Comparison of intraocular lens fixation techniques performed during penetrating keratoplasty

Use of Yamane technique for secondary intraocular lens implantation following open globe injury

A woman in her 50s presented with suspected open globe injury (OGI) of the right eye after being hit with a high velocity piece of plastic. Visual acuity at the time of presentation was counting fingers in the affected eye. Slit lamp examination revealed a full thickness laceration of the cornea and a traumatic cataract. Primary corneal repair was performed and the patient was left aphakic after cataract removal. Secondary intraocular lens placement was deferred for 2 years, after which time a scleral-fixated intraocular lens was implanted using the Yamane technique. Postoperative visual acuity of 20/50 was achieved, with the vision limited by persistent diabetic macular oedema. Thus, this case of successful implantation of a secondary lens using the Yamane technique in a patient with prior corneal laceration and traumatic cataract highlights that the Yamane technique can result in visual improvement in patients with prior OGI.

Trends in Secondary Intraocular Lens Surgery among Vitreoretinal Surgeons

OBJECTIVE

To identify changes in secondary lens techniques over time and to determine common complications of each technique.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All patients in the database from January 2015 to December 2021 who underwent secondary lens placement (anterior chamber intraocular lens [IOL, ACIOL], scleral-fixated IOL [SFIOL], or scleral-sutured IOL [SSIOL]).

METHODS

Rates of secondary IOL surgery techniques were analyzed in 3597 participants in a nationwide aggregated electronic health care database using 2-sample independent t tests. Rates of postoperative rhegmatogenous retinal detachment (RRD) after secondary IOL surgery were assessed using chi-square test of proportion. Postoperative visual acuity (VA) was assessed using 2-sample independent t tests.

MAIN OUTCOME MEASURES

The primary outcome was change in IOL technique over time. Secondary data points examined were the development of postoperative RRD after secondary IOL surgery, VA changes, the development of endophthalmitis, suture erosion, haptic erosion, or corneal edema after IOL surgery.

RESULTS

Anterior chamber IOL use decreased over the 7-year period from 93% of cases to 36% of cases (P < 0.0001), while SFIOL use increased from 3% to 34% (P < 0.0001) and SSIOL use increased from 4% to 30% (P < 0.0001). Visual acuity increased for each surgical technique (ACIOL: 44.1 vs. 49.2 ETDRS letters, P < 0.001; SFIOL: 48.7 vs. 57.6 letters, P < 0.001; SSIOL: 51.5 vs. 61.2 letters, P < 0.001), with larger VA gains seen in SFIOL and SSIOL use (ACIOL vs. SFIOL, P = 0.004; ACIOL vs. SSIOL, P = 0.002; SFIOL vs. SSIOL, P = 0.64). Average RRD rates did not significantly differ between techniques. Rates of endophthalmitis, haptic erosion, and suture erosion were low and did not significantly differ between techniques. Rates of corneal edema were significantly higher in ACIOL cases (vs. SFIOL, P < 0.0001; vs. SSIOL, P < 0.0001).

CONCLUSIONS

Rates of ACIOL implantation performed by vitreoretinal surgeons have decreased over time with more vitreoretinal surgeons electing to place either an SFIOL or SSIOL toward the end of the study period; complication profiles among the 3 techniques may be similar.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Sekundäre Linsenimplantation: chirurgische Techniken und Ergebnisse

Es stehen verschiedene alternative chirurgische Optionen zur Verfügung, um eine sekundäre Intraokularlinse (IOL) in Augen mit unzureichender Kapselunterstützung zu implantieren. Erfolgreiche Techniken umfassen die Implantation einer irisfixierten IOL (IFIOL), einer kammerwinkelgestützten Vorderkammerlinse (ACIOL) oder verschiedene Variationen zur Sklerafixierung (SFIOL). Jede dieser Methoden hat sich als sicher und effektiv erwiesen, weist jedoch verfahrensspezifische Einschränkungen auf. Jüngste Studien zeigen, dass die Entwicklung neuer chirurgischer Techniken diesen Patienten weiterhin sichere und reproduzierbare Behandlungsmöglichkeiten bietet. Obwohl die Implantation von sekundären IOLs ohne Kapselunterstützung von vielen Faktoren, einschließlich der Präferenz des Chirurgen, abhängt, sind nahtlose sklerafixierende Techniken für die chirurgische Gemeinschaft von wachsendem Interesse. Das Bestreben nach kürzeren und weniger traumatischen Operationen sowie nach reproduzierbaren und funktionell guten Ergebnissen, fördert dabei die Entwicklung von neuen Operationstechniken, Intraokularlinsen und Instrumenten. Diese Übersichtsarbeit gibt einen Einblick in alte und neue Behandlungsmethoden zur Korrektur von Aphakie mit sekundären Intraokularlinsen

New surgical approach for sutureless scleral fixation

Purpose:

The aim of this article is to describe a novel surgical technique for sutureless scleral fixation of an intraocular lens using the newly developed FIL SSF Carlevale IOL (Soleko, Italy).

Methods:

Four eyes of four patients with poor capsular support were recruited to our study, three resulting from intraocular lens subluxation and one case resulting from traumatic cataract. A novel sutureless sclera-fixated intraocular lens was implanted into the posterior chamber of each eye with sclerocorneal plugs fixating the lens to the wall of the eye.

Results:

Mean age of patients was 52 ± 16 years, ranging from 35 to 70 years. Mean follow-up was 6.50 ± 1.29 months (range: 5–7 months). Mean preoperative best-corrected visual acuity was 0.50 ± 0.33 logMAR (range: 1–0.3 logMAR). Postoperative best-corrected visual acuity improved to 0.08 ± 0.08 logMAR (range: 0.2–0 logMAR). There was no significant change in the mean intraocular pressure and there were no postoperative complications, such as iatrogenic distortion or breakage of the intraocular lens haptic, intraocular lens decentration, endophthalmitis, or retinal detachment.

Discussion:

To the best of our knowledge, this is the first report of outcomes using the novel sutureless sclera-fixated FIL SSF Carlevale IOL. This new surgical technique offers a simplified and effective approach for sutureless scleral intraocular lens fixation with good refractive outcomes.

Secondary intraocular lens implantation: Complication rates, visual acuity, and refractive outcomes

PURPOSE

To compare complication rates, visual acuity, and refractive outcomes of secondary intraocular lens (IOLs) implantation.

