Iris-sutured posterior chamber intraocular lens implantation during penetrating keratoplasty

PURPOSE: To evaluate the clinical indications and postoperative results of iris-sutured posterior chamber intraocular lens implants performed during penetrating keratoplasty. METHODS: Medical records were retrospectively reviewed for preoperative indications and postoperative results of 342 consecutive patients (366 eyes) who underwent iris suturing of a posterior chamber intraocular lens implant during penetrating keratoplasty over a 9-year period. RESULTS: Mean follow-up was 36 months. The principal indications for corneal transplantation were pseudophakic and aphakic bullous keratopathy. Mean postoperative best spectacle-corrected visual acuity was better than preoperatively at all measured time points (P < 0.0001) and improved from 20/474 preoperatively to 20/85 at 1 year. Nine eyes (7.7%) with known preoperative glaucoma required escalation of therapy by medication or surgery to control the intraocular pressure. Seventy-two eyes (29%) without known preoperative glaucoma required treatment of elevated intraocular pressure. Seventy-nine eyes (28%) without known preoperative cystoid macular edema were additionally diagnosed. Mean endothelial cell counts declined throughout the study time frame. Corneal donor rejection episodes occurred in 36 (9.8%) eyes, with the majority having a single episode. Overall, 27 (7.4%) eyes had known graft failure at last follow-up. Two eyes (0.5%) were enucleated following wound disruption. CONCLUSIONS: These long-term results of iris-sutured posterior chamber intraocular lens implants performed during penetrating keratoplasty suggest acceptable visual acuity, graft survival, and complication rates. They are similar to published retrospective and prospective results of flexible open-loop anterior chamber and transsclerally-sutured posterior chamber intraocular lens implants placed during penetrating keratoplasty.     

人工晶体植入后大泡性角膜病变的穿透性角膜移植

目的：评价穿透性角膜移植（Penetrating Keratoplasty,PK）治疗人工晶体植入后大光性角膜病变（Bullous Keratopathy,BK）的临床疗效。方法：采用PK治疗人工晶体植入后的BK12例（12眼）,观察术后角膜植片及视力变化。结果：随访8～14个月,平均10.6个月,角膜植片透明10例,半透明2例,术后视力提高8例,视力无改变的3例,视力下降1例。全部病人眼部刺激症状消失。术后继发青光眼3例。结论：PK是治疗人工晶体植入后BK的一种理想的手术方式,术中对人工晶体的处理和防止玻璃体脱出及出血是手术成功的关键。     

穿透性角膜移植治疗人工晶状体植入后大泡性角膜病18例

目的：评价穿透性角膜移植治疗人工晶状体植入后大泡性角膜病的方法和疗效。方法：人工晶状体植入后大泡性角膜病18例行穿透性角膜移植，其中9例单纯行穿透性角膜移植，8例行穿透性角膜移植联合术，1例取出前房植入普通后房型人工晶状体后行穿透性角膜移植，随访时间为4mo～2a。结果：术后随访13例植片透明，3例植片半透明，2例植片混浊。16例矫正视力在0．04～0．6，疼痛症状全部解除。结论：穿透性角膜移植联合术是目前治疗人工晶状体植入后大泡性角膜病较合理而有效的方法。     

Intraocular lens removal during penetrating keratoplasty for pseudophakic bullous keratopathy

Pseudophakic bullous keratopathy is now the most common reason for penetrating keratoplasty. In previous reports, the type of intraocular lens (IOL) most frequently encountered in these eyes was the iris plane IOL. The authors reviewed 27 cases of IOL removal during penetrating keratoplasty. Lenses were removed if they were dislocated or associated with iritis, recurrent hyphema, glaucoma, or persistent cystoid macular edema. The IOL encountered most often was the anterior chamber lens (in 22 eyes); closed thin loop, semiflexible or flexible anterior chamber lenses accounted for 19 of these. Iris plane lenses were removed from five eyes. No posterior chamber lenses were removed. Clear grafts were obtained in 24 of 27 cases (89%); visual acuity improved or remained the same in 24 cases, to 20/60 in 11 cases. The most common causes of poor postoperative vision were retinal disease (6/27 cases) and glaucoma (6/27 cases). The association between anterior chamber lenses and pseudophakic bullous keratopathy is probably the result of both the increase in use of these lenses and the documented propensity of the closed loop semiflexible anterior chamber lenses to cause complications.     

Posterior chamber lens implantation during keratoplasty without posterior lens capsule support

An easy and successful technique is described for implanting a posterior chamber lens at the time of corneal grafting in patients who have no posterior lens capsule for support. Using the principle of pupil entrapment with the lens optic in the anterior chamber, the lens loops are placed behind the iris and secured with McCannel sutures one at a time. Finally, the lens body is placed behind the pupil and covered with Healon, and then the grafting is completed.     

Results of penetrating keratoplasty with posterior chamber intraocular lens implantation in the absence of a lens capsule.

We studied 21 consecutive cases of posterior chamber intraocular lens implantation in the absence of an intact lens capsule performed during penetrating keratoplasty. Twenty patients had iris sutures to support the posterior chamber intraocular lenses (one required no suture). Twelve patients had closed-loop anterior chamber intraocular lenses, and five patients had other types of intraocular lenses explanted at the time of surgery. Postoperative follow-up time averaged 10 months, ranging from 2 to 19 months, with ten eyes having at least 1 year follow-up. All 21 grafts remained clear at their latest examinations. Seven eyes (33%) had 20/50 or better visual acuity, nine (43%) had a visual acuity from 20/60 to 20/150, and five (24%) had a visual acuity of 20/200 or worse at their latest examinations. All patients had improved vision postoperatively, and nine eyes (43%) achieved an improvement in vision of five lines or better. Of the ten eyes with at least 1 year follow-up, all had their sutures removed and four (40%) had 20/40 or better visual acuity. Of the remaining six patients (60%) with visual acuity worse than 20/40, all had significant retinal disease and/or glaucoma.     

