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Zhang LJ, Dana R, Lorch AC, Elze T, Miller JW, Dohlman TH, Oke I. Complications After Pediatric Penetrating Keratoplasty: An IRIS Registry Study. Cornea 2024:00003226-990000000-00645. [PMID: 39137435 DOI: 10.1097/ico.0000000000003656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 07/01/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE To describe the frequency of postoperative complications in children undergoing penetrating keratoplasty (PK). METHODS This retrospective cohort study included pediatric patients (aged 0-18 years) in the Intelligent Research in Sight (IRIS) Registry who underwent primary PK between January 2013 and December 2020. Patients were identified using Current Procedure Terminology codes. Postoperative complications were identified using International Classification of Diseases Revision 9 and 10 codes and categorized as complications affecting the anterior segment (epithelial defect, infectious keratitis, neurotrophic keratitis, and glaucoma) or posterior segment (vitreous hemorrhage, retinal detachment, choroid detachment, choroidal hemorrhage, endophthalmitis, epiretinal membrane, and proliferative vitreoretinopathy). RESULTS Of the 544 pediatric patients undergoing PK, 259 (47.6%) experienced postoperative complications. Anterior segment complications (n = 222, 40.8%) were more common than posterior segment complications (n = 96, 17.6%). The most common anterior complication was infectious keratitis (n = 163, 30.0%) with a median onset time of 275 days (IQR 50-560 days) after surgery. Vitreous hemorrhage (n = 52, 9.6%) and retinal detachment (n = 48, 8.8%) were the most common posterior segment complications. CONCLUSIONS Infectious keratitis was the most common postoperative complication in children undergoing PK. More complications occurred in the anterior segment (70%) of the eye as compared with the posterior segment (30%). These findings demonstrate the challenges associated with pediatric PK and may help guide postoperative monitoring and management.
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Affiliation(s)
- Lyvia J Zhang
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA; and
| | - Reza Dana
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA; and
| | - Alice C Lorch
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA; and
| | - Tobias Elze
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA; and
| | - Joan W Miller
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA; and
| | - Thomas H Dohlman
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA; and
| | - Isdin Oke
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA; and
- Boston Children's Hospital, Harvard Medical School, Boston, MA
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Baur ID, Mueller A, Labuz G, Naujokaitis T, Auffarth GU, Khoramnia R. Refractive Lens Exchange: A Review. Klin Monbl Augenheilkd 2024; 241:893-904. [PMID: 39146574 DOI: 10.1055/a-2346-4428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
In recent decades, technical advancements in lens surgery have considerably improved safety and refractive outcomes. This has led to a much broader range of indications for refractive lens exchange (RLE). Effective restoration of uncorrected distance and near visual acuity is possible with modern presbyopia correcting intraocular lenses (IOLs). Hyperopic patients who are fully presbyopic were identified as ideal candidates for RLE. For myopic patients, an increased risk of retinal detachment has been reported, which leads to a higher threshold to perform RLE in this patient group. The most frequent postoperative complications include posterior capsular opacification, deviation from the target refraction and cystoid macular edema. Thus, adequate planning of surgery, careful patient selection, as well as comprehensive counseling are crucial for successful RLE.
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Affiliation(s)
| | - Arthur Mueller
- Department of Ophthalmology, University Hospital Augsburg, Germany
| | - Grzegorz Labuz
- International Vision Correction Research Centre (IVCRC) and David J Apple International Laboratory for Ocular Pathology, Department of Ophthalmology, University Hospital Heidelberg, Germany
| | - Tadas Naujokaitis
- International Vision Correction Research Centre (IVCRC) and David J Apple International Laboratory for Ocular Pathology, Department of Ophthalmology, University Hospital Heidelberg, Germany
| | - Gerd U Auffarth
- International Vision Correction Research Centre (IVCRC) and David J Apple International Laboratory for Ocular Pathology, Department of Ophthalmology, University Hospital Heidelberg, Germany
| | - Ramin Khoramnia
- International Vision Correction Research Centre (IVCRC) and David J Apple International Laboratory for Ocular Pathology, Department of Ophthalmology, University Hospital Heidelberg, Germany
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Jacob S, Parashar P, Assaf J, Knyazer B, Agarwal A, Kumar A. Temporary Pupil Scaffolding Technique for Managing Positive Vitreous Pressure and Impending IOL and Vitreous Extrusion During Penetrating Keratoplasty. Cornea 2024:00003226-990000000-00606. [PMID: 38985894 DOI: 10.1097/ico.0000000000003618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/29/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Positive vitreous pressure (PVP) secondary to intraoperative acute hypotony during penetrating keratoplasty can result in extrusion of the intraocular lens and vitreous. Currently described techniques are difficult or impossible to apply intraoperatively when positive vitreous pressure is noticed in an "open sky" situation after excision of the host corneal button. METHODS We describe a technique where pupil scaffolding is used to prevent intraocular lens or crystalline lens extrusion by simply closing the pupil with a temporary suture that holds the retropupillary contents back. Once the eye is thus stabilized, the donor cornea is sutured rapidly after which the pupillary knot is cut and removed using microscissors and microforceps. RESULTS Five patients undergoing penetrating keratoplasty under peribulbar anesthesia underwent this technique after experiencing PVP after host corneal button excision. PVP was successfully controlled in all 5 patients, and the optical grafts remained clear in the postoperative period. CONCLUSIONS Temporary pupillary scaffolding can help control PVP and prevent ocular content extrusion during PKP surgeries.