SETTING

Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA.

DESIGN

Retrospective case series.

METHODS

All secondary IOLs placed by the anterior segment service were reviewed. Preoperative data, operative reports, and data from each subsequent postoperative visit were evaluated. Patients were divided into 5 groups based on the final IOL position: (1) sulcus with optic capture, (2) sulcus without optic capture, (3) anterior chamber (AC), (4) iris-fixated, and (5) transscleral-sutured. Complication rates, visual acuity, and refractive outcomes were compared for each group.

RESULTS

The sulcus with and without optic capture groups had the lowest complication rates and best visual acuity outcomes. There was no difference in final corrected distance visual acuity (CDVA) between the transscleral-sutured IOL, iris-fixated IOL, and AC IOL groups, although the AC IOL group had the lowest rates of early postoperative complications and a significant improvement in vision. The transscleral-sutured IOL group had the highest complication rates, and 25% of patients in the iris-fixated IOL group lost 2 or more lines of CDVA.

CONCLUSIONS

When a secondary IOL cannot be placed within the capsular bag, sulcus with optic capture is the best alternative, followed by sulcus without optic capture. There was no difference in visual acuity outcomes between transscleral-sutured IOLs, iris-fixated IOLs, and AC IOLs. Anterior chamber IOLs resulted in fewer early complications.

Secondary intraocular lens implantation with absence of capsular support: Scleral versus iris fixation

PURPOSE

To assess the outcomes of iris fixated (IF) posterior chamber (PC) intraocular lens (IOL) versus scleral-fixated (SF) PC IOL implantation, and compare them with the results reviewed from the literature.

SETTING

The study took place in the ophthalmology department of the Eye and Ear Hospital (Lebanon).

DESIGN

This is a retrospective institutional study that collected the records of patients admitted for secondary IOL implantation between January 2007 and December 2016.

METHODS

A total of 28 eyes that underwent PC IOL fixation were included, 13 of which underwent trans-scleral PC IOL fixation and 15 of which underwent iris PC IOL fixation. Data were analyzed over a period of 3 years.

RESULTS

Of the 28 patients, 18 (64.3%) were male and 10 (35.7%) were female (mean age at intervention 36.78±23.47 [standard deviation, SD] years). There were no significant intergroup differences with regard to baseline values and demographic characteristics. Trauma was the most common etiology for posterior capsule insufficiency (82.1%). The mean preoperative baseline BCVA was 0.58±0.27 logMAR for SF and 0.27±0.20 logMAR for IF (P=0.07). Both groups had significant improvement in vision during the follow up period. No significant differences were noted regarding early or late postoperative complications between the two groups.

CONCLUSION

SF and IF techniques for PC IOL have similar outcomes and result in a significant improvement in BCVA. When compared to AC (anterior chamber) IOL, both techniques seem to yield fewer complications.

Secondary Intraocular Lens (IOL) Implantation: Anterior Chamber versus Scleral Fixation Long-Term Comparative Evaluation

Purpose

To compare the long-term efficacy of a secondarily implanted flexible angle supported anterior chamber (AC) intraocular lens (IOL) with sclerally fixated IOL as a secondary procedure in patients with aphakia.

Methods

Sixty patients with aphakia were recruited for this study. The patients were randomly divided into two groups: Group I patients underwent secondary implantation with AC IOL (Kelman Z type multiflex Domi classic AC IOL) and Group II patients underwent secondary implantation with scleral fixated IOL (Hanita lens with two eyelets). Postoperatively, the patients were followed up at 1 week, monthly for 6 months, and at twice yearly intervals for 5 years (mean follow-up was 3 years).

Results

Best-corrected visual acuity of 6/18 or better was achieved in 36.6% (11/30) of patients in Group I and 30% (9/30) of patients in Group II after a mean follow-up of 3 years. The complication rate was higher in Group II as compared to Group I. The authors encountered a total of 23 complications in the sclerally fixated group and 11 in the AC IOL group (p=0.004). Uveitis and ciliary tenderness were the most common complications in Groups I and II, respectively.

Conclusions

For secondary implantation of IOL in aphakic patients, Kelman Z type multiflex Domi classic AC IOL is a better rehabilitation modality as compared to the scleral fixated Hanita IOL.

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.

Long Term Clinical and Visual Outcomes of Retrofixated Iris Claw Lenses Implantation in Complicated Cases

Aims:

To evaluate the visual outcomes and complications after implantation of retrofixated iris claw (RFIC) lens in various challenging situations.

Settings and Design:

Retrospective, single centre, 8 year clinical audit.

Materials and Methods:

A retrospective analysis of cases who underwent RFIC lens implantation alone (group 1) or in combination with vitreoretinal (VR), corneal or glaucoma procedures (group 2) was performed. The main outcomes evaluated were corrected distant visual acuity (CDVA) and postoperative complications. The mean follow up was 13.09±6.8 (range 6-24) months.

Results:

The study involved 100 eyes of 83 patients with mean age of 51.1±25.4 years. Group 1 included 59 eyes and group 2 had 41 eyes. In group 1, the mean CDVA improved from 0.86±0.81 to 0.38±0.51 LogMAR (p<0.001) with 72.8% eyes having gain in lines (≥ 2 lines) of CDVA with safety index of 1.73. The mean CDVA in group 2 improved from 0.71±0.65 to 0.38±0.34 LogMAR (p=0.003) with 65.8% eyes having gain in lines (≥ 2 lines) of CDVA with a safety index of 1.54. Group 2 showed a higher complication rate of 36.59% compared to group 1 (20.34%). Significant complications noted were secondary glaucoma (8%), disenclavation of haptic (4%), subluxation of RFIC lens (1%).

Conclusion:

The visual outcome with RFIC lenses when combined with other intraocular procedures is mainly affected by the complexity of co-existing pathologies .The complications are more related to the combined procedures performed rather than RFIC lens implantation alone. This may still be acceptable when complication profile of other intraocular lenses is evaluated in similar challenging situations.

Iris Fixation of Unstable Anterior Chamber Intraocular Lenses

PURPOSE

To present a surgical approach for the treatment of unstable anterior chamber intraocular lenses (ACIOLs).

METHODS

We present a series of 8 patients who underwent iris fixation of an unstable open-looped ACIOL associated with progressive corneal damage. The loops of the intraocular lens were firmly fixated to the iris using 9-0 or 10-0 polypropylene sutures. In 2 cases, iris fixation was associated with penetrating keratoplasty. The other cases were performed using a relatively closed-system technique.

