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

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.

Visual outcomes of posterior chamber intraocular lens intrascleral fixation in the setting of postoperative and posttraumatic aphakia

Background

Several techniques for fixation of the posterior chamber intraocular lens (IOL) have been developed. We evaluate long-term functional outcomes and safety of posterior chamber IOL implantation using Hoffman scleral haptic fixation and sutureless Sharioth technique in patients with posttraumatic and postoperative aphakia.

Methods

This retrospective case-series included 42 eyes operated by one surgeon. The data including demographic data, ocular history, preoperative, early postoperative and final best corrected visual acuity (BCVA), rate of complications as well as postoperative IOL position were collected. The mean follow-up was 14.5 months. Hoffman haptic scleral fixation was performed in 31 eyes, Sharioth technique—in 11 eyes. Aphakia was due to eye trauma (19) or complicated cataract surgery (23).

Results

Overall, the final BCVA improved in 26 eyes, did not change in 5 eyes, and worsened in 11 eyes. No significant differences in BCVA were found between groups operated with Hoffman scleral fixation and Sharioth technique. Postoperatively, we noticed two dislocations of IOL fixated using Sharioth technique and none after Hoffman technique. No severe complications were observed.

Conclusion

Both transscleral fixation techniques are feasible methods of secondary IOL implantation in posttraumatic and postoperative aphakia. with low incidence of complications, however visual outcomes are diverse.

Secondary Artisan–Verysise aphakic lens implantation

PURPOSE

To evaluate efficacy, predictability and safety of Artisan-Verysise intraocular lens (IOL) secondary implantation for aphakia correction.

SETTING

Instituto de Microcirugía Ocular, and Autonoma University of Barcelona, Barcelona, Spain.

METHODS

Uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), manifest refraction, endothelial cell count, and clinical complications were evaluated. Sixteen consecutive eyes of 14 patients with aphakia were submitted to surgery. Postoperative examinations were done at 6 weeks, 6 months, 1 year, and every year for at least 3 years. An iris-supported Artisan-Verysise IOL was implanted for aphakia correction.

RESULTS

Thirty-six months after Artisan-Verysise lens implantation, BSCVA was 20/40 or better in 6 eyes (37.5%). Preoperatively, 5 eyes had the same BSCVA (31.25%). Mean postoperative spherical equivalent (SE) was 0.46 diopter (D). Mean endothelial cell loss was 10.9% 36 months postoperatively. The cell loss occurred predominantly during the first year (7.78%). Cystoid macular edema was observed in 2 cases, 1 of them associated with chronic unresponsive low intraocular pressure. No other serious complications were observed.

CONCLUSION

Artisan-Verysise IOL implantation seems a safe, predictable, and effective option for aphakic eyes without capsule support.

Techniques of intraocular lens suspension in the absence of capsular/zonular support

Implantation of intraocular lenses has become the standard of care in the aphakic state. Ideally, the lens is placed in the capsular bag, which affords stable fixation at a position closest to the nodal point of the eye. However, there will always be instances where this will not be possible. Congenital weakness of the lens zonules in various conditions, trauma, and surgical complications of cataract surgery are just some examples. In this article, we review the methods that have been devised to allow intraocular lens implantation in the absence of capsular or zonular support. These include anterior chamber angle and iris-fixated lenses, as well as posterior chamber iris- and scleral-sutured lenses. The various lenses are described, and the techniques involved, advantages and disadvantages, complications, and results of each method are discussed. It is hoped that this article will provide a comprehensive overview of ways to deal with a problem that can still result in a very good visual outcome for the patient. This is particularly relevant given the many recent developments and refinements of methods in implanting intraocular lenses.

Anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support

PURPOSE

To compare the clinical outcomes and complications of patients who had surgical placement of anterior chamber (AC IOLs) and sutured posterior chamber intraocular lenses (PC IOLs) after cataract surgery resulting in poor capsular support.

SETTING

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida.

