Soemmering's ring support for posterior chamber intraocular lens implantation during penetrating keratoplasty. Changing trends in bullous keratopathy.

BACKGROUND: Changing trends in cataract extractions have resulted in a new category of bullous keratopathy: corneal decompensation after complicated extracapsular cataract extraction. These cases of bullous keratopathy are associated with rupture of the posterior capsule, vitreous loss, and significant intraocular inflammation at the time of the original complicated extracapsular cataract extraction. METHODS: The authors reviewed 14 consecutive cases of penetrating keratoplasty for bullous keratopathy in which posterior chamber intraocular lens implantation was supported by remnants of the posterior capsule and/or Soemmering's ring without suture fixation. All 14 patients had a history of complicated extracapsular cataract extraction with capsule rupture and vitreous loss. RESULTS: All 14 patients had clear, compact grafts without migration of the intraocular lens with a mean follow-up of 12.1 months. Vision improved in 93% of cases, and there was no significant worsening of glaucoma. CONCLUSIONS: Pseudophakic bullous keratopathy after traumatic extracapsular cataract extraction with an anterior chamber intraocular lens and aphakic bullous keratopathy after traumatic extracapsular cataract extraction are two relatively new clinical entities that present new intraocular lens management options. Bullous keratopathy after complicated extracapsular cataract extraction should be recognized as a distinct clinical entity. Intraocular lens implantation into the ciliary sulcus with Soemmering's ring and peripheral capsular support provide the advantages of a posterior chamber intraocular lens without the risk of iris or scleral sutures. The authors predict that bullous keratopathy associated with traumatic extracapsular cataract extraction will become one of the more common indications for penetrating keratoplasty.     

Core vitrectomy preceding triple corneal procedure in patients at high risk for increased posterior chamber pressure

We evaluated the effectiveness of performing a core vitrectomy to prevent intraoperative posterior chamber pressure elevation in eyes at high risk for development of this complication, prior to penetrating keratoplasty, extracapsular cataract extraction and posterior chamber lens (IOL) implantation. Results in 10 cases with core vitrectomy were compared with 10 cases without (controls); in all eyes with vitrectomy, a posterior chamber IOL was easily implanted but four eyes of the control group developed vitreous complications. Our results indicate that core vitrectomy does facilitate IOL implantation during a triple corneal procedure in eyes at increased risk of elevated posterior chamber pressure.     

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

We report on 29 consecutive patients with pseudophakic bullous keratopathy who underwent in one eye penetrating keratoplasty with an exchange of the original intraocular lens for a Pearce tripod posterior chamber lens, and who were available for a follow up of at least 12 months. The average interval between cataract extraction with lens implantation and the appearance of bullous keratopathy was five and a half years (range 10 months to 16 years). The mean follow-up period after penetrating keratoplasty was 36 months (range 12 to 56 months). The corneal graft remained clear in 22 (76%) eyes. One year after the operation 45% of the eyes had a vision of 20/40 or better, and 20% had visual acuities between 20/40 and 20/100. The remaining 31% had a vision of 20/100 or less (one unknown). Nine eyes (31%) had cystoid macular oedema or macular degeneration. 45% of the eyes had a refraction within approximately 2 dioptres of emmetropia. In patients with pseudophakic corneal oedema we continue to exchange the intraocular lens by a Pearce tripod posterior chamber lens sutured to the iris when it is necessary to remove the lens.     

The association of Fuchs''s corneal endothelial dystrophy with axial hypermetropia, shallow anterior chamber, and angle closure glaucoma.

