Complications of sulcus-supported intraocular lenses with iris sutures, implanted during penetrating keratoplasty after intracapsular cataract extraction

Corneal astigmatism correction with scleral flaps in trans-scleral suture-fixed posterior chamber lens implantation: a preliminary clinical observation

AIM

To study the impact of scleral flap position, under which the posterior chamber intraocular lenses (PC-IOL) were sulcus-fixed by trans-scleral suture, on cornea astigmatism.

METHODS

Twenty-six aphakic or cataract eyes were comprised in this prospective noncomparative case series study. Eleven eyes had traumatic cataract removed without sufficient capsular support, 3 had blunt trauma with subluxated traumatic cataract, 8 had undergone vitreoretinal surgery and 4 had congenital cataract removed. The average age was 54 years (range 21-74 years), with 17 men and 7 women. The foldable PC-IOL was fixed in sulcus by trans-scleral suture. The incision for IOL implantation was made 1mm posterior to limbus along the steepest meridian of cornea, while scleral flaps to bury the knots of trans-scleral suture were made along the flattest meridian. All the surgeries were performed by a single doctor (Ma L), and the follow up was at least 13 months (range 13-28 months). The preoperative, 3 months and 1 year postoperative corneal curvature along the steepest and flattest cornea meridian and overall cornea astigmatism were compared.

RESULTS

The curvature along the steepest meridian changed from 44.25±2.22D preoperatively to 44.08±2.16D at 3 months postoperatively, and 43.65±5.23D at 1 year postoperatively (P>0.05); the curvature along the flattest meridian changed from 41.24±2.21D preoperatively to 43.15±3.94D at 3 months postoperatively, and 42.85±5.17D at 1 year postoperatively (P<0.05); and the surgery induced astigmatism (SIA) on cornea was calculated by vector analysis, which was 2.42±2.13D at 3 months postoperatively, and 2.18±3.42D at 1 year postoperatively, the difference was statistically significant (P<0.05).

CONCLUSION

The scleral flap made along the flattest meridian, under which the posterior chamber intraocular lenses (PCIOL) were sulcus-fixed by trans-scleral suture, can steepen the cornea in varying degrees, thus reducing preexisting corneal astigmatism.

Subluxation of Iris-Sutured Intraocular Lenses and Results of a Closed Chamber Technique for Repositioning After Penetrating Keratoplasty

PURPOSE

To describe subluxation of iris-fixated intraocular lenses (IOLs) after penetrating keratoplasty (PK) as a postoperative complication and report the long-term outcomes of a closed-chamber refixation technique used in the management.

METHODS

This was a retrospective, noncomparative interventional case series in which 19 consecutive patient charts with a subluxated iris-fixated IOL after PK were retrospectively reviewed. Fourteen of the patients underwent surgery using a closed-chamber refixation technique. These patients were evaluated for visual outcome and surgical complications associated with the procedure.

RESULTS

In 13 patients, postoperative follow-up was available. In all 13 cases, the fixated IOL appeared stable and remained well positioned during a follow-up period of 56 months (range, 6-122). All patients (100%) achieved improved uncorrected visual acuity. The postoperative visual acuity ranged from 20/20 to 20/100 with a mean of 20/40. Vitreous hemorrhage occurred in 1 patient, and an additional patient required a second surgery using the same technique. Both of these patients did well with a final visual acuity of 20/40 and 20/50, respectively.

CONCLUSIONS

Subluxation of iris-fixated IOL after PK can occur as a postoperative complication. The technique that we herein describe enables secure refixation of subluxated IOLs and yields favorable long-term results.

Iris-sutured posterior chamber intraocular lens implantation during penetrating keratoplasty

PURPOSE

To evaluate the clinical indications and postoperative results of iris-sutured posterior chamber intraocular lens implants performed during penetrating keratoplasty.

METHODS

Medical records were retrospectively reviewed for preoperative indications and postoperative results of 342 consecutive patients (366 eyes) who underwent iris suturing of a posterior chamber intraocular lens implant during penetrating keratoplasty over a 9-year period.

