Primary intraocular lens implantation in the setting of penetrating ocular trauma

Management and Outcomes of Traumatic Cataract During Open Globe Repair

PURPOSE

To compare outcomes of primary lensectomy (PL) versus no lensectomy (NL) during repair of zone I (involving cornea and limbus) and II (up to 5mm posterior to the limbus) open globe injuries (OGIs) with lens involvement.

DESIGN

Retrospective clinical cohort study.

METHODS

107 patients with OGIs involving both blunt and penetrating injury to the lens who presented to Wills Eye Hospital between April 1, 2017 and August 31, 2022 were included. Data from presenting visit was collected including demographic information, time from injury to surgery, visual acuity (VA), intraocular pressure (IOP), injury characteristics, and years since residency graduation of surgeon. VA, IOP, retinal detachment (RD) rate, and endophthalmitis incidence were compared between PL and NL groups at postoperative week 1 (POW1) and postoperative month 1 (POM1). VA, peak IOP, need for further surgeries, and types of additional surgery were compared between the two groups at the final visit.

RESULTS

19 (17.8%) patients underwent PL. Age, sex, and initial VA were similar between groups (all p≥0.05). The PL group had surgery later from the time of injury (6.1±14.6 days vs. 1.3±1.9 days; p=0.010), higher IOP at presentation (12.9±11.6 mmHg vs. 7.7±11.3 mmHg; p=0.046), shorter wounds (2.3±1.4mm vs. 4.7±3.2mm; p=0.003), more frequent lens capsule violation (89.5% vs. 50%; p=0.010), increased likelihood of intraocular foreign bodies (52.6% vs. 17.0%; p=0.004), and were more likely to be operated on by surgeons with ≥ 5 years of experience post-residency (68.4% vs. 28.4%; p<0.001). At POW1, the PL group had significantly better logMAR VA (1.2±0.9 vs. 2.0±1.0; p=0.002), and this continued at POM1 (1.0±0.8 vs. 1.6±1.1; p=0.031) and the final visit (0.4±0.7 vs. 1.0±1.1; p=0.010). The PL group had lower IOP at POW1 (12.4±3.0 mmHg vs. 17.3±8.2 mmHg; p=0.005) than the NL group. There was no difference in RD or endophthalmitis rates between the two groups at POW1 or POM1 (p>0.05 for all). The NL group was more likely to require additional surgery by final follow-up (77.3% vs. 47.4%; p<0.001). In the multivariable analysis, PL had better final VA and decreased need for further surgery (both p<0.05).

CONCLUSIONS

In the appropriate circumstance, PL during lens-involving anterior OGI repair may lead to improved patient outcomes.

Comparison of the effectiveness of different corneal curvature measurement methods for IOL implantation in traumatic aphakic eyes with corneal injury

BACKGROUND/AIM

To assess the refractive outcomes of secondary intraocular lenses (IOL) in patients with traumatic aphakic eyes with corneal penetrating injury and compare different corneal curvature measurement methods.

METHODS

Patients with unilateral penetrating eye injuries underwent corneal wound repair and cataract extraction, followed by secondary IOL implantation. Corneal curvature measurements were taken on the contralateral healthy eye (Group A), from the affected eye before removing corneal sutures (Group B), or after suture removal (Group C). The refractive outcomes were compared among the three groups.

RESULTS

The study included 261 eyes. The Mean Absolute Error (MAE) in Group C (0.99 ± 0.85 D) was significantly smaller than that in Group A (1.87 ± 1.71 D) and Group B (1.37 ± 1.20 D) (both P < 0.001). Moreover, the percentage of eyes with IOL prediction errors within ± 0.50 D in Group C (40%) was higher than that in group A (21.7%) (OR = 2.364, 95%CI: 1.272-4.392, P = 0.006) and group B (28.0%) (OR = 1.714, 95%CI: 0.948-3.099, P = 0.073), and the percentage of eyes with IOL prediction errors within ± 1.0 D in Group C (90.9%) was higher than that in group A (67.9%) (OR = 4.758, 95%CI: 2.131-10.626, P < 0.001) and group B (75.0%) (OR = 3.370, 95%CI: 1.483-7.660, P = 0.003) as well.

CONCLUSIONS

In traumatic aphakic eyes with corneal sutures, IOL power calculation based on the corneal curvature of the injured eye after removing the corneal sutures yields the best refractive outcomes.

Visual Outcomes of Traumatic Lens Dislocations and Subluxations Managed by Pars Plana Vitrectomy and Lensectomy

AIM

The aim of this study was to evaluate the visual outcome of lens dislocation and subluxation managed by pars plana vitrectomy (PPV) and lensectomy in patients with open (OGIs) or closed globe injuries (CGIs).

METHODS

Medical records of 70 consecutive patients treated by PPV and lensectomy over a period of 11 years (1 January 2010-31 December 2020) were retrospectively reviewed. We collected demographic data, best corrected visual acuity (BCVA) using a Snellen Chart pre- and postoperatively, associated ocular injuries and treatment strategy. Visual outcome was evaluated according to the final BCVA which was defined as poor <0.1 or good ≥0.1.

RESULTS

The mean age was 57.9 ± 17.6 years. CGIs were present in 49 (70.0%) cases and open OGIs in 21 (30.0%) cases. The dislocation mechanism was zonular lysis in 59 cases (84.3%) and capsular rupture in 11 cases (15.7%). The intraocular lens implant (IOL) was sutured to the sclera in 51 (72.9%) cases or positioned in the capsular bag or in the sulcus in 3 (4.3%) cases and 1 (1.4%) case, respectively, whereas 15 (21.4%) patients remained aphakic. A good BCVA ≥ 0.1 was achieved in 45.71% of the eyes. The presence of retinal detachment (RD) (p = 0.014), iridodonesis (p = 0.011) and initial BCVA (p = 0.000) achieved statistical significance in predicting visual outcome. After treatment, 45.71% of patients achieved a final BCVA ≥ 0.1.

CONCLUSION

RD, iridodonesis and initial BCVA were risk factors for poor visual outcome in our series.

Difference between both eyes in the calculation of the dioptre power of the intraocular lens in a series of 7994 patients

PURPOSE

To analyse the distribution of the difference between both eyes in the calculation of the dioptric power of the intraocular lens in a series of 7994 patients and the biometric variables that determine it.

