Penetrating keratoplasty and Artisan iris-fixated intraocular lens implantation in the management of aphakic bullous keratopathy

Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens

Purpose

To assess the incidence of glaucoma after combined Descemet's stripping endothelial keratoplasty (DSEK) and retropupillary fixated iris-claw intraocular lens (IOL) implantation in the patients with bullous keratopathy (BK) who required secondary IOL or IOL exchange.

Methods

In this retrospective case series, medical records of 22 patients who underwent combined DSEK and retropupillary fixated iris-claw IOL implantation were evaluated. Preoperative vision, intraocular pressure (IOP), postoperative IOP at different time periods, and intraoperative and postoperative complications were analyzed.

Results

A total of 22 eyes of 22 patients (7 females and 15 males) were analyzed. The median age was 62 years, and the median duration of the postoperative follow-up was 106.5 days. The corrected distance visual acuity improved from a median of 1.85 logMAR to 1.68 logMAR. None of the patients had intraoperative complications. Three patients (13.6%) had dislocation of the donor tissue on the 1^st postoperative day and were successfully rebubbled. Six eyes (27.3%) had graft failure and required penetrating keratoplasty. Eleven eyes (50%) had a sustained rise in the IOP, of which 2 (9.09%) had ocular hypertension and 9 eyes (40.9%) progressed to glaucoma.

Conclusions

DSEK combined with retropupillary fixated iris-claw lens is a good surgical option for the management of aphakic/pseudophakic BK in patients who require secondary IOL or IOL exchange. Regular IOP monitoring after the surgery is an essential, as there is a risk of IOP rise and glaucoma in the postoperative period. Clinicians should be vigilant and control the IOP to prevent glaucoma progression.

Iris-Claw Intraocular Lens Implantation in Various Clinical Indications: A 4-Year Study

An iris-claw intraocular lens (IOL) has been widely used as a secondary implant in aphakic patients. The study presents the results of implanting the anterior chamber iris-claw Artisan IOL in cases of where an appropriate posterior capsular support is lacking. The study included 132 patients subjected to primary IOL implantation during complicated cataract surgery with damage to the posterior capsule (I), secondary implantation in aphakia (II), secondary implantation during penetrating keratoplasty (III), and secondary implantation during pars plana vitrectomy with luxated IOL extraction (IV). We analyzed the records of best-corrected visual acuity (BCVA), spherical equivalent (SE), intraocular pressure (IOP), and corneal endothelial cell count (cECC), taken before and 1, 2, 3, and 4 years after the surgery. BCVA depended on the time after IOL implantation and the primary indication. Four years post-surgery, the SE values were the lowest in group III. IOP was the same in all groups both before and after the surgery, but 4 years after the surgery IOP values in group IV were higher than in group III. The cECC decreased every year after the surgery in all groups, but four years after the IOL implantation, the lowest cECC values were observed in group IV. At the same time, all groups of patients showed improved BCVA, stable refraction, and a low percentage of postoperative complications.

Penetrating Keratoplasty With Sutureless Intrasclerally Fixated Intraocular Lens

OBJECTIVES

In this retrospective study, we reviewed the use of penetrating keratoplasty with sutureless intrasclerally fixated intraocular lens implantation in a closed anterior chamber in patients with several corneal pathologies and aphakia.

MATERIALS AND METHODS

The medical records of 6 patients, who underwent the procedure, were reviewed. In the procedure, lamellar scleral tunnels at the 2- and 8-o'clock positions were created with a microvitreoretinal blade, 1.5 mm away from the limbus. Two 27-gauge bent needles were passed, first horizontally, through these tunnels, and then vertically, which allowed them to enter the posterior chamber and to be left in position. Partial thickness trephination was made, and anterior stroma was removed where necessary. An incision was made at the 11-o'clock position, where the trephination was made, which was then extended to both sides for about 6 mm with corneal scissors. From the superior incision, the anterior haptic of a 3-piece intraocular lens was pushed through the needle at the 2-o'clock position, then the posterior haptic was pushed through the needle at the 8-o'clock position, and both haptics were removed through the sclera. Both ends were cauterized and placed into the sclera. Residual stroma was removed, and the donor graft was sutured.

RESULTS

At the last follow-up visit, the mean bestcorrected visual acuity was significantly increased. No serious complications were seen, with the exception of increased intraocular pressure in 3 patients.