RESULTS

Mean follow-up was 36 months. The principal indications for corneal transplantation were pseudophakic and aphakic bullous keratopathy. Mean postoperative best spectacle-corrected visual acuity was better than preoperatively at all measured time points (P < 0.0001) and improved from 20/474 preoperatively to 20/85 at 1 year. Nine eyes (7.7%) with known preoperative glaucoma required escalation of therapy by medication or surgery to control the intraocular pressure. Seventy-two eyes (29%) without known preoperative glaucoma required treatment of elevated intraocular pressure. Seventy-nine eyes (28%) without known preoperative cystoid macular edema were additionally diagnosed. Mean endothelial cell counts declined throughout the study time frame. Corneal donor rejection episodes occurred in 36 (9.8%) eyes, with the majority having a single episode. Overall, 27 (7.4%) eyes had known graft failure at last follow-up. Two eyes (0.5%) were enucleated following wound disruption.

CONCLUSIONS

These long-term results of iris-sutured posterior chamber intraocular lens implants performed during penetrating keratoplasty suggest acceptable visual acuity, graft survival, and complication rates. They are similar to published retrospective and prospective results of flexible open-loop anterior chamber and transsclerally-sutured posterior chamber intraocular lens implants placed during penetrating keratoplasty.

A review of suturing techniques for posterior chamber lenses

PURPOSE OF REVIEW

To evaluate the outcome of last the 15 years' experience with the transscleral suture fixation technique of posterior chamber intraocular lens (PC IOL).

RECENT FINDINGS

The implant of an anterior chamber IOL, especially the iris-claw lens, is safer and a better option than the transsclerally fixed IOL.

SUMMARY

After bibliographic review of anterior chamber lenses implant results with transscleral fixation, we conclude that the number of complications is less in the iris fixation lens.

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.

Transscleral suture fixation of posterior chamber lenses combined with trabeculectomy

OBJECTIVE

To evaluate the outcome of transscleral suture-fixated posterior chamber intraocular lens (PCIOL) implantation in glaucoma patients when combined with a trabeculectomy.

DESIGN

A retrospective study of 56 consecutive glaucoma patients with a minimum follow-up of 6 months after transscleral suture-fixated PCIOL implantation combined with trabeculectomy.

SETTING

Patients were drawn from the clinical glaucoma practice of the Kresge Eye Institute, Detroit, MICHIGAN:

PATIENTS

Fifty-six eyes of 56 consecutive chronic glaucoma patients who had undergone transscleral suture-fixated PCIOL implantation in combination with a trabeculectomy were included in the analysis.

RESULTS

The mean follow-up time was 38.5 +/- 19.1 months. Mean intraocular pressure (IOP) was significantly reduced, from 22.9 +/- 10.9 mmHg before surgery to 16.7 +/- 6.7 mmHg at the last follow-up visit (P = 0.0005), with the mean number of medications used also significantly decreased, from 2.3 +/- 0.9 to 1.9 +/- 0.9 (P = 0.0002). Postoperative IOP control to 21 mmHg or less was achieved or maintained in 84% of patients. Visual acuity improved or remained stable within two Snellen lines of the preoperative level in 39 eyes (70%) and within three Snellen lines in 45 eyes (80%) at the last follow-up visit. Overall, 46% to 68% of the patients had both stable visual acuity and satisfactory pressure control at the last postoperative visit, depending on criteria of varying stringency. However, 19 eyes (34%) required one or more additional surgical interventions for pressure control. Patients with anterior chamber intraocular lens (ACIOL) complications, diabetes mellitus, or a preoperative IOP level of more than 21 mmHg on maximum tolerated medications were especially prone to requiring additional surgical interventions.

CONCLUSIONS

We conclude that transscleral suture-fixated PCIOL implantation can be combined successfully with a trabeculectomy and can be useful in glaucoma patients in need of both visual rehabilitation and IOP control. However, patients with ACIOL complications, diabetes, or preoperative IOP of more than 21 mmHg on maximum tolerated medications were prone to requiring additional surgical interventions.

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.

Traumatic Aphakia Treated with an Iris Prosthesis/Intraocular Lens or Epikeratophakia

OBJECTIVE

We retrospectively analyzed the visual results and postoperative complications associated with severely traumatized eyes in which aphakia was corrected with epikeratophakia or a sutured iris prosthesis/intraocular lens (IOL).

METHODS

Fourteen eyes (14 patients) with traumatic aphakia and severe anterior segment complications were corrected either with epikeratophakia or a sutured iris prosthesis/IOL. All eyes lacked lens capsule or iris support for an IOL. The surgical technique of implanting an iris prosthesis/IOL employed transcleral suturing in the ciliary sulcus combined with penetrating keratoplasty.