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Affiliation(s)
- Soosan Jacob
- Dr. Agarwal's Refractive and Cornea Foundation, Chennai, India
- Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India
| | - Parnika Parashar
- Dr. Agarwal's Refractive and Cornea Foundation, Chennai, India
- Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India
| | - Jad Assaf
- Casey Eye Institute, Oregon Health & Science University, Portland, OR; and
| | - Boris Knyazer
- Department of Ophthalmology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amar Agarwal
- Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India
| | - Arun Kumar
- Dr. Agarwal's Refractive and Cornea Foundation, Chennai, India
- Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India
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Andres C, Trouvain AM, Szurman P, Seitz B, Fries FN, Rickmann A. Descemet Membrane Endothelial Keratoplasty (DMEK) Anesthesia Analysis. Klin Monbl Augenheilkd 2024. [PMID: 38574678 DOI: 10.1055/a-2268-9295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
PURPOSE Comparison of safety and clinical results of Descemet membrane endothelial keratoplasty (DMEK) in topical, peribulbar, or general anesthesia. METHODS Retrospective, post hoc matched study of 346 patients who received DMEK surgery with different types of anesthesia (n = 54 topical, n = 137 peribulbar, n = 155 general anesthesia). Outcome criteria were intraoperative complications, endothelial cell count (ECC), central corneal thickness (CCT) and graft rejection rate, rebubbling rate, and visual acuity (VA). Mean follow-up time was 9.4 ± 2.8 months. RESULTS The group with topical anesthesia showed intraoperative difficulties such as vitreous pressure (p = 0.01) and difficult graft unfolding (p = 0.4), possibly leading to a higher rebubbling rate (p = 0.03) and therefore graft failure (p = 0.39). However, rebubbling and graft failure occurred more often when the graft preparation was more difficult (p = 0.2, p = 0.13, respectively), which was independent of anesthesia. All three groups achieved comparable functional results regarding VA, ECC, and CCT after 6 months. CONCLUSION DMEK under topical anesthesia is feasible and shows comparable final visual outcomes but should be limited to selected cooperative patients and performed by experienced surgeons due to the potential for increased intraoperative challenges.
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Affiliation(s)
| | | | - Peter Szurman
- Ophthalmology, Saar Knappschaft Hospital, Sulzbach, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Hospital, Homburg/Saar, Germany
| | - Fabian Norbert Fries
- Department of Ophthalmology, Saarland University Hospital, Homburg/Saar, Germany
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research, Saarland University, Homburg/Saar, Germany
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Bayley KD, Gates MC, Anastassiadis Z, Read RA. The use of sub-Tenon's anesthesia versus a low-dose neuromuscular blockade for canine cataract surgery: A comparative study of 224 eyes. Vet Ophthalmol 2024; 27:114-126. [PMID: 37199512 DOI: 10.1111/vop.13111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 04/11/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Assess the utility of a Sub-Tenon's anesthesia (STA) protocol to provide suitable operating conditions for canine cataract surgery and compare it to an alternative low-dose neuromuscular blockade (LD-NMB) protocol used for canine cataract surgery. PROCEDURES Clinical study of dog eyes undergoing cataract surgery with either an STA or LD-NMB protocol. While intraoperative vitreal expansion scores and intraoperative complications were collected prospectively, globe position, intraocular pressure, return of vision, and postoperative complications were collected retrospectively. Statistical testing was used to compare results between the STA and the LD-NMB groups for the data available. RESULTS A total of 224 eyes from 126 dogs were assessed, with 133/224 (59.4%) eyes from 99/126 (78.6%) dogs receiving STA and 91/124 (40.6%) eyes from 72/126 (57.1%) dogs receiving LD-NMB. Forty-five of these dogs (45/126; 37.7%) received STA for one eye and LD-NMB for the other eye. There was no significant change in intraocular pressure measurements following STA administration. This was not measured for the LD-NMB group. The globe achieved a central