METHODS

The data of patients between 3 and 99 years old, residents of the city of Guayaquil and neighbouring sites, who received ocular biometry by partial optical coherence interferometry between 2004 and 2020 were reviewed. Ocular biometrics, including axial length (AL), anterior chamber depth (ACD), and the mean corneal dioptre power (CD), were measured by partial coherence interferometry. Refraction without or with cycloplegia was recorded in spherical equivalent (SE). The Haigis formula from the IOL Master instrument was used to calculate the dioptric power of the intraocular lens in both eyes.

RESULTS

Data from the bilateral optical biometry of 7994 patients were analysed. The mean and standard deviation of AL, CD, ACD and dioptre power of the IOL were 23.66 ± 1.25, 43.70 ± 1.49, 3.34 ± 0.40 and +20.46 ± 3.84, respectively. 2538 (31.7%) patients had equal dioptre power of the IOL between both eyes. 3243 (40.6%) patients had a 0.50 D difference; 1162 (14.5%), 1.0 D; 425 (5.3%), 1.5 D. 626 patients (7.8%) had a difference in IOL dioptre of 2 D or more, with a maximum of 24 D. The asymmetry of AL between OU was ≥0.4 mm in 10.49%, while that of CD reached ≥1 D in 1.9%.

CONCLUSIONS

92.16% of patients had a difference within 1.5 D between both eyes in the calculation of the dioptre power of the intraocular lens. In case an eye is programmed in which it is impossible to perform a reliable biometry, either due to trauma or due to white or brunescent cataract, the calculation of the intraocular lens could be done taking as a reference the biometry of the contralateral eye.

The Effect of Secondary Intraocular Lens Implantation Time on Visual Prognosis in Aphakia Cases After Open Globe Injury

Purpose

We investigated the effect of the time of secondary intraocular lens (IOL) implantation on final visual acuity and other causes affecting visual prognosis in cases left aphakic after open globe injury.

Methods

The study included 62 eyes of 62 patients left aphakic after the repair of open globe injury between 2012-2019. Demographic characteristics, trauma zone, ocular trauma score (OTS), type of injury, time of secondary IOL implantation, final best corrected visual acuity (BCVA), and complications were recorded for each patient.

Results

The mean follow-up time of 62 patients was 25.05 ± 12.59 months. The preoperative BCVA was found to be 2.40±0.86 LogMAR, while the postoperative final BCVA was found to be 0.53±0.70 LogMAR (p<0.01). The mean interval timing of secondary sulcus foldable IOL implantation was determined to be 3.79 ± 4.04 months. No correlation was observed between secondary IOL implantation time and final BCVA (r= 0.140, p=0.319). Furthermore, when only pediatric patients were taken, an excellent positive correlation was found between the secondary IOL implantation time and final BCVA LogMAR (r=0.895, p<0.01). Multiple linear regression on final BCVA with age, revealed a significant model explaining 48.0% of the variability with younger age and better final BCVA with as significant coefficients (p= 0.007).

Conclusion

Although time interval between primary repair and secondary IOL implantation to correct aphakia does not effect final BCVA in adult patients, earlier surgery should be considered for amblyopia management in pediatric patients.

Intraocular Foreign Body: Diagnostic Protocols and Treatment Strategies in Ocular Trauma Patients

Intraocular foreign bodies (IOFBs) are critical ophthalmic emergencies that require urgent diagnosis and treatment to prevent blindness or globe loss. This study aimed to examine the various clinical presentations of IOFBs, determine the prognostic factors for final visual outcomes, establish diagnostic protocols, and update treatment strategies for patients with IOFBs. We retrospectively reviewed patients with IOFBs between 2005 and 2019. The mean age of the patients was 46.7 years, and the most common mechanism of injury was hammering (32.7%). The most common location of IOFBs was the retina and choroid (57.7%), and the IOFBs were mainly metal (76.9%). Multivariate regression analysis showed that poor final visual outcomes (<20/200) were associated with posterior segment IOFBs (odds ratio (OR) = 11.556, p = 0.033) and retinal detachment (OR = 4.781, p = 0.034). Diagnosing a retained IOFB is essential for establishing the management of patients with ocular trauma. To identify IOFBs, ocular imaging modalities, including computed tomography or ultrasonography, should be considered. Different strategies should be employed during the surgical removal of IOFBs depending on the material, location, and size of the IOFB.

Lenticular fungal infection caused by Aspergillus in a patient with traumatic corneal laceration: a case report

Background

To report a case of lenticular infection caused by Aspergillus, which was diagnosed 13 weeks after traumatic corneal laceration.

Case presentation

A 60-year-old woman presented with traumatic corneal laceration including anterior lens capsule rupture and traumatic cataract after being hit with a chestnut in the right eye. There were multiple injuries due to tiny thorns of the chestnut, including the conjunctiva, sclera, cornea, and anterior lens capsule. But no visible foreign body was detected by slit-lamp examination. Topical corticosteroid was prescribed to resolve the conjunctival inflammation induced by the thorns of chestnut, which could have caused persistent irritation. As conjunctival injection and edema being decreased during outpatient clinical follow-up, embedded conjunctival foreign body was detected and surgically removed (1st surgery). Approximately 10 weeks after the trauma, severe inflammation of the anterior segment accompanied with hypopyon developed suddenly and at the same time embedded scleral foreign body was revealed. After removal of scleral foreign body (2nd surgery), unspecified mold species was cultured from the scleral foreign body in SDA (Sabouraud dextrose agar) plate. Suspicious corneal foreign body was removed as 3rd surgery and phacoemulsification of traumatic cataract was planned as 4th surgery. Aspergillus was finally detected from removed anterior capsule and fibrotic membrane during the operation. Fungal infection resolved successfully after administration of topical (1% voriconazole and 5% natamycin) and systemic (fluconazole) antifungal agents and phacoemulsification of traumatic cataract.

Conclusion

Chestnut thorns can damage multiple ocular tissues simultaneously. Lens capsular rupture could result in fungal inoculation and lead to delayed lenticular fungal infection with complicated cataract formation. In cases of ocular trauma due to organic substances such as thorns and branches, the possibility of fungal infection should be considered.

Secondary Sulcus-Fixed Foldable IOL Implantation with 25-G Infusion in Patients with Previous PPV after Open-Globe Injury

PURPOSE

To evaluate the safety and efficacy of secondary sulcus-fixed foldable intraocular lens (IOL) implantation through a clear corneal incision with 25-G infusion in patients with previous pars plana vitrectomy (PPV) after open-globe injury, and to analyze postoperative outcomes and prognostic factors of treatment.