RESULTS

All procedures were uneventful, with no intraoperative or postoperative complications. Suture fixation effectively prevented anterior-posterior or propelling movement. The ACIOLs in all cases were stable and well centered at the end of follow-up.

CONCLUSIONS

Fixation of an existing unstable angle-supported ACIOL to the iris is an effective and simple alternative to intraocular lens exchange and posterior chamber fixation.

Prevention of suture exposure in transscleral intraocular lens fixation: an original technique

BACKGROUND

In this retrospective study, we evaluated our surgical outcomes of transscleral intraocular lens (IOL) fixation and introduced a simple, quick, and effective method to fixate and bury the sutures in the sclera to avoid suture exposure.

METHODS

Eyes were divided into 3 groups according to surgical technique. Half-thickness scleral flaps were prepared, and polypropylene suture ends were cut short in group 1 (12 eyes). Suture ends were left long without flaps in group 2 (47 eyes) and were buried into the scleral tunnel in group 3 (21 eyes).

RESULTS

The suture exposure rate was significantly lower in group 3 (0%) compared with group 2 (p = 0.006) and group 1 (p = 0.040). There was no significant difference in group 1 (25%) compared with group 2 (27.6%) (p = 1.000).

INTERPRETATION

Burying the suture ends into the scleral tunnel is a simple, safe, and effective technique for avoiding suture exposure in scleral-fixated IOL implantation.

Late dislocation of scleral-sutured posterior chamber intraocular lenses

PURPOSE

To examine a recent series of late scleral-sutured posterior chamber intraocular lens (PCIOL) dislocations to identify possible causes and preventive measures.

SETTING

Price Vision Group, Indianapolis, Indiana, USA.

METHODS

In this retrospective non-comparative interventional case series, 5 consecutive patients received treatment for dislocated scleral-sutured PCIOLs between July 2002 and March 2004. Dislocated lenses were resutured or replaced with another scleral-sutured PCIOL.

RESULTS

Dislocation of scleral-sutured PCIOLs occurred 7 to 14 years after implantation. Four dislocations were spontaneous, and 1 was precipitated by trauma. In each case, the suture affixing 1 or both haptics failed. There was no evidence that the suture had eroded through the tissue or that the knot had untied. Microscopic analysis of an explanted IOL with remnants of the suture attached showed localized degradation and cracking of the polypropylene suture material where it had been embedded in the scleral tissue.

CONCLUSION

Suture-fixated PCIOLs can dislocate due to degradation of the suture material over time. The use of larger diameter (9-0 instead of 10-0) polypropylene suture material and placement of the haptic and sutures in the ciliary sulcus to promote attachment of scar tissue may enhance the long-term stability of scleral-fixated PCIOLs.

Anterior chamber intraocular lens (ACIOL) placement after pars plana lensectomy in pediatric Marfan syndrome

INTRODUCTION

The management of subluxed crystalline lenses in patients with Marfan syndrome is challenging and may require lensectomy. Options for postoperative optical correction include aphakic spectacles, aphakic contact lens, posterior chamber IOLs sutured to the ciliary sulcus, and open-loop flexible anterior chamber IOLs (ACIOL). We recently began placing ACIOLs in all patients with Marfan Syndrome who were younger than 18 years of age and required lensectomy.

METHODS

We used a retrospective chart review design for this study.

RESULTS

Eight eyes of 5 patients were treated with pars plana vitrectomy, pars plana lensectomy, and primary ACIOL placement. Follow-up ranged from 9 to 16 months, with a mean of 12.7 months. Ages ranged from 5 to 17 years with a mean of 9 years. Three eyes were functionally aphakic at the time of surgery. Of the 5 eyes with a portion of the lens remaining in the visual axis, none maintained accommodative function by near visual acuity testing. Best-corrected distance visual acuity preoperatively ranged from 20/50 to 20/400, with an average of 20/80 (0.65 logMAR). Postoperative acuity ranged from 20/20 to 20/50, with an average acuity of 20/32 (0.20 logMAR). One patient had an iatrogenic sector iridectomy. No patients experienced corneal decompensation, increased intraocular pressure, persistent inflammation, IOL displacement, or explantation during the follow-up period.

CONCLUSIONS

Although long-term follow-up data are unavailable, our cases of primary ACIOL placement in children with Marfan syndrome indicate that this therapy should be considered.

Scleral-fixated posterior chamber intraocular lenses in nonvitrectomised eyes

OBJECTIVE

To assess the long-term outcome of scleral-fixated sutured posterior chamber intraocular lens (SPCIOL) implantation in non pars plana vitrectomised eyes (1) to evaluate the long-term visual outcome, (2) to identify preoperative risk factors for poor visual outcomes, and (3) to identify the incidence of vitreoretinal complications.

METHOD

A retrospective review of 65 eyes, which had not undergone pars plana vitrectomy prior to scleral-fixated SPCIOL implantation.

RESULTS

In all, 65 eyes of 61 patients were analysed. The median follow-up period was 16 months (range 1-68 months). At final follow-up, 43 (66%) eyes had unchanged or improved BCVA at final follow-up. A total of 20 (31%) eyes had at least a two line improvement and eight (12%) eyes had at least a two line deterioration in final BCVA. No significant preoperative risk factors for a poor visual outcome were identified. In all, 24 eyes (37%) had per- and postoperative adverse events. These eyes were significantly more likely to have a poor visual outcome. Three eyes (4.6%) had a retinal detachment in the postoperative period, all of which had no perception of light at final follow-up.

CONCLUSIONS

This study confirmed that while scleral-fixated SPCIOL intraocular lens implantation might be beneficial, there is a significant risk of per- and postoperative complications leading to loss of best-corrected vision in some eyes.

Suture fixation of a posterior chamber intraocular lens in anticoagulated patients

PURPOSE

To describe a technique of suture fixating posterior chamber silicone intraocular lenses (PC IOLs) to the iris through a limbal incision and to evaluate its effectiveness in preventing intraocular hemorrhages.

SETTING

Price Vision Group, Indianapolis, Indiana, USA.

