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

Comparison of outcomes between modified double-flanged sutureless scleral fixation and conventional sutured scleral fixation

This retrospective study aimed to compare the outcomes of modified double-flanged sutureless scleral fixation versus sutured scleral fixation. Medical records of 65 eyes from 65 patients who underwent double-flanged scleral fixation (flange group) or conventional scleral fixation (suture group) between 2021 and 2022 were reviewed. Visual and refractive outcomes, as well as postoperative complications, were compared 1, 2, and 6 months after surgery. We included 31 eyes in the flange group and 34 eyes in the suture group. At 6 months postoperatively, the flange group showed better uncorrected visual acuity (0.251 ± 0.328 vs. 0.418 ± 0.339 logMAR, P = 0.041) and a smaller myopic shift (- 0.74 ± 0.93 vs. - 1.33 ± 1.15 diopter, P = 0.007) compared to the suture group. The flange group did not experience any instances of iris capture, while the suture group had iris capture in 10 eyes (29.4%; P < 0.001). In the flange group, all intraocular lenses remained centered, whereas in the suture group, they were decentered in 8 eyes (23.5%; P = 0.005). The double-flanged technique not only prevented iris capture and decentration of the intraocular lens but also reduced myopic shift by enhancing the stability of the intraocular lens.

Contact Lens-Assisted DMEK for Corneal Decompensation With an Anterior Chamber Intraocular Lens: A Novel Technique

PURPOSE

To describe a novel technique in which a contact lens was used to facilitate Descemet membrane endothelial keratoplasty (DMEK) in an eye with an anterior chamber intraocular lens (ACIOL).

METHODS

A 71-year-old man with a long-standing ACIOL developed bullous keratopathy. As the patient was at high risk of complications due to multiple ocular comorbidities, DMEK was performed with the ACIOL left in the anterior chamber. An inserted cosmetic contact lens was used as a platform for the graft unfolding.

RESULTS

Partial graft detachment on the third postoperative day required rebubbling. This successfully cleared up the cornea after a few weeks. At the one-month follow-up, the uncorrected distance visual acuity improved to 20/50, with an endothelial cell loss of 35.2%. Steroid-induced ocular hypertension necessitated a trabeculectomy by the fifth postoperative month. At the sixth follow-up month, endothelial cell loss was 64%.

CONCLUSIONS

Contact lens-assisted DMEK is a safe procedure for eyes with an ACIOL. However, good foresight is needed regarding whether the ACIOL should be kept or exchanged.

Facilitated trailing haptic externalization technique for intrascleral intraocular lens fixation

PURPOSE

To describe the facilitated trailing haptic externalization technique for intrascleral intraocular lens (IOL) fixation.

METHODS

In this technique, first the direction of the 4-5 mm tip of the trailing haptic is straightened with the help of forceps. After the second needle enters the posterior chamber, the edge of the IOL optic is pushed towards the opposite scleral tunnel with the needle. The trailing haptic approaching the center from the periphery and the straightened distal part of the haptic towards the direction of the needle facilitate the relatively easily and gently placing of the haptic into the lumen with a one-time use of forceps.

RESULTS

This technique was performed on 65 eyes of 58 patients, with a mean patient age of 53.0 ± 14.6 years (range, 22-78). No complications such as endothelial touch, vitreous loss, iris or ciliary body damage, and hyphema were encountered during surgery. The mean operation duration was 14.8 ± 2.3 min (range, 12-20). In the postoperative period, there was only mild postoperative anterior chamber reaction in all eyes. Postoperative transient intraocular pressure (IOP) elevation that responded well to topical antiglucomatous therapy was observed in only two cases (3%). No patient developed haptic exposure, IOL dislocation, iris capture, postoperative hypotony, vitreous hemorrhage, choroidal effusion, cystoid macular edema, or retinal detachment.

CONCLUSION

The facilitated trailing haptic externalization technique provides a safer, simpler, and minimally invasive surgery without significant complications while easing the surgical difficulties of the Yamane technique.

Surgical management of aphakia

Despite the safety and efficacy of cataract surgery, intraoperative complications can hamper the ability to place an intraocular lens in the capsular bag. With vast numbers of cataract surgeries performed daily, complications occur often enough that every ophthalmologist should be equipped with techniques to manage aphakia. Medical management of aphakia used to be commonplace but these techniques have their disadvantages including thick bulky lenses, poor cosmesis, and aniseikonia. Surgical management of aphakia overcomes these disadvantages and offers patients the possibility of a spectacle and contact lens-free lifestyle. This article reviews the various options of surgical management of aphakia and their advantages and disadvantages. Comparison of outcomes between techniques and a protocol for deciding between techniques is presented.