METHODS

Clinical data of 89 eyes of 89 patients with open-globe injury who underwent secondary sulcus-fixed foldable IOL implantation through a clear corneal incision with 25-G infusion after vitrectomy in our hospital between January 2008 and June 2015 were retrospectively analyzed. The examinations before IOL implantation mainly included visual acuity, slit-lamp examination, direct and indirect ophthalmoscope, visual electrophysiology, corneal endothelium, B scan, ultrasound biomicroscope, and intraocular pressure. Five eyes underwent suturing of peripheral iris and 7 eyes underwent suturing of iris laceration simultaneously. The mean follow-up was 18 months with a range from 6 months to 8 years.

RESULTS

The mean interval between secondary sulcus-fixed foldable IOL implantation and vitrectomy was 2.8 months with a range from 2 to 6 months. The uncorrected visual acuity improved in all patients with a well-centered IOL ranging from 0.1 to 0.8 with the best-corrected visual acuity from 0.1 to 1.0 after secondary IOL implantation. The postoperative complications mainly included mild anterior chamber exudates in 10 eyes (11%), temporary IOP elevation in 12 eyes (13%), and recurrent retinal detachment in 5 eyes (6%), which were subsequently managed by surgery.

CONCLUSIONS

The interval of 2.8 months between vitrectomy and secondary IOL implantation is an appropriate and safe option to correct aphakia in patients receiving vitrectomy for open-globe injury.

Repairing the corneal epithelium using limbal stem cells or alternative cell-based therapies

INTRODUCTION

The corneal epithelium is maintained by limbal stem cells (LSCs) that reside in the basal epithelial layer of the tissue surrounding the cornea termed the limbus. Loss of LSCs results in limbal stem cell deficiency (LSCD) that can cause severe visual impairment. Patients with partial LSCD may respond to conservative therapies designed to rehabilitate the remaining LSCs. However, if these conservative approaches fail or, if complete loss of LSCs occurs, transplantation of LSCs or their alternatives is the only option. While a number of clinical studies utilizing diverse surgical and cell culture techniques have shown favorable results, a universal cure for LSCD is still not available. Knowledge of the potential risks and benefits of current approaches, and development of new technologies, is essential for further improvement of LSCD therapies.

AREAS COVERED

This review focuses on cell-based LSCD treatment approaches ranging from current available clinical therapies to preclinical studies of novel promising applications.

EXPERT OPINION

Improved understanding of LSC identity and development of LSC expansion methods will influence the evolution of successful LSCD therapies. Ultimately, future controlled clinical studies enabling direct comparison of the diverse employed approaches will help to identify the most effective treatment strategies.

Pediatric traumatic cataract and surgery outcomes in eastern China: a hospital-based study

AIM

To evaluate the etiologies, management, and outcomes of pediatric traumatic cataract in eastern China.

METHODS

Pediatric traumatic cataract were reviewed for demographic information, type of injury, mode of injury, time of injury, interval between injury and first visiting doctors, hospital of first visiting, surgeries, complications and prognosis.

RESULTS

A total of 117 eyes of 117 patients (96 boys and 21 girls) with unilateral injuries (66 right and 51 left eyes) were included in the study. The mean (SEM) age at diagnosis was (6.6±3.2) years (range, 1.3-13.8 years). Each cataract was categorized according to the type of trauma: closed-globe (n=26) or open-globe (n=91) injuries. The most common injuring objects were sharp metal objects (37.61%). The most common complication in open-globe injuries was corneal laceration, whereas traumatic mydriasis was most common in closed-globe injuries. Of 68 eyes in patients with open-globe injuries who received cataract extraction, intraocular lens (IOLs) were primarily implanted in 47 eyes (68.12%), whereas 18 eyes with closed-globe injuries received cataract extraction, and IOLs were primarily implanted in 17 eyes (94.4%). The surgical procedures included reconstruction of the anterior segment, synechiolysis, excision of the membrane, lensectomy, vitrectomy and related techniques. Postoperative vision was significantly improved compared with preoperative vision.

CONCLUSION

Pediatric traumatic cataract should be treated in time to attenuate the complications, and education on pediatric traumatic cataract and improvements in pediatric health care are needed for the early detection of cataract in children.

Cataract surgery in the setting of trauma

PURPOSE

To review the changes in the surgical techniques used for cataract removal in the setting of trauma and their postoperative outcome.

RECENT FINDINGS

Primary cataract removal with intraocular lens (IOL) implantation is the commonly followed procedure for penetrating injuries with cataract. IOL implantation has evolved through various techniques namely 'in the bag', 'in the sulcus', epilenticular implantation, anterior chamber IOL, scleral fixated IOL and recently glued IOL.

SUMMARY

Certain lacerating injuries of the anterior segment are particularly amenable to cataract extraction and IOL implantation at the time of primary laceration repair. This approach obviates additional operative and anesthetic risks, while affording timelier visual rehabilitation. Secondary lens removal may also be indicated in cases of severe corneal injury and marked edema, which may interfere with intraocular visualization.

Combined pars plana vitrectomy and lens management in complex vitreoretinal disease

Concurrent cataract and vitreoretinal disorders are relatively common. Additionally, a considerable number of phakic eyes develop visually significant cataract following pars plana vitrectomy. The ophthalmic literature is replete with reports of a combined procedure consisting of simultaneous cataract extraction, intraocular lens implantation, and pars plana vitrectomy to treat a wide range of vitreoretinal disorders and co-existing cataracts. Historical concerns of increased risk of complications with the combined procedure have been shown not to be clinically significant. The combined procedure offers the advantages of a single procedure, including faster recovery time and cost effectiveness. Earlier reports of the combined procedure describe pars plana lensectomy and extracapsular cataract extraction as techniques for cataract extraction. Currently, phacoemulsification with implantation of a foldable posterior intraocular lens implantation has become the preferred technique of cataract removal. With advances in instrumentation and surgical techniques, the combined procedure offers a safe and effective way to manage concurrent cataract and complex vitreoretinal disease.

Combined lensectomy, vitrectomy, and primary intraocular lens implantation in patients with traumatic eye injury

PURPOSE

To analyse the postoperative anatomic and functional outcomes in addition to complications after combined lensectomy, vitrectomy, and primary intraocular lens (IOL) implantation in patients with traumatic eye injury.

