Intrascleral-fixated intraocular lenses for aphakic correction in the absence of capsular support

PURPOSE: To present results of experience with the authors" technique for intrascleral fixation of intraocular lenses for the correction of aphakia in the absence of capsular support. METHODS: Eleven patients (four children and seven adults) underwent surgery with the use of the method proposed by the authors (11 operations). The patients ranged in age from 11 to 75 years. The equatorial remnants in the lower segment of the capsular bag were revealed in 5 patients (45.5%). Absence of the capsular bag was observed in 6 patients (54.5%). RESULTS: During long-term follow-up evaluation, visual acuity without correction (mean 0.33+/-0.05) corresponded to the preoperative corrected one. Better visual acuity outcome of 0.41+/-0.06 was achieved with added correction. With intrascleral fixation, a mean refractive error of 1.48+/-0.39 D should be taken into account when calculating intraocular lens power with use of the SRK II formula. CONCLUSIONS: The results indicate that posterior chamber intraocular lens implantation with intrascleral fixation of haptics is a safe and effective technique for aphakic correction in the absence of capsular support and the presence of its defects. The technique used in the present study offers safety and stability of the intraocular lens position.     

Posterior chamber intraocular lens implantation in the absence of posterior capsular support

Because of the high incidence and great variety of complications associated with anterior chamber intraocular lenses, we have developed a technique for the implantation of a posterior chamber intraocular lens in the absence of posterior capsular support. The posterior chamber IOL is placed in the ciliary sulcus by suturing the superior haptic to the iris and the inferior haptic to the sclera at the ciliary sulcus. We have used this technique successfully in both complicated extracapsular surgery and secondary intraocular lens implantation.     

Techniques of intraocular lens suspension in the absence of capsular/zonular support

Implantation of intraocular lenses has become the standard of care in the aphakic state. Ideally, the lens is placed in the capsular bag, which affords stable fixation at a position closest to the nodal point of the eye. However, there will always be instances where this will not be possible. Congenital weakness of the lens zonules in various conditions, trauma, and surgical complications of cataract surgery are just some examples. In this article, we review the methods that have been devised to allow intraocular lens implantation in the absence of capsular or zonular support. These include anterior chamber angle and iris-fixated lenses, as well as posterior chamber iris- and scleral-sutured lenses. The various lenses are described, and the techniques involved, advantages and disadvantages, complications, and results of each method are discussed. It is hoped that this article will provide a comprehensive overview of ways to deal with a problem that can still result in a very good visual outcome for the patient. This is particularly relevant given the many recent developments and refinements of methods in implanting intraocular lenses.     

Foldable posterior chamber intraocular lens implantation in the absence of capsular and zonular support

PURPOSE: To implant foldable posterior chamber intraocular lenses in the absence of capsular and zonular support. METHODS: Case reports. In two patients, two eyes with aphakia, lack of capsular or zonular support, and contact lens intolerance underwent the implantation of a silicone and an acrylic foldable posterior chamber intraocular lens, respectively. RESULTS: In the two eyes, final visual acuity was 20/25 and 20/50, respectively. No intraoperative vitreal, retinal, or choroidal complications were noted. The postoperative recovery was rapid, and there was minimal induced astigmatism. CONCLUSIONS: The implantation of foldable posterior chamber intraocular lenses in aphakic eyes without capsular and zonular support may result in fewer intraoperative complications. It also allows for faster postoperative recovery and less postoperative astigmatism.     

Lens epithelial cell death secondary to acanthamoeba keratitis: absence of capsular bag opacification six years after cataract surgery

Purpose

To show the evolution of anterior chamber structures 6 years after cataract surgery in a case with Acanthamoeba keratitis (AK).

Methods

A 37-year-old woman with AK receiving long-term treatment with chlorhexidine, propamidine isethionate and steroids developed a white cataract and iris atrophy. Penetrating keratoplasty and cataract surgery were performed with subsequent intraocular pressure elevation requiring Molteno shunt implantation. Two years after the last surgery, endothelial decompensation developed and another penetrating keratoplasty was performed. Intraoperatively, the anterior and posterior capsules were completely transparent.

Results

Six years after cataract surgery, the intraocular lens was centered with clear anterior and posterior capsules without lens epithelial cells proliferation. No Soemmering''s ring formation or posterior capsule opacification was found. Also, no zonular damage or pseudophacodonesis was observed.

Conclusions

This case suggests that AK infection and AK treatment not only cause white progressive cataract but also lens epithelial cell death. The capsules may be completely clear 6 years after cataract surgery, with a good quality of vision regardless of intraocular lens material or design.Key words: Acanthamoeba keratitis, Lens epithelial cells, Penetrating keratoplasty, Glaucoma, Cataract, Iris atrophy     

Refractive change after transscleral fixation of posterior chamber intraocular lenses in the absence of capsular support

PURPOSE: To report the refractive change that occurred over 12 years after secondary transscleral fixation of posterior chamber intraocular lenses (PC IOLs). METHODS: A total of 21 patients who underwent transscleral fixation of PC IOLs were studied. We were able to follow 15 eyes of 15 patients for more than 12 years. We evaluated refractive change in each patient for 12 years after the operation. RESULTS: The spherical refractive equivalent was -0.95 +/- 2.21 D immediately after the operation, -1.16 +/- 2.28 D after 2 years and -1.37 +/- 1.94 D after 12 years. CONCLUSION: There were few changes in the spherical refractive equivalent up to 12 years after the operation.     

