Late-onset secondary pigmentary glaucoma following foldable intraocular lenses implantation in the ciliary sulcus: a long-term follow-up study

Single-piece Foldable Intraocular Lenses versus Three-piece Intraocular Lenses in the Sulcus following Posterior Capsular Rupture in a Philippine Tertiary Hospital

Objective

Successful intraocular lens (IOL) placement in cataract surgery is synonymous with the IOL being placed in the capsular bag. When the capsular bag is violated, the ciliary sulcus becomes an option to approximate an in- the-bag position. Studies report that single-piece foldable acrylic (SPA) IOLs are a poor choice for the sulcus. This study aimed to report the visual outcomes and complications of sulcus placement of single-piece intraocular lenses and three-piece intraocular lenses, and compare the design and characteristics to the occurrences of complications.

Methods

The medical records of patients were retrospectively reviewed in a single center from 2016-2019.

Results

A total of 245 eyes from 237 patients were included in the study with a mean age of 61 years and male predominance. Majority of sulcus implantation occurred during phacoemulsification (87%). Around 82% (n=202) were implanted with single-piece IOLs and 18% (n=43) were three-piece IOLs. Best corrected distance visual acuity (BCDVA) was 20/20 after six months for both groups. Comparison between two groups showed no superiority with each other. Complications notable were elevated intraocular pressure, corneal edema, loss of IOL centration, and pigment dispersion. Smaller optic diameter and overall length predispose to higher probabilities of loss of centration. Pliability, hydrophobicity/hydrophilicity, and material do not correlate with postoperative complications. There were significantly higher numbers of pigment dispersions in IOLs with square-edged design.

Conclusions

In conclusion, visual outcomes remain equally excellent for both single-piece and three-piece groups. In contrast, there were more notable complications in single-piece group. Loss of centration tends to occur more with mean optic diameters lower than or equal to 5.50 mm and an overall length of less than 12.50 mm or lower. While appropriate for the capsular bag, square-edged designs were found to be inappropriate for the sulcus. The retrospective design does not allow strong inferences hence caution should be taken in correlating results.

Impact of scleral tunnel length on the position of intraocular lenses in flanged intrascleral haptic fixation

PURPOSE

To investigate the effect of scleral tunnel length on the effective lens position and tilt of the intraocular lens (IOL) in flanged intrascleral haptic fixation (ISHF) using anterior segment optical coherence tomography (AS-OCT).

SETTING

Tertiary institution.

DESIGN

Retrospective case-control study.

METHODS

This study included 55 and 42 eyes that underwent ISHF with 1.0 and 2.0 mm scleral tunnels, respectively. 23 eyes that underwent sutured fixation were used as a control. The anterior chamber depth (ACD), scleral tunnel length, incident angle of haptic, and tilting of optic were analyzed using AS-OCT.

RESULTS

The mean postoperative ACD, vertical tilt angle, and spherical equivalent of the 1.0 mm were 5.27 ± 0.39 mm, 6.04 ± 4.87 degrees, and 0.38 ± 1.03 diopters, respectively. The ACD and vertical tilt angle of the 1.0 mm were larger than those of the others ( P < .001 and P < .05, respectively), and the postoperative spherical equivalent was more hyperopic ( P < .05). The 2.0 mm exhibited a lower frequency of tilting greater than 7 degrees. The intereye difference in ACD between in-the-bag fixation and ISHF of the 1.0 mm tunnel was significantly greater than that in the 2.0 mm tunnel ( P < .05). The 1.0 mm tunnel had a significantly larger incident angle and a longer tunnel length ( P < .001, respectively) and showed a greater difference in the tunnel length on both sides ( P < .05).

CONCLUSIONS

A shorter tunnel yielded a more unstable IOL position, greater variation in angle and tunnel length, and longer ACD during ISHF. An exact 2.0 mm tunnel must be created on both sides to achieve a stable and predictable IOL position.

Timing of Diagnosis and Treatment of Glaucoma following Infantile Cataract Surgery

PURPOSE

To report timing of diagnosis and treatment of glaucoma following cataract surgery (GFCS) in a large cohort of infants undergoing cataract surgery at a tertiary care center.

STUDY DESIGN

Cross-sectional study.

PARTICIPANTS

All consecutive infants that underwent cataract surgery over a 30-year period from January 1991 to December 2021 were included if they had at least 1 year follow-up.