METHODS

This retrospective single-center study comprised 7 eyes (5 patients) that had suture fixation of a silicone PC IOL from a limbal approach to the midperipheral iris using 9-0 polypropylene (Prolene(R)) suture. All patients were taking warfarin sodium (Coumadin(R)) preoperatively and postoperatively. At each follow-up examination, visual acuity and intraocular pressure were measured, the stability of the PC IOL was assessed, and the anterior chamber and posterior segment were evaluated for blood.

RESULTS

There was no incidence of intraocular hemorrhage during surgery in any eye. In 6 eyes, there was no blood in the anterior chamber or posterior segment at any postoperative examination. A nonlayering hyphema that resolved within 1 week without sequelae was noted in 1 patient 6 weeks postoperatively. The mean follow-up was 10.7 months (range 6 to 25 months).

CONCLUSION

Suture fixating a PC IOL to the iris through a limbal approach was an effective means of placing an IOL in anticoagulated patients without capsule support.

Long-term outcomes of combined penetrating keratoplasty with iris-sutured intraocular lens implantation

PURPOSE

To evaluate the long-term outcomes of combined penetrating keratoplasty with iris-sutured posterior chamber intraocular lens implantation.

PARTICIPANTS

Patients (264 eyes) with aphakic and pseudophakic bullous keratopathy.

DESIGN

Retrospective case series.

INTERVENTION

Penetrating keratoplasty combined with implantation of an iris-sutured posterior chamber intraocular lens performed by a single surgeon.

METHODS

Data were gathered from the institutional database during a period of 10 years (1989-1999) and analyzed using customized software.

MAIN OUTCOME MEASURES

Graft survival rate, visual acuity, and intraoperative and postoperative complications.

RESULTS

Two-hundred fifty-two consecutive patients (264 eyes) were operated. Graft survival rates were 95% at 1 year, 89% at 2 years, and 81% at 5 years and were comparable to the results of previous corneal transplant studies. Among 180 patients (191 eyes) with a follow-up of at least 2 years (range, 2-11 years; mean, 5 years), the visual acuity at final follow-up visit, compared with preoperative visual acuity was improved in 72% of eyes (mean preoperative visual acuity, 20/250; mean postoperative visual acuity, 20/60). No intraoperative complications were encountered.

CONCLUSIONS

Combined penetrating keratoplasty with iris-sutured posterior chamber intraocular lens implantation offers significant vision benefits in this patient group.

Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology

OBJECTIVE

This review was conducted to determine the safety and efficacy of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber intraocular lenses (IOLs) in eyes with inadequate capsular support for posterior chamber implantation in the capsular bag or ciliary sulcus. It also attempted to determine whether there is a preferred IOL or fixation site of choice in eyes with inadequate capsular support.

METHODS

A literature search conducted for the years 1980 to 2001 yielded 189 citations related to IOL implantation in the absence of capsular support. An update search, conducted in March 2002, yielded an additional 28 articles. The Anterior Segment Panel members reviewed these abstracts and selected 148 articles of possible clinical relevance for review. Of these, 89 were considered sufficiently clinically relevant for the panel methodologist to review and rate according to the strength of evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating was assigned to well-designed cohort and case-control studies; and a level III rating was assigned to case series. Articles comparing the safety and efficacy of the IOL type and fixation site were further evaluated for the quality of the statistical methods used in the study. Studies with a rating of A or B were considered acceptable, C was borderline, and D and F were considered unacceptable as medical evidence.

RESULTS

Forty-three articles with data concerning outcome of IOL insertion in eyes with inadequate capsular support had an evidence rating of level III or higher and were used in the final review of the safety and efficacy of one or more lens types and/or fixation sites. Seven articles had data about more than one lens type. Six had a statistical method rating of C or higher and were used to evaluate differences in visual outcomes and complication rates between lens types and fixation sites.

CONCLUSIONS

The literature supports the safe and effective use of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber IOLs for the correction of aphakia in eyes without adequate capsular support for placement of a posterior chamber lens in the capsular bag or ciliary sulcus. At this time, there is insufficient evidence to demonstrate the superiority of one lens type or fixation site. Precise determination of small differences in visual outcome or complication rates will require a large prospective, randomized clinical trial.

Scleral fixation suture technique without lens removal for posteriorly dislocated intraocular lenses

BACKGROUND

Posterior chamber intraocular lenses (IOLs) may dislocate into the vitreous or over the retina at the time of, or several months after, surgery or following injury. Techniques described to reposition dislocated lenses have drawbacks, such as lens removal, lens exchange, difficulties of lens repositioning procedures and high cost We describe a technique in which the haptics of dislocated IOLs are fixed to the sclera after the haptics are externalized solely through a pars plicata incision site and tied with a 10-0 Prolene suture.

METHODS

After pars plana vitrectomy, the IOL was grasped with an intraocular forceps and moved to the pupillary area. A second intraocular forceps was inserted from the site of planned fixation, and the tip of the haptic was pulled out and heated to form a knob to avoid suture slipping. A 10-0 Prolene suture was then tied to the haptic by means of a sailor knot The haptic was reinserted intraocularly, and the outstaying sutures were tied with conventional knots over the sclera or under the scleral flaps. The procedure was then repeated on the other side.

RESULTS

This technique has been used in 12 patients (12 eyes), 7 men and 5 women ranging in age from 45 to 77 (mean 63.8 [standard deviation 8.5]) years. The time between diagnosis of dislocation and surgery was 10 to 20 days in six cases and 21 to 39 days in six cases. The IOL was dislocated into the vitreous in eight cases (67%) and over the retina in four cases (33%). The preoperative best corrected visual acuity ranged from 20/200 to 20/30. Intraoperatively, mild vitreous hemorrhage developed in two patients (17%), macular edema developed in two patients (17%), and rhegmatogenous retinal detachment developed in one patient (8%). The final visual acuity ranged from 20/50 to 20/20 in 11 patients; the patient with retinal detachment had hand movement vision.

INTERPRETATION

The technique of scleral fixation of posteriorly dislocated IOLS without lens removal is a safe, inexpensive and useful complement to other techniques.

