Results of penetrating keratoplasty for pseudophakic bullous keratopathy with the exchange of an intraocular lens

Complications and clinical outcomes of descemet stripping automated endothelial keratoplasty with intraocular lens exchange

PURPOSE

To evaluate complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with intraocular lens (IOL) exchange compared with DSAEK alone.

DESIGN

Retrospective, interventional case series.

METHODS

DSAEK was performed in 19 eyes in which the anterior chamber IOL was exchanged for a posterior chamber IOL (study group) and in 188 eyes in which the posterior chamber IOL was left in place (comparison group). The complications of graft dislocations, primary graft failure episodes, and pupillary block were recorded for all eyes. Six-month best spectacle-corrected visual acuity and mean central endothelial cell density were measured prospectively and then compared with preoperative values for all eyes.

RESULTS

Dislocations occurred in 0 (0%) of 19 eyes in the study group and in 5 (3%) of 188 eyes in the comparison group (P = .47), with 0 primary graft failures and 0 pupillary block episodes in either group. Preoperative mean best spectacle-corrected visual acuity for those eyes without any underlying ocular comorbidities was 20/205 and 20/100 in the study and comparison groups, respectively (P = .18). Mean best spectacle-corrected visual acuity at 6 months improved to 20/48 in the study group and to 20/34 in the comparison group, a statistically significant difference (P = .01). Mean donor cell loss at 6 months was 33% in the study group and 26% in the comparison group (P = .18).

CONCLUSIONS

Concurrent IOL exchange with DSAEK surgery does not increase the dislocation, primary graft failure, or pupillary block rates in the immediate postoperative period. Donor endothelial cell loss in DSAEK was not increased significantly by IOL exchange. Visual acuity was slightly worse after combined surgery than after DSAEK alone.

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.

Pseudophakic corneal edema: A review of mechanisms and treatments

PURPOSE

To review the pathological mechanisms and treatments for pseudophakic corneal edema (PCE), one of the most common indications for penetrating keratoplasty.

METHODS

The literature was examined for the molecular biology associated with PCE and for the surgical and medical treatments for this disorder.

RESULTS

The incidence of PCE has recently been decreasing because of improved surgical instrumentation, including improvements in intraocular lens designs that cause less trauma to the corneal endothelium. Extracellular matrix and growth factor abnormalities occur in PCE corneas and recently, the role of aquaporins, which are involved in the regulation of fluid movement across cells, has been investigated.

CONCLUSIONS

Although newer treatment options have been suggested, penetrating keratoplasty still remains the most definitive treatment and has the highest success rate.

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

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

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

In a retrospective study, the authors analyzed visual results and postoperative complications in a series of 14 consecutive patients who had undergone penetrating keratoplasty and implantation of a posterior chamber intraocular lens (PC IOL) in the absence of the posterior capsule. Seven patients suffered from aphakic bullous keratopathy and seven from pseudophakic bullous keratopathy. Postoperative follow-up was 7.6 months on the average. Best-corrected postoperative visual acuity was 20/60 or better in four cases and 20/200 or better in eight. Glaucoma was present before surgery in four eyes, which persisted in all cases and developed in four new cases. Results of gonioscopic examination showed the postoperative development of goniosynechiae in four eyes. Pseudophakodonesis of various extent was present in ten eyes. Preoperatively, cystoid macular edema was diagnosed angiographically in one case. It did not improve after surgery and was seen in three additional eyes postoperatively. Causes for postoperative visual acuity lower than 20/200 were cystoid macular edema in three cases, graft rejection in one case, central retinal scar in one case, and optic nerve atrophy in one case. A distortion of the pupil was seen in three eyes in miosis and in four additional eyes in mydriasis. Corneal thickness as well as anterior chamber depth were within normal limits. Fluorophotometric evaluation of the blood-aqueous barrier showed values comparable with those obtained after intracapsular cataract extraction and implantation of an iris-fixated IOL. Despite the relatively good visual results, the high postoperative incidence of cystoid macular edema and/or glaucoma may discourage the use of this technique.