Surgical reconstruction of traumatic ciliary body dialysis: a case report

BACKGROUND

A cyclodialysis cleft is a gap resulting from disruption of the longitudinal fibers constituting the ciliary body attachment to the scleral spur. The cyclodialysis cleft can be of traumatic or iatrogenic origin, and it may occur during intraocular surgery or as a result of a glaucoma operation. In this report we present a surgical technique to treat cyclodialysis: cyclopexy combined with phacoemulsification subluxation lens, transscleral suturing of Cionni ring, and intraocular lens implantation with iris cerclage suture.

CASE PRESENTATION

A 44-year-old Polish woman experienced a traumatic cyclodialysis cleft in her left eye, complicated by persistent hypotony, maculopathy, lens subluxation, and pupillary sphincter injury. Her corrected distance visual acuity was 0.1 (Snellen chart) and intraocular pressure 3.0 mmHg. We performed direct cyclopexy, anterior vitrectomy, removal of the subluxated lens by phacoemulsification, followed by an insertion of a capsular tension ring with 1-point scleral suture fixation with implantation of intraocular lens in the capsular bag and suturing around the pupil. Anterior segment optical coherence tomography revealed closure of the cleft by reattachment of the ciliary body to the sclera spur. Her corrected distance visual acuity was 0.8 and intraocular pressure 18 mmHg.

CONCLUSIONS

The choice of operating technique depends on the area of the ciliary body dialysis, the number of clefts and their location, the presence of other abnormalities of the ocular structures, and the surgical skills of the operator. Cyclopexy combined with phacoemulsification and transscleral suturing of Cionni ring and intraocular lens implantation with iris cerclage suture can be a good solution in cases of this type. The applied surgical technique proved to be effective.

Sealed-capsule irrigation with distilled deionized water to prevent posterior capsule opacification--prospective, randomized clinical trial

PURPOSE

To evaluate the efficacy and safety of sealed-capsule irrigation (SCI) using distilled water (DW) to prevent posterior capsule opacification (PCO).

MATERIALS AND METHODS

Phacoemulsification was performed in 60 patients. Patients were randomly selected into groups. In the control the capsular bag was mechanically cleaned (MC), in the DW group DW for 3' in SCI was additionally applied. SN60WF IOL was implanted in all eyes. Examinations were performed before and 1, 30, 180 days, one and two years after surgery. Uncorrected and corrected distance visual acuity (UDVA, CDVA), intraocular pressure (IOP), surgically induced astigmatism (K2-SIA), spherical equivalent (SEQ), endothelial cell and the complications were examined. Total PCO score in the area of 1 and 3 mm zone and capsulorhexis (CAPS) were determined using EPCO 2000. One patient was withdrawn from the DW group as he did not report for the examinations.

RESULTS

As far as safety parameters are concerned, no differences were observed between groups in two-year follow-up (p > 0.05). However, in the DW group the endothelial cell loss was higher (p < 0.05). Total PCO score differences were observed in both groups between the areas (p < 0.05). In the CAPS area, both Total PCO score and PCO area were decreased in the DW group (p < 0.05). PCO was also lower within 3 mm zone in the DW group (p < 0.05).

CONCLUSIONS

SCI is a safe procedure and the endothelial cells loss can be associated with the Perfect Capsule™ device (Milvella) in the anterior chamber insertion. DW irrigated for 3' reduces PCO in long-term follow-up.

Phacoemulsification-deep sclerectomy modified by trabeculum microperforations and implantation of lens anterior capsule as autologous scleral implant

OBJECTIVE

To evaluate the efficacy and safety of Phacoemulsification-deep sclerectomy modified by trabeculum microperforations and anterior lens capsule as autologous scleral implant (mPDS) for open-angle glaucoma.

RESEARCH DESIGN AND METHOD

A case series study comprised 127 patients and 127 eyes after mPDS. The applied modification of deep sclerectomy consisted in creating microperforations within the posterior trabeculum and in fixing the anterior lens capsule, removed during phacoemulsification, in the scleral lake as an autologous intrascleral implant. Primary open-angle glaucoma without satisfying intraocular pressure (IOP) control (>or=21 mmHg) despite maximally tolerated medications or with progression of visual field and cataract was the indication for surgery. For statistical analyses paired Student's t-test, the Wilcoxon signed rank test and one-dimensional ANOVA with repeated measures were used; survival analysis was performed using the Kaplan-Meier method.

MAIN OUTCOME MEASURES

IOP, number of medications and best corrected visual acuity (BCVA) were examined. On the basis of the assessment of the anterior and posterior segments of the eye, the character and also the degree of intensification of postoperative complications were established. Follow-up examinations were performed on days 1 and 7, and at 1, 3, 6, 12, 18 and 24 months and thereafter every 6 months. The complete success rate was defined as IOP <or= 18 mmHg without, and the qualified success rate as IOP <or= 18 mmHg with and without antiglaucoma medications.

RESULTS

The mean follow-up was 32.2 +/- 9.1 months. Mean IOP decreased by 30.4%. Mean IOP decreased from 20.1 +/- 5.1 to 14.0 +/- 2.9 mmHg (p < 0.001). The mean number of medications was reduced from 2.2 +/- 0.7 to 0.6 +/- 0.8 (p < 0.001). Complete and qualified success rates were 74.4 % and 93.3 %, respectively. Mean logMAR of BCVA changed from 0.52 +/- 0.40 to 0.16 +/- 0.16 (p < 0.001). Subconjunctival 5-FU injections together with suturolysis because of bleb fibrosis were performed in 20 eyes, which represented 15.7% of the cases operated on. 5-FU-induced complications involved corneal epitheliopathy in nine eyes (7.1 % of cases) and irregular astigmatism in one eye (0.8% of cases). Among early complications the most frequent was transient hypotony observed in 55 eyes (41.7% of cases).