position in 110/133 (82.7%) of eyes that received STA. This was not measured for the LD-NMB group. Intraoperative vitreal expansion scores were slightly higher in STA-treated eyes compared to LD-NMB-treated eyes. The intraoperative complication rate for STA-treated eyes was higher (73/133; 54.8%) compared to NMB-treated eyes (12/91; 13.2%). The most common intraoperative complication for STA was chemosis (64/133; 48.1%), the risk of which increased with an increase in the volume of local anesthetic injected. The post-operative complication rate was higher in STA-treated eyes (28/133; 21.1%) compared to NMB-treated eyes (16/91; 17.6%). Post-operative corneal ulceration was the most common postoperative complication in STA-treated eyes (6/133; 4.5%). CONCLUSION The STA protocol described resulted in suitable operating conditions, but more intraoperative and postoperative complications compared to the LD-NMB protocol. Despite these complications, the STA protocol did not cause a significant deleterious impact on post-operative outcomes as defined in the present study.
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Affiliation(s)
| | - M Carolyn Gates
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | | | - R A Read
- Veterinary Ophthalmic Referrals, Adelaide, Australia
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Moumneh K, Pollack S, Perich LM. Deep Anterior Lamellar Keratoplasty Over Penetrating Keratoplasty to Mitigate Positive Vitreous Pressure Complications. Cureus 2023; 15:e51120. [PMID: 38274923 PMCID: PMC10808883 DOI: 10.7759/cureus.51120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 01/27/2024] Open
Abstract
This report describes deep anterior lamellar keratoplasty over penetrating keratoplasty (DALK-over-PKP) as an alternative technique to mitigate complications related to positive vitreous pressure (PVP) during PKP. We accomplished this by repairing the punctured cornea and performing a modified DALK where a full-thickness donor graft is placed over the host Descemet membrane, which is then removed after partial suturing of the graft. This mitigates the driving force behind the PVP by maintaining a closed-anterior chamber.
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Affiliation(s)
- Khaled Moumneh
- Ophthalmology, HCA Florida Bayonet Point Hospital, Hudson, USA
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Indications and Results of Emergency Penetrating Keratoplasty With Simultaneous Cataract Surgery ("Triple-PKP à Chaud"). Cornea 2023; 42:272-279. [PMID: 35587899 DOI: 10.1097/ico.0000000000003035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/17/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to analyze the indications and clinical results of emergency penetrating keratoplasty with simultaneous cataract surgery ("Triple-PKP à chaud"). METHODS This study included all subjects who underwent Triple-PKP à chaud between 2006 and 2020 at the Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar in Germany. Data obtained from patient records were retrospectively analyzed. RESULTS Triple-PKP à chaud was successfully performed in 27 of 29 eyes with a mean age of 66.0 ± 19.9 years. Previous surgery was performed in 20 eyes (69.0%), most frequently amniotic membrane transplantation in 11 eyes (37.9%) and previous keratoplasty in 9 eyes (31.0%). The most common indication was infectious keratitis (62.1%). In 27 subjects (93.1%), capsulorhexis was performed using the open-sky technique. The most frequent intraoperative complication was positive vitreous pressure (24.1%). In 2 eyes (6.9%), no intraocular lens implantation was performed because of posterior capsule rupture. The preoperative uncorrected visual acuity improved from 2.2 ± 0.6 logMAR (range = 3.0-0.7 logMAR) to 1.3 ± 0.7 logMAR (range = 3.0-0.18 logMAR) postoperatively ( P < 0.001). Common postoperative complications were suture loosening (44.4%) and corneal epithelial defects (33.3%). Repeat keratoplasty was necessary in 14 eyes (51.9%), including 9 eyes (64.2%) within 12 months postoperatively. The mean graft survival was 12.2 ± 17.9 months (range = 1-69 mo). CONCLUSIONS Triple-PKP is also feasible in emergency conditions. Nevertheless, the surgery is associated with an increased risk of intraoperative and postoperative complications. Combined surgery should, therefore, only be performed in severely diseased eyes with progressed stage of cataract.