Lens implant surgery in pars planitis

Intraocular lens (IOL) implantation is usually contraindicated in eyes with active inflammation, but patients with "burned-out" pars planitis also may be considered as candidates. Fifteen of 16 eyes in eight patients underwent extracapsular cataract extraction (ECCE) with posterior chamber IOL (PC IOL) implantation combined with pars plana vitrectomy for both cataracts and chronic cystoid macular edema (CME); 60% achieved visual acuity of 20/40 or better. Even with "low-grade" inflammation in these patients, however, a persistent veil of debris accumulated over the posterior and anterior surface of the IOL. One patient (patient 2) required 27 YAG procedures for two eyes, and another required 11 YAG procedures and eventual removal of the IOL. Another patient required surgical "brushing-off" of the IOL and vitrectomy. Even in eyes with "burned-out" uveitis, a continual low-grade inflammation may complicate the use of IOL implantation.     

Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology

OBJECTIVE: This review was conducted to determine the safety and efficacy of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber intraocular lenses (IOLs) in eyes with inadequate capsular support for posterior chamber implantation in the capsular bag or ciliary sulcus. It also attempted to determine whether there is a preferred IOL or fixation site of choice in eyes with inadequate capsular support. METHODS: A literature search conducted for the years 1980 to 2001 yielded 189 citations related to IOL implantation in the absence of capsular support. An update search, conducted in March 2002, yielded an additional 28 articles. The Anterior Segment Panel members reviewed these abstracts and selected 148 articles of possible clinical relevance for review. Of these, 89 were considered sufficiently clinically relevant for the panel methodologist to review and rate according to the strength of evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating was assigned to well-designed cohort and case-control studies; and a level III rating was assigned to case series. Articles comparing the safety and efficacy of the IOL type and fixation site were further evaluated for the quality of the statistical methods used in the study. Studies with a rating of A or B were considered acceptable, C was borderline, and D and F were considered unacceptable as medical evidence. RESULTS: Forty-three articles with data concerning outcome of IOL insertion in eyes with inadequate capsular support had an evidence rating of level III or higher and were used in the final review of the safety and efficacy of one or more lens types and/or fixation sites. Seven articles had data about more than one lens type. Six had a statistical method rating of C or higher and were used to evaluate differences in visual outcomes and complication rates between lens types and fixation sites. CONCLUSIONS: The literature supports the safe and effective use of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber IOLs for the correction of aphakia in eyes without adequate capsular support for placement of a posterior chamber lens in the capsular bag or ciliary sulcus. At this time, there is insufficient evidence to demonstrate the superiority of one lens type or fixation site. Precise determination of small differences in visual outcome or complication rates will require a large prospective, randomized clinical trial.     

晶状体囊夹持固定光学部矫正人工晶状体偏位

目的 探讨晶状体囊夹持固定人工晶状体(IOL)光学部矫正IOL植人术后偏位的临床疗效.方法 13例(13眼)IOL植入术后明显偏位者接受了IOL光学部晶状体囊夹持固定手术,术后随访6个月,观察视力、眼压、IOL位置、眼底,同时进行裂隙灯显微镜眼前段摄像系统拍照确定IOL的偏心值,光学相干断层显像(OCT)检查黄斑中心凹厚度为(151.15±8.90) μm.结果 13例术前平均偏心值为(2.55 ±0.25) mm,术前黄斑中心凹厚度为(151.15±8.90) μm.随访观察6个月,所有患者术后自觉症状均明显减轻,视力明显提高,平均提高3行.术后3例眼压升高,经前房放液,局部滴0.5％马来酸噻吗洛尔滴眼液72 h内恢复正常.未出现视网膜脱离等其他并发症.术后1个月、6个月IOL平均偏心值分别为(0.47 ±0.08) mm、(0.50±0.05)mm,与术前相比,差异有统计学意义(P＜0.05).术后1个月、6个月黄斑中心凹平均厚度分别为( 153.92 ±9.17)μm、(154.85 ±8.76)μm,与术前相比,差异无统计学意义(P＞0.05).结论 晶状体囊夹持固定光学部可有效地矫正IOL植入术后偏心,且对眼后段不产生明显影响.     

Lens implant surgery in a developing country

Unilateral, mostly traumatic cataract in children and adults is considered a good indication for lens implant surgery in developing countries. In Suriname fourteen patients with unilateral, non-senile cataract underwent pseudophakos surgery, from 1975 to 1980. No major complications occurred. In ten of the fourteen patients good binocular vision was achieved. Two patients had good visual acuity with poor fusion. One patient had persistent deprivation amblyoplia. Six patients were ultimately lost to follow-up.     