LIMITATIONS

The explanation of the role of the anterior capsule in the mechanism of mPDS requires inclusion into the study of histological observations of surgeries performed on an animal model as well as prospective ultrasound biomicroscopy (UBM) examinations performed in humans.

CONCLUSIONS

Phacoemulsification-deep sclerectomy modified by trabecular microperforations and anterior capsule as a scleral implant lead to an effective decrease in the IOP in medium-term follow-up. The profile of the observed complications indicates that it can be a safe procedure. However, a larger group of patients should be observed to confirm this.

Lens epithelial cell damage after exposure to deionized water to prevent posterior capsule opacification after phacoemulsification: an in vitro study

BACKGROUND

The aim was to study the effects of distilled deionized water (DDW) on lens epithelial cells (LECs) after two different exposure times in the context of preventing posterior capsule opacification (PCO) after phacoemulsification.

MATERIAL/METHODS

Twenty-one subjects (21 eyes) (12 women, 9 men), with a mean age of 74.5 + or - 7.1 years, were in this study. Anterior capsulotomy specimens obtained during cataract phacoemulsification were immersed in a hypotonic solution of DDW. In group I (10 eyes) the anterior capsule fragments were exposed to DDW for 1 minute and in group II (11 eyes) for 3 minutes. The fragments then underwent histological examination; photographic documentation was made and measurements were done with an image analysis system. Log-linear analysis was performed to determine the odds ratio (OR). The significance of particular histological findings was evaluated with Fisher's exact test and Kendall's tau b coefficient was determined by analyzing contingency tables.

RESULTS

Basement membrane and LECs showing different degrees of damage, from vacuolar degeneration to epithelial detachment and from karyorrhexis to total cytolysis, were detected in the microscopic specimens. The probability of lens epithelial cell cytolysis after 3-minute exposure was 3.5 times higher than after 1-minute exposure to DDW.

CONCLUSIONS

Exposure to DDW causes different degrees of damage to LECs, ranging from reversible changes to total cell death. The changes seen in LECs are dependent on the duration of their exposure to DDW.

[Sealed-capsule irrigation during cataract surgery to prevent posterior capsule opacification]

The possibility of isolated use of pharmacological agents to selectively destroy anterior capsule epithelial cells and avoid toxic side effects on other tissues has become the aim of numerous research studies. Creation of a precise, tight, safe system which would allow delivery of pharmaceutical agents into the lens capsule following cataract extraction seems to be a solution. Thus, the aim of our study is to present a surgical technique preventing the development of posterior capsule opacification (PCO) after cataract surgery with the use of sealed-capsule irrigation system (SCI)--Perfect Capsule device.

Comparison of surgically induced astigmatism of temporal versus superior clear corneal incisions

PURPOSE

Comparison of the astigmatism induced by the operation based on the 2.8 mm incisions in the clear cornea, performed by temporal approach and superior approach.

MATERIAL AND METHODS

Retrospective analysis was performed on the group of 65 patients (41 women and 24 men), mean age 74.5 +/- 7.1 years old. We studied a series of 70 eyes (32 right eyes and 38 left eyes). All of the patients underwent cataract surgery by means of ultrasonic phacoemulsification conducted at the Department of Ophthalmology, Military Health Services Institute in Warsaw, Poland within 2004-2005. Follow-up examinations took place 6 months after operation. There were DBCVA. NBCVA, intraocular pressure, anterior segment of the eye and fundus examined. Curvature of the cornea was measured by means of Javal's ophthalmometry. The results were assumed as significant in view of corneal curvature stabilization. Vector analysis of astigmatism was performed on the basis of method described by Jaffe. There was preoperative astigmatism vector (K1) and post-operative astigmatism vector (K3) calculated, as well as surgically inducted astigmatism (SIA)--vector (K2). From the group of 70 eyes, 19 were excluded from the study, where vector K1 was > 1.0 D as well as four eyes, where the main opening site depended on the size and axis of K1 vector. The group of 47 eyes was divided according to the opening site into two subgroups--group I (temporal approach--2.8 mm)--25 eyes and group II (superior approach 2.8 mm)--22 eyes. Statistical analysis was performed based on Statistica package 6.0 PL., using U-Mann-Whitney's test, Chi square Yates' test, Kruskal-Wailis' variance analysis, logistic regression and W Shapiro-Wilk's test.

RESULTS

Studied groups were homogeneous with respect to age structure, sex, number of operated eyes and pre-operative size of corneal astigmatism vector K1 (p > .05). The mean values of SIA in group I and II were respectively: 0.63 +/- 0.28 and 1.00 +/- 0.54 and were statistically significant (p < .05). The mean values of K3 post-operative vector measured 6 months following the operation was: 0.54 +/- 0.35 in the group I and 0.96 +/- 0.43 in the group II. Differences between two groups show statistical significance (p < .05). Size of SIA has crucial influence on generating post-operative astigmatism > 1.0 D (p = .03).

CONCLUSIONS

Clear corneal temporal approach 2.8 mm is more beneficial method comparing to superior approach of the same width, because of the scale of SIA.