A series of 24 patients with Fuchs's dystrophy are presented in whom detailed clinical measurement showed an association with axial hypermetropia and shallow anterior chamber. In 14 of these patients one cornea had developed oedema, of which 11 had required penetrating keratoplasty. Comparison of these eyes with the fellow eyes without corneal oedema revealed that the anomalies in measurement were not due to the process of decompensation. These 14 patients were then compared with the remaining 10 patients without corneal oedema in either eye, and a similar profile of anomalous measurements was observed. The whole group of 24 patients were then compared with three separate control groups, and in each case a significant trend towards hypermetropia, short axial length, and shallow anterior chamber was noted. The mean spherical equivalent refractive error in the patients with Fuchs's dystrophy was +2.48 D compared with -0.31 D for controls; corresponding means for axial length were 22.1 mm compared with 23.4 mm; and for anterior chamber depth were 2.2 mm compared with 2.7 mm. Each of these differences was statistically significant, but there was no significant difference for the keratometry measurements between patients and controls. Five of 24 (21%) of the patients had problems related to shallow anterior chambers of whom 3 (12%) had manifest angle closure glaucoma requiring surgical peripheral iridectomy. The aetiology of Fuchs's dystrophy and of ametropia is discussed and possible modes of association outlined. This previously unrecognised association gives a rational basis for the widely accepted practice of combining penetrating keratoplasty with lens extraction and has several other practical implications which are important in the differential diagnosis and treatment of Fuchs's dystrophy and angle closure glaucoma.     

Results of neodymium:YAG laser posterior capsulotomy following penetrating keratoplasty

Fifty-six eyes which had a triple procedure (penetrating keratoplasty, extracapsular cataract extraction, and posterior chamber intraocular lens implantation) were evaluated for the incidence, results, and complications of neodymium:YAG laser posterior capsulotomy. Ten of the 56 eyes (17.8%) required YAG laser posterior capsulotomy. Overall, nine of the ten eyes (90.0%) improved their visual acuity one Snellen line or more. Lens pitting (one case) and bleeding (one case) were complications of the laser treatment. The addition of the corneal transplant does not appear to alter the results of the YAG laser posterior capsulotomy, nor does it jeopardize the success of the corneal transplant.     

Implantation of scleral-sutured posterior chamber intraocular lenses during penetrating keratoplasty

PURPOSE: To evaluate the clinical outcome in 29 patients (29 eyes) who underwent penetrating keratoplasty and scleral-fixation of an intraocular lens. METHODS: The indications for penetrating keratoplasty with scleral-fixation of an intraocular lens were anterior chamber pseudophakic corneal edema, aphakic corneal edema, trauma, and corneal scars. Patients with pseudophakic corneal edema underwent IOL exchange and penetrating keratoplasty and patients with lens subluxation underwent cataract extraction and penetrating keratoplasty in the same operation session. RESULTS: Preoperative spectacle-corrected visual acuity was hand motion in 13 eyes (44.8%) and 20/400 in 18 eyes (61.5%). Postoperative spectacle-corrected visual acuity of 20/400 or better was observed in 25 eyes (86.2%). At last follow-up, 26 corneal grafts (89.7%) remained clear. Three grafts (10.3%) failed, two because of glaucoma and one because of endophthalmitis. Glaucoma was observed in 7 eyes. CONCLUSION: Trans-scleral fixation of intraocular lenses combined with penetrating keratoplasty was a useful surgical technique in eyes with keratopathy and lacking posterior capsular support.     

穿透性角膜移植联合白内障摘除人工晶体植入术的临床效果

目的探讨穿透性角膜移植联合白内障摘除人工晶体植入术的临床效果。方法采用三联手术治疗角膜混浊合并白内障患者11例12只眼,术后随访6个月-8年。结果10只眼术后角膜移植片透明,植片透明率83．3％。10例术后视力不同程度的提高。结论准确掌握手术适应证,三联手术是治疗角膜白斑合并自内障安全有效的方法。     

Effects of posterior chamber lens implantation on the endothelium of transplanted corneas