METHODS

A retrospective interventional comparative case series of 181 eyes of 181 patients that had implantation of an intraocular lens with inadequate capsular support was conducted. A chart review of all patients that had implantation of AC IOLs or sutured PC IOLs at a tertiary care eye hospital between 1995 and 2001 was conducted.

RESULTS

Outcome measures included final best-corrected visual acuity, spherical equivalent, and postoperative complications (pseudophakic bullous keratopathy, elevated intraocular pressure [IOP] inflammation, retinal detachment, suture erosion, cystoid macular edema). Of 702 charts reviewed, 181 were found to fit inclusion and exclusion criteria. The postoperative complication risk ratio was 0.80 (95% confidence interval [CI]: 0.52-1.23) for AC IOLs compared with PC IOLs. The most common complication experienced by patients having implantation of either lens type was elevated IOP (AC IOL: 38%; PC IOL: 42%). The incidence of other complications was similar between the groups. Best-corrected visual acuity was similar; however, final spherical equivalent trended toward more myopic values in the PC IOL group (-0.82 +/- 1.67 for AC IOL versus -1.32 +/- 2.12 for PC IOL).

CONCLUSIONS

The findings suggest that no significant differences in outcome exist when comparing AC IOLs to sutured PC IOLs in complicated cataract extraction with poor capsular support. Recent advances in AC IOL design have yielded lenses that provide a safe, effective alternative to sutured PC IOLs.

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.

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.

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.

Long-term observation of aqueous flare following penetrating keratoplasty

PURPOSE

To understand the influence of preoperative corneal conditions, combined implant surgeries, and subsequent rejection on the aqueous flare value following penetrating keratoplasty (PK).

METHODS

A total of 86 eyes of 86 patients were included. PK alone was performed on eyes with keratoconus (n = 7), corneal scar (from previous trauma or nonherpetic infection; n = 19), pseudophakic bullous keratopathy (PBK) (n = 16), and for regraft (n = 14). Combined ECCE and PC-IOL implantation (triple procedure) was performed on 17 eyes with corneal scar, and combined AC-IOL exchange was performed on 13 eyes with PBK. Aqueous flare was measured with a laser flare-cell meter at 1 week and 1, 3, 6, 12, and 24 months postoperatively. The mean follow-up was 24.7 (range 7-76) months.

RESULTS

There were 11 cases (12.8%) of endothelial rejection (two in PK for corneal scar group, two in triple procedure group, two in PK for PBK group, three in PK and AC-IOL exchange group, and two in regraft group). Two corneas in PK for corneal scar group, one in PK and AC-IOL exchange group, and one in regraft group cleared up later; the remaining seven cases failed subsequently. Another 10 grafts (11.6%) failed from other causes. Eventually, 69 grafts (80.2%) remained clear at last follow-up. There was a significant difference in aqueous flare values among eyes undergoing PK only for keratoconus, corneal scar, PBK, and regraft from 1 week to 3 months postoperatively. In the corneal scar group, aqueous flare value was significantly higher from 1 week to 3 months when combined with cataract surgery. In the PBK group, the value was significantly higher from 1 week to 1 month and 6 months again when combined with AC-IOL exchange. Notably, significantly higher flare values were measured from 1 week to 6 months in eyes with later rejection.

CONCLUSIONS

Preoperative diagnoses and additional implant surgeries influenced the aqueous flare counts at the early postoperative period. Persistently elevated flare value may be associated with later rejection.

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.

[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.