Angle-supported intraocular lens versus scleral-sutured posterior chamber intraocular lens in post-cataract surgery aphakic patients: two-year follow-up cost-effectiveness analysis

PURPOSE

To compare visual, anatomical and economical outcomes of patients with secondary anterior chamber intraocular lens (AC-IOL) implantation and secondary scleral fixated intraocular lens (SF-IOL) implantation.

METHODS

In this retrospective observational study, 38 aphakic patients after complicated phacoemulsification divided in two groups, AC-IOL group (17 patients receiving AC-IOL implantation) and SF-IOL group (21 patients receiving SF-IOL implantation). Corrected distance visual acuity (CDVA), patient reported visual outcome (VF-14) and endothelial cell density (ECD) were measured at baseline and two-year follow-up. Complication rate was registered. The global cost of each procedure and the incremental cost-effectiveness ratio (ICER) were calculated.

RESULTS

No statistically significant difference was found in CDVA (logMAR 0.24 ± 0.17 vs. 0.32 ± 0.26, p = 0.27), VF-14 (68 ± 18 vs. 61 ± 20, p = 0.24), ECD (1456.48 ± 525.15 vs. 1341.71 ± 374.33, p = 0.48) and overall complication rate (p = 0.79) postoperatively between the SF-IOL group and the AC-IOL group. The ECD loss rate was significantly higher in the AC-IOL group (15.5% vs. 3.5%, p = 0.004). The average global cost of the two procedures was higher in the SF-IOL group (p < 0.005) and ICER showed an additional payment of 693 € for each patient in SF-IOL group against a saving of 186 endothelial cells 2 years postoperatively.

CONCLUSION

AC IOL and SF-IOL implantation showed similar outcomes in terms of visual function and safety profile. Higher ECD loss was found in AC-IOL group. The global cost of implantation was significantly lower for AC-IOL, but the ICER seems to justify the SF-IOL implantation in patients with low ECD.

Anterior chamber intraocular lens - An effective alternative in traumatic and surgical aphakia in the era of scleral-fixated intraocular lens

Purpose:

To evaluate outcomes of anterior chamber intraocular lens (ACIOL) implantation with vitrectomy in eyes with surgical or traumatic aphakia, and subluxated or dislocated lens.

Methods:

In this retrospective study, we evaluated patients who underwent pars plans vitrectomy with ACIOL implantation from April 2016 to March 2019. Patients with minimum follow-up period of 1 year and operated by single surgeon were included. Ophthalmic history, indication for surgery, BCVA, IOP, slit-lamp examination, and fundus assessment findings were noted. Postoperatively best-corrected visual acuity (BCVA), intraocular pressure (IOP) and complications if any were noted.

Results:

Ninety eyes of 88 patients were included in the study. The mean age of the patients was 60.2 ± 10.2 yrs. Majority (75.6%) were males and 24.4% were females. Indications for pars-plana vitrectomy (PPV) with ACIOL implantation were nucleus drop in 16.6%, IOL drop in 25.5%, large posterior capsular rupture (PCR) with vitreous disturbance or zonular dehiscence (ZD) during cataract surgery in 33.3%, more than 180° subluxation of lens in 10% and traumatic lens or intraocular lens (IOL) drop in 14.4% cases. Preoperative and postoperative mean Log MAR visual acuity was 1.59 ± 0.44 and 0.36 ± 0.33 respectively, with few complications like cystoid macular edema (CME) in 8.8%, persistently raised IOP in 4.4%, persistent uveitis in 2.2%, retinal detachment (RD) in 2.2%, and tilted IOL in 1.1% cases.

Conclusion:

Out of different options available for secondary IOL implantation in patients with poor capsular support ACIOL has the advantages of cost-effectiveness, small learning curve, faster surgical time with a lesser rate of complications like IOL tilt, vitreous hemorrhage, and suture erosion as compared to scleral-fixated IOL (SF-IOL). Comparable visual outcome can be obtained by proper patient selection in these cases.

