anterior chamber (ACIOLs), fixation to the iris, or fixation to the sclera. The surgical techniques for each of these approaches have improved considerably over the last several decades resulting in improved visual and ocular outcomes. If no capsular or iris support exists, the surgeon can fixate an IOL to the sclera or the patient can remain aphakic. IOLs can be fixated to the sclera using sutures or by tunneling the IOL haptics into the sclera without sutures. This review summarizes the pre-operative considerations, surgical techniques, outcomes, and unique complications associated with implantation of scleral-fixated IOLs.

Pars Plana Vitrectomy Combined With Either Secondary Scleral-Fixated or Anterior Chamber Intraocular Lens Implantation

PURPOSE

To compare visual outcomes among eyes that underwent pars plana vitrectomy (PPV) in combination with either anterior chamber intraocular lens implantation (ACIOL) or scleral suturing of posterior chamber lens (PCIOL).

DESIGN

Retrospective comparative case series.

METHODS

All eyes presented with aphakia or luxated or subluxated posterior chamber intraocular lens (IOL) following complicated cataract surgery, trauma, or spontaneous dislocation. Eyes involving visually significant macular pathology, past retinal detachment, follow-up of less than 6 months, and surgeries requiring the removal of an ACIOL were excluded. The main outcomes measured were final best-corrected visual acuity (BCVA) and surgical complication rates.

RESULTS

Fifty-seven eyes met inclusion criteria; median follow-up was 13.2 months. Initial median BCVA for ACIOL patients was logMAR 1.301 (Snellen equivalent 20/400, range 20/20 to light perception); final median BCVA was logMAR 0.477 (Snellen equivalent 20/60, range 20/20 to light perception, P < .001). Initial median BCVA for PCIOL patients was logMAR 1.239 (Snellen equivalent 20/347, range 20/60 to light perception); final median BCVA was logMAR 0.301 (Snellen equivalent 20/40, range 20/20 to hand motions, P < .001). The change in BCVA between the 2 groups over the course of the study was similar (P > .05). More epiretinal membrane (ERM) formations occurred postoperatively in the ACIOL group (P = .011). Other complication rates were similar between both groups.

CONCLUSIONS

PPV with secondary IOL placement is safe and effective, resulting in improved visual outcomes regardless of the technique used. Patients undergoing ACIOL placement have a higher incidence of ERM formation.

Pseudoexfoliation Syndrome and Pseudoexfoliation Glaucoma: A Review of the Literature with Updates on Surgical Management

Pseudoexfoliation syndrome (PES) is a systemic disorder caused by progressive accumulation of extracellular material over various tissues. PES usually determines increased intraocular pressure, changes in the anatomical aspects of the optic nerve, and visual field alterations leading to the diagnosis of pseudoexfoliation glaucoma (PEG). Use of topical medical treatment usually leads to poor results in terms of long-term follow-up but many surgical techniques, such as Argon Laser or Selective Laser Trabeculoplasty, have been proposed for the management of PEG affected patients. The present paper is a review on the pseudoexfoliation syndrome and pseudoexfoliation glaucoma with an update on surgical management.

A modified technique for extracting a dislocated lens with perfluorocarbon liquids and viscoelastics

The authors describe a modified technique for extraction of a dislocated crystalline lens or large and hard lens fragments displaced into the vitreous cavity. An ophthalmic viscosurgical device was used around and on top of the heavy liquid bubble to keep the lens centered and less mobile for easier phacofragmentation or removal by the cutting-suction probe. This technique was used in 10 eyes, including cases of traumatic dislocation and Marfan syndrome, with excellent anatomical results and no complications that could be attributed to the surgical technique. The technique has also been used to retrieve and reposition dislocated intraocular lenses.

Intravitreal bimanual surgery for residual lens fragments and displaced crystalline lenses

The authors have developed a new technique for removing large and hard lens fragments or crystalline lenses with hard nuclei dislocated into the vitreous cavity using an optic fiber-free intravitreal surgical system (OFFISS). The OFFISS visualizes the fundus without a fiberoptic and facilitates the bimanual technique. The lens materials are stabilized with one hand and the fragmatome to emulsify the lens fragments is controlled with the other. The lens fragments or subluxated crystalline lenses can be removed through 20-gauge incisions. This technique was used in 14 cases and was found to be safe and not invasive.

Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review

Pseudoexfoliation syndrome is a risk factor in cataract surgery because of the increased weakness of zonular apparatus and reduced pupillary dilatation. The surgical outcome of using phacoemulsification in the central zone, inducing minimal stress on the zonules, inserting a capsular tension ring in selected cases, and stretching the pupil mechanically in eyes with miotic pupils, may turn out to be uneventful in most cases. Postoperative fibrosis with subsequent shrinkage of the capsule is increased in these eyes, and these centripetal forces will further loosen the zonular fibres. Late in-the-bag intraocular lens dislocation is therefore anticipated to become a growing problem in the future. Despite the dysfunctioning of the blood-aqueous barrier in eyes with pseudoexfoliation syndrome, the frequency of postoperative inflammatory reaction is low due to the improvements made in surgical technique and equipment in recent years. Glaucoma frequently occurs in eyes with pseudoexfoliation syndrome. Compared with primary open-angle glaucoma, optic damage is more pronounced in these eyes at the time of diagnosis and response to medical therapy is poorer. Although responses to argon laser therapy and filtering surgery are roughly similar between the two types of glaucoma, there are indications that primary laser trabeculoplasty has a higher success rate in pseudoexfoliation glaucoma than in primary open-angle glaucoma.