METHODS

Retrospective review of patients with traumatic cataract and posterior segment injury who underwent combined lensectomy, vitrectomy, and primary IOL implantation with a minimum follow up (FU) of 3 months.

RESULTS

Thirteen consecutive patients (all male) with a mean age of 42.8 years (range 17-82 years) underwent combined lensectomy, vitrectomy, and primary IOL implantation from February 2000 to January 2006. Postoperative FU ranged from 3 to 54 months (mean 17.6 months). Best corrected visual acuity (BCVA) at presentation ranged from 20/30 to hand movement and was worse than 20/200 in eight patients (61%). Four patients (31%) had blunt trauma with no globe rupture. Of the nine patients (69%) with a penetrating eye injury (PEI), eight had an intraocular foreign body (IOFB) with one retinal detachment at presentation. Four patients had primary closure at the time of the vitrectomy. All eight IOFBs were removed. Seven patients had additional scleral buckling and four intravitreal gas injection. BCVA at last FU ranged from 20/20 to 20/300 and was 20/40 or better in eight eyes (62%). All patients had an attached retina at last FU. One eye had further surgery for epiretinal membrane proliferation and ptosis.

CONCLUSIONS

These results suggest that combined vitrectomy, lensectomy and primary intraocular implantation can offer good visual rehabilitation in patients with traumatic cataract and posterior segment injury.

Corneal epithelial stem cells: characterization, culture and transplantation

The epithelium covering the cornea at the front of the eye is maintained by stem cells located at its periphery, in a region known as the limbus. A lack or dysfunction of these so-called limbal stem cells (LSCs) results in the painful and blinding disease of LSC deficiency. In this review, current knowledge regarding the biology of these particular stem cells will be outlined, including recent advances that are enabling the gene expression analysis of these cells. The use of LSCs in therapeutic interventions for LSC deficiency will also be discussed, including the role for ex vivo expansion. In particular, the translation of basic science advances in LSC biology into therapeutic strategies will be highlighted.

[Optical lamellar-penetrating keratoplasty with stem cell transplantation in high-risk cases]

BACKGROUND

Stem cells of the corneal epithelium are located mainly at the sclerocorneal limbus, and are essential for the maintenance of a healthy corneal surface. Limbal stem cell deficiency leads--depending on intensity and extension--to several corneal alterations. The appearance of limbal stem cell deficiency is chiefly concentrated on pemphigoids, Herpes relapses and alkali burns and represents the main part of high-risk keratoplasty. The different types of limbal stem cell deficiency (partial or total) are usually treated with several surgical techniques. Total limbal deficiency can be treated with limbal transplantation, either of the healthy eye (limbal autograft), or using material of another donor (limbal allograft).

METHODS AND RESULTS

Lamellar-penetrating keratoplasty (L-P-KP) has been carried out in five patients. Unlike recent surgical techniques containing ring-shaped or circular transplantations, a stripe-like lamellar preparation was performed. L-P-KP involves a peripheral lamellar and a central penetrating keratoplasty combined with limbal stem cell transplantation. In four of six cases, the transplant has been successfully kept clear without the occurrence of corneal decompensation or ulceration. No major changes could be seen between pre- and postoperative visual acuity. The mean observation period was 24 months.

DISCUSSION

L-P-KP offers a new surgical opportunity in the treatment of high-risk cases of limbal deficiency.

Secondary intraocular lens implantation of traumatic cataract in open-globe injury

BACKGROUND

The purpose of this study was to determine the visual outcome and accuracy of biometry in traumatic cataract in open-globe injury.

METHODS

A clinical retrospective study of 30 consecutive patients treated for ocular penetrating trauma was conducted. Patient demographics, causes of injury, wound categories, timing and procedures of the primary repair, interval of subsequent intraocular lens (IOL) implantation, follow-up, and postoperative complications were recorded. Additionally, binocular biometry was documented. Twenty-six eyes (86.7%) were open-globe injuries occurring in the workplace. All patients received cataract extraction with primary repair of the penetrating wound, 18 eyes (60%) underwent trans pars plana vitrectomy with lensectomy and 12 eyes (40%) underwent lens aspiration or extracapsular cataract extraction. Simultaneously, 16 eyes (53.3%) underwent intraocular foreign body removal.

RESULTS

The mean visual improvement after secondary IOL implantation was statistically significant (p = 0.002). Seventeen eyes (56.7%) achieved final best-corrected visual acuity of 20/40 or better. The mean deviation of final refraction and target refraction was -0.69 +/- 0.56 diopter, and 23 eyes (76.7%) were within 1 diopter based on biometry of the traumatic eye. In 18 eyes (60%), the difference was within 1 diopter according to biometry of the fellow eye. In 5 cases (16.7%), there was no improvement of vision because of central corneal scar, secondary glaucoma, macular pucker, or recurrent retinal detachment.

INTERPRETATION

The vision of patients with traumatic cataract in open-globe injury was improved after prompt surgical intervention and subsequent IOL implantation. A minority of patients experienced no change in vision or a deterioration of vision due to irregular astigmatism caused by a corneal wound or variable damage to the posterior segment. Using biometry of the injured eye after primary repair was more accurate than using biometry of the fellow eye to determine the power of the lens for IOL implantation in variable open-globe injury.

Foldable versus rigid intraocular lenses in conjunction with pars plana vitrectomy and other vitreoretinal procedures

PURPOSE

To compare the results of foldable acrylic intraocular lens (IOL) implantation through a clear corneal incision with those of rigid IOL implantation in eyes having pars plana vitrectomy (PPV).

SETTING

Tertiary referral-based university institute.

METHODS

A consecutive retrospective comparative chart review was performed in all eyes that had PPV and foldable IOL implantation between May 15, 1999, and November 1, 2000 (n = 30), and all eyes that had PPV and rigid IOL implantation between April 1, 1996, and May 14, 1999 (n = 30). Preoperative baseline data and postoperative outcome data were recorded. Pars plana vitrectomy and associated vitreoretinal procedures were performed as indicated according to individual circumstances. A minimum of 1 week of follow-up information was available for all eyes.