METHODS

The data collection included age at time of cataract surgery, presence of associated ocular or systemic conditions, age at diagnosis of GFCS, and treatment required to control GFCS. Glaucoma diagnosis required intraocular pressure (IOP) > 21 mmHg on > 2 visits with glaucomatous optic nerve head changes and/or visual field changes, or in young children, other anatomic changes such as corneal enlargement or haze or accelerated axial elongation and myopic shift.

MAIN OUTCOME MEASURES

The incidence of GFCS was calculated. Linear regression was performed to assess the effect of age at time of cataract surgery. Analysis of risk factors and treatment modalities was performed using univariate and multivariate analysis.

RESULTS

Three hundred eighty-three eyes (260 patients) were analyzed. Median age at surgery was 52 days and median follow-up, 8 years. Glaucoma following cataract surgery was noted in 27% (104/383 eyes; median age at surgery, 45 days; median follow-up, 13 years.) Young age at surgery (< 3 months) was the greatest risk factor (P = 0.001) but the incidence was similar for infants operated in the first, second, or third month of life (25%, 36%, 40%, respectively, P = 0.4). Microcornea (41%, P < 0.0001), poorly dilating pupils (25%, P = 0.001), persistent fetal vasculature (PFV, 13%; P = 0.8), or anterior segment dysgenesis (3%, P = 0.02) were considered as additional risk factors. Surgical intervention was needed for 73% (24/33) eyes with early-onset GFCS compared with 14% (10/71) eyes with later-later onset GFCS (P < 0.0001). Medical treatment was effective in 86% with later-onset GFCS (P = 0.006).

CONCLUSIONS

The incidence of GFCS was 27%, and timing of diagnosis occurred in a bimodal fashion. Early-onset GFCS usually requires surgical intervention; medical treatment is effective for later-onset GFCS. Cataract surgery within the first 3 months of life, microcornea, and poorly dilating pupils were major risk factors.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Meta-Analysis of the Comprehensive Efficacy of Intraocular Lens Implantation in Glaucoma Patients

This study is aimed at investigating the efficacy of intraocular lens (IOL) implantation in patients suffering from glaucoma through meta-analysis of the previously published research. For this purpose, different literature databases were searched for identification of clinical studies published between January 2000 and January 2022 on evaluating IOL's efficacy in treating glaucoma. RevMan 5.3 was used to conduct a meta-analysis of the pertinent data. The central anterior chamber depth (ACD), corneal endothelial cell counts, best-corrected visual acuity (BCVA), intraocular pressure (IOP), anti-glaucoma medications (AGM), and axial length (AL) changes were compared, and the incidence of postoperative complications was thoroughly evaluated. The Cochran chi-square test was used to examine the heterogeneity of the evaluation results. According to the inclusion and exclusion criteria, 20 studies included 948 glaucomatous eyes. IOP was significantly lower than before treatment (MD = 8.64, 95 CI: 5.75-11.53; Z = 5.86, P < 0.0001), while ACD increased significantly (MD = -1.38, 95 percent CI: -1.74-1.02; Z = 7.49, P < 0.0001). The corneal endothelial cell counts were homogeneous (MD = 225.08, 95% CI: -64.17 to -514.33; Z = 1.53, P = 0.20). AGM utilisation decreased (MD = 1.43, 95% CI: 0.752.12, Z = 4.09, P < 0.0001). AL decreased significantly (MD = 0.31; 95% CI: 0.09-0.54; Z = 2.71; P = 0.007). The incidence of complications remained insignificant after IOL treatment (OR = 1.05, 95% CI: 0.42 to 2.60; Z = 0.10, P = 0.92; P = 0.92). These findings indicate that IOL treatment can significantly reduce intraocular pressure, glaucoma drug use, and aqueous level (AL) in glaucoma patients while increasing the depth of the central anterior chamber. This study offers a theoretical foundation for selecting glaucoma treatment methods.

Self-identified Black Race as a Risk Factor for Intraocular Pressure Elevation and Iritis Following Prophylactic Laser Peripheral Iridotomy

PRCIS

In primary angle closure suspects (PACS), self-identified Black race was a risk factor for intraocular pressure (IOP) elevation and iritis following laser peripheral iridotomy (LPI). Laser type was not associated with either immediate post-LPI IOP elevation or iritis in multivariate analysis.

PURPOSE

The aim was to determine the impact of laser type and patient characteristics on the incidence of IOP elevation and iritis after LPI in PACS.