The simply modified intrascleral fixation using round flange (SMURF) technique for intrascleral intraocular lens fixation

We describe a simply modified intrascleral fixation using round flange (SMURF) technique and report the clinical outcomes of the surgery. Forty-one eyes of 41 consecutive patients, with intraocular lens (IOL) dislocation, crystalline lens subluxation, and zonular weakness, who underwent surgery using the SMURF technique were included. The modified technique included the use of a conventional 27-gauge needle, a non-bent needle, oblique sclerotomy, direct threading of the leading haptic, and simple placement of the following haptic. IOLs were successfully placed and showed good centring. There were no cases of wound leakage or hypotony during the early postoperative period. Postoperative complications included vitreous haemorrhage in one eye (2.4%), intraocular pressure elevation in one eye (2.4%), and iris capture in six eyes (14.6%). There were no cases of postoperative retinal detachment, cystoid macular oedema, endophthalmitis, or IOL dislocation during the follow-up period. We proposed a few modifications in the intrascleral flanged technique for IOL fixation. The modified technique is a simple, easy, and minimally invasive procedure for successful IOL intrascleral fixation.

Intraocular Lens Complications: Decentration, Uveitis-Glaucoma-Hyphema Syndrome, Opacification, and Refractive Surprises

As cataract surgery has evolved, intraocular lens (IOL) complications are rare. The purpose of this review was to report the incidence, diagnosis, and management of IOL decentrations, uveitis-glaucoma-hyphema (UGH) syndrome, IOL opacifications, and refractive surprises. Literature review was performed by searching PubMed, MEDLINE, EMBASE, and the Cochrane Controlled Trial Database and the reference lists of original studies as well as reviews. Intraocular lens decentrations and dislocations can appear at any time, particularly in patients with predisposing factors such as pseudoexfoliation, prior vitreoretinal surgery, or trauma. Recognizing when they require surgical intervention for UGH or to improve visual function is critical in limiting long-term sequela. Intraocular lens opacifications such as glistenings rarely require intervention, but others, such as subsurface nanoglistenings, calcifications, or discolorations, may require IOL exchange. Finally, despite our best efforts to enhance measurements and IOL calculations, refractive surprises still occur. Intraocular lens complications are uncommon with modern cataract surgery. A number of these complications require proper identification and care to optimize patient outcomes.

Histopathological changes in the anterior segment with anterior and posterior chamber intraocular lens

OBJECTIVE

Patients have shown a lowering of intraocular pressure (IOP) after cataract surgery. Histopathology studies have reported trabecular meshwork (TM) changes in pseudophakic eyes with posterior chamber intraocular lens (PCIOL) and have eluded to the mechanisms for IOP decrease. Unlike PCIOLs, TM histopathology changes after implantation of an anterior chamber intraocular lens (ACIOL) have not been studied, to our knowledge. Therefore, this study aims to examine the histopathological changes in both the TM and corneal endothelium among donor eyes with ACIOL, PCIOL, and phakic eyes.

METHODS

Forty fixed postmortem donor eyes were obtained, sectioned, and embedded. Slides were stained with Masson's trichrome and CD31 vascular endothelial antibody, and further digitalized. Customized Medical Parachute TMAN software quantified the cellular components, the trabecular extracellular matrix (ECM), ECM fibrosis, and trabecular area. Schlemm's canal and corneal endothelium were quantified across the ACIOL, PCIOL, and phakic groups.

RESULTS

Cellular area component of the TM was lower in the ACIOLs and PCIOLs than in phakic eyes, but statistically significant only between PCIOL and phakic eyes (p = 0.0023). ECM area component, TM fibrosis score and TM lamellae area, ciliary process fibrosis, and CD31 expression in Schlemm's canal showed no differences (p = 0.40, 0.99, 0.10, 0.83, 0.45). Significantly lower corneal endothelial cells were seen in ACIOLs compared with both PCIOLs and phakic eyes (p = 0.0002).

CONCLUSIONS

ACIOLs and PCIOLs in our sample group showed that there is loss of cellular components in the TM compared with the phakic eyes, with PCIOLs displaying the least amount of TM cells statistically, in this cohort. The ACIOLs led to a greater loss of corneal endothelial cells than both PCIOLs and phakic eyes after cataract surgery. The endothelial cells in Schlemm's canal did not seem to be affected by the IOL placements. Therefore, this study illustrates that there are histopathological differences seen with the placements of ACIOLs in both TM and cornea.

[Explantation of two historical posterior chamber phakic intraocular lenses 31 years after implantation]

This article reports the case of a 56-year-old male patient who had undergone implantation of posterior chamber phakic intraocular lenses in 1987 in Russia. The patient presented to this clinic 31 years after the initial surgery with anterior cortical cataracts and initial stages of corneal decompensation in both eyes. Strategic planning and execution of surgical treatment and the further clinical course are portrayed in this report.