RESULTS

Baseline characteristics in both groups of patients, including age, sex, eye involved, and phakic state, were similar. The preoperative visual acuities were also similar, ranging from 20/30 to hand motions; the mean visual acuity was 20/200. The IOL was implanted in all eyes uneventfully and did not restrict fundoscopy. The mean follow-up was significantly longer in the rigid IOL group (20 months) than in the foldable IOL group (7 months) (P<.001), probably because of the earlier case acquisition. The mean postoperative best corrected visual acuity was 20/200 in the foldable IOL group and 20/100 in the rigid IOL group. There was no difference between the 2 groups in the rate of postoperative retinal detachment, recurrent macular hole, or repeat PPV. Elevated intraocular pressure (IOP) on the first postoperative day was more common in the rigid IOL group than in the foldable IOL group (P =.078) because more patients in the rigid IOL group had surgery for diabetic ocular complications and these patients had a greater IOP rise.

CONCLUSION

Acrylic IOLs can be safely implanted in conjunction with PPV in selected cases.

Limbal autograft and allograft transplantations in patients with corneal burns

AIM

To investigate and compare the surgical outcomes of limbal autograft and limbal allograft transplantations in patients with corneal burns.

METHODS

In total, 20 patients (n=22 eyes) with chemical burn and two patients (n=2 eyes) with thermal burn were included in this study. Limbal autograft or limbal allograft transplantation surgery was performed in all patients. HLA-typing was tested before allograft surgeries. Limbal allografting was performed in all eyes using donor tissue from live relatives. Systemic cyclosporine A was administered for immunosuppression.

RESULTS

The corneal surface was successfully reconstructed in all eyes (100%) after limbal autografting, two eyes required additional amniotic membrane transplantation and one eye required allografting. The mean follow-up period for limbal autografts was 13.9 +/- 7.0 months. Limbal allografting failed to reduce corneal vascularity and opacification in five (55.6%) eyes and was successful only in four (44.4%) eyes (mean follow-up 16.2 +/- 11.2 months) (P=0.002). In all, 15 eyes undergoing limbal autografting completed re-epithelialization of the cornea at a mean of 35.6 +/- 60.2 days. The mean epithelial healing time in nine eyes undergoing limbal allografting was 13.0 +/- 7.3 days (P=0.525). After limbal autografting, functional vision (> or =1/10) was attained in 12 (80%) eyes. Only one eye (11.1%) achieved functional vision after limbal allografting (P=0.036). Penetrating keratoplasty was performed in three patients following limbal allografting. No cyclosporine-associated side effects were observed.

CONCLUSIONS

Limbal autograft transplantation is an effective and safe procedure for unilateral corneal burns. It seems that limbal allograft transplantation is better combined with penetrating keratoplasty for a better visual outcome and higher graft survival rate. Systemic immunosuppression seems to be necessary for limbal allografts even in the presence of HLA-matched donor tissues.

[Primary implantation of posterior chamber lenses after traumatic cataract peneration]

PURPOSE

To analyze the postoperative outcome and complication rate after phacoemulsification, lens aspiration or lensectomy with primary intraocular lens (IOL) implantation after traumatic cataract penetration.

METHODS

We retrospectively reviewed the data of 15 patients who were admitted to our hospital from 1997 to 2001 because of traumatic cataract with corneal laceration with and without intraocular foreign body (IOFB). In all patients phacoemulsification, lens aspiration or lensectomy and primary IOL implantation were performed. Removal of IOFB was performed in 6 patients.

RESULTS

The mean follow-up was 19.6 months, 8 eyes (53%) achieved a final visual acuity of 20/40 or better and 12 eyes achieved 20/100 or better final visual acuity. One patient (final visual acuity=1/40) had an additional macular pathology. Due to irregular astigmatism two patients achieved a final vision of less than 20/100. Major causes of limited visual acuity were central corneal scars and in one patient a photopic maculopathy. Four eyes (25%) developed secondary cataract and underwent YAG laser capsulotomy. In one patient PVR retinal detachment had to be treated by pars-plana vitrectomy with silicone oil tamponade.

CONCLUSIONS

Primary implantation of posterior chamber lenses after penetrating ocular trauma is associated with a favourable visual outcome and a low rate of postoperative complications.

Multifocal intraocular lens implantation in patients with traumatic cataract

OBJECTIVE

To evaluate the postoperative outcome and complication rate of cataract extraction with implantation of a zonal-progressive multifocal intraocular lens (IOL) for traumatic cataract.

DESIGN

Prospective, nonrandomized, comparative trial.

PARTICIPANTS

Fifty-one eyes of 51 subjects with traumatic cataract caused by nonpenetrating, penetrating, and perforating ocular trauma at two university institutions with more than 12 months follow-up.

INTERVENTIONS

Temporal clear corneal phacoemulsification with foldable IOL implantation was performed in all eyes. In 29 subjects, a zonal-progressive optic multifocal IOL (Array SA40-N Allergan, Irvine, CA) was implanted, whereas 22 subjects received a monofocal IOL and served as controls.

RESULTS

Preoperative subjects demographics, mean postoperative spherical equivalent, astigmatism, and uncorrected and best-corrected distance visual acuity were similar in the two groups. Subjects with a multifocal IOL achieved a significantly better uncorrected near visual acuity than subjects with monofocal IOL (0.24 vs. 0.40; P = 0.0001). With distance correction only, mean near visual acuity was 0.21 vs. 0.43 (P = 0.0001). Best-corrected near visual acuity was 0.17 for both groups (P = 0.91), with +1.24 diopters (D) for the multifocal group and +2.45 D for the monofocal group (P = 0.0001). Spectacle dependency differed significantly between the two groups, with 18 (81%) subjects of the monofocal group commonly requiring an additional plus add for near tasks compared with 5 (17%) subjects in the multifocal group (P = 0.001). Stereopsis was superior in the multifocal group (P < 0.001), with 20 (69%) and 16 (55%) patients with a multifocal IOL responding positively to the Lang and Titmus tests, respectively. In the monofocal group, only eight (36%) and five (22%) subjects gave correct answers.

CONCLUSIONS

Multifocal IOL implantation is a viable alternative to monofocal pseudophakia in subjects with traumatic cataract.

Primary repair and intraocular lens implantation after perforating eye injury

PURPOSE

To evaluate the clinical outcome after primary treatment of lens injuries with corneal or corneoscleral trauma.