MATERIALS AND METHODS

The electronic medical records of 1485 PACS (2407 eyes) who underwent either neodymium-doped yttrium-aluminum-garnet or sequential argon and neodymium-doped yttrium-aluminum-garnet LPI at the University of Pennsylvania between 2010 and 2018 were retrospectively reviewed. Average IOP within 30 days before LPI (baseline IOP), post-LPI IOP within 1 hour, laser type, laser energy, and the incidence of new iritis within 30 days following the procedure were collected. Multivariate logistic regression accounting for intereye correlation was used to assess factors associated with incidence of post-LPI IOP elevation and iritis, adjusted by age, sex, surgeon, and histories of autoimmune disease, diabetes, and hypertension.

RESULTS

The incidence of post-LPI IOP elevation and iritis were 9.3% (95% confidence interval: 8.1%-10.5%) and 2.6% (95% CI: 1.9%-3.2%), respectively. In multivariate analysis, self-identified Black race was a risk factor for both IOP elevation [odds ratio (OR): 2.08 compared with White; P=0.002] and iritis (OR: 5.07; P<0.001). Higher baseline IOP was associated with increased risk for post-LPI IOP elevation (OR: 1.19; P<0.001). Laser type and energy were not associated with either post-LPI IOP elevation or iritis (P>0.11 for all).

CONCLUSIONS

The incidence of immediate IOP elevation and iritis following prophylactic LPI was higher in Black patients independent of laser type and energy. Heightened vigilance and increased medication management before and after the procedure are suggested to help mitigate these risks.

Reopening the severely contracted lens capsular bag post-phacovitrectomy by injecting OVD and removing the fibrous membranous material

Implantation of an intraocular lens (IOL) after combined vitrectomy and cataract surgery is usually required to reduce postoperative refraction errors. However, because of the severe fibrosis of the anterior capsule and the adhesion between the anterior and posterior capsules, it is difficult to reopen the capsular bag to complete the secondary IOL implantation. In this study, a surgical approach is described for reopening the severe adhesion between capsules and removing the significant fibroproliferative membranous material by injecting ophthalmic viscosurgical device into the periphery of the capsular bag to separate the anterior and posterior capsules. The IOL was implanted into the capsular bag without any zonular rupture or posterior capsule tear. The position of the IOL was stable during postoperative follow-up up to 3 months. This procedure to open a severely fibrosis capsule was safe and effective.

A Case of Repeating Transient Increase in Intraocular Pressure by Instability of an Intraocular Lens Implanted in the Capsular Bag

We observed repeated episodes of rapid increases in intraocular pressure (IOP) considered to be caused by an in-the-bag intraocular lens (IOL) instability in a patient with an implanted IOL. As acute glaucoma attack-like increase in IOP was noted in the left eye on November 8, she was admitted to Wakayama Medical University Hospital. The findings at the first examination included an IOP of 62 mm Hg, instability of a PMMA one-piece IOL, shallow anterior chamber, narrow angle, moderate mydriasis, and loss of pupillary light reaction in the left avitreous eye. On November 15, a 6-mm Hg increase in IOP was observed during 60-min dark room prone provocative testing. After the first examination, the patient perceived pain and reduced visual acuity of the left eye and emergently consulted our hospital twice. Despite miosis, normalization of the anterior chamber depth and IOP with widening of the angle were achieved by resting in the supine position. These episodes were thought to be caused by instability and anterior shift of the IOL. On January 17, 2018, suture fixation of the in-the-bag IOL was performed. The IOL was fixed by transscleral suturing of the bilateral supporting parts to the sclera. Recurrence of sudden ophthalmalgia, instability of the in-the-bag IOL, and an increase in IOP have not been observed for 1 year after surgical treatment. Instability of an in-the-bag IOL caused repeated acute angle-closure glaucoma-like attacks. The situation was well treated by suturing and fixing the haptics of IOL to the sclera.

Residual Iris Retraction Syndrome After Artificial Iris Implantation

PURPOSE

To evaluate the effect of an artificial iris implant on the remnant iris.

DESIGN

Interventional case series.

METHODS

Setting: Single center.

PATIENT POPULATION

Forty-two consecutive patients.

OBSERVATION PROCEDURES

Morphologic evaluation over 24 ± 14 months.

MAIN OUTCOME MEASURES

Remnant pupillary aperture, iris color, visual acuity, intraocular pressure, and endothelial cell count.