Anterior chamber lens implantation in vitrectomised eyes

PurposeTo investigate long-term visual acuity (VA) outcomes and complication rates in vitrectomised eyes undergoing anterior chamber intraocular lens (ACIOL) insertion.Patients and methodsA single-centre, retrospective case series including all patients who had undergone ACIOL placement at the time of vitrectomy surgery or having had previous vitrectomy, between January 2007 and January 2013. Patients were identified using an electronic database and paper casefile notes were analysed for all patients. Patients were excluded if they had <3 months follow-up.ResultsTwo hundred and seventy-one patients were included in the analysis. Mean follow-up was 27 months. One hundred and forty-eight patients were vitrectomised before ACIOL placement. One hundred and twenty-three patients underwent vitrectomy at the time of ACIOL placement. Mean best-corrected visual acuity (BCVA) before ACIOL placement was 1.27 LogMar (SD 0.95). Mean BCVA at final follow-up was 0.51 LogMar (SD 0.66) (paired-sample T-test P<0.001). Forty (15%) patients developed postoperative cystoid macular oedema (CMO). Eighty-seven (32%) patients had an intraocular pressure (IOP) rise acutely post ACIOL insertion. Fifteen (6%) patients developed corneal decompensation. Five subsequently required corneal grafting. Sixteen patients had ACIOL displacement or instability requiring further surgery.ConclusionsACIOL insertion after vitrectomy is effective. Ninety-two per cent of patients maintained or gained VA, comparable to previous studies of ACIOL insertion post complicated cataract surgery. Raised IOP was the most frequent complication: 61 patients were on topical therapy at most recent follow-up. CMO tended to be acute. Corneal decompensation was infrequent.

Surgical refixation of posteriorly dislocated intraocular lens with scleral-tuck technique

Purpose:

To report the outcomes of surgical refixation of posteriorly dislocated intraocular lens (IOL) using scleral-tuck method, and to compare the “scleral groove” and the “scleral flap” techniques used.

Study Design:

Single-center, retrospective, interventional, comparative study.

Methods:

Medical records of patients undergoing closed globe scleral refixation of posteriorly dislocated posterior chamber IOL (PCIOLs) by scleral-tuck method using two different techniques (”scleral groove” vs. “scleral flap” technique) were reviewed. This approach involved retrieving the dislocated PCIOL, externalizing the haptics through 2 sclerotomies created in paralimbal lamellar scleral grooves, or under lamellar scleral flaps and tucking the haptics into limbus-parallel scleral tunnels. No specific haptic architecture, haptic suturing, or large incisions were needed. Main outcome measures included best-corrected visual acuity (BCVA), final mean refractive error, and intra- and post-operative complications.

Results:

Thirteen eyes of 13 patients (scleral groove, n = 6; scleral flap, n = 7 eyes) with a mean follow-up of 20.6 months were included. BCVA in all eyes was maintained or improved postoperatively, with three eyes (23%) showing ≥2 line improvement. Median astigmatic error at 6-week follow-up was −1.25 D cylinder (range: −0.5 D–−2.0 D) which remained stable till final follow-up. All IOLs remained stable and well centered. None of the eyes had a recurrent dislocation, retinal detachment, endophthalmitis, or glaucoma. Both techniques were comparable in terms of postoperative BCVA, and refraction.

Conclusion:

Intrascleral haptic fixation by scleral-tuck method is reliable and effective for secure IOL refixation of posteriorly dislocated IOLs, providing good IOL centration and stability with minimal surgically-induced astigmatism. Both techniques (scleral groove and scleral flap) appear to have similar outcomes in the short term.

Iris fixation of unstable anterior chamber intraocular lenses

Cataract surgeons are sometimes challenged with a patient who has an unstable anterior chamber intraocular lens (AC IOL). Over time, an unstable AC IOL can lead to significant complications. This problem is most often addressed with an IOL exchange using an appropriately sized AC IOL or a posterior chamber IOL with iris or scleral fixation. We present a technique of 2-point iris fixation of unstable AC IOLs as a simpler and less traumatic alternative.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