Histopathologic findings in a transsclerally sutured posterior chamber intraocular lens

A 77-year-old woman had penetrating keratoplasty (PKP), removal of an anterior chamber intraocular lens (IOL), and implantation of a transsclerally sutured posterior chamber IOL for painful pseudophakic bullous keratopathy. Postoperatively, preexisting anterior synechias led to painful secondary angle-closure glaucoma and the eye was enucleated 8 months after the PKP. Light microscopy of the eye revealed that the haptics of the IOL were surrounded by a variably dense fibrous membrane consisting of connective tissue and fibroblasts. In some areas, the haptics had eroded into the superficial stroma of the ciliary body. Except for rare foreign-body giant cells, no inflammatory cells were present near the haptics. This case illustrates that haptics of transsclerally sutured posterior chamber IOLs may be stabilized by fibrous membranes and/or by erosion into the ciliary body relatively soon after implantation. This should be considered if surgical centration, removal, or exchange of such a lens is planned.

[History of the development of intraocular lenses]

Even though cataract surgery has been practiced for over 2000 years, modern cataract surgery started just some 50 years ago. with the first IOL implantation by Sir Harold Ridley. The development of intraocular lenses was accompanied by great successes and disasters. With the fast development of cataract surgical techniques over the past 15 years (ECCE, Phacoemulsification, Capsulorhexis) a successful marriage between IOL-developments and surgery was established. Indication profiles for cataract surgery and IOL implantation extended to more and more patient groups. At this time classical cataract surgery is further developing into refractive intraocular lens surgery to correct higher ametropia in clear lens or phakic eyes. This development was only possible because of the improvements of surgical techniques and implants in classical cataract surgery.

Pars plana vitrectomy and sutured posterior chamber lens implantation

Transcleral suturing of posterior chamber intraocular lenses (IOLs) was developed to extend the benefits of IOL visual rehabilitation to eyes lacking capsular support and to avoid the complications of closed loop interior chamber IOLs. Although most frequently implanted after complicated cataract surgery or penetrating keratoplasty, they are indicated in several situations following pars plana vitrectomy. The surgical techniques have evolved to minimize the risk of complications, but the surgery remains technically more demanding and time-consuming than insertion of a modern open loop anterior chamber IOL. No randomized trials have compared the relative risks of each lens type, which leaves surgeon preference as the major determinant of what lens is implanted. It is likely, however, that in eyes with extensive anterior chamber angle damage or large iris defects, sutured posterior chamber IOLs will remain the first choice for surgical rehabilitation.

Implantation of Scleral-sutured Posterior Chamber Intraocular Lenses During Penetrating Keratoplasty

PURPOSE

To evaluate the clinical outcome in 29 patients (29 eyes) who underwent penetrating keratoplasty and scleral-fixation of an intraocular lens.

METHODS

The indications for penetrating keratoplasty with scleral-fixation of an intraocular lens were anterior chamber pseudophakic corneal edema, aphakic corneal edema, trauma, and corneal scars. Patients with pseudophakic corneal edema underwent IOL exchange and penetrating keratoplasty and patients with lens subluxation underwent cataract extraction and penetrating keratoplasty in the same operation session.

RESULTS

Preoperative spectacle-corrected visual acuity was hand motion in 13 eyes (44.8%) and 20/400 in 18 eyes (61.5%). Postoperative spectacle-corrected visual acuity of 20/400 or better was observed in 25 eyes (86.2%). At last follow-up, 26 corneal grafts (89.7%) remained clear. Three grafts (10.3%) failed, two because of glaucoma and one because of endophthalmitis. Glaucoma was observed in 7 eyes.

CONCLUSION

Trans-scleral fixation of intraocular lenses combined with penetrating keratoplasty was a useful surgical technique in eyes with keratopathy and lacking posterior capsular support.

Iris fixation of posterior chamber intraocular lenses

PURPOSE

To describe a technique for suture fixation of silicone intraocular lenses (IOLs) to the iris and compare the outcomes to those in published data.

SETTING

Subspecialty cornea/anterior segment private practice, Indianapolis, Indiana, USA.

METHODS

This retrospective review comprised 121 consecutive cases of secondary IOL implantation or IOL exchange between 1993 and 1998. All cases had concurrent anterior or posterior vitrectomy. Intraocular lens exchange was performed in 96 eyes, secondary IOL implantation in 20 eyes, and primary IOL implantation in 5 eyes. Penetrating keratoplasty (PKP) was performed concurrently in 93 eyes, extracapsular cataract extraction in 1 eye, intracapsular cataract extraction in 2 eyes, pars plana lensectomy in 2 eyes, and Molteno tube shunt placement for uncontrolled glaucoma in 1 eye. Outcomes measured were graft survival, visual acuity, new onset or worsening of glaucoma, and complications related to surgery.

RESULTS

Graft survival at last follow-up was 89.2% in patients having PKP. Visual acuity was 20/80 or better in 58.3% and 20/40 or better in 30.5% of eyes with transplants. Without transplants, visual acuity was 20/80 or better in 82.0% and 20/40 or better in 57.1%. Glaucoma developed or worsened in 24.7% and improved in 16.1% with transplants; it developed or worsened in 7.0% and improved in 17.8% without transplants. Retinal detachment occurred in 1 eye with a transplant. In the nontransplant group, major complications were bullous keratopathy (n = 2) and tilted IOL (n = 1).

CONCLUSIONS

Iris fixation of posterior chamber silicone IOLs may decrease the possibility of late suture breakage and dislocation of the IOL, as well as the risk of endophthalmitis. Graft survival, visual acuity, glaucoma, and complications are similar to those of other methods of IOL fixation reported in the literature.

Scleral-fixated intraocular lens implantation in unilateral aphakic children

OBJECTIVE

To assess the feasibility of scleral-fixated intraocular lens (IOL) implantation as an alternative form of optical correction in aphakic children intolerant of contact lenses and whose anterior segments lack capsular support.

DESIGN

Prospective, noncomparative case series.

PARTICIPANTS

A total of 11 eyes of 11 unilateral aphakic children in the age group 4 to 9 years (mean, 6.45 years) were included in the study.

INTERVENTION

Secondary scleral-fixated IOL implantation was performed in all cases. The patients underwent anterior vitrectomy at the time of IOL implantation. Amblyopia therapy in the form of patching was given post-IOL surgery. The follow-up ranged from 4 to 18 months (mean, 10.90 months).

MAIN OUTCOME MEASURES

Postoperative best-corrected visual acuity (BCVA) in comparison to preoperative visual status and complications from the procedure were analyzed.