RESULTS

In 7 of 42 cases (16.7%), the residual iris aperture dilated from 36.6 ± 15.4 mm² preoperatively to 61.1 ± 12.5 mm² 1 year postoperatively (66.9% increase). In 5 of 7 affected eyes the artificial iris had been implanted into the ciliary sulcus; in 2 eyes it had been sutured to the sclera. Four of the 7 patients presented with remarkable complications: 2 eyes needed glaucoma shunt surgeries owing to pigment dispersion; 1 suffered from recurrent bleedings; and in 1 case artificial iris explantation was performed owing to chronic inflammation. Anterior chamber depth and angle, endothelial cell count, and visual acuity did not change in this cohort. Changes in color were not observed in the remnant iris.

CONCLUSIONS

The implantation of an artificial iris prosthesis can lead to a residual iris retraction syndrome. It is likely that residual iris is trapped in the fissure between the artificial iris and the anterior chamber angle, preventing further pupil constriction. Another possibility could be a constriction or atrophy of the residual iris. A scleral-sutured implant and an implantation in the capsular bag were both found to prevent the iris retraction. The study group number is inadequate to allow statistical comparison of these different implantation methods. As the use of artificial irises increases, we may expect more patients with iris retraction syndrome in the future.

Case report of secondary pigment dispersion glaucoma, recurrent uveitis and cystoid macular oedema following inadvertent implantation of an intraocular lens into the ciliary sulcus following cataract surgery

Background

This case highlights the important sequelae that can occur following the inadvertent implantation of a single-piece intraocular lens into the ciliary sulcus during cataract surgery; secondary pigment dispersion glaucoma, recurrent anterior uveitis and macular oedema.

Case presentation

A 67-year-old lady underwent routine left cataract surgery in a separate unit but subsequently attended our eye casualty with recurrent hypertensive anterior uveitis. She was found to have secondary pigment dispersion glaucoma as the intraocular lens had been inadvertently placed into the ciliary sulcus. She underwent a trabeculectomy to control the intraocular pressure and initially settled well but 12 months later developed persistent anterior segment inflammation and macular oedema. She subsequently had the intraocular lens removed and the macular oedema was treated successfully with intravitreal Bevacizumab.

Conclusions

We provide a summary of the evidence and a discussion over the management options available in managing such a difficult case.

Outcome of Single-piece Intraocular Lens Sulcus Implantation following Posterior Capsular Rupture during Phacoemulsification

Purpose:

To assess the safety and outcome of single-piece posterior chamber intraocular lens (PC-IOL) implantation in the ciliary sulcus following posterior capsular rupture during cataract surgery.

Methods:

Patients with posterior capsular rupture during cataract surgery with a single-piece acrylic IOL implanted into the ciliary sulcus were studied. Complete ocular examinations were performed after 6 months postoperatively.

Results:

Twenty-four eyes were included. Mean follow-up duration was 8.33 ± 2.33 months. There was no significant difference between preoperative and postoperative keratometric cylinder or intraocular pressure. Visual acuity of 87.50% of patients was ≥20/40 after surgery. Complications included foveopathy (10 eyes), iris transillumination defect (4 eyes), iris chafing (2 eyes), pigmented keratic precipitate (KP) (4 eyes), clinical IOL tilt (6 eyes), endothelial pigment dusting (14 eyes), IOL pigment dusting (17 eyes), iris bowing (6 eyes), IOL decentration (4 eyes), and IOL tilt detected with ultrasonography biomicroscopy (UBM) (4 eyes). IOL pigment dusting was significantly higher in eyes with short axial lengths, high IOL power, small sulcus-to-sulcus (STS) diameter, large STS IOL diameter mismatch, and small anterior chamber depth and angle. Significant relationships were observed between pigmented KP with small STS diameter and large STS IOL diameter mismatch, UBM and clinical IOL tilt with large anterior chamber depth and between iris transillumination defect and STS IOL diameter mismatch.

Conclusion:

This implantation is associated with higher incidence of complications. Single-piece acrylic IOLs are not designed for sulcus implantation. However, they may be used in eyes with longer axial length if the 3-piece IOL is not available.

Pupillary block due to reverse implantation of a sulcus intraocular lens

An 88-year-old woman with a history of complicated cataract extraction by phacoemulsification with sulcus intraocular lens (IOL) placement developed pseudophakic pupillary block after reverse implantation of the IOL. In the postoperative period, she had persistently elevated intraocular pressures (IOP) and was diagnosed with chronic angle-closure glaucoma that was treated medically. She presented 5 years later with acute pupillary block. The diagnosis of reverse IOL implantation was confirmed by ultrasound biomicroscopy. An IOL repositioning, anterior synechialysis, and Baerveldt tube shunt placement led to resolution of the pupillary block and a well-controlled IOP.