Lens implant selection with absence of capsular support

If contact lens or spectacle correction is not viable, little debate exists that the secondary placement of an intra-ocular lens (IOL) is the method of choice in the absence of capsular support. The choice of IOL mainly depends on the preoperative status of the eye (eg, aphakia in children) and the selected location for the implant. Theoretically, there are several IOL implantation approaches in cases without capsular support: an angle-supported anterior chamber (AC) IOL, an iris-fixated ACIOL, an iris-sutured or iris-fixated posterior chamber (PC) IOL and a transsclerally sutured PCIOL. No consensus exists, however, on the indications as well as on the relative safety and efficacy of these different options. Implantation of modern ACIOLs, like the refined open-loop or iris-fixated claw (toric) ACIOLs, have regained popularity and provide a valuable alternative to sutured PCIOLs. However, in the absence of capsular support, the transsclerally sutured PCIOLs offer numerous advantages for certain eyes. Because of its anatomic location, the sutured PCIOL is more appropriate for eyes with compromised cornea, peripheral anterior synechiae, shallow anterior chamber, or glaucoma. Moreover, sutured PCIOLs are appropriate if the patient with aphakia is young or has a life expectancy of 10 years or more. Recent technological advances, including PCIOL with iris diaphragm for aniridia, toric ACIOLs, and small-incision surgery with foldable, transsclerally sutured IOLs, seem to further improve clinical outcomes.

Sutured posterior chamber intraocular lenses: indications and procedure

Intraocular lens (IOL) implantation is the standard of care for treating aphakia when spectacle or contact lens correction is not viable. There is considerable controversy about the relative efficacy and safety of the different IOL implantation approaches, as well as their indications. Since the development of the modern, open-loop anterior chamber IOL (ACIOL) and the re-emergence of the iris-fixated claw IOL, ACIOL implantation for aphakia has regained popularity. However, the posterior chamber IOL (PCIOL)--namely, the capsular-supported PCIOL and, in the absence of capsular support, the iris-sutured or transsclerally sutured PCIOL--offers numerous advantages for certain patients. By virtue of their anatomic location in the eye, capsular-supported or sutured PCIOLs are appropriate for patients with glaucoma, diabetes, cornea guttata or low endothelial cell count, peripheral anterior synechiae, or known or suspected cystoid macular edema. They may also be appropriate when the patient with aphakia is young and has a relatively long life expectancy. The sutured PCIOL procedure--specifically, the transsclerally sutured PCIOL procedure--is far from benign, however, and surgical expertise is an important consideration. Recent surgical and technological advances, including the technique of burying the suture knot in sclera, use of an ab externo suturing approach in the normotonic eye, and the use of intraoperative endoscopy, have improved the accuracy of the transsclerally sutured PCIOL technique. Additional advances, including diagnostic ultrasound biomicroscopy and small-incision surgery with foldable, transsclerally sutured IOLs, may further improve patient management and clinical outcomes.

The South Asian cataract management study: complications, vision outcomes, and corneal endothelial cell loss in a randomized multicenter clinical trial comparing intracapsular cataract extraction with and without anterior chamber intraocular lens implantation

OBJECTIVE

To determine clinical outcomes of primary intracapsular cataract surgery with and without implantation of anterior chamber lenses.

DESIGN

A multicenter randomized clinical trial.

PARTICIPANTS

One thousand two hundred twenty-nine male and female patients 40-75 years of age with senile cataract.

METHODS

Study patients were recruited from screening eye camps and outpatient clinics. Randomization to the two treatment groups was performed after screening for predetermined inclusion and exclusion criteria. Demographics, visual acuity, intraocular pressures, and corneal endothelial cell data were recorded before surgery and at 6 weeks, 12 months, and 24 months after surgery. Monitoring of the study was secured by a standardized image documentation procedure on all patients using the IMAGEnet digital imaging system. Analysis of corneal endothelial cell images was performed with the Cell Soft software (Topcon Corporation, Japan).

MAIN OUTCOME MEASURES

Visual acuity and central corneal endothelial cell loss.

RESULTS

The patients were randomized to intraocular lens (IOL; n = 616) and no IOL (n = 613) implantation. Surgical complications were reported in 177 (14.4%) patients (IOL = 14.8%; no IOL = 14.0%). The most frequent complication observed was vitreous loss which occurred in 10.3% of eyes (IOL = 11.2%; no IOL = 9.5%). At the final examination (2 years after surgery), 88% of the operated eyes had a best corrected vision of 6/18 or better (IOL = 88.8%; no IOL = 86.6%). Analysis of corneal endothelial cell data showed a small but significantly greater cell loss 6 weeks after surgery in eyes with IOL compared with those without IOL, but no overall difference was found between the treatment groups in the long term follow-up.