CONCLUSIONS

Penetrating keratoplasty with sutureless intrasclerally fixated intraocular lens implantation can be used safely in patients with aphakia. With this technique, the globe stabilization can be maintained, and the trauma to the donor graft endothelium can be minimized.

Anterior-segment optical coherence tomography investigation of corneal deturgescence and epithelial remodeling after DSAEK

PURPOSE

The aim of this study was to evaluate via Fourier-domain anterior-segment optical coherence tomography 3-dimensional corneal, epithelial, and graft thickness changes after Descemet stripping automated endothelial keratoplasty (DSAEK).

METHODS

Sixteen eyes were investigated preoperatively and up to 6 months postoperatively for preoperative and postoperative central corneal thickness (CCT), minimum corneal thickness, central graft thickness (CGT), and for epithelial topographic thickness variability. An age-matched and gender-matched control group of 32 healthy eyes was used for comparison.

RESULTS

In the DSAEK group, the preoperative CCT was 582.32 ± 45.24 (550-615) μm. One-month postoperatively, the CCT was 736.26 ± 34.52 (713-771) μm, and the CGT was 210.42 ± 34.52 (145-243) μm. Three months postoperatively, the CCT was 641.39 ± 38.75 (569-684) μm, and the CGT was 171.23 ± 27.54 (119-185) μm. The preoperative center epithelial thickness was 55.74 ± 9.29 (45-74) μm, the minimum was 32.53 ± 14.30 (13-53) μm, the maximum was 76.00 ± 11.32 (64-105) μm, and the topographic thickness variability was 10.84 ± 4.09 (5.90-18.80) μm. Three months postoperatively, the center epithelial thickness was 47.21 ± 5.45 (43-56) μm, the minimum was 35.11 ± 4.70 (30-41) μm, the maximum was 58.11 ± 6.51 (49-65) μm, and the topographic variability was 4.77 ± 1.48 (2.90-6.50) μm. The average differences were -8.53, +4.53, and -17.89 μm for the center, minimum, and maximum (P < 0.001, <0.001, and <0.001). Similar results were obtained 3 and 6 months postoperatively.

CONCLUSIONS

We present a near-term postoperative investigation of the corneal and epithelial thickness changes after DSAEK for bullous keratopathy, by in vivo, clinical anterior-segment optical coherence tomography. Epithelial thickness recovery and normalization and corneal deturgescence were noted as early as in the first postoperative month.

Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty

BACKGROUND

To evaluate the indication, visual outcome, and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL) during penetrating keratoplasty.

METHODS

This retrospective study comprised 23 eyes (23 patients) without adequate capsule support undergoing posterior iris-claw aphakic IOL implantation (Verisyse/Artisan) during penetrating keratoplasty between 2005 and 2010. Mean follow-up was 18 months (range from 12 to 37 months).

RESULTS

The IOLs were inserted during an IOL exchange in 17 eyes and as a secondary procedure in six aphakic eyes. Pseudophakic bullous keratopathy with corneal scar after anterior chamber intraocular lens (ACIOL) was the main indication for penetrating keratoplasty in 16 eyes (69.6 %). The final corrected distance visual acuity (CDVA) in logMAR (mean 1.0 ± 0.46) improved significantly (p < 0.05) compared to the preoperative CDVA (mean 1.8 ± 0.73). Twenty eyes (86.9 %) had a final visual acuity in logMAR better than the pre-operative CDVA. The mean postoperative IOP 16.3 mmHg ± 4.0 was not significantly (p > 0.05) higher compared to the preoperative IOP 15.6 mmHg ± 5.1. Complications included slight temporary pupil ovalization in three eyes (13.0 %) and iris-claw IOL sublocation in three eyes (13.0 %); all IOLs could be easily repositioned. Cystoid macular edema occured in one eye (4.3 %) 8 weeks after primary surgery. All grafts remained clear without any sign of graft rejection.

CONCLUSIONS

Retropupillar iris-claw IOL during penetrating keratoplasty provides good visual outcomes with a favorable complication rate, and can be used for a wide range of indications in eyes without adequate capsule support.

Three-year follow-up of secondary anterior iris fixation of an aphakic intraocular lens to correct aphakia

PURPOSE

To evaluate the efficacy, predictability, stability, safety, and complications of secondary anterior iris fixation of the Artisan iris-fixated intraocular lens (IOL) to correct aphakia in eyes without sufficient capsule support.

SETTING

Department of Ophthalmology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China.