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Alkharashi M, AlAbdulhadi HA, Otaif W, Alahmadi AS, Alanazi B, Al Habash A, Aldayel A, Aljindan M, Almulhim A, Bin Helayel H. Incidence, Pathophysiology, Complications, and Management of Positive Vitreous Pressure During Penetrating Keratoplasty: A Literature Review. Clin Ophthalmol 2023; 17:583-590. [PMID: 36820300 PMCID: PMC9938663 DOI: 10.2147/opth.s382502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/20/2022] [Indexed: 02/16/2023] Open
Abstract
Positive vitreous pressure (PVP) is common during open anterior segment surgery and penetrating keratoplasty (PKP) has a reported incidence rate of 40-50%. Despite adequate perioperative preventive precautions, positive pressure occurs during surgery and optimum management of PVP is required to avoid serious complications. Many pharmacological and mechanical approaches can be employed either preoperatively or intraoperatively to decrease vitreous pressure. Surgical techniques such as graft-over-host technique, the modified graft-over-host technique, techniques employed mattress sutures and needle, or Vitreous aspiration or vitrectomy can be effectively used to manage intraoperative PVP during PPK. This article reviews the incidence, risk factors, prevention, and different approaches to the management of positive vitreous pressure during PKP to analyze the available evidence in order to improve the safety profile of PKP and prevent sight-threatening complications.
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Affiliation(s)
- Majed Alkharashi
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Halla A AlAbdulhadi
- Anterior Segment Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Wael Otaif
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Correspondence: Wael Otaif, Department of Ophthalmology, King Saud University, Riyadh, Saudi Arabia, Tel +966 549778998, Email
| | - Adel Salah Alahmadi
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia,Department of Ophthalmology, MOH, Madinah, Saudi Arabia
| | - Bader Alanazi
- Department of Ophthalmology, College of Medicine, Jouf University, Sakakah, Saudi Arabia
| | - Ahmed Al Habash
- Department of Ophthalmology, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ahmed Aldayel
- Anterior Segment Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Mohanna Aljindan
- Department of Ophthalmology, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulmohsen Almulhim
- Department of Ophthalmology, College of Medicine, Jouf University, Sakakah, Saudi Arabia
| | - Halah Bin Helayel
- Anterior Segment Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
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Gregori NZ, Staropoli P, Swaminathan S, Zukerman RJ. Needle aspiration for management of acute intraoperative fluid misdirection during phacoemulsification. Am J Ophthalmol Case Rep 2022; 29:101773. [PMID: 36561879 PMCID: PMC9764170 DOI: 10.1016/j.ajoc.2022.101773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Purpose Acute intraoperative fluid misdirection is a serious complication that may occur during phacoemulsification. We provide a detailed description and a video of our preferred technique for prompt management of acute intraoperative fluid misdirection. Observations A 79-year-old male developed sudden shallowing of the anterior chamber and marked elevation of intraocular pressure at hydrodissection during phacoemulsification surgery. Treatment consisted of a needle aspiration of trapped fluid from the retrolental space, employing a 5/8th inch, 25-gauge needle on a medium-size syringe leading to immediate softening of the globe and deepening of the anterior chamber. The rest of the case proceeded uneventfully. The patient had uncomplicated recovery and final best-corrected visual acuity of 20/20. Conclusions and importance Acute subcapsular infusion fluid entrapment may occur during uneventful phacoemulsification. Needle aspiration of retrolental fluid is a simple and inexpensive method for immediate resolution of high IOP and deepening of the anterior chamber, allowing the case to proceed.
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Affiliation(s)
- Ninel Z. Gregori
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, USA,Miami Veterans Affairs Medical Center, 1201 NW 16th Street, Miami, FL, USA,Corresponding author. Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL, 33136, USA.
