Ciliary sulcus reconstruction for posterior implantation in the absence of an intact posterior capsule

Secondary implantation of a posterior chamber intraocular lens in an aphakic eye devoid of an intact posterior capsule requires a special surgical approach. When lens capsule remnants remain in the periphery, the ciliary sulcus can be reconstructed to accommodate a posterior chamber lens. The fibrotic lens or capsular residues that often remain adherent to the posterior surface of the iris are divided with sharp intraocular scissors, and a shelf is created that is sufficient to support the lens haptics. A series of 28 cases, including 16 involving young children, demonstrates the feasibility and the favorable visual results obtainable with this surgical technique.     

A technical variation of posterior chamber IOL implantation

In posterior chamber intraocular lens (IOL) implantation, one of the most delicate phases is placing the loops in the capsular bag or in the ciliary sulcus. We describe a technique to simplify the phase of IOL insertion by tying the superior loop with a nylon suture. No changes to the lens and no special instruments are required.     

Techniques of posterior chamber lens implantation without capsular support during penetrating keratoplasty: a review

Posterior chamber intraocular lenses have numerous advantages over iris-supported lenses and many types of anterior chamber lenses; therefore, the implantation of sutured posterior chamber lenses in the absence of a lens capsule during penetrating keratoplasty has become more common. Suture fixation of the lens implant may be achieved by either 1) sewing the optic or haptics to the iris, or 2) sewing the haptics in the ciliary sulcus using transscleral sutures. In the case of the iris-suture technique, the implant acquires its stability mainly from the fixation sutures, but to some degree, placement of the haptics in the ciliary sulcus may enhance stability. In the case of the scleral fixation technique, implant stability is derived from placement of the haptics in the ciliary sulcus and the transsscleral sutures. Several variations upon these two basic suture fixation techniques currently exist, each with its own putative advantages and disadvantages. The different methods are schematically reviewed with diagrams and the comparative benefits and deficits are discussed.     

Posterior chamber IOL implantation with suboptimal posterior capsular support

A posterior chamber intraocular lens (PC/IOL) was implanted in 24 patients with suboptimal posterior capsular support due to preoperative or intraoperative rupture of the posterior capsule or zonules in which at least six clock hours of peripheral zonular support remained. The PC/IOLs were implanted, with ciliary sulcus haptic placement, with special attention to sulcus fixation of the haptics over the zone of residual zonular support. All of the IOLs have remained centered after a mean follow-up 10.5 months. We conclude that a PC/IOL can be successfully implanted and its position maintained if at least six clock hours of peripheral zonules remain.     

A new endoscope for ophthalmic microsurgery.

We present an endoscope designed for ophthalmic microsurgery. The handpiece contains a charge-coupled device, a solid-state imager (250,000 pixels), and a probe (either 0.89 or 1.5 mm in diameter), including the light guide. The light source is a halogen lamp. The clear views the instrument provides of the ciliary sulcus and ciliary body behind the iris make it useful in secondary posterior chamber intraocular lens implantation using the ciliary sulcus suturing technique, and in endolaser photocoagulation of the ciliary body in end-stage glaucoma. It also is useful in performing vitrectomy in cases in which visualization is difficult because of corneal opacification or fluid-gas exchange.     

Transscleral fixation of posterior chamber intraocular lenses in the absence of capsular support

We present results obtained by transscleral ciliary sulcus fixation of posterior chamber intraocular lenses in secondary implantation, lens exchange, and in primary implantation of transsclerally fixated lenses during complicated cataract extraction. Follow-up data on 38 patients, 17 of whom have been followed for more than 12 months, are included. We conclude that the procedure is safe, effective, and predictable.     

Anterior megalophthalmos and intraocular lens implantation

The problems associated with intraocular lens (IOL) implantation in two patients with megalophthalmic eyes are discussed. One patient initially received a posterior chamber IOL that proved to be too small for the internal diameter of the ciliary sulcus. It was removed and replaced with an iris-supported lens. The second patient received an iris-supported IOL that appears to be a satisfactory pseudophakic alternative for anterior megalophthalmic eyes.     