DESIGN

Cohort study.

METHODS

Eyes having implantation of aphakic iris-fixated IOLs for aphakia correction were followed for 3 years.

RESULTS

The study evaluated 72 eyes (72 patients). After 3 years, the uncorrected distance visual acuity improved in all eyes (P<.05); 53 eyes (73.6%) reached 20/40 or better. Two eyes had a postoperative corrected distance visual acuity (CDVA) worse than the preoperative CDVA due to postoperative ischemic optic neuropathy and retinal detachment, respectively. The mean spherical equivalent (SE) decreased from 11.65 diopters (D) ± 1.21 (SD) to -0.58 ± 0.56 D (P<.05); the SE at the last follow-up was within ±1.00 D of the target refraction in 63 eyes (87.5%). The mean endothelial cell loss 3 years postoperatively was 9.78%. There was no significant postoperative intraocular pressure increase throughout the follow-up. Twelve patients (16.7%) reported glare and halos during night driving. Iris pigment precipitates on the IOLs occurred in 4 eyes (5.6%) 3 years postoperatively. No other serious complications occurred.

CONCLUSIONS

Three-year results indicate that secondary implantation of aphakic IOLs is effective, predictable, and safe for the correction of aphakia in eyes without capsule support. However, longer follow-up with a larger cohort is necessary to confirm these conclusions.

Scleral fixation of intraocular lenses combined with penetrating keratoplasty

I describe a technique for transscleral fixation of a posterior chamber intraocular lens (PC IOL) combined with penetrating keratoplasty. Partial-thickness trephination of the cornea is followed by full-thickness penetration of the anterior chamber at 12 o'clock and 6 o'clock through 5.5 and 2.0mm incisions, respectively. Scleral fixation of a PC IOL is performed through the incisions under a closed chamber followed by replacement of the diseased graft with a donor button. The results in 5 eyes of 5 patients with aphakic bullous keratopathy and lack of capsule support are reported.

Secondary iris claw intraocular lens implantation for the correction of aphakia after pars plana vitrectomy

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of iris claw intraocular lens implantation for correction of aphakia in vitrectomized eyes without capsular support.

METHODS

This was a prospective interventional case series. Twelve aphakic vitrectomized eyes without capsular support underwent iris claw intraocular lens implantation. The main outcome measures were changes in uncorrected visual acuity, best-corrected visual acuity, spheric equivalent, corneal endothelial cell density, corneal thickness, central macular thickness, and complications.

RESULTS

Mean follow-up was 15.58 +/- 3.80 months with no intraoperative complications. Postoperatively, uncorrected visual acuity increased significantly at all follow-up visits (P < 0.05). Mean best-corrected visual acuity increased 10 letters/2 lines at the final follow-up visit (P = 0.023). Mean postoperative spheric equivalent at the last visit was -1.68 +/- 063 D, and the spheric equivalent was within +/-2.00 D of emmetropia in 9 (75%) eyes. Mean central macular thickness increased only at postoperative Month 3 (P = 0.043). Mean endothelial cell density loss was 23.87% at the last visit. Mean corneal thickness did not change during follow-up (P > 0.05). No corneal edema was observed. Complications were transient intraocular pressure increase (n = 1), cystoid macular edema (n = 1), and haptic dislocation replaced by surgery (n = 1). Retinas remained attached in all eyes.

CONCLUSION

Secondary iris claw intraocular lens implantation is clinically safe and effective to correct aphakia in vitrectomized eyes without capsular support. Larger studies with longer follow-up are warranted.

Artisan iris-fixated toric phakic and aphakic intraocular lens implantation for the correction of astigmatic refractive error after radial keratotomy

We report 2 patients who had radial keratotomy (RK) to correct myopia. The first patient developed a postoperative hyperopic shift and cataract. Nine years post RK, she had intracapsular cataract extraction and implantation of an Artisan aphakic intraocular lens (IOL). Twenty years post RK, hyperopia and astigmatism progressed to +7.0 -5.75 x 100 with a best corrected visual acuity (BCVA) of 20/20. Due to contact lens intolerance, the Artisan aphakic IOL was exchanged for an Artisan toric aphakic IOL. Three months later, the BCVA was 20/20 with +1.0 -0.50 x 130. The second patient demonstrated residual myopic astigmatism 6 years after bilateral RK and had become contact-lens intolerant. An Artisan toric phakic IOL was implanted in both eyes. Four months later, the BCVA was 20/25 with a refraction of +0.25 -1.0 x 135 and 20/20 with a refraction of -1.0 x 40. Both patients were satisfied with the visual outcomes.