RESULTS

Postoperative BCVA remained within 1 Snellen line of the preoperative visual status in six eyes, or 54.5% of patients; it improved by more than 1 Snellen line in three eyes, or 27.2% of patients, and decreased by more than 1 Snellen line in two eyes, or 18.1% of patients. The complications encountered were suture erosion through the conjunctiva in two eyes (18.18%), marked postoperative anterior chamber reaction in two eyes (18.18%), IOL decentration in one eye (9.09%), glaucoma in one eye (9.09%), and cystoid macular edema in one eye (9.09%).

CONCLUSION

Secondary scleral-fixated IOL implantation was successful in achieving BCVA comparable to preoperative BCVA. However, a longer follow-up is required to document any further complications.

Ten-year postoperative results of penetrating keratoplasty

OBJECTIVE

To investigate the changes in central corneal endothelial cells and corneal thickness in transplanted corneas from 5 to 10 years after grafting. This study also aimed to investigate the development of glaucoma, graft rejection, and graft failure during the first 10 postoperative years.

DESIGN/PARTICIPANTS

Longitudinal cohort study of 500 consecutive penetrating keratoplasties by 1 surgeon. Patients were asked to return for follow-up examinations at 2 months and at 1, 3, 5, and 10 years after grafting. The authors excluded eyes regrafted during the study and the fellow eyes of bilateral cases, leaving 394 grafts in 394 patients for analysis.

INTERVENTION

Penetrating keratoplasty was performed.

MAIN OUTCOME MEASURES

Using specular microscopy, the authors measured endothelial cell density, coefficient of variation of cell area, percentage of hexagonal cells, and corneal thickness. The authors performed clinical examinations to determine graft rejection or failure and the development of glaucoma.

RESULTS

By 10 years postkeratoplasty, 80 of the 394 patients had died and 68 grafts had failed. Of the remaining 246 patients, 119 (48%) returned for their 10-year examinations. For the 72 patients who returned for all of the scheduled postoperative visits and had no rejection episodes, reoperations, or failure, endothelial cell loss from preoperative donor levels at 10 years was 67 +/- 18% (mean +/- standard deviation), endothelial cell density was 958 +/- 471 cells/mm2, coefficient of variation was 0.32 +/- 0.11, hexagonal cells were 56 +/- 12%, and corneal thickness was 0.58 +/- 0.05 mm. The 5- to 10-year changes for all these values were significant (P < or = 0.004). The mean rate of late endothelial cell loss from 5 to 10 years postkeratoplasty was 4.2% per year. Eyes that were aphakic after grafting had the lowest endothelial cell loss (57 +/- 24%) and the lowest interval cell loss from 5 to 10 years postkeratoplasty (4 +/- 19%). Eyes that were phakic had the highest endothelial cell loss (73 +/- 8%) and 5- to 10-year-interval cell loss (17 +/- 31%). Eyes with posterior chamber lenses had a greater endothelial cell loss (71 +/- 9%) than did eyes with anterior chamber lenses (51 +/- 25%, P = 0.03). The 10-year cumulative risk of glaucoma, rejection, or failure was 21%, 21%, and 22%, respectively. Late endothelial failure became the major cause for graft failure, accounting for 9 of the 11 failures after 5 postoperative years.

CONCLUSIONS

From 5 to 10 years after penetrating keratoplasty, the annual rate of endothelial cell loss was seven times the normal rate. The endothelial cell loss, pleomorphism, polymegethism, and corneal thickness increased significantly during this time, indicating continued endothelial instability and dysfunction, resulting in an increasing rate of late endothelial failure.

Intraocular lens complications requiring removal or exchange

Intraocular lens (IOL)-related complications are caused primarily by mechanical trauma, inflammatory or infectious complications, or optical problems. Complications may occur at the time of surgery or be the result of an ongoing postoperative process. Mechanical and inflammatory injury may produce corneal decompensation, cystoid macular edema, hyphema, uveitis, and glaucoma, causing reduced vision and in some cases chronic pain. Optical problems may be due to a wrong power of the IOL or to postoperative decentration or dislocation of the lens. Ophthalmologists should be aware of the indications for IOL removal or exchange in those patients who have ongoing IOL-induced injury or impairment. Removal or exchange of an IOL frequently involves a complex decision-making process and is often associated with immense technical challenge. Various medical and surgical treatments may be tried to correct IOL problems before the decision is made to remove or exchange the lens.

Uveitis-glaucoma-hyphema syndrome after handmade, anterior chamber lens implantation

Two patients developed uveitis-glaucoma-hyphema syndrome secondary to implantation of handmade anterior chamber intraocular lenses (IOLs). The IOLs were designed and made by the patients' ophthalmologists in their native Ukraine. The cases illustrate innovative and unusual solutions to the shortage of quality IOLs in the developing world and the challenging management of patients who present with complications arising from these IOLs.

Preoperative ultrasound biomicroscopy to assess ease of haptic removal before penetrating keratoplasty combined with lens exchange

PURPOSE

To evaluate a method of assessing anterior chamber intraocular lens (IOL) haptics before combined penetrating keratoplasty and IOL exchange in eyes with poor corneal clarity resulting from pseudophakic bullous keratopathy (PBK).

SETTING

Department of Ophthalmology, Toronto Hospital, Ontario, Canada.

METHODS

Twelve eyes (25 haptics) with PBK were studied using ultrasound biomicroscopy (UBM). The degree of haptic encasement was graded. The result was compared with the degree of difficulty and the complications encountered in removing the IOL at the time of surgery. The surgeons were masked as to the UBM results.

RESULTS

All haptics were easily visualized with UBM, with 23 in the angle and 2 passing through a peripheral iridectomy. On UBM, 9 haptics were noted to lie free in the angle, and 16 were encased by fibrotic tissue. Eight were covered by less than 100 microns and 8 by more than 100 microns of tissue. Calculations using Kappa statistics found a strong predictive value for the UBM in identifying the presence or absence of fibrotic encasement and degree of difficulty in removing the anterior chamber IOL haptics. Ultrasound biomicroscopy also allowed assessment of the adjacent angle for synechias.

CONCLUSION

Ultrasound biomicroscopy provides an alternative method for evaluating anterior chamber IOL haptics when gonioscopy is not possible because of corneal opacity. This method allows the surgeon to predict preoperatively the degree of difficulty that will be encountered in explanting the IOL.