| | - Patrick Staropoli
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, USA,Miami Veterans Affairs Medical Center, 1201 NW 16th Street, Miami, FL, USA
| | - Swarup Swaminathan
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, USA
| | - Ryan J. Zukerman
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, USA,Miami Veterans Affairs Medical Center, 1201 NW 16th Street, Miami, FL, USA,Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
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Surgical correction of corneal opacity and aniridia with penetrating keratoplasty and a new iris prosthesis implant. Graefes Arch Clin Exp Ophthalmol 2022; 261:1331-1338. [PMID: 36480049 DOI: 10.1007/s00417-022-05920-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study is to describe the clinical outcome of penetrating keratoplasty combined with implantation of a novel intraocular lens with an artificial iris, aided by continuous vitreous chamber infusion, in patients with severe aniridia and corneal alterations. METHODS This was a prospective single-center case series study involving five patients with corneal alterations and aniridia. All subjects underwent simultaneous penetrating keratoplasty and implantation of a new intraocular lens with an artificial iris with the assistance of infusion into the vitreous chamber to regulate intraocular pressure during the surgical procedure. Visual acuity, corneal endothelial cell density, and intraocular pressure assessments were performed in the postoperative period. The final cosmetic outcome of the iris prosthesis placement was also evaluated. RESULTS In all cases, increased visual acuity and a good aesthetic result were observed in all affected eyes except one in which, despite the excellent aesthetic outcome, the eye was very hypotonic as it had high myopia and had undergone several previous surgeries. CONCLUSION The single surgical procedure combining implantation of an intraocular lens-iris prosthesis with penetrating keratoplasty is an effective technique for the simultaneous treatment of aphakia and aniridia. However, larger series with longer-term follow-up are needed to definitively establish the benefits of this technique.
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Clinical features, management and outcomes of expulsive choroidal hemorrhage during cataract surgery: 13 years experience from a tertiary eye center. J Cataract Refract Surg 2022; 48:1037-1043. [PMID: 35239576 DOI: 10.1097/j.jcrs.0000000000000921] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/16/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To study the risk factors, clinical features, management, and outcomes of intraoperative expulsive choroidal hemorrhage (ECH) during cataract surgery. SETTING Aravind eye hospital, Madurai, Tamil Nadu, India. DESIGN Retrospective hospital-based study. METHODS Of the 1167250 patients who underwent cataract surgery between 2008 to 2020, patients diagnosed with intraoperative ECH were included. Demography, ocular and systemic risk factors, visual acuity, type of ocular anesthesia, intraoperative and postoperative records, management, and surgical outcomes were analyzed. RESULTS A total of 52 eyes (0.004%) of 1167250 patients had ECH. Of the 52 cases, 43 cases (incidence rate 0.006%) were reported in the years 2008 to 2015 and 9 cases (incidence rate 0.002%) in the years 2016 to 2020. The change in the ocular anesthesia from peribulbar and retrobulbar anesthesia (2008-2015) to sub-Tenon's anesthesia (2016-2020) was associated with a reduced rate of ECH (p-value 0.002). Twenty-eight eyes (53.8%) were having limited ECH and 24 eyes (46.2%) were having full-blown ECH. The visual outcome was better in eyes with limited ECH compared to full-blown SCH in all follow-up visits. The median vision (IQR) before the cataract surgery and immediate postoperative day 1 were 1.30 (0.78 - 2.60) and 2.45 (1 - 2.75) respectively. The median final vision (IQR) after the secondary surgical intervention was 2.2 (0.60 - 2.60). CONCLUSIONS This series included 52 eyes with ECH, recognized associations of ECH with different types of anaesthesia as well as with different cataract surgical procedures, and described management of ECH. Postoperative visual outcome was poor.
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12
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Kataria M, Agarwal A. Intra-operative control of positive vitreous pressure in a graded manner by pars plana sutureless, small gauge trocar-cannula. Eur J Ophthalmol 2021; 32:11206721211009446. [PMID: 33853364 DOI: 10.1177/11206721211009446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this paper is to delineate a technique of using a 23G, single, sutureless transconjunctival pars plana sclerotomy to facilitate anterior segment surgery in eyes with increased positive vitreous pressure (PVP) ascribe to predisposing or intraoperative factors. METHODS We have implemented this technique in five eyes when PVP was anticipated before the surgery because of risk factors or it was encountered during anterior segment surgery. Different case scenarios in which PVP occurs during the surgery comprising phacolytic glaucoma, corneal tear repair combined with cataract surgery with IOL in a case with traumatic corneal injury, anterior capsule rupture and secondary glaucoma, Trabeculectomy in case of uveitic glaucoma, routine phacoemulsification cataract surgery with PVP encountered during surgery were addressed by using this technique. RESULTS The new technique outlined by the authors consists of passing sutureless 23 G trocar cannula which enables controlled and gradual efflux of clear watery fluid, resulting in passive vitreous decompression with minimal risk of vitreous traction and retinal breaks. Once PVP is reduced, anterior segment surgery can be safely completed without risk of developing devastating complications. CONCLUSIONS This sutureless single port pars plana trocar cannula technique is minimally invasive, safe, effective and fast technique which can cause reduction of PVP intraoperatively in a controlled and graded manner, thereby minimizing complication rates in difficult case scenarios.