Ultrasound biomicroscopy study of the Verisyse aphakic intraocular lens combined with penetrating keratoplasty in pseudophakic bullous keratopathy

PURPOSE

To evaluate anterior segment modifications after penetrating keratoplasty (PKP), previous anterior chamber intraocular lens (IOL) removal, and Verisyse IOL (AMO) implantation over the iris or under the iris for the treatment of pseudophakic bullous keratopathy (PBK) using ultrasound biomicroscopy.

SETTING

Department of Ophthalmology, Poitiers University Hospital, Poitiers, France.

METHODS

A prospective randomized comparative case series included 27 patients (27 eyes) with PBK who had PKP and implantation of a Verisyse VRSA54 aphakic IOL. The IOL was implanted over the iris in 13 patients (Group A) and under the iris in a reversed position in 14 patients (Group B). Ultrasound biomicroscopy scans 6 months after surgery measured central anterior chamber depth (ACD), iris thickness (IT), distance of the haptics from the corneal endothelium (CED), distance of the haptics from the ciliary body (CBD), angle opening distance (AOD) 500 mum from the scleral spur (AOD500) and the iridocorneal angle theta on the 4 o'clock meridian lines (AOD3; AOD9; AOD12; AOD6/theta12, theta6, theta3, theta9).

RESULTS

No significant difference was found in IT, CBD, or AOD12 between Group A and Group B (P >.05). In Group B, the mean ACD was deeper by approximately 55% (P = .008); CED3 was larger by 69% (P = .0162), CED9 by 80% (P = .0128), AOD3 by 57% (P = .0309), AOD9 by 140% (P = .0057), and AOD6 by 44% (P = .0399); and theta3 was wider by 52% (P = .046), theta9 by 123% (P = .0068), theta12 by 50% (P = .0492), and theta6 by 81% (P = .0237).

CONCLUSION

Ultrasound biomicroscopy showed that in eyes that had PKP with Verisyse IOL enclavation to the posterior plane of the iris, which involved posterior translation of the iridal plane, the ACD was significantly deeper and the CED and AOD were significantly larger than in eyes with anterior enclavation of the IOL.

Long-Term Follow-Up of the Corneal Endothelium After Artisan Lens Implantation for Unilateral Traumatic and Unilateral Congenital Cataract in Children

PURPOSE

To retrospectively estimate the long-term corneal endothelial cell loss in children after perforating corneal trauma and implantation of an iris-fixated anterior-chamber intraocular lens (IOL), either the Artisan aphakia lens or the Artificial Iris Implant, and to compare this corneal endothelial cell loss to that in children who received an Artisan aphakia lens to correct aphakia after cataract extraction for unilateral congenital cataract.

METHODS

A retrospective study was performed, evaluating the charts and endothelial photographs of 6 patients with unilateral traumatic cataract, with a mean age at IOL implantation of 9.5 years (range: 5.8-12.8 years) and a mean follow-up after IOL implantation of 10.5 years (range: 8.0-14.7 years), and of 3 children who were operated on for unilateral congenital cataract at a mean age of 2.7 years and who received an Artisan aphakia IOL, with a mean follow-up after IOL implantation of 9.5 years (range: 4.7-14.5 years). Parameters that were studied were central endothelial cell density (CECD) in both the operated and the normal eye at the last follow-up visit, percentage of cell loss in the operated eye compared with the normal eye, and length and location of the corneal scar in the injured eye.

RESULTS

: In the traumatic cataract group, CECD was, on average, 41% (range: 22%-58%) lower in the operated eye (1.647 +/- 322 [SD] cells/mm) than the normal eye (2.799 +/- 133 cells/mm). A significant negative linear correlation was found between the length of the corneal perforation scar and CECD. In the congenital cataract group, no statistical difference in CECD was found between the operated (3.323 +/- 410 cells/mm) and the unoperated (3.165 +/- 205 cells/mm) eye.

CONCLUSION

Endothelial cell loss 10.5 years after iris-fixated IOL implantation for traumatic cataract was substantial and related to the length of the corneal scar of the original trauma. In children operated on for congenital cataract, no difference was found in CECD in the operated and unoperated eyes 9.5 years after Artisan aphakia IOL implantation.