CONCLUSIONS

The findings indicate that there is a rationale for the use of anterior chamber intraocular lenses in primary intracapsular cataract surgery.

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.

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.

The South Asian Cataract Management Study. I. The first 662 cataract surgeries: a preliminary report

AIMS

The first 662 cases of a multicentre randomised clinical trial of intracapsular cataract extraction (ICCE) with and without implantation of a four point multiflex (Cilco Kelman Choyce Modification) anterior chamber intraocular lens (AC IOL) were studied after 6 weeks to compare frequency of surgical complications, short term clinical outcomes, and corneal endothelial cell loss between groups.

METHODS

Randomisation was performed after screening for predetermined inclusion and exclusion criteria. Demographics, visual acuities, intraocular pressures, and corneal endothelium cell data were recorded preoperatively and at 6 weeks. Details of surgical procedure, complications, and postoperative adverse reactions were recorded. Monitoring of the study was secured by a standardised image documentation procedure on all patients using the IMAGEnet digital imaging system. Analysis of corneal endothelial cell images was done using the CELL SOFT software analysis program.

RESULTS

343 patients were randomised to IOL and 319 to no IOL. Twelve IOL implantations (3.5%) were aborted because of complications. A complication was reported in 103 (15.6%) of the surgical procedures (IOL = 16.9%, no IOL = 14.1%, p = 0.37). The most frequent complication observed was vitreous loss followed by plain capsular rupture, unplanned ECCE, and iris dialysis. Mean corneal endothelial cell loss 6 weeks after surgery was 17.2% (SD 13.1%) in the total study population (IOL = 18.5% no IOL = 16.1%, p = 0.05). The postoperative complications registered until 6 week follow up were significantly higher in the IOL group (IOL = 6.9%, no IOL = 2.6%, p = 0.02), mainly due to mild to moderate iritis needing prolonged use of steroids. Eighty nine per cent of the patients had a best corrected visual acuity of 6/18 or better. There was no significant difference in visual outcome between study groups.

CONCLUSIONS

The implantation of a multiflex AC IOL in primary ICCE surgery in the centres of this study did not increase the risk of surgical complications or short term sight threatening adverse clinical outcomes compared with ICCE without lens. Comparisons of corneal endothelial cell loss after 6 weeks between study groups showed no clinically significant difference. The difference in mean cell loss between groups was statistically significant.

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.

How successful is corneal transplantation? A report from the Australian Corneal Graft Register

Corneal graft outcome was assessed within a large, prospectively collected database of 4499 records. Penetrating corneal graft survival was 91% at 1 year, 72% at 5 years and 69% at 7 years. The three most common indications for graft were keratoconus (30%), bullous keratopathy (25%) and failed previous graft (18%); the three most common causes of graft failure were rejection (34%), infection (18%) and glaucoma (9%). The vast majority of grafts were performed for improved visual acuity. About four-fifths of recipients achieved at least one line of better acuity on the Snellen chart post-operatively; of the remainder with unchanged or worse acuity, only 21% had failed grafts. Overall, 43% of recipients achieved a best corrected Snellen acuity of 6/12 or better, 52% achieved 6/18 or better, and 20% had acuitities of less than 6/60. Reasons for poor post-operative acuity (recorded as less than 6/60) included graft failure (41%) and comorbidities in the grafted eye (43%). A number of risk factors for graft failure were examined: in most instances, there was little room for decision-making or expert intervention.

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.