Alternative method for sulcus fixation of posterior chamber lenses in the absence of capsular support

The realization that posterior chamber intraocular lenses have many advantages over anterior chamber ones has induced many practitioners to try methods of fixating the lenses in the ciliary sulcus when there is inadequate capsular support. Most of these methods require the use of sutures to anchor the lens to the sclera or the iris. We describe a modification of these techniques which allows the surgeon to place a stiff all-polymethylmethacrylate (PMMA) lens in the sulcus in a way that makes it unnecessary to anchor the lens, although a safety suture may be placed through the scleral lip. We believe this modification makes sulcus fixation simpler to perform and possibly safer for the patient. We have used this technique in six patients with good results.     

Results of exchanging anterior chamber lenses with sulcus-fixated posterior chamber IOLs without capsular support in penetrating keratoplasty

We retrospectively reviewed the charts of 47 patients who had had penetrating keratoplasty and intraocular lens exchange with fixation of a posterior chamber lens to the ciliary sulcus. Follow-up ranged from 5 to 30 months (mean, 13 months). The corneal grafts remained clear in 46 eyes. The average visual acuity of patients followed for more than 12 months was 20/60. Complications have been minor. Because of complications associated with anterior chamber lenses and these findings, we now utilize this technique in all patients who require penetrating keratoplasty and intraocular lens insertion without posterior capsule support.     

Ciliary sulcus fixation of a dislocated posterior chamber intraocular lens using liquid perfluorophenanthrene.

A posterior chamber intraocular lens was transsclerally sutured to the ciliary sulcus with the aid of liquid perfluorophenanthrene (Vitreon). This vitreous substitute facilitates the procedure and reduces the possibility of damage to the retina.     

Observing posterior capsule lens haptics in living postoperative eyes

The cycloscope, an aid for observing the ciliary body, was used to study lens haptic fixation in 100 living eyes (200 haptics). Although the whole aspect of the lens could be viewed in only about 20 haptics (10%), in 102 haptics (51%), judgment about whether fixation was in or out of the bag could be made based on the relationship of the visible part of the lens haptic and the surrounding tissues. Thus, the method was found to be useful in studying the fixation mechanism of posterior chamber lens haptics in living postoperative eyes. Two cases of J-loop posterior chamber lens implantation studied by cycloscopy are reported.     

A comparison of ciliary sulcus and capsular bag fixation of posterior chamber intraocular lenses

We compare indications, advantages, and disadvantages of ciliary sulcus and lens capsular bag (lens capsular sac) fixation of posterior chamber intraocular lenses (IOLs). Our findings suggest that, whenever possible, it is efficacious to implant the loops of posterior chamber IOLs within the capsular bag. This positions the lens optic and the supporting loops in the natural anatomical position, sequestered from highly vascular uveal tissue and the blood aqueous barrier. This should minimize the potential for complications that may be associated with iris-ciliary body contact. Considering the rapid increase in the number of implantations of IOLs now being performed (approximately 700,000 per year in the United States alone), a possible reduction of even 1% in clinically significant complications would make this effort worthwhile. Widespread application of in-the-bag implantation is predicated on the assumption that the surgeon is proficient with this procedure and that careful follow-up of patients does not reveal any significantly increased incidence of lens dislocation due to zonular rupture.     

Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant

We have devised a technique to fixate a posterior chamber lens in the ciliary sulcus when no posterior capsular support exists. Our short-term follow-up of 22 eyes with lenses thus fixated has shown these eyes to be quiet and to have good pupillary motility after at least 3 months. We believe this new technique is a significant advancement in corneal and anterior segment surgery.     