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Affiliation(s)
- Manisha Kataria
- Department of Ophthalmology, Shri Jagdamba Charitable Eye Hospital, Sri Ganganagar, Rajasthan, India
| | - Abhishek Agarwal
- Department of Ophthalmology, Shri Jagdamba Charitable Eye Hospital, Sri Ganganagar, Rajasthan, India
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13
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Cheung AY, Davis AR, Denny MR, Chan CC, Trinh T, Pierson KL, Kurji KH, Holland EJ. "Basket" mattress suture to manage positive vitreous pressure during penetrating keratoplasty. Can J Ophthalmol 2020; 55:509-517. [PMID: 32730748 DOI: 10.1016/j.jcjo.2020.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/15/2020] [Accepted: 06/23/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe a new/modified technique to manage posterior vitreous pressure (PVP) during penetrating keratoplasty (PKP) and report a small series. DESIGN Retrospective interventional case series and technique description. PARTICIPANTS PKP eyes necessitating mattress suture placement owing to PVP. METHODS Retrospective chart review from 2016 to 2019 was undertaken. Placed prophylactically (before trephination) or after trephination, the mattress suture is placed limbus-to-limbus across the anterior chamber. A second mattress suture can be placed in the opposite meridian (perpendicularly) for added support (safety basket configuration). Variations of suture technique are described based on lens status (i.e., phakic, pseudophakic, aphakic) and intraoperative timing. Parameters assessed included demographics, lens status, suture indications, intraoperative technique details, successful PKP completion, and presence of primary failure. RESULTS There were 6 phakic eyes (5 patients) and 9 pseudophakic/aphakic eyes (8 patients). Indications for the phakic subgroup were obesity (83%), poor scleral rigidity (83%), repeated iris prolapse (67%), dense mature cataract (33%), and planned large-diameter PKP (33%). Indications for pseudophakic/aphakic eyes included intraocular lens/iris prolapse (100%), pre-existing iris defects (67%), and planned large-diameter PKP (33%). Successful PKP was performed in all cases. Whereas one case had residual corneal edema in the setting of a persistent epithelial defect owing to limbal stem cell deficiency, all other cases demonstrated no primary graft failure. CONCLUSIONS Although increased PVP can present a stressful and challenging situation, it is important to have multiple options for management. This simple mattress suture technique normalizes the lens-iris complex behaviour and appears safe for the donor graft.
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Affiliation(s)
- Albert Y Cheung
- From the Virginia Eye Consultants (CVP), Norfolk, VA; Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, VA.
| | - Andrew R Davis
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, VA
| | - Matthew R Denny
- Department of Ophthalmology, Cincinnati Eye Institute (CVP)/University of Cincinnati, Cincinnati, OH
| | - Clara C Chan
- Department of Ophthalmology & Vision Sciences Toronto, University of Toronto, Toronto, Ont.; Rosedale Medical Centre, Toronto, Ont
| | - Tanya Trinh
- Department of Ophthalmology & Vision Sciences Toronto, University of Toronto, Toronto, Ont
| | | | - Khaliq H Kurji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Edward J Holland
- Department of Ophthalmology, Cincinnati Eye Institute (CVP)/University of Cincinnati, Cincinnati, OH
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14
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Zhou C, Zhang Z, Luo D, Gu C, Lahm T, Draga D, Qiu Q. A relatively higher intraocular pressure set at the end of vitrectomy is associated with a more stable and rapid visual recovery for patients with vitreous haemorrhage. Acta Ophthalmol 2020; 98:e428-e433. [PMID: 31686430 DOI: 10.1111/aos.14293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/07/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare structural and functional improvements in patients with vitreous haemorrhage (VH) with different IOPs re-established at the end of pars plana vitrectomy (PPV). METHODS It is a prospective, randomized, comparative, interventional study. Ninety-five patients with nonclearing VH were randomized to receive PPV with normalized IOPs of 15 mmHg (Group I: 32 eyes), 25 mmHg (Group II: 32 eyes) and 35 mmHg (Group III: 31 eyes) at the end of surgery. The grade of vitreous opacity and best-corrected visual acuity (BCVA) on postoperative day 1, week 1, month 1 and month 3 were compared with a mixed model for repeated measures analysis. RESULTS All 3 groups achieved significant improvement on postoperatively in BCVA (p < 0.01) and vitreous opacity (p < 0.01) compared with the baseline. The group difference was significant at the end of week 1 and showed a trend of higher IOP set at the end of PPV with better anatomical (p < 0.01) and visual recovery (p < 0.01). However, at postoperative month 1 and month 3, equivalent anatomical (month 1: p = 0.56; month 3: p = 0.36) and visual outcomes (month 1: p = 0.16; month 3: p = 0.88) were obtained in the 3 groups. The average effect of IOP on BCVA (group II versus group III: effect size (ES): 0.41, p < 0.01; group I versus group III: ES: 0.66, p < 0.01) and vitreous opacity (group II versus group III: ES: 0.70, p < 0.01; group I versus group III: ES:1.09, p < 0.01) over the course of the study period was statistically significant. The only postoperative complication was recurrent VH in two patients allocating in group I and II, respectively. CONCLUSIONS A relatively higher IOP set at the end of vitrectomy resulted in a more stable and rapid recovery with fewer complications in patients with non-complex VH.