AIMS—The morphological changes of the corneal endothelium after posterior chamber lens implantation in the transplanted corneas were investigated.
METHODS—36 patients underwent extracapsular cataract extraction with posterior chamber lens implantation. Among these, penetrating keratoplasty had been performed in 18 patients before cataract surgery. The indications for penetrating keratoplasty in these cases included keratoconus, herpetic keratitis, and macula cornea. 18 cataract patients with normal corneas were also studied as controls. The central corneal endothelium in each subject was examined with a wide field specular microscope at a few days before and 3 months after cataract surgery.
RESULTS—Although the transplanted corneas showed lower endothelial cell densities, marked polymegethism, and pleomorphism in the baseline variables, the endothelial morphological changes in the transplanted corneas after posterior chamber lens implantation were comparable with those in the normal corneas. Also, there was no clinical evidence, especially, of corneal epithelial and/or endothelial rejections and corneal decompensation in all corneas.
CONCLUSION—Even though the transplanted corneas have a lower endothelial cell density and marked polymegethism, it is believed that cataract surgery does not induce corneal decompensation in cases where the peripheral recipient endothelium can be considered to have normal morphology.

     

Trypan blue assisted phacoemulsification in corneal opacities

AIM: To evaluate the efficacy of trypan blue for enhancing visualisation during phacoemulsification and foldable lens implantation in cases of cataract with corneal opacities. METHODS: 11 eyes of 11 patients with nebulomacular corneal opacities involving the visual axis with partially and visually debilitating cataract underwent trypan blue assisted phacoemulsification with foldable intraocular lens implantation. The patients were followed at the first day, first week, first month, and third month postoperatively. Completion of capsulorhexis, phacoemulsification with foldable lens implantation, and postoperative best corrected visual acuity were measured. RESULTS: The dye improved visualisation of the anterior capsule and a complete capsulorhexis could be performed successfully in all eyes. In all but one eye phacoemulsification was accomplished successfully. In one eye with Fuchs' dystrophy penetrating keratoplasty was performed later. Visual acuity was < or = 6/60 preoperatively in all eyes and improved to > or = 6/24 in eight eyes postoperatively. CONCLUSION: Trypan blue assisted phacoemulsification may be performed in selected cases of corneal haze/opacification with cataract. It provides acceptable visual outcome in cases awaiting penetrating keratoplasty or in cases where it is not feasible or promising.     

Clinical indications for and procedures associated with penetrating keratoplasty, 1983-1988

We reviewed the preoperative clinical indications and associated surgical procedures for 2,299 penetrating keratoplasties performed at our institution from 1983 through 1988. Pseudophakic bullous keratopathy was the most common indication overall, accounting for 526 cases (23%). A marked increase was noted in the incidence of pseudophakic bullous keratopathy as an indication for penetrating keratoplasty beginning in 1985. The association of anterior chamber intraocular lenses in eyes with pseudophakic bullous keratopathy undergoing penetrating keratoplasty increased from 19 of 43 cases (44%) in 1983 to 79 of 108 cases (73%) in 1988. The incidence of intraocular lens exchange at the time of penetrating keratoplasty in cases of pseudophakic bullous keratopathy increased from six of 43 (14%) in 1983 to 63 of 108 (58%) in 1988. Other major indications for penetrating keratoplasty included Fuchs' dystrophy (375 cases, 16%), keratoconus (348 cases, 15%), aphakic bullous keratopathy (331 cases, 14%), and regraft (233 cases, 10%). Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 397 of 1,532 phakic eyes (26%). The incidence of triple procedure (penetrating keratoplasty, cataract extraction, and intraocular lens implantation) increased from 27 of 248 phakic eyes (11%) in 1983 to 68 of 258 phakic eyes (26%) in 1988.     

角膜伤口修补白内障摘除联合人工晶体植入术

目的：评价角膜伤口修补、白内障摘除联合人工晶体植入术的临床疗效。方法：对36例角膜穿通伤患者施行角膜伤口修补的同时行白内障摘除联合人工晶体植入术。人工晶体前膜、后发性白内障给予YAG激光切除。角膜中央疤痕严重影响视力者行穿透性角膜移植术。对所有病例进行3－12个月的随访。结果：术后末次随访时裸眼视力0．1－0．3者8例（22．8％）,0．4－0．5者14例（40％）,0．6－0．8者13例（37．1％）。无因人工晶体植入术引起的严重并发症。结论：只要能准确地把握好手术适应症,在角膜伤口修补的同时行人工晶体植入术能取得较好的疗效。     