Penetrating keratoplasty and transscleral fixation of posterior chamber lens

We reviewed the charts of 21 patients who underwent penetrating keratoplasty and transscleral fixation of a posterior chamber lens. One lens was sutured in an aphakic eye and 20 lenses were sutured after removal of an anterior chamber lens. Postoperative follow-up averaged 13 months (2-39 months). Visual acuity improved in 20 patients (95%) and remained the same in 1 patient (5%). Postoperative visual acuity was less than 0.1 in 5 patients (23.8%), 0.1 to 0.33 in 14 patients (66.7%) and better than 0.33 in 2 patients (9.5%). Twelve patients (57.1%) expressed a substantial reduction in ocular pain, 7 patients (33.3%) had no pain either before or after the operation, 2 patients (9.5%) expressed no reduction in pain. No cases of endophthalmitis, choroidal hemorrhage or retinal detachment were found. In one case, the sutured lens was dislocated without disturbing vision. Intraocular pressure increased in 3 of 9 patients with preoperative glaucoma. New-onset glaucoma developed in 1 patient. We find transscleral fixation of a posterior chamber lens to be an acceptable procedure in penetrating keratoplasty with IOL implantation where capsular support is inadequate for conventional implantation of a posterior chamber lens.

Transscleral fixation of posterior chamber intraocular lenses

In a retrospective study of 75 consecutive eyes having transscleral suturing of a posterior chamber intraocular lens (IOL) (mean follow-up five months), 57% had improved best corrected visual acuity; 67% of those obtained a visual acuity of 20/40 or better. Thirty-seven eyes had an IOL exchange without penetrating keratoplasty (PKP) at the time of implantation, 15 had simultaneous PKP, and 23 had secondary lens implantation without IOL exchange or a corneal transplant. Transscleral fixation is an effective means of implanting a posterior chamber lens in eyes without capsular support. It allows secure two-point lens fixation with minimal risk of IOL tilting or suture erosion through the conjunctiva or sclera.

Combined pars plana vitrectomy-lensectomy and open-loop anterior chamber lens implantation

PURPOSE

To investigate the effectiveness of open-loop, one-piece, flexible, Kelman-style, all-polymethylmethacrylate (PMMA) anterior chamber intraocular lenses (AC IOLs) in patients undergoing pars plana vitrectomy surgery for a variety of vitreoretinal disorders.

METHODS

Fifteen patients (6 women and 9 men) underwent combined pars plana vitrectomy with insertion of an open-loop AC IOL. Postoperative results were evaluated.

RESULTS

The average preoperative visual acuity of 20/360 (logMAR scale, 1.25 +/- 0.80) improved to 20/52 (logMAR scale, 0.42 +/- 0.35) after an average follow-up of 10.2 months (range, 1-41 months). Of 15 eyes, 7 (47%) achieved a visual acuity of better than 20/40. There was no evidence of glaucoma exacerbation or corneal decompensation. Visual acuity was limited primarily by chronic cystoid macular edema in 4 (27%) of 15 eyes.

CONCLUSION

In this preliminary series of patients, open-loop, flexible, all-PMMA, Kelman-style AC IOLs appear to be well tolerated and represent a viable, simple alternative to transscleral fixation of a posterior chamber IOL or surgical aphakia in patients undergoing vitrectomy surgery.

Surgical techniques for repositioning a dislocated intraocular lens, repair of iridodialysis, and secondary intraocular lens implantation using innovative 25-gauge forceps

PURPOSE

We developed surgical techniques for the sulcus fixation of a posteriorly dislocated or secondarily implanted posterior chamber intraocular lens, repair of an iridodialysis, and the management of a decentered intraocular lens during vitreous surgery using innovative 25-gauge forceps.

METHODS

The 25-gauge forceps have a curved shaft, a tip with a distal platform for grasping a suture, and a proximal groove for gripping a haptic. The forceps are inserted through a grooved scleral incision into the plane of the ciliary sulcus, facilitating manipulations such as fastening a suture loop around a haptic, repositing an intraocular lens at the ciliary sulcus, and grasping sutures during repair of a iridodialysis or implantation of a secondary intraocular lens. Seven patients underwent vitreous surgery using the new forceps.

RESULTS

In all seven patients the surgical objectives were accomplished with the 25-gauge forceps without postoperative complications such as hemorrhage, hypotony, or lens decentration.

CONCLUSIONS

The 25-gauge forceps are innovative instrumentation designed specifically for anterior segment applications during vitreous surgery.

Are there acceptable anterior chamber intraocular lenses for clinical use in the 1990s? An analysis of 4104 explanted anterior chamber intraocular lenses

PURPOSE

The authors pose the question as to whether there are any anterior chamber intraocular lenses (AC IOLs) acceptable for clinical use in the 1990s.

METHODS

Data on the incidence and types of complications of 4104 AC IOLs that were submitted to the Center for IOL Research from 1982 to 1993 were retrieved from the laboratory database and analyzed using cumulative frequency calculations and the chi-square test. Normalized explantation rates were related to implantation rates that were derived from market-share analysis.

RESULTS

Of 4104 explanted IOLs, 50% were closed-loop designs (n = 2095/4104); 26% (1100/4104) were miscellaneous, older designs; and 22% (919/4104) were open-loop lenses. The most important complications were corneal pathology (2065/4104) and inflammation (1370/4104). Closed-loop designs were responsible for almost 80% of corneal pathology, with an increasing complication rate with ongoing implant duration (P < 0.0001). Open-loop AC IOLs showed, in relation to their normalized rate of implantation, a significantly lower rate of complications and explantations (P < 0.01).

CONCLUSION

Complication rates of flexible, open-loop AC IOLs are much lower than previously assumed. They should be distinguished clearly from most older AC IOL designs. Consideration of these lenses as an alternative to sutured posterior chamber IOLs for secondary or exchange implantation may be warranted for selected clinical indications. They also could provide an alternative to the aphakic spectacle rehabilitation program in developing countries, which will have a positive impact on the overwhelming backlog of patients with cataract in the underprivileged world.

Functional results of posterior chamber lens implantation with scleral fixation

Recently, scleral fixation has been used in posterior chamber intraocular lens implantation in the absence of the posterior capsule. Fixation is achieved with a suture through the ciliary sulcus and sclera at a horizontal or vertical position. To achieve good functional results, the optical portion of the lens must lie on the optical axis. Unilateral lens implantation in the absence of the posterior capsule was performed with scleral fixation in 48 patients. Follow-up ranged from 14 months to 2.6 years. The position of the posterior chamber lens was defined in relation to the limbus and the pupillary margin. There was no evidence of lens decentration in miosis. Under conditions of extreme mydriasis, decentration of less than 1.0 mm was found in four patients; four others had approximately 1.5 mm of decentration. Magnetic resonance imaging was used to determine lens position in some cases. Scleral fixation is a viable alternative for implantation of posterior chamber lenses in the absence of the posterior capsule.