METHODS

Ten eyes of 10 patients were retrospectively evaluated. There were no foreign bodies in any eye. After primary repair, an anterior chamber maintainer (ACM) was introduced through the inferotemporal corneal quadrant. Sodium hyaluronate 1.4% (Healon GV(R)) was injected, and the anterior capsule was stained with trypan blue 0.1% vital stain (Vision Blue) under the viscoelastic substance. After a capsulorhexis was created, the lens material was aspirated. The nucleus was delivered from the scleral tunnel, which was opened from the superior/superotemporal corneal quadrant. A conventional 21.0 diopter poly(methyl methacrylate) intraocular lens (IOL) with a 5.5 mm optic and overall diameter of 12.5 mm (Dr. Schmidth(R), Hannan Kibbutz) was implanted through the scleral tunnel. The scleral tunnel was not sutured, and the corneal entry sites were closed with stromal hydration.

RESULTS

The final best spectacle-corrected visual acuity (BSCVA) was better than 20/100 in all patients, and 6 patients had a BSCVA of 20/20. The IOL was in the capsular bag in all patients at the last follow-up. The mean follow-up was 12.3 months (range 7 to 25 months). The main visually limiting factors were corneal scar, irregular astigmatism, and traumatic maculopathy.

CONCLUSIONS

Primary IOL implantation in carefully selected patients with penetrating corneoscleral lens injury may yield visually rewarding results. The use of a vital stain to increase the visibility of the injured anterior capsule and of a closed scleral tunnel system with an ACM increased the surgical safety.

Inaccuracy of intraocular lens power calculation after traumatic corneal laceration and cataract

A 53-year-old man sustained a perforating, central corneal injury with a nail in his right eye. After primary repair of the laceration, a traumatic cataract was removed and a Multiflex-style intraocular lens (IOL) was inserted. A 4.00 diopter surprise resulted, probably due to calculation of the IOL power using measurements from the contralateral normal eye. Inability to wear a contact lens for visual correction resulted in IOL exchange surgery in which a sulcus-sutured IOL was implanted. The IOL power was calculated using simulated keratometry from videokeratoscopy and axial length measurements of the injured eye. This resulted in an IOL power closer to emmetropia, allowing for a best spectacle-corrected visual acuity of 20/20 and comfortable wearing of spectacles.

Primary cataract extraction and intraocular lens implantation in penetrating ocular trauma

PURPOSE

To analyze the postoperative outcome and complication rate after cataract extraction or lensectomy with primary intraocular lens (IOL) implantation for penetrating traumatic cataract.

DESIGN

Retrospective, nonconsecutive, noncomparative case series.

METHODS

We retrospectively reviewed the files of 21 patients who were admitted to our departments because of traumatic cataract with corneal or scleral laceration caused by penetrating trauma with or without intraocular foreign body (IOFB) from 1992 through 1997. Lens aspiration or manual extracapsular cataract extraction with primary IOL implantation was performed in all patients. Removal of an IOFB was performed in eight patients.

MAIN OUTCOME MEASURES

Final visual acuity and deviation of actual refraction from emmetropia and from expected postoperative refraction.

RESULTS

The mean follow-up was 20.4 months. Fourteen eyes (67%) achieved final visual acuity of 20/40 or better, 95% obtained 20/60 or better final visual acuity, and all eyes achieved 20/100 or better final visual acuity. Major causes of limited visual acuity were central corneal scar and central retinal injury. Eleven eyes (57%) experienced secondary cataract and underwent neodymium:yytrium-aluminum-garnet capsulotomy.

CONCLUSIONS

Primary implantation of posterior chamber lenses after penetrating ocular trauma is associated with favorable visual outcome and a low rate of postoperative complications.

Acrylic intraocular lens placement in conjunction with pars plana vitrectomy

PURPOSE

To report the results of placing a foldable acrylic intraocular lens through a clear cornea incision in eyes undergoing pars plana vitrectomy.

METHODS

This interventional case series is a retrospective report of 15 eyes of 15 consecutive patients undergoing foldable (acrylic) intraocular lens insertion in conjunction with pars plana vitrectomy in a single academic institution. Outcome measures included visual acuity and complications.

RESULTS

The intraocular lens was successfully implanted and retained in position in all 15 cases. The intraocular lens did not pose difficulty in examining the fundus or cause any vitreoretinal complications. With mean follow-up of 4.5 months (range, 1--10 months), final median postoperative visual acuity range was 20/200 (range, 20/40--2/200) and consistent with the level of vitreoretinal disease.

CONCLUSION

Acrylic intraocular lenses may be safely implanted in conjunction with pars plana vitrectomy in selected cases.

Identifying the origin of single corneal cells by DNA fingerprinting: part I--implications for corneal limbal allografting

PURPOSE

To demonstrate that the combination of impression cytology and single cell DNA fingerprinting represents a powerful tool that is suitable for detecting transplanted cells after corneal limbal allografting.

METHODS

Fifty single cells were obtained by corneal impression cytology from 12 patients undergoing cataract surgery. Individual cells were isolated from samples by micromanipulation. Polymerase chain reaction and short tandem repeat profiling was used to obtain forensic standard "DNA fingerprints" from single cells. Blood samples taken at the time of impression cytology provided control "fingerprints."

RESULTS

Informative DNA fingerprints were obtained from all corneal samples and 66% (33 of 50 cells) of isolated single cells. Of all fingerprints obtained, most (91%, 30 of 33 fingerprints) corneal fingerprints matched corresponding blood sample fingerprints. At least one corneal fingerprint matched the corresponding blood sample fingerprint in 83% (10 of 12 patients) of the patients in the study.

CONCLUSIONS

This extremely specific single cell DNA fingerprinting system permits accurate identification of individual corneal epithelial cells, allowing very reliable determination of their origin, which will enable host and donor cells to be distinguished from each other after keratolimbal allografting procedures, even if the host and donor are the same sex or siblings. These DNA fingerprinting methods allow assessment of quality and quantity of donor cell survival, as well as survival time. The extreme sensitivity and accuracy of the technique means that should contamination occur, it would be identified, thus ensuring meaningful results.

Amniotic membrane transplantation for partial limbal stem cell deficiency

AIM

To examine the efficacy, safety, and long term outcomes of amniotic membrane transplantation for corneal surface reconstruction in cases of partial limbal stem cell deficiency.

METHODS

17 eyes of 15 patients with partial limbal stem cell deficiency underwent superficial keratectomy of the conjunctivalised corneal surface followed by amniotic membrane transplantation. Cases were followed up for at least a year.