葡萄膜炎并发白内障乳化吸出人工晶状体植入

目的 探讨晶状体超声乳化吸出联合人工晶状体植入术在葡萄膜炎并发白内障治疗中的应用。方法 对36例(44眼)葡萄膜炎并发白内障术后，观察其疗效及并发症。结果 所有患者术后视力均有不同程度的提高，其中27眼(61．36％)术后最佳矫正视力≥0．5。术中发生前房积血2眼(4.55％)，后囊破裂1眼(2.27％)；术后瞳孔均能维持圆形居中。术后并发症：早期角膜水肿14眼(31．82％)；前房轻度炎症反应39眼(88.64％)；1周后出现成形性前房渗出1眼(2．27％)；后囊浑浊7眼(15．91％)。结论 超声乳化品状体摘出联合人工晶状体植入术治疗葡萄膜炎并发白内障是安全有效的。     

Retention of iris supported intraocular lenses at the time of penetrating keratoplasty for pseudophakic corneal oedema.

The long-term follow-up of patients undergoing penetrating keratoplasty for pseudophakic corneal oedema is reported. The cause and frequency of corneal decompensation following intracapsular cataract extraction with insertion of an iris supported lens was assessed and found to be unrelated to the implant in the majority of cases. The most common cause of decompensation was endothelial touch during the cataract extraction. In all eyes the intraocular lens was retained at the time of penetrating keratoplasty. The hazards of removal of the lens are discussed and the recommendations made that lenses be retained when penetrating keratoplasty is undertaken for pseudophakic corneal oedema, other than in exceptional cases.     

Outpatient penetrating keratoplasty

Elective penetrating keratoplasty has been performed on an outpatient basis on 37 patients since July 1987. The commonest indications have been herpetic keratitis, keratoconus, and pseudophakic or aphakic corneal oedema. Local anaesthesia, with little or no sedation, was used in most cases, and only three patients had a general anaesthetic. Accompanying procedures have included anterior vitrectomy, extracapsular cataract extraction with posterior chamber lens implantation and IOL exchange. The results demonstrate that outpatient keratoplasty is a safe, effective alternative to hospitalisation, and has a very high level of patient acceptance.     

Outpatient penetrating keratoplasty

Abstract
Elective penetrating keratoplasty has been performed on an outpatient basis on 37 patients since July 1987. The commonest indications have been herpetic keratitis, keratoconus, and pseudophakic or aphakic corneal oedema. Local anaesthesia, with little or no sedation, was used in most cases, and only three patients had a general anaesthetic. Accompanying procedures have included anterior vitrectomy, extracapsular cataract extraction with posterior chamber lens implantation and IOL exchange. The results demonstrate that outpatient keratoplasty is a safe, effective alternative to hospitalisation, and has a very high level of patient acceptance.     

角膜穿孔伤修补,白内障摘出,人工晶状体植入联合手术

目的为评价角膜穿孔伤修补，外伤性白内障摘出和后房人工晶状体植入联合手术的疗效。对38例符合手术标准的患者行此联合手术。结果未决随访时最佳矫正视≥0．5者27眼，0．3者11眼。唯一的额外处理是对4眼后囊严重混浊者行YAG激光截囊。结论该联合手术一次完成通常分2次执行的手术，即最初的角膜修补和二期白内障摘出及人工晶状体植入。视力恢复快，方便患者又节约经费。     

Endocapsular triple procedure--a new triple procedure technique

The triple procedure (penetrating keratoplasty, cataract extraction, and intraocular lens implantation) performed using endocapsular cataract extraction and posterior chamber intraocular lens implantation offers advantages over the extracapsular technique. The most significant advantage is easier, assured placement of the posterior chamber intraocular lens entirely in the bag. Another advantage is less chance of injury to the endothelial cells. This paper describes a technique using endocapsular cataract extraction in the triple procedure.     