Spontaneous Scleral Perforation of an Anterior Chamber Intraocular Lens

A routine eye examination of a 69-year-old man revealed a scleral perforation of one of the haptics of the anterior chamber intraocular lens (AC IOL) which had been implanted many years ago. The patient was asymptomatic with good visual acuity. His history was negative for any trauma, eye rubbing, topical corticosteroid use, or autoimmune disease. The horizontal and vertical white-to-white diameters of the cornea in the right eye were 11.5 and 10.5 mm, respectively. Anterior segment optical coherence tomography showed the anterior chamber length to be 12.28 mm horizontally and 10.63 mm vertically. The patient underwent an IOL exchange, and the length of the explanted AC IOL was measured to be 12 mm. We speculate that the AC IOL, which was vertically aligned, was oversized. This case demonstrates the need for proper sizing and positioning of an AC IOL. In complex cases where AC IOL may be used, measuring the horizontal and vertical lengths of the anterior chamber by anterior segment optical coherence tomography prior to surgery may be useful.

One-year outcomes of eyes treated with a sutureless scleral fixation technique for intraocular lens placement or rescue

PURPOSE

To report the 1 year results of a novel surgical technique for sutureless scleral fixation of a 3-piece intraocular lens.

METHODS

Retrospective consecutive series of patients who underwent sutureless scleral fixation of a three-piece intraocular lens. All patients were required to have at least 1 year of follow-up to be included in the series. Outcomes data were obtained and treated with simple statistical analyses.

RESULTS

A total of 24 patients were included in the study population. The average age was 75 years (range, 44-87). Short-term complications were few and included vitreous hemorrhage (n = 2), elevated intraocular pressure (n = 1), and hypotony (n = 1). Long-term complications included intraocular lens dislocation (n = 3) and cystoid macular edema (n = 1). Mean visual acuity improved from logMAR 1.30 (Snellen 20/399) to 0.52 (Snellen 20/66) at 1 year.

CONCLUSION

This novel technique for sutureless scleral fixation of a three-piece intraocular lens was well-tolerated 1 year after surgery.

Complications of sulcus placement of single-piece acrylic intraocular lenses: recommendations for backup IOL implantation following posterior capsule rupture

PURPOSE

To describe complications arising from sulcus placement of single-piece acrylic (SPA) intraocular lenses (IOLs), evaluate IOL options for eyes that lack adequate capsule support, and examine the appropriateness of various IOL designs for sulcus placement.

SETTING

University and private anterior segment surgery practices.

METHODS

Patients referred for complications of SPA IOLs in the ciliary sulcus from 2006 and 2008 were identified. Demographic information, examination findings, and complications of the initial surgery were recorded. Details of surgical interventions and the most recent corrected distance visual acuity (CDVA) were noted. A thorough review of the literature was undertaken to analyze options for IOL placement.

RESULTS

Complications of sulcus SPA IOLs included pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage, and cystoid macular edema. Two patients in the series of 30 patients experienced 1 complication; 8 experienced 2 complications; 13 experienced 3 complications; 4 experienced 4 complications; and 2 experienced 5 complications. Twenty-eight eyes (93%) required surgical intervention; IOL exchange was performed in 25 (83%). Postoperatively, the mean CDVA improved, with most eyes attaining 20/20.

CONCLUSIONS

Intraocular lenses designed solely for the capsular bag should not be placed in the ciliary sulcus. Backup IOLs in appropriate powers, sizes, and designs should be available for every cataract procedure. The development, investigation, and supply of IOLs specifically designed for placement in eyes that lack adequate capsule support represent clinically important endeavors for ophthalmology and the ophthalmic industry.

Endophthalmitis due to exposure of anterior chamber intraocular lens haptic tip

After bilateral implantation of an angle-supported anterior chamber intraocular lens (AC IOL) in an allergic patient, the haptic tips were exposed through the limbus in the left eye. Endophthalmitis developed in the eye and was treated by pars plana vitrectomy, IOL extraction, and intravitreal antibiotic injection. Haptic repositioning was performed in the right eye. In this report, we assess the possibility that exposure of the angle-supported AC IOL haptics caused the endophthalmitis. We hypothesized that vigorous rubbing of the eye of the atopic patient might cause limbal erosion that could lead to exposure of the angle-supported AC IOL haptic through the limbus.