A randomized trial of intraocular lens fixation techniques with penetrating keratoplasty

PURPOSE

Pseudophakic corneal edema is the principal indication for penetrating keratoplasty in the United States. Currently, three techniques of intraocular lens (IOL) fixation during penetrating keratoplasty for this condition are commonly used--flexible anterior chamber IOL (AC IOL) implantation, iris suture fixation of a posterior chamber IOL (PC IOL), and transscleral suture fixation of a PC IOL. This study represents the first prospective, randomized comparison of these three techniques.

METHODS

One hundred seventy-six consecutive patients with pseudophakic corneal edema who underwent penetrating keratoplasty with IOL exchange were randomized to one of the three implantation techniques. Standardized evaluations were performed at baseline and at 6, 12, and 18 months postoperatively. Life-table analysis provided cumulative risk estimates for specific complications.

RESULTS

Randomization produced comparable groups at baseline. The cumulative risk of macular edema was significantly less for the iris fixation cohort than for either the AC IOL or scleral fixation group. A complications index was constructed based on the major adverse outcomes of glaucoma escalation, cystoid macular edema, IOL dislocation, and graft failure. A significantly lower risk of complication was found for iris compared with scleral fixation of PC IOLs.

CONCLUSION

The authors conclude that transscleral fixation of the PC IOL at the time of penetrating keratoplasty for pseudophakic corneal edema is associated with a greater risk of adverse outcome than iris fixation of a PC IOL.

Sulcus fixation without flaps

BACKGROUND

Numerous techniques for sulcus fixation of posterior chamber implants in the absence of capsular support have been reported. All rely on partial thickness scleral flaps or the conjunctiva to prevent the requisite polypropylene knot from eroding. The author compares their success with that of a new surgical procedure. This new technique buries the knot within the eye.

METHODS

One hundred scleral-sutured, sulcus-fixated cases were studied retrospectively. Each case was performed by the author or by a resident under this direction. Suture erosion was defined as the absence of scleral or conjunctival cover on part of the polypropylene suture.

RESULTS

On 60 patients, partial thickness scleral flaps were used to protect the knot from exposure. Twelve (20%) of these patients had some degree of externalization of the suture. Of the 40 patients in whom knots were buried and no scleral flap was used, no (0%) erosion was observed.

CONCLUSION

Sulcus fixation of posterior chamber knots has been criticized for increasing the risk of endophthalmitis. The track formed by an exposed suture allows an infectious agent to pass from the external eye to the supported intraocular lens (IOL). Scleral flaps add a degree of safety, but the knot can erode after several months. The author advocates burying the knot within the eye to avoid erosion and therefore endophthalmitis.

Penetrating keratoplasty and transscleral fixation of posterior chamber lens

We reviewed the outcome in 115 patients who underwent penetrating keratoplasty and transscleral fixation of a posterior chamber lens. One patient died soon after surgical procedures, and nine patients were lost to follow-up, leaving a cohort of 105 patients. Mean follow-up time was 26.8 months (range, six to 43 months). Visual acuity of 20/40 or better was found in 29 patients (27.6%) and 20/50 to 20/200 in 37 patients (35.2%). Reasons for poor visual outcome included cystoid macular edema in ten patients (9.5%), age-related macular degeneration in six patients (5.7%), and retinal detachment in four patients (3.8%). None of the patients developed lens decentration. There were no instances of hyphema and only one patient had a perioperative limited suprachoroidal hemorrhage. New-onset increase in intraocular pressure developed in 20 of 66 patients (30.3%). Analysis of the 39 patients with preoperative increase in intraocular pressure that required medical treatment demonstrated an improvement in 13 patients (33.3%), worsening in 12 patients (30.8%), and unchanged status in 14 patients (35.9%). The exposed haptic suture was covered by using one of the following three alternative methods: a conjunctival flap, a scleral flap, or a corneal tissue button. Exposure of the haptic suture through the conjunctiva was a complication in 21 patients (20%). Of these 16 (76.1%) occurred in the group with a conjunctival covering, five (23.8%) occurred in the group with a scleral flap, and none occurred in the corneal tissue button group. This study demonstrated that transscleral fixation of a posterior chamber lens is a viable option in the treatment of patients undergoing penetrating keratoplasty and intraocular lens implantation with absent capsular support.

Soemmering's ring support for posterior chamber intraocular lens implantation during penetrating keratoplasty. Changing trends in bullous keratopathy

BACKGROUND

Changing trends in cataract extractions have resulted in a new category of bullous keratopathy: corneal decompensation after complicated extracapsular cataract extraction. These cases of bullous keratopathy are associated with rupture of the posterior capsule, vitreous loss, and significant intraocular inflammation at the time of the original complicated extracapsular cataract extraction.

METHODS

The authors reviewed 14 consecutive cases of penetrating keratoplasty for bullous keratopathy in which posterior chamber intraocular lens implantation was supported by remnants of the posterior capsule and/or Soemmering's ring without suture fixation. All 14 patients had a history of complicated extracapsular cataract extraction with capsule rupture and vitreous loss.

RESULTS

All 14 patients had clear, compact grafts without migration of the intraocular lens with a mean follow-up of 12.1 months. Vision improved in 93% of cases, and there was no significant worsening of glaucoma.

CONCLUSIONS

Pseudophakic bullous keratopathy after traumatic extracapsular cataract extraction with an anterior chamber intraocular lens and aphakic bullous keratopathy after traumatic extracapsular cataract extraction are two relatively new clinical entities that present new intraocular lens management options. Bullous keratopathy after complicated extracapsular cataract extraction should be recognized as a distinct clinical entity. Intraocular lens implantation into the ciliary sulcus with Soemmering's ring and peripheral capsular support provide the advantages of a posterior chamber intraocular lens without the risk of iris or scleral sutures. The authors predict that bullous keratopathy associated with traumatic extracapsular cataract extraction will become one of the more common indications for penetrating keratoplasty.