Extracapsular cataract extraction and implantation in the capsular sac during vitrectomy in diabetics]

Removal of the lens is often performed during pars plana vitrectomy for complications of proliferative diabetic retinopathy, but correction of aphakia often remains unsatisfactory. Some authors have reported posterior chamber intraocular lens implantation during pars plana vitrectomy in diabetic patients who presented with coexisting cataract and vitreoretinal complications from proliferative diabetic retinopathy. Some patients were operated by pars plana lensectomy and vitrectomy followed by posterior chamber intraocular lens implantation in the ciliary sulcus, others by extracapsular extraction, posterior chamber intraocular lens implantation in the ciliary sulcus, and pars plana vitrectomy. Other authors have described phacoemulsification through the limbus, pars plana vitrectomy and implantation in the capsular bag in one operation in various indications, including complications of proliferative diabetic retinopathy. We inserted a posterior chamber intraocular lens into the capsular bag in 18 eyes of 16 patients with complications of proliferative diabetic retinopathy after extracapsular cataract extraction and pars plana vitrectomy in a single session. A standard extracapsular cataract extraction was performed before pars plana vitrectomy. Sufficient anterior capsule was left in place in order to facilitate implantation in the capsular bag after pars plana vitrectomy. The anterior chamber was filled with sodium hyaluronate in order to maintain anterior chamber depth, corneal clarity, and good mydriasis during the continuation of the procedure. A standard three port pars plana vitrectomy was performed in all cases. After closure of superior sclerotomies, superior corneal incision was partially reopened, an intraocular lens specifically designed for the capsular bag with an optic size of 7 mm was inserted, and the corneal incision was closed with interrupted 10/0 sutures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraocular lens implantation in traumatic cataract

PURPOSE: The evaluation of postoperative results and complications after traumatic cataract extraction with intraocular lens implantation. MATERIAL AND METHODS: Forty two eyes of 41 patients (31 male and 10 female) aged from 10 to 66 years (mean 37.8) with traumatic cataract were the subject of our study. They were operated on between 1996 and 1997. A penetrating injury in 33 eyes (78.6%) and blunt trauma in 9 eyes (21.4%) caused the cataract. The interval between trauma and cataract surgery ranged from 1 day to 40 years. The mean follow up was 13.5 months. Despite of cataract corneal scars, pupil deformations, posterior and anterior synechiae were observed in most of the eyes. Extracapsular cataract extraction was performed in all cases. Posterior chamber IOLs were implanted in 33 eyes. Anterior vitrectomy and anterior chamber IOL implantation was performed in 9 eyes due to the lack of capsular support. RESULTS: Very good or good visual acuity (5/5-5/16) was achieved in 71.4% of cases. Low visual acuity (below 5/50) was observed in 6 eyes (14.3%) because of severe damage to the retina, optic nerve atrophy or amblyopia. Fibrin reaction in anterior chamber (30.9%), hyphaema (19%) and haemophtalmus (4.8%) were the most severe postoperative complications. CONCLUSIONS: An intraocular lens implantation in traumatic cataract, despite many postoperative complications, enables most of the patients to achieve satisfactory and useful vision. Patients with severe posterior segment damage do not benefit functionally from cataract surgery.     

援非小切口手术治疗黑人白内障287例报告

目的:观察在援非期间对287例黑人白内障实施小切口手术的临床效果。方法:在非洲简陋的条件下对287例287眼黑人白内障实施巩膜隧道小切口非超乳白内障摘除术,植入硬质型人工晶状体,观察各类白内障术后裸眼视力及并发症。结果:一次性植入人工晶状体275例275眼,术后1wk裸眼视力≥0.3者240眼(83.6%),≥0.5者166眼(57.8%);角膜水肿53眼(18.5%),后囊膜破裂5眼(1.7%),前房反应38眼(13.2%)。结论:在非洲对于大规模黑人白内障选择小切口白内障摘除及人工晶状体植入手术,疗效可靠。