Professor Peter Choyce: an early pioneer of intraocular lenses and corneal/refractive surgery

Professor Peter Choyce, FRCS, DOMS, MS, was one of the pioneers of intraocular lens implant surgery. He developed an interest in artificial lens implantation following cataract surgery, a procedure that was widely criticized by the ophthalmic establishment in the UK, Europe, North America and other countries. Owing to the opposition to the intraocular lenses, Peter Choyce together with Sir Harold Ridley co-founded the International Intraocular Implant Club in 1966, which was responsible for the gradual acceptance of artificial lens implantation. Peter Choyce developed several models of intraocular lens, but did not patent the majority of them. The Choyce Mark IX, manufactured by Rayner Intraocular Lenses, became the first US Food and Drug Administration-approved intraocular lens in 1981. A review of Peter Choyce's record confirms a significant number of original innovations in the field of anterior segment surgery, including many procedures taken for granted today, but not associated with his name. These include early work on both kerato- and intraocular lens-refractive procedures, keratoprosthesis, pioneering paediatric implant procedures and others. Unfortunately his tenacious adherence to anterior chamber lens technology, while in general clinically sound, caused many to question his influence and hence he remained poorly understood even until after his death. He passed away on 8 August 2001 after a long fight with colon cancer. In this article, we provide evidence and elaborate Peter Choyce's accomplishments, which places him as one of the most innovative ophthalmologist in his surgical field in the twentieth century.

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.

A comparison of anterior and posterior chamber lenses after cataract extraction in rural Africa: a within patient randomised trial

BACKGROUND

Extracapsular cataract extraction (ECCE) with a posterior chamber intraocular lens (PC IOL) is the preferred method of cataract surgery in developed countries. However, intracapsular cataract extraction (ICCE) with an anterior chamber lens (AC IOL) may be appropriate in rural Africa. A randomised controlled trial was carried out to compare these surgical strategies.

METHODS

Participants over 50 years requiring bilateral cataract surgery were recruited from outreach clinics in rural north and east Uganda. One eye was randomly allocated to AC IOL or PC IOL, the other eye being allocated to the second strategy. The main outcome measure was WHO distance visual acuity (VA) category after a minimum of 1 year. Secondary outcomes were numbers and causes of complications and refractive corrections.

RESULTS

Of the 110 participants recruited, 98 (89%) were assessed at least 1 year after the operation (median follow up 17.5 months). Nine eyes randomised to PC IOL were converted to AC IOL; one eye randomised to AC IOL inadvertently received PC IOL. There was no difference in VA between 95 pairs of eyes for which data for both eyes were available (uncorrected VA, p = 0.26; corrected VA, p = 0.59). 80 (82%, 95% CI 73 to 89) and 82 (84%, 95% CI 75 to 90) eyes randomised to AC IOL and PC IOL respectively had corrected VA of 6/18 or better. 16 (16%, 95% CI 10 to 25) and eight (8%, 95% CI 4 to 15) eyes respectively had secondary procedures or other complications.

CONCLUSIONS

Where both strategies are available, ECCE with PC IOL should be first choice because of fewer complications. Where ECCE with PC IOL is not immediately feasible, ICCE with AC IOL is an acceptable interim technique.

Transscleral fixation of a foldable intraocular lens in aphakic vitrectomized eyes

PURPOSE

To evaluate the clinical outcomes of transscleral fixation of a foldable intraocular lens (IOL) in eyes that had pars plana lensectomy combined with pars plana vitrectomy for severe vitreoretinal disease.

SETTING

Seoul National University Hospital, Seoul, Korea.

METHODS

The medical records of 21 patients who had a transscleral fixation of a foldable IOL after previous vitrectomy combined with lensectomy for severe posterior segment pathology were reviewed. The underlying vitreoretinal diseases were complicated proliferative diabetic retinopathy (n = 9), proliferative vitreoretinopathy (n = 5), traumatic retinal detachment (n = 3), intraocular foreign body (n = 2), and uveitic retinal detachment (n = 2). The postoperative best corrected visual acuity (BCVA) was compared with the preoperative BCVA. Autorefractometry and keratometry measurements and central endothelial cell counts were evaluated 1 day preoperatively and 6 months postoperatively.

RESULTS

The mean age of the patients was 54.5 years. The preoperative aphakic period ranged from 2 to 22 months. The visual acuity reached the preoperative BCVA by 2 months after surgery and was better than the preoperative BCVA at 6 months (P =.006) and at the final visit (P =.003). Six months postoperatively, the mean myopic shift by cycloplegic autorefractometry was -1.0 diopter (D) and the mean scalar shift in surgically induced keratometric cylinder, 1.0 D. The mean central corneal endothelial loss at 6 months was 6.7% (range 2.4% to 22.2%). The only vitreoretinal complications were a transient vitreous hemorrhage and a reopened macular hole that was reattached after fluid-gas exchange.