RESULTS

In the eight eyes treated with epikeratophakia, four (50%) had spectacle-corrected visual acuity of 20/40 or better. Almost all of these eyes lost one or two Snellen lines of baseline spectacle-corrected visual acuity. Few complications occurred after epikeratophakia; none were severe. Of six eyes with penetrating keratoplasty and a sutured iris prosthesis/IOL or a sutured posterior chamber IOL, two (33%) achieved a visual acuity of 20/40 or better. In the IOL group, severe complications occurred, including posterior dislocation of the lens and secondary glaucoma.

CONCLUSIONS

The surgical correction of aphakia in severely traumatized eyes requires specialized surgical techniques. Epikeratophakia is a low-risk operation that can be performed in eyes in which an IOL is contraindicated. The iris prosthesis/IOL technique results in good cosmetic results; however, due to complications, this technique should be used with caution.

Penetrating Keratoplasty and Transsclerally Suture-Fixated Intraocular Lenses

BACKGROUND

One of the options the surgeon has, in the absence of lens capsule in an eye to be rendered pseudophakic, is a transsclerally sutured posterior chamber intraocular lens. This procedure can be combined with penetrating keratoplasty, in aphakic or pseudophakic covered edema.

METHODS

We studied retrospectively the results of the first 10 cases of bullous keratopathy in which we performed penetrating keratoplasty combined with transsclerally suture fixated intraocular lenses.

RESULTS

Nine grafts remained transparent and 1 became opaque due to graft rejection with a mean follow up of 26.4 months. Postoperative visual acuity was improved in 7 eyes, remained the same in 2 and became worse in 1 (graft rejection) The poor postoperative visual acuity in 2 eyes was attributed to cystoid macular edema. All sutured intraocular lenses remained in situ; there was no apparent degradation of the Prolene suture. Two eyes developed postoperative medically controlled glaucoma.

CONCLUSIONS

Intraocular lens scleral fixation with sutures, combined with penetrating keratoplasty, seems to be a good procedure for visual rehabilitation for aphakic or pseudophakic bullous keratopathy.

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.

Penetrating keratoplasty for pseudophakic corneal oedema

AIMS

The study was designed to investigate the results of penetrating keratoplasty (PK) for pseudophakic corneal oedema (PCO).

METHODS

Retrospective analysis of 80 consecutive patients (82 eyes) who underwent PK for PCO between the years 1980-1992 with a minimum follow up of 12 months.

RESULTS

PKs for PCO have accounted for as many as 20% of all grafts performed in the hospital in recent years. The interval between cataract extraction and PK ranged from 6 to 161 months (mean 51 months). The intraocular lens was removed in 45 (55%), left in situ in 30 (37%), and exchanged in seven (8%) of cases respectively. Of the intraocular lenses involved 62% were iris supported, 31% angle supported, and 7% were posterior chamber lenses. Actuarial analysis shows graft survival to be 91% at 1 year and 86% at 2 years after surgery. The likelihood of graft survival was significantly enhanced by removal of the intraocular lens (p < 0.01). A corrected Snellen visual acuity worse than 6/60 was present in 36% of patients with a clear corneal graft. Ocular comfort was achieved in all patients with a clear corneal graft.

CONCLUSION

PK for PCO resulted in a disappointing visual result in a large proportion of patients. PK was, however, successful in relieving pain and corneal ulceration when present.

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.

Back to front AC IOL implantation combined with penetrating keratoplasty

In this retrospective study a simple modification of implanting an intraocular lens into the anterior chamber during penetrating keratoplasty is presented. In 14 patients who underwent penetrating keratoplasty after cataract extraction, the intraocular lens was placed back to front in the anterior chamber so that the haptic was angled anteriorly. Postoperative follow-up was 18 months on the average. There was significant improvement in vision. All 9 patients with painful bullous keratopathy were relieved of their pain. One case of mild, transient uveitis and glaucoma and two dilated pupils were seen postoperatively. No major complications have been observed so far. This study suggests that this simple method, in some cases, might be favourable when implanting an intraocular lens during penetrating keratoplasty, in the absence of capsular support.