Lens cell populations studied in human donor capsular bags with implanted intraocular lenses

PURPOSE: Posterior capsule opacification is an ongoing cellular redistribution process. The level of viable cell coverage was therefore determined in human donor capsular bags with implanted intraocular lenses, and cellular morphology and ultrastructure were investigated in relation to cell type and level of differentiation. METHODS: Donor capsular bags, retrieved at intervals of 4 months to 13 years after surgery, were investigated by phase optics before fixation. Postfixation techniques included scanning electron microscopy and transmission electron microscopy of sections and immunofluorescent staining of cytoskeletal proteins in wholemounts. RESULTS: All the capsular bags contained a large population of viable cells on the capsular surfaces. Cells on the anterior face of the anterior capsule and in the spaces around the intraocular lens had an elongated morphology and expressed alpha-smooth muscle actin. The cells formed light-scattering, multilayered aggregates and strands that were surrounded by layers of extracellular matrix. The regions between the intraocular lens and the equator of the bags were populated by monolayers of epithelial cells of normal morphology and ultrastructure, on both the anterior and posterior capsules. In some regions the apical surfaces of the two epithelial monolayers were in contact, and in some parts of the equatorial regions, differentiation of cells into well-organized fiberlike cells was evident. CONCLUSIONS: Human capsular bags contain a large population of viable cells for many years after cataract surgery. Cells in the regions around the intraocular lens undergo transition to a mesenchymal type. Cells peripheral to these regions can form a stable closed microenvironment in which both normal epithelial morphology and differentiation to fiberlike cells are maintained.     

Modified capsular tension ring for patients with congenital loss of zonular support

PURPOSE: To evaluate the results of implantation of a modified capsular tension ring (MCTR) and a posterior chamber intraocular lens (PC IOL) in patients with congenitally subluxated crystalline lenses. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio, USA. METHODS: Ninety eyes of 57 patients with congenital loss of zonular support (Weill-Marchesani syndrome, idiopathic ectopia lentis, and Marfan's syndrome) had phacoemulsification with PC IOL and MCTR implantation. The preoperative examination included best corrected visual acuity (BCVA) and the presence or absence of phacodonesis, lens decentration, and vitreous prolapse. The postoperative evaluation included BCVA and the presence or absence of pseudophacodonesis, PC IOL centration, and posterior capsule opacification (PCO). RESULTS: At the last postoperative examination, the BCVA was 20/40 or better in 80 eyes (88.9%); 1 eye (1.1%) lost 1 line of acuity. Preoperatively, 18 eyes (20%) had phacodonesis; 1 eye had postoperative pseudophacodonesis. Decentration before surgery was present in 86 eyes (95.6%); 6 eyes (6.7%) developed late symptomatic PC IOL decentration a median of 17.84 months +/- 10.73 (SD) after surgery. Other complications were increased intraocular pressure (2.2%), persistent iritis (3.3%), broken suture (10.0%), retinal detachment (1.1%), and PCO (20.0%). CONCLUSIONS: Use of the MCTR resulted in centration of the capsular bag and PC IOL in 90 eyes with congenitally subluxated crystalline lenses. Fixation of a 9-0 polypropylene suture is recommended to decrease the risk for late suture breakage.     

Sulcus fixation without capsular support in children.

PURPOSE: To evaluate long-term follow-up in eyes of children who had sulcus fixation of an intraocular lens (IOL) without capsular support. SETTING: St. Eriks Eye Hospital/Karolinska Institute, Stockholm, Sweden. METHODS: This retrospective study included 21 eyes of 13 children. Seven eyes had Marfan's syndrome, 7 essential lens dislocation, 2 perforation with lens injury, and 5 spherophakia. The IOL implantation was primary in 16 eyes and secondary in 5 eyes. Lensectomy was performed with a limbal approach. An IOL with holes in the haptics was sutured in the sulcus, with the knots buried in the scleral bed. RESULTS: Mean patient age was 5.8 years +/- 2.6 (SD). Follow-up ranged from 9 to 33 months. No complications occurred during surgery. In all cases after IOL implantation, best corrected visual acuity was equal to or better than preoperatively. After surgery, no opacification of the visual axis, secondary glaucoma, or retinal complication was recorded. Posterior synechia formation occurred in 4 eyes, and 4 had cells on the IOL surface in 2 eyes, the IOL optic subluxated into the anterior chamber with the haptics in place. Both cases were successfully treated with pilocarpine 4%. CONCLUSION: Our results suggest that sulcus fixation of an IOL without capsular support is an option to correct aphakia in children.     

Implantation in the posterior chamber without capsular support

The relatively high incidence of complications of anterior chamber implants has encouraged ophthalmologists to implant in the posterior chamber, even in eyes without posterior capsules. A new surgical technique for implantation of posterior chamber lenses in the ciliary sulcus is described. Twenty posterior chamber lenses were implanted in eyes which had had intracapsular cataract extraction, with a follow-up ranging from three to 14 months (mean 7.4 months). Although no serious complications occurred in this small series, the safety and viability of this technique will be established with a longer follow-up.