Phakic intraocular lenses

PURPOSE OF REVIEW

Laser in-situ keratomileusis has been tremendously successful in treating patients with mild and moderate ametropias. For patients with high degrees of refractive error, however, phakic intraocular lenses provide superior quality of vision without the risk of corneal ectasia. Early international results, as well as United States Food and Drug Administration clinical trials, have demonstrated the early safety and efficacy of phakic intraocular lenses. Nevertheless, long-term corneal endothelium cell density and crystalline lens clarity remain a concern.

RECENT FINDINGS

Several new studies demonstrate the superior visual outcomes of phakic intraocular lenses over laser in-situ keratomileusis in patients with moderate and high myopia, particularly in the areas of visual quality and contrast sensitivity. New anterior segment imaging and measurement technologies have provided valuable information about in-vivo structure and function, with and without phakic lens implants. More is being learned about long-term endothelial cell stability and cataract formation, particularly in relation to implant positioning. New applications of phakic intraocular lenses in presbyopia and in other conditions are being explored.

SUMMARY

Once plagued by complications and marginal outcomes, improved designs of phakic intraocular lenses are providing increasing safety and efficacy for the correction of severe ametropias. Long-term concerns with endothelial cell loss remain, but recent data suggest stabilization with time. Proper sizing and positioning are important and increasingly achievable with new imaging modalities. With continued research and experience, phakic intraocular lenses are becoming an invaluable addition to the mainstream refractive surgery armamentarium.

Implantation of Verisyse Phakic Intraocular Lens to Correct Myopic Refractive Error After Penetrating Keratoplasty in Pseudophakic Eyes

PURPOSE

We report 2 cases in which a Verisyse phakic intraocular lens (PIOL) was used to successfully treat high myopia after penetrating keratoplasty (PK) in pseudophakic patients.

METHODS

Case 1 involved a 69-year-old pseudophakic man with a manifest refraction (MR) of -6.50 + 1.75 x 048 and a best spectacle corrected visual acuity (BSCVA) of 20/40 approximately 16 months after PK in the right eye. Case 2 was a 78-year-old pseudophakic man who had an MR of -9.00 + 5.75 x 132 with a BSCVA of 20/100 approximately 24 months after PK in the left eye.

RESULTS

In case 1, 10 months after Verisyse PIOL implantation, the MR was pl +2.00 x 135 with a BSCVA of 20/30. Endothelial cell density (ECD) in this patient decreased from 1926.1 to 815.3 cells/mm over 17 months. In case 2, 24 months after Verisyse PIOL implantation, the MR was -3.25 + 3.50 x 105 with a BSCVA of 20/60. ECD in this patient decreased from 2108.4 to 753.8 cells/mm in 30 months.

CONCLUSION

The Verisyse PIOL may provide an alternative method to correct high myopia for anisometropia in pseudophakic patients after PK. In this report, PIOL implantation was associated with a decrease in ECD. Further studies are required to determine the long-term effects and ultimate safety of PIOL placement on the integrity of the cornea endothelium after corneal transplant in pseudophakic patients.

Penetrating keratoplasty combined with posterior Artisan® iris-fixated intraocular lens implantation

PURPOSE

To present a new surgical technique combining penetrating keratoplasty and open-sky posterior iris fixation of the Artisan iris-claw intraocular lens (IOL) for treatment of pseudophakic bullous keratopathy in a case series of five patients.

METHODS

A graft diameter of 8.25 mm was chosen. The formerly implanted angle-supported IOL was removed. The IOL was enclosed, entrapping a fraction of the mid-peripheral iris within the haptics whilst being held firmly with the implantation forceps. The corneal button was sutured to the recipient bed with 10-0 nylon sutures. A specular microscope was used for making an endothelial cell count. Patients underwent an ultrasound biomicroscope (UBM) scan before and 6 months after surgery and postoperative macular oedema was assessed by optical coherence tomography (OCT). The minimum follow-up was 12 months.

RESULTS

Visual acuity (VA) improved in all five cases (mean best corrected VA was 0.4 postoperatively versus 1.28 preoperatively). No complications were noted. The mean endothelial cell density obtained after 1 year was 1508 cells/mm(2). The UBM study showed a deep anterior chamber and an open iridocorneal angle of 360 degrees in all cases.

CONCLUSION

The implantation of the Artisan device behind the iris better preserves the anatomy of the anterior segment with respect to the iridocorneal angle.