Temporary keratoprosthesis for transscleral fixation of posterior chamber intraocular lenses with penetrating keratoplasty

In the absence of zonular and capsular support, cataract surgeons increasingly prefer suture-fixated posterior chamber intraocular lenses (IOLs) to angle-supported anterior chamber lenses as a secondary IOL. Various suturing techniques have been proposed for fixating the posterior chamber IOL. Transscleral suture fixation appears advantageous but problematic when performed on an open globe. Moreover, excision of the vitreous base is impeded by the iris and the dark, unstable image. This article describes a technique that takes advantage of a temporary keratoprosthesis (TKP). When sutured onto the trephination opening, the TKP provides a bright, stable image and permits peripheral indentation of the globe, allowing for controlled, thorough vitrectomy. With the infusion pressure supplying adequate eye tone, ab externo transfixation, and thus a targeted passage of the sulcus, is possible. If the cornea permits transfixation, TKP may be used to tamponade after trephination and as a lens rest while the surgeon ties the sutures to the haptics.

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.

Transsclerally sutured intraocular lenses in penetrating keratoplasty

We reviewed the charts of 114 consecutive patients who underwent penetrating keratoplasty with transscleral fixation of a posterior chamber intraocular lens. Two patients died within three months of follow-up and were excluded from the study. In the remaining 112 patients, follow-up ranged from four to 47 months (mean, 17.2 months). Postoperative visual acuity improved in 95 patients (85%), remained the same in 13 patients (11.5%), and worsened in four patients (3.5%). In 71 patients with at least one year of follow-up, best-corrected visual acuity was 20/40 or better in 17 patients (24%), 20/50 to 20/80 in 25 patients (35%), 20/100 to 20/400 in 17 patients (24%), and counting fingers or worse in 12 patients (17%). Problems with lens decentration, tilt, dislocation, or scleral suture-related infections were minimal. Glaucoma and cystoid macular edema were the most common causes of decreased visual acuity. Four patients (3.6%) developed intraoperative choroidal detachments. Three patients (2.7%) developed rhegmatogenous retinal detachments early in the postoperative course.

Comparison of intraocular lens fixation techniques performed during penetrating keratoplasty

We reviewed the charts of 41 patients who had undergone penetrating keratoplasty, anterior vitrectomy, and placement or exchange of an intraocular lens during a two-year period with a median follow-up time of 15 months (range, five to 26 months). The median preoperative visual acuity was 20/400 (range, 20/40 to hand motions). The median postoperative visual acuity was 20/70 (range, 20/25 to hand motions). Of 41 corneal grafts, 38 (93%) remained clear. New intraocular lenses were inserted by anterior chamber, iris, or transscleral fixation. The median visual acuity was 20/70 for the anterior chamber lens group, 20/100 for the iris fixation group, and 20/70 for the transscleral fixation group. Analysis of variance demonstrated no significant difference by type of fixation in postoperative visual acuity, central corneal thickness, and intraocular pressure.

Implantation of Kelman-style, open-loop anterior chamber lenses during keratoplasty for aphakic and pseudophakic bullous keratopathy. A comparison with iris-sutured posterior chamber lenses

The clinical and specular microscopic results of 40 cases (39 patients) of penetrating keratoplasty during which a Kelman-style anterior chamber intraocular lens was implanted were reviewed retrospectively. Thirty-one pseudophakic eyes received an intraocular lens exchange and nine aphakic eyes received a secondary intraocular lens. Postoperative follow-up averaged 24.5 months (range, 3 to 51 months). At 1, 2, and 3 years after keratoplasty, 39.3%, 63.2%, and 63.6% of eyes, respectively, had visual acuities of 20/40 or better. Ninety-five percent of the grafts remained clear. Causes of poor postoperative visual acuity included cystoid macular edema (32.5%), new glaucoma (22.5%), and age-related macular degeneration (10.0%). Other causes were endothelial rejection leading to graft failure, corneal ulceration, and retinal detachment. Corneal endothelial cell loss by specular microscopy was 11.5% at 1 years, 21.3% at 2 years, and 25.0% at 3 years. These results were compared with cell loss associated with iris-sutured posterior chamber lenses in penetrating keratoplasty. Visual outcomes and complication rates were similar between these two methods; however, the endothelial attrition at 1 and 2 years for the sutured posterior chamber lens was greater than that of the Kelman anterior chamber lens.