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Affiliation(s)
- Chuandi Zhou
- Department of Ophthalmology Shanghai General Hospital Shanghai Key Laboratory of Ocular Fundus Diseases Shanghai Engineering Center for Visual Science and Photomedicine Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Zhenzhen Zhang
- Department of Ophthalmology Ninth People's Hospital Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Dawei Luo
- Department of Ophthalmology Shanghai General Hospital Shanghai Key Laboratory of Ocular Fundus Diseases Shanghai Engineering Center for Visual Science and Photomedicine Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Chufeng Gu
- Department of Ophthalmology Shanghai General Hospital Shanghai Key Laboratory of Ocular Fundus Diseases Shanghai Engineering Center for Visual Science and Photomedicine Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Tashi Lahm
- Department of Ophthalmology Shigatse People's Hospital Shanghai China
| | - Deji Draga
- Department of Ophthalmology Shigatse People's Hospital Shanghai China
| | - Qinghua Qiu
- Department of Ophthalmology Shanghai General Hospital Shanghai Key Laboratory of Ocular Fundus Diseases Shanghai Engineering Center for Visual Science and Photomedicine Shanghai Jiao Tong University School of Medicine Shanghai China
- Department of Ophthalmology Shigatse People's Hospital Shanghai China
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15
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Huang X, Zhou Q, Wang S, Zhang J, Niu G, Bi Y. Stepwise Decreasing of Vitreous Pressure by Anterior Vitrectomy: A Novel Method for Preventing Positive Vitreous Pressure During Penetrating Keratoplasty. Adv Ther 2020; 37:617-629. [PMID: 31728826 DOI: 10.1007/s12325-019-01139-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study evaluates the clinical effects of the stepwise anterior vitrectomy on the prevention of positive vitreous pressure (PVP) during penetrating keratoplasty (PKP). METHODS PKP in conjunction with stepwise anterior vitrectomy was performed on 15 eyes of 15 patients under retrobulbar anesthesia. A preset vitrectomy trocar-cannula was inserted into the vitreous cavity before PKP. During the opening of the anterior chamber, intermittent vitrectomy and corneal incision expansion were performed alternately to keep the lens or artificial intraocular lens (IOL) and iris flat until the entirety of the pathological cornea had been dissected. The main outcome measures include visual acuity, crystalline lens rise (CLR), corneal curvature and diopter, and corneal endothelial cell loss. RESULTS All surgical procedures were performed successfully without any PVP-related intraoperative complications. The mean time of the stepwise vitrectomies was 3.1 ± 0.7 s, the duration of each vitrectomy was 8.1 ± 5.3 s, and the duration of the total surgery was 60.5 ± 5.3 min. The anterior segment reaction was mild and the shape of the pupil remained normal 1 day after surgery. The mean preoperative and mean 3-month postoperative CLR values were 0.48 ± 0.09 mm and - 0.16 ± 0.04 mm, respectively (p < 0.0001). The mean preoperative endothelial cell density in donor buttons was 2570 ± 171 cells/mm2, and the mean 6- and 12-month postoperative endothelial cell density in donor buttons was 2207 ± 127 cells/mm2 and 2000 ± 198 cells/mm2, respectively. CONCLUSIONS The novel and stabilized PKP procedure, performed in conjunction with the stepwise anterior vitrectomy, effectively avoided the PVP during open-sky surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR1900021227.