RESULTS

All eyes exhibited a stable, intact corneal epithelial surface after a mean follow up period of 25.8 months with no eyes developing recurrent erosion or persistent epithelial defect. The mean time to re-epithelialisation was 22.8 days. Overall improvement in visual acuity was observed in 92.9% of 14 eyes with visual potential. Of those, five eyes gained six or more lines, two eyes gained between four and five lines, six eyes gained between one and three lines, and one eye lost three lines of Snellen acuity. Pain and photophobia were abolished in 86% of cases and substantially reduced in 14%, with all eyes exhibiting decreased vascularisation and inflammation at final follow up.

CONCLUSIONS

Amniotic membrane transplantation appears to be a safe and effective method of restoring a stable corneal epithelium for cases of partial limbal stem cell deficiency and can be considered as an alternative to limbal autograft or allograft.

Reconstruction of damaged corneas by transplantation of autologous limbal epithelial cells

BACKGROUND

Stevens-Johnson syndrome, ocular pemphigoid, and thermal or chemical burns can cause scarring and opacification of the cornea and loss of vision. Transplantation of epithelial cells from the limbus of the contralateral cornea can restore useful vision. However, this procedure requires a large limbal graft from the healthy eye and is not possible in patients who have bilateral lesions.

METHODS

We took specimens of limbal epithelial cells from the healthy contralateral eyes of six patients with severe unilateral corneal disease. The epithelial cells were cultured and expanded on amniotic membrane. The amniotic membrane, together with the sheet of limbal epithelial cells, was transplanted to the denuded corneal surface of the damaged eye after superficial keratectomy to remove fibrovascular ingrowth. The mean (+/-SD) follow-up period was 15+/-2 months.

RESULTS

Complete reepithelialization of the corneal surface occurred within two to four days of transplantation in all six eyes receiving transplants. By one month, the ocular surface was covered with corneal epithelium, and the clarity of the cornea was improved. In five of the six eyes receiving transplants (83 percent), the mean visual acuity improved from 20/112 to 20/45. In one patient with a chemical burn who had total opacification of the cornea, the acuity improved from the ability to count fingers at 40 cm to 20/200. No patient had recurrent neovascularization or inflammation in the transplanted area during the follow-up period.

CONCLUSIONS

Transplantation of autologous limbal epithelial cells cultured on amniotic membrane is a simple and effective method of reconstructing the corneal surface and restoring useful vision in patients with unilateral deficiency of limbal epithelial cells.

Amniotic membrane transplantation or conjunctival limbal autograft for limbal stem cell deficiency induced by 5-fluorouracil in glaucoma surgeries

PURPOSE

To determine if human amniotic membrane transplantation or limbal stem cell transplantation is effective to restore the corneal surface with partial or total limbal stem cell deficiency, respectively, caused by 5-fluorouracil (5-FU) toxicity after glaucoma surgeries.

METHODS

Partial and total limbal stem cell deficiency was confirmed by impression cytology as the cause of reduced vision and corneal surface breakdown in a 69-year-old man and a 67-year-old man, respectively, who both had received a total of 105 mg 5-FU injections. Amniotic membrane transplantation or conjunctival limbal autograft was performed for corneal surface reconstruction, respectively.

RESULTS

For a period of 15 months of follow-up, the visual acuity improved, and their corneal surfaces remained avascular, smooth, and without recurrence of limbal stem cell deficiency.

CONCLUSION

Limbal stem cell deficiency can occur as a late complication for patients receiving 5-FU after glaucoma filtering surgeries. Partial limbal stem cell deficiency can be treated with amniotic membrane transplantation alone, whereas limbal transplantation must be considered as an alternative for total limbal stem cell deficiency to restore the corneal surface integrity and vision.

Autologous limbal transplantation in patients with unilateral corneal stem cell deficiency

AIM

To describe a surgical technique for autologous limbal stem cell transplantation and the outcome of a series of patients with unilateral stem cell deficiency.

METHODS

A report of six consecutive patients who underwent autologous limbal stem cell transplantation is presented. The primary diagnosis included alkali burn (n=3), conjunctival intraepithelial neoplasia (CIN) (n=1), recurrent pterygium (n=1), and contact lens induced keratopathy (n=1). The autologous transplanted tissue consisted of peripheral cornea, limbus, and conjunctiva obtained from the contralateral eye. Three of the above patients underwent penetrating keratoplasty in association with auto-limbal transplantation. A significant modification to established techniques was the close monitoring of conjunctival epithelial migration in the immediate postoperative period. If conjunctival epithelium threatened to migrate on to the corneal surface, it was mechanically removed at the slit lamp and prevented from crossing the limbus. This was required in three patients.

RESULTS

The mean follow up was 18.8 months. The outcome was satisfactory in all cases: a stable corneal surface was restored and there was a substantial improvement in vision and symptoms. One patient had a primary failure of the corneal allograft associated with glaucoma, and 6 months later developed a retinal detachment. No complications were noted in the donor eye with the exception of one patient who developed filamentary keratitis along the edge of the donor site.

CONCLUSION

Autologous limbal transplantation with corneal, limbal, and conjunctival carriers was found to be useful for ocular surface reconstruction, over a mid-term follow up, in patients with unilateral stem cell deficiency. Close monitoring of the migration of conjunctival epithelium in the immediate postoperative period, and preventing it from crossing the limbus, ensured that the corneal surface was re-epithelialised exclusively from epithelial cells derived from the transplanted limbal tissue. This approach should improve the success of this procedure.