CONCLUSION

Transscleral fixation of a foldable IOL was safe and led to favorable visual outcomes in aphakic vitrectomized eyes with previous severe vitreoretinal disease.

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.

Retrospective evaluation of intraocular lenses in adults younger than 60 years

Data from the U.S. Food and Drug Administration, the American Academy of Ophthalmology's National Eyecare Outcomes Network, and Storm Eye Institute databases were analyzed for short- and long-term safety and efficacy outcomes of intraocular lens (IOL) implantation in adults younger than 60 years and 60 years and older. Statistical analyses for significance were performed where appropriate. A comprehensive literature review was conducted to identify safety and efficacy outcomes and their relationship to patient age at the time of implantation. Analyses established that the performance of IOLs in adults younger than 60 years was comparable to that in adults older than 60 years and supported the use of IOLs in the younger adult population.

Posterior chamber intraocular lens supported by an intact vitreous face

We describe a technique of posterior chamber intraocular lens (IOL) implantation in eyes with inadequate capsule support caused by inadvertent or planned intracapsular cataract extraction (ICCE) or in eyes having secondary IOL implantation after previous ICCE. The procedure is only performed in eyes with an intact anterior vitreous face, no vitreous prolapse into the anterior chamber, and no vitreous loss. The anterior vitreous is pushed back by viscoelastic material or air. The viscoelastic material is injected under the iris to create a free space between the iris and anterior vitreous. A single-piece, C-loop, poly(methyl methacrylate) IOL is slid onto the iris to rest on the anterior vitreous face; care is taken not to disturb the anterior vitreous. The technique was used in 15 eyes with a follow-up from 19 months to 5 years. All eyes had a stable IOL at each follow-up, and the visual acuity was 6/12 or better at the last follow-up.

Retinal detachment in eyes with vitreous loss and an anterior chamber or a posterior chamber intraocular lens: comparison of the incidence

PURPOSE

To compare the incidence of retinal detachment within 6 months of cataract surgery complicated by vitreous loss in eyes with a posterior chamber intraocular lens (PC IOL) or an anterior chamber IOL (AC IOL).

SETTING

Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel.

METHODS

In this retrospective consecutive nonrandomized comparative case series, all cases of cataract surgery complicated by vitreous loss between January 1991 and March 1998 were reviewed. Included were patients who had thorough anterior vitrectomy and primary IOL implantation and at least 6 months follow-up. Exclusion criteria were congenital and traumatic cataract, previous intraocular surgery, and previous retinal detachment. Patients receiving an unsutured single-piece poly(methyl methacrylate) (PMMA) PC IOL formed the PC group, while those receiving flexible open-loop single-piece PMMA AC IOLs formed the AC group. The incidence of postoperative retinal detachment in the 2 groups was compared.

RESULTS

Of the 151 eyes of 149 patients, 66 received a PC IOL and 85 received an AC IOL. Two eyes (3.0%) in the PC group and 2 (2.4%) in the AC group developed retinal detachment; the difference between groups was not statistically significant (P = 1.00, Fisher exact test).

CONCLUSIONS

In eyes that have vitreous loss and thorough anterior vitrectomy, AC IOL implantation did not appear to increase the incidence of retinal detachment.

Bipseudophakia: clinicopathological correlation of a dropped lens

PURPOSE

To examine postmortem human globes containing an anterior chamber and a posterior chamber intraocular lens (IOL).

SETTING

Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Charleston, South Carolina, USA.

METHODS

The globes were sectioned at the equator, and the anterior and posterior segments were macroscopically examined. Gross photographs were taken using the Miyake-Apple posterior photographic technique. Histological sections were cut and stained with hematoxylin and eosin, periodic acid-Schiff, and Masson's trichrome.

RESULTS

Histopathological findings included a large Soemmering's ring, a tear in the posterior capsule, 1 haptic of the anterior chamber IOL displaced into the iridectomy, thin and atrophic corneal epithelium, separation of Bowman's layer and stroma by fibrovascular tissue, and atrophy of the retinal ganglion cell layer and nerve fiber layer.

CONCLUSION

In cases in which secondary IOL implantation is indicated, removing the dislocated IOL appears to be a reasonable choice.

Preservation of anterior capsule during vitrectomy and lensectomy for retinal detachment with proliferative vitreoretinopathy

PURPOSE

To report a series of 15 eyes with rhegmatogenous retinal detachment and proliferative vitreoretinopathy (PVR) or at high risk for advanced PVR, which underwent pars plana vitrectomy (PPV) and lensectomy (PPL) with preservation of the anterior capsule.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Fifteen consecutive patients with retinal detachment and varying degrees of PVR in one eye.