Ciliary sulcus suturing of a posterior chamber intraocular lens

We describe a method for ciliary sulcus fixation of a posterior chamber intraocular lens (PC-IOL) in the absence of an intact posterior capsule. This method, which combines a lens fixation procedure with trans pars plana vitrectomy techniques to ensure safe manipulation of the lens implant in the absence of an intact anterior hyaloid face, is ideally suited for retrieval and repositioning of PC-IOLs dislocated into the vitreous. It also permits closed system repositioning and fixation of the implant, thereby avoiding the complications of vitreous loss and the need for reopening the limbal incision.     

Pseudophakic keratoplasty: posterior chamber lens implantation in the presence of ruptured capsule

A technique is described for implantation of a posterior chamber intraocular lens during keratoplasty for bullous keratopathy when a large capsulotomy and vitreous prolapse are present. Seven cases of pseudophakic or aphakic bullous keratopathy with anterior chamber, iris-fixated, or no intraocular lens in place are reported. A completely intact posterior capsule is not necessary to support safely a sulcus-fixated posterior chamber lens. Anterior segment reconstruction, careful removal of existing intraocular lenses (except a posterior chamber lens), vitrectomy through the ruptured posterior capsule, and assessment of the remaining posterior capsule rim are important surgical objectives.     

Late onset, progressive, peripheral anterior synechiae with posterior chamber intraocular lenses

Four eyes of three patients who had had posterior chamber intraocular lens implantation developed peripheral anterior synechiae overlying the lens haptics many months after the original implantation. The synechiae progressed over time, but a portion of the chamber angle remained open in all cases. Two of the three patients had had an underlying open-angle glaucoma and were on pilocarpine therapy prior to the implantation surgery. The exacerbation of their glaucoma from new peripheral anterior synechiae required advancement in medical therapy in three of four eyes with the fourth requiring filtration surgery. Patients with posterior chamber intraocular lenses should have gonioscopy preoperatively and on a regular basis following implantation surgery.     

A modified iris fixation suture utilizing a peripheral iridectomy

To help ensure proper placement of an iris fixation suture, a peripheral iridectomy can be performed to allow visualization of the superior haptic of a posterior chamber intraocular lens (PC-IOL). In cases where support for the PC-IOL is in question, an iris fixation suture using this technique provides an easy way of ensuring adequate support.     

The Shearing-style intraocular lens and the posterior chamber

We observed the Shearing-style intraocular lens in human cadaver eyes and in dog eyes. In human cadaver eyes the lens loops rest in the ciliary body sulcus without exerting undue pressure; the only major problem occurred when the posterior capsule was torn and a loop found its way into the pars ciliaris of the ciliary body or into the vitreous base. Seven Shearing-style lenses were implanted in four dogs: six-month preliminary histopathology showed four of these lenses to be well tolerated with abundant synechiae formation around the loops. Two eyes exhibited loop pressure necrosis due to slight lens displacement.     

Optical lamellar keratoplasty using the barraquer microkeratome

The Barraquer microkeratome may be used to cut donor and host lenticules for lamellar keratoplasty. Eleven eyes of nine patients with visually symptomatic anterior corneal opacification underwent optical lamellar keratoplasty using this technique. In three eyes, this was combined with extracapsular cataract extraction and posterior chamber intraocular lens implantation. Preoperatively, four patients had anterior stromal scars in the visual axis. There were three patients with Reis-Bückler, and two with granular corneal dystrophy. Postoperatively, visual acuity improved in ten eyes and was unchanged in one. We conclude that the Barraquer microkeratome facilitates lamellar keratoplasty and may be successfully combined with extracapsular cataract extraction and posterior chamber intraocular lens implantation. Optical lamellar keratoplasty may be an alternative to penetrating keratoplasty in selected patients with localized anterior corneal opacification.     

An insertion technique for the double-closed-loop posterior chamber lens

We have developed a technique for inserting double-closed-loop posterior chamber implants that minimizes zonular stress with both ciliary sulcus and capsular bag insertion and facilitates in-the-bag placement if desired.