Controversies in the management of open-globe injuries involving the posterior segment

There are numerous unresolved issues and controversies regarding the management of open-globe injuries involving the posterior segment. These areas include, but are not limited to, the following issues. Although vitrectomy has been shown to improve visual outcomes and allow retention of the eye in many cases, the extent of visual improvement is often limited because of the nature of the injury. Timing of vitrectomy surgery has been and will continue to be debated by proponents of early versus delayed intervention. The multiple features of acute ocular injury make it very difficult to interpret retrospective data regarding the most appropriate timing for surgical intervention. The use of prophylactic cryotherapy, in the setting of a scleral laceration with possible retinal damage, is not as controversial at present, as there is now sufficient data indicating that cryotherapy may actually exacerbate intraocular proliferation and worsen the situation. The role and benefit of a prophylactic scleral buckle is very widely contested, and it is not known if it truly decreases the risk of subsequent retinal detachment. Another area of debate centers on the use of antibiotics. When there is a known clinical infection, intravitreal antibiotics are the mainstays of therapy. However, in the absence of clinical infection, the use of prophylactic antibiotics and their routes of administration are quite controversial. Although there are significant data regarding the use of antibiotics in the postoperative setting, this information cannot be extrapolated into the setting of open-globe injuries, as organisms and virulence factors differ. Similarly, the use of vitrectomy versus vitreous tap in the setting of traumatic endophthalmitis is not fully resolved, although vitrectomy is used in most cases to repair concurrent damage from the injury itself. Finally, the placement of intraocular lenses in the acute trauma setting is controversial, as the risk of complications is quite high. Prospective, controlled clinical studies have not been done. This article reviews pertinent data regarding these management issues and controversies, and provides recommendations for treatment based on the available published data and the authors' personal experience.

Allo-limbal transplantation in patients with limbal stem cell deficiency

AIM

To report the outcome of a series of patients with stem cell deficiency who underwent allo-limbal transplantation and to describe a technique for this procedure.

METHODS

Six consecutive patients underwent allo-limbal stem cell transplantation. The primary diagnosis included alkali burn (n = 2), trachoma (n = 1), chronic rosacea blepharitis and kerato-conjunctivitis (n = 1), aniridia (n = 1), and Stevens-Johnson syndrome (n = 1). The limbal rim consisted of peripheral cornea and perilimbal sclera. FK-506 was used postoperatively for immunosuppression.

RESULTS

The length of follow up ranged from 3 to 24 months (mean follow up 11.8 (SD 9.3) months). The outcome was considered satisfactory in five of six cases. The corneal surface was completely epithelialised within 2 weeks, and there was a substantial improvement in vision and symptoms. One patient had recurrent epithelial defects related to eyelid abnormalities. No side effects associated with systemic immunosuppression were noted.

CONCLUSION

Allo-limbal transplantation, with systemic immunosuppression with FK-506 is useful in reconstruction of the ocular surface with improvement in vision in patients with severe stem cell deficiency.

Combined surgery for severe eye trauma with extensive iridodialysis, posterior lens dislocation, and intractable glaucoma

A 44-year-old woman sustained a severe left eye contusion from the explosion of a plastic bottle containing fermented orange juice. This resulted in extensive iridodialysis, posterior crystalline lens dislocation, and intractable glaucoma. Eleven days after the injury, combined surgery of trabeculectomy with mitomycin-C, pars plana vitrectomy, lens removal, iridodialysis repair, and scleral-fixated intraocular lens implantation under general anesthesia was performed. Intraocular pressure (IOP) was under control until 5 weeks postoperatively; glaucoma implant surgery was then performed. At the last follow-up 15 months after the combined surgery, best corrected visual acuity was 20/50 and IOP was 15 mm Hg without medication. Combined surgery can be considered a safe, effective option in the management of severe eye trauma in selected cases.

Combined phacoemulsification, pars plana vitrectomy, removal of intraocular foreign body (IOFB), and primary intraocular lens implantation for patients with IOFB and traumatic cataract

PURPOSE AND METHODS

Small-incision cataract extraction by phacoemulsification through an anterior continuous circular capsulorhexis, pars plana vitrectomy, forceps removal of intraocular foreign body (IOFB) and primary intraocular lens implantation were performed in 4 eyes (4 patients) with IOFB and traumatic cataract, as an emergency combined procedure.

RESULTS

At a mean follow-up of 12.3 months (range 7-19 months) the best corrected visual acuity of the 4 eyes ranged from 6/6 to 6/12. The only complication encountered in our series was an opacified posterior capsule that developed 10 months post-operatively in one case. This was easily dealt with by neodymium:YAG laser capsulotomy, with good final visual outcome.

CONCLUSIONS

The results of combined one-stage instead of sequential surgeries, and phacoemulsification instead of lensectomy or extracapsular cataract extraction for patients with IOFB and cataract are encouraging. It could be a good option in selected cases. However, the safety and efficacy of this combined procedure need to be evaluated further by a larger-scale, longer follow-up study.

Simultaneous posterior chamber intraocular lens implant combined with vitreoretinal surgery for intraocular foreign body injuries

To evaluate the safety of simultaneous posterior chamber intraocular lens (IOL) implant combined with complex vitreoretinal surgery for ocular trauma due to intraocular foreign body (IOFB).

METHODS

We undertook a retrospective analysis of 10 patients who had undergone simultaneous cataract extraction, vitreoretinal surgery, removal of IOFB and posterior chamber IOL implant, for ocular trauma due to IOFB. The visual outcome and complications were noted. The surgical procedure is described.

RESULTS

Ten young, male patients were followed for 5-30 months post-operatively. The post-operative visual acuity in the operated eye remained the same or improved as compared with their pre-operative vision. Eight patients had a visual acuity of 6/9 or better. One patient developed post-operative infective endophthalmitis. Three patients had retinal detachment post-operatively. The IOL was stable in all patients.

CONCLUSIONS

Simultaneous posterior chamber IOL implant with vitreoretinal surgery is safe in selected cases of severe ocular trauma due to IOFB. It allows early visual rehabilitation of young, working patients.

Lens preservation after intraocular foreign body injuries

PURPOSE

Ocular missile injuries often involve the lens. Some have suggested that lens capsular violation by a foreign body is an indication for immediate lens removal. Sometimes, however, the resultant lens opacity may remain localized without visual compromise. The authors report a series of patients who had lens capsular disruption from an intraocular foreign body that resulted in visually insignificant lens opacities.

METHODS

A series of five patients with lens capsular disruption as a result of an intraocular foreign body injury were reviewed retrospectively.

RESULTS

All five patients had lens injury from a small foreign body in a peripheral lenticular location. In three patients the foreign body was intralenticular, whereas in the other two patients the foreign body transversed the lens and was located in the posterior segment. In two patients, the foreign body was not removed. Three of the patients required pars plana vitrectomy. In all patients, final visual acuity was at least 20/40, and the lenticular opacity remained localized to an eccentric location.

CONCLUSIONS

A progressive, visually significant cataract is not the inevitable result of lens injury by an intraocular foreign body. When indicated, surgical removal of the foreign body may be attempted using a lens-sparing procedure.