METHODS

All eyes had undergone PPV and PPL with preservation and polishing of the anterior capsule and had at least 6 months of follow-up. Of the 15 eyes, grade C PVR was present preoperatively in 11 and was anterior in 5. Seven of 15 eyes had gas and 8 of 15 had silicone oil tamponade. Eight of 15 eyes had subsequent posterior chamber intraocular lens (PCIOL) placement; 5 eyes had simultaneous silicone oil removal. One eye had a PCIOL placed at the time of the PPL.

MAIN OUTCOME MEASURES

Visual acuity, retinal reattachment, complications of gas or silicone oil tamponade, and anterior capsular clarity.

RESULTS

Fourteen eyes had complete retinal reattachment at the final visit (1 of 15 had macular redetachment only). Final visual acuity was better or equal to preoperative acuity in all eyes, improving by 4 +/- 4 lines overall. No eyes had corneal decompensation, pupillary block, or other vision-threatening anterior segment complication. The anterior capsule remained centrally clear in the 13 eyes that did not have a primary central capsulotomy. One eye with minimal preoperative PVR developed hypotony.

CONCLUSIONS

Vitreoretinal surgeons can preserve the anterior capsule in eyes with retinal detachment and PVR to help prevent intraoperative and postoperative complications of gas or silicone oil, simplify future PCIOL placement, and maintain a normal iris appearance.

[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.

Pediatric secondary lens implantation in the absence of capsular support

PURPOSE

To describe and evaluate alternate techniques for implanting intraocular lenses in children in the absence of adequate capsular support for traditional lens implantation.

METHODS

Postoperative results of 18 eyes with posterior chamber intraocular lenses (PCIOLs) sutured to the ciliary sulcus and 10 eyes implanted with anterior chamber intraocular lenses (ACIOLs) were reviewed. Visual outcomes were divided into 2 groups: onset of aphakia during the critical period of visual development (< or = 9 years) and onset after the critical period (> 9 years). Visual outcomes and complications were recorded.

RESULTS

Average follow-up was 10.3 months in the PCIOL group and 49.2 months in the ACIOL group. Eyes that became aphakic after the critical period of visual development achieved better overall final visual acuity than the eyes that became aphakic during the critical period; indeed, the eyes that became aphakic during the critical period did not achieve significantly improved vision. There were no complications in the PCIOL group. Complications in the ACIOL group included corectopia, haptic migration through the operative wound requiring removal, and pigment deposits on the lens.

CONCLUSIONS

PCIOLs sutured to the ciliary sulcus offer a superior option to ACIOLs for correction of childhood aphakia in children lacking capsular support. ACIOLs had a high rate of serious complications (10%) in this small series. Secondary implantation with transsclerally sutured PCIOLs should be considered in complicated cases when more conservative options have been exhausted.

Visual outcome and complications after posterior capsule rupture during phacoemulsification surgery

PURPOSE

To determine the visual outcome and incidence of complications after posterior capsule rupture during phacoemulsification surgery.

METHODS

Forty-four eyes of 43 patients which sustained posterior capsule rupture or zonulysis during phacoemulsification surgery between April 1993 and May 1996 were retrospectively studied. Eyes With pseudoexfoliation syndrome, traumatic cataract and myopia > 6 dioptres were excluded from the study. The mean postoperative follow-up period was 26 months (range 3 to 47 months).

RESULTS

Forty-one eyes had posterior capsule rupture and 3 eyes had zonulysis. Of these 44 eyes, 41 eyes had vitreous loss and anterior vitrectomy at the time of surgery or subsequently. Excluding 2 eyes with pre-existing conditions that precluded good vision, 36 out of 42 eyes (85.7%) achieved spectacle corrected visual acuity of 6/12 or better post-operatively. Of all 42 eyes, 20 had anterior chamber intraocular lens (ACIOL) implantation while the others had posterior chamber intraocular lens (PCIOL) implantation. For eyes with ACIOL, 17 out of 20 eyes (85.0%) had best corrected visual acuity of 6/12 or better. For eyes with PCIOL, 19 out of 22 eyes (86.4%) had best corrected visual acuity of 6/12 or better.

CONCLUSIONS

Phacoemulsification surgery, even if complicated by posterior capsule rupture or zonulysis, is compatible with good visual outcome. This is provided prompt attention is paid to the management of complications.

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.