Corneal endothelium five years after transplantation

We asked the recipients of 500 consecutive corneal transplants to return for examination and endothelial photography at two months and at one, three, and five years postoperatively. Thirty-six regrafts and 70 fellow eyes of bilateral cases were excluded, leaving 394 eyes for analysis. We also recorded episodes of graft rejection and failure. In 129 grafts in patients who returned at each postoperative interval and had no rejection episodes, the mean endothelial cell density continued to decrease 7.8% per year from three years to five years after keratoplasty, compared with approximately 0.5% per year in unoperated-on normal corneas. The mean cell loss compared with the preoperative examination was 58.9% five years after keratoplasty. The percentage of hexagonal cells did not return to preoperative levels by five years after keratoplasty, suggesting that the endothelium continued to be unstable. The mean corneal thickness increased significantly with time. The Kaplan-Meier rates of rejection episodes and failure were 19% and 17%, respectively, five years after keratoplasty. Eyes with posterior chamber lens implants lost more endothelial cells by five years after keratoplasty than did eyes with open-looped anterior chamber lens implants. Low endothelial cell densities were statistically significantly associated with increased corneal thickness and with an increased risk of subsequent failure. The central endothelial cells of successful corneal transplants five years after keratoplasty form an unstable monolayer with continued accelerated loss of cells and abnormal cellular morphologic features. This process results in fewer endothelial cells remaining on the central graft with an associated increase in stromal swelling and graft failure.

Epidermal growth factor and insulin use in corneal preservation. Results of a multi-center trial. The Corneal Preservation Study Group

PURPOSE

The ability of DexSol medium, supplemented with two growth factors, human epidermal growth factor (hEGF) and human insulin, to improve long-term endothelial survival after penetrating keratoplasty was evaluated in a multi-center, randomized, prospective, double-masked clinical trial.

METHODS

Donor cornea pairs, one stored in DexSol and the other in DexSol with hEGF (10 ng/ml) and human insulin (10 micrograms/ml) (ProCell), were transplanted into 105 pairs of recipients matched by diagnosis and procedure and followed postoperatively for graft and endothelial survival.

RESULTS

No primary donor failures occurred in either group. Graft clarity did not differ between the ProCell and DexSol groups at all postoperative periods: 3 months (98% versus 99%), 6 months (94% versus 98%), and 1 year (95% versus 97%), respectively. Postoperative complications (e.g., glaucoma, rejection) occurred with comparable frequencies in both groups. Mean endothelial cell loss did not significantly differ between the ProCell and DexSol groups at 3 months (5.7% versus 5.1%), 6 months (8.1% versus 10.1%), and 1 year (12.3% versus 15.6%), respectively. Similarly, there were no clinically and statistically significant differences in other endothelial morphometric parameters.

CONCLUSIONS

The use of corneas stored in DexSol medium with added hEGF and insulin in corneal transplantation resulted in a safety and efficacy profile comparable with that observed in patients receiving DexSol-stored corneas; however, there were no clinically and statistically significant differences in postoperative endothelial morphometric parameters.

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.

Intraocular lens exchange for anterior chamber intraocular lens-induced corneal endothelial damage

BACKGROUND

Anterior chamber and iris-plane intraocular lenses (IOLs) have been implicated in causing corneal endothelial damage and progression to pseudophakic bullous keratopathy.

METHODS

The authors performed IOL exchanges on 102 eyes with signs of early corneal decompensation or progressive endothelial cell loss associated with these anterior chamber or iris-plane IOLs. Replacement IOLs were posterior chamber lenses sutured to the iris (87 eyes), sutured to the sclera (3 eyes), or placed in the ciliary sulcus (12 eyes).

RESULTS

Seventy-two eyes (71%) had the same or improved vision after a mean follow-up period of 18.6 months (range, 6 to 60 months). Only 24 eyes (23.5%) progressed to corneal decompensation. Of the eyes that decompensated, 75% had preoperative endothelial cell counts of 500 cells/mm2 or less (P < 0.0001), and 83% had preoperative signs of early corneal decompensation (P < 0.001). Biomicroscopic signs of early corneal decompensation seen preoperatively in 50 eyes resolved in 17 eyes (34%) and remained unchanged in 12 eyes (24%) at the last postoperative follow-up visit.

CONCLUSION

Removal of anterior chamber and iris-plane intraocular lenses in eyes showing signs of endothelial damage may prevent progression to pseudophakic bullous keratopathy if performed before a critical degree of endothelial cell loss or dysfunction has developed.

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.

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.