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Affiliation(s)
- Xinyu Huang
- Department of Ophthalmology, Tongji Hospital Affiliated with Tongji University School of Medicine, Shanghai, 200065, People's Republic of China
| | - Qi Zhou
- Department of Ophthalmology, Tongji Hospital Affiliated with Tongji University School of Medicine, Shanghai, 200065, People's Republic of China
| | - Sangsang Wang
- Department of Ophthalmology, Tongji Hospital Affiliated with Tongji University School of Medicine, Shanghai, 200065, People's Republic of China
| | - Juan Zhang
- Department of Ophthalmology, Tongji Hospital Affiliated with Tongji University School of Medicine, Shanghai, 200065, People's Republic of China
| | - Guozhen Niu
- Department of Ophthalmology, Tongji Hospital Affiliated with Tongji University School of Medicine, Shanghai, 200065, People's Republic of China
| | - Yanlong Bi
- Department of Ophthalmology, Tongji Hospital Affiliated with Tongji University School of Medicine, Shanghai, 200065, People's Republic of China.
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16
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Sharma VK, Trehan HS, Raji K, Dhar SK. New use of a pupillary expansion ring to avoid intraoperative positive vitreous pressure during triple procedures. J Cataract Refract Surg 2019; 45:544-546. [PMID: 30876783 DOI: 10.1016/j.jcrs.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
Positive vitreous pressure can complicate cataract surgery during a triple procedure by inadvertently extending the capsulorhexis. This occurs because the procedure is open sky and positive vitreous pressure cannot be countered by injecting ophthalmic viscosurgical devices. We describe a new use of a pupillary expansion ring (Malyugin) to achieve a stable open anterior chamber under open sky during triple procedures. The scrolls are tucked under cut margins of the host cornea to create the capsulorhexis, the cataractous nucleus is removed, and an intraocular lens (IOL) is implanted in the bag. This technique is especially useful in cases of hypermature cataract and nondilating pupils with positive vitreous pressure in patients having triple procedures. The technique provides a stable open anterior chamber, increasing to the safety of the procedure and the chance of achieving a continuous curvilinear capsulorhexis and IOL implantation in the capsular bag.
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Affiliation(s)
- Vijay Kumar Sharma
- Department of Ophthalmology, Army Hospital Research and Referral, New Delhi, India.
| | - Hemant Singh Trehan
- Department of Ophthalmology, Army Hospital Research and Referral, New Delhi, India
| | - Kurumkattil Raji
- Department of Ophthalmology, Army Hospital Research and Referral, New Delhi, India
| | - Sanjay Kumar Dhar
- Department of Ophthalmology, Army Hospital Research and Referral, New Delhi, India
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17
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Chronopoulos A, Herbert J, Thumann G, Schutz JS. Avoiding Complications From Patient Positioning for Intraocular Surgery. Anesth Analg 2017; 126:1206-1211. [PMID: 28759486 DOI: 10.1213/ane.0000000000002319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Collaboration of the surgical and anesthesia teams for patient positioning is essential to assure patient comfort and safety, preventing systemic and ophthalmic complications. The goals and rationales of positioning for intraocular surgery are discussed including placing the head above the heart, elevating the chin, using a head rest that is sufficiently firm, maximizing anesthesia care team access and minimizing fire risk, and taping the patient's head to the operating table to reduce unexpected movement with intraocular injury.
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Affiliation(s)
- Argyrios Chronopoulos
- From the Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
| | - John Herbert
- Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, New York
| | - Gabriele Thumann
- From the Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
| | - James S Schutz
- From the Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
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18
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Rentka A, Kemeny-Beke A. Factors to be Considered when Performing Cataract Surgery in Patients Unable to Recline Flat. Semin Ophthalmol 2017; 33:443-448. [PMID: 28272966 DOI: 10.1080/08820538.2017.1296167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Although phacoemulsification is routinely performed with the patient in a supine position, certain locomotor deformities and other severe ailments can lead to the inability of the patient to recline flat. METHODS The present article surveys publications and summarizes our own experience regarding positioning techniques during cataract surgery on patients unable to adopt a supine position. RESULTS The successful and effective performance of cataract surgery by phacoemulsification depend on the comfortable positioning of both the patient and the surgeon. In order to achieve the highest possible success rate in phacoemulsification surgery, optimal positioning of the patient and the operating microscope are essential. There are other features of pivotal importance, including the construction of the operating table, the anesthesia technique, and the surgical approach. CONCLUSIONS Surgeons often have to rely on their own imagination and experience in finding optimal positioning in order to perform effective and successful phacoemulsification surgery.
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Affiliation(s)
- Aniko Rentka
- a Department of Ophthalmology, Faculty of Medicine , University of Debrecen , Debrecen , Hungary
| | - Adam Kemeny-Beke
- a Department of Ophthalmology, Faculty of Medicine , University of Debrecen , Debrecen , Hungary
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