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.     

Penetrating keratoplasty for pseudophakic bullous keratopathy. Management of the intraocular lens

Management of the intraocular lens (IOL) at the time of penetrating keratoplasty (PK) for pseudophakic bullous keratopathy has been based on lens-related factors and coexisting anterior segment abnormalities. The authors reviewed the results of PK for 102 cases of pseudophakic bullous keratopathy (43 anterior chamber, 50 iris-supported, and 9 posterior chamber) with respect to: (1) the type of IOL, (2) coexisting abnormalities, and (3) management of the IOL at surgery. Graft failure after 2 years of follow-up was: (1) retained iris-supported IOLs, 9%; (2) retained anterior chamber IOLs, 60%; (3) retained posterior chamber intraocular lenses (PC IOL), 0%; (4) removed IOLs, 9%; and (5) exchanged IOLs, 20%. After 5 years of follow-up, 13 of 13 PKs with retained closed-loop anterior chamber IOLs had failed. Visual results were best in eyes with retained iris-supported, rigid anterior chamber or PC IOLs and when the IOL was removed without replacement. The authors recommend that closed-loop anterior chamber lenses and unstable lenses of any type be removed or exchanged and that well-fixated PC IOLs and iris-clip IOLs be retained at the time of PK for pseudophakic bullous keratopathy.     

Corneal edema and penetrating keratoplasty after anterior chamber phakic intraocular lens implantation

Phakic intraocular lens (IOL) implantation is an increasingly popular option in surgical correction of refractive error. To date, reports of long-term morbidity are infrequent in the literature. We encountered 3 patients who experienced corneal decompensation and cataract progression following angle-fixated anterior chamber phakic IOL placement.     

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.     

Penetrating keratoplasty and Artisan iris-fixated intraocular lens implantation in the management of aphakic bullous keratopathy

OBJECTIVE: To evaluate the safety and efficacy of aphakic bullous keratopathy (ABK) management with combined PK, anterior vitrectomy, angle synechiolysis, and Artisan intraocular lens implantation. METHODS: Fourteen eyes of 11 patients underwent the procedure. Mean follow-up was 12-36 months (mean 24) for visual acuity (Va), refractive error (RE), intraocular pressure (IOP), tonography, graft clarity, intraocular lens centration, and any complications. RESULTS: The postoperative mean values were: Va improved from 20/400 to 20/50, spherical RE was -2.65 diopters, IOP was 17.5 mmHg, tonography improved by 55%, all grafts were clear; no IOL decentrations or serious complications were noted. CONCLUSIONS: This iris-fixated intraocular lens appears to offer simplicity in implantation and may be combined with PK, anterior vitrectomy, and angle synechiolysis. It may be a safe and effective alternative with PK in the management of ABK.     

A prospective study on the implantation of anterior chamber intraocular lenses during keratoplasty for pseudophakic and aphakic bullous keratopathy

Between April 1986 and April 1989, the authors conducted a prospective study of the use of open-loop anterior chamber intraocular lenses (AC IOLs) in patients undergoing penetrating keratoplasty for pseudophakic bullous keratopathy or monocular aphakic bullous keratopathy. All patients underwent the same operation--a penetrating keratoplasty combined with insertion of an open-loop AC IOL. Pseudophakic patients had an IOL exchange at the time of surgery. Thirty-six patients have been followed an average of 15 months. Thirty-two (89%) of the grafts are clear. Preoperatively, 100% of eyes had visual acuity less than 20/200. Postoperatively, 11 eyes (31%) have visual acuity better than 20/40 and 23 eyes (64%) have visual acuity better than 20/100. The most common causes for visual acuity less than 20/200 were cystoid macular edema, glaucoma, and immunologic graft failure. Using open-loop AC IOLs in patients with pseudophakic or aphakic bullous keratopathy can give good postoperative results and functional vision.     

有晶状体眼后房型人工晶状体植入术的研究进展

随着有晶状体眼后房型人工晶状体(phakic posterior chamber intraocular lens,PPCIOL)制作材料、设计和工艺的日趋改善,PPCIOL植入术在治疗中高度近视、远视及散光方面,与激光手术比较具有明显优势,术后屈光状态稳定,并且手术具有可逆性,手术并发症发生概率低.因此越来越多的医生和患者将其作为矫正屈光不正的首选手术.本文就PPCIOL的设计、手术适应证及禁忌证、手术方法、术后观察、并发症及其防治等方面进行综述,以期为临床应用提供参考.     

有晶状体眼后房型人工晶状体植入术的研究进展

随着有晶状体眼后房型人工晶状体(phakic posterior chamber intraocular lens,PPCIOL)制作材料、设计和工艺的日趋改善,PPCIOL植入术在治疗中高度近视、远视及散光方面,与激光手术比较具有明显优势,术后屈光状态稳定,并且手术具有可逆性,手术并发症发生概率低.因此越来越多的医生和患者将其作为矫正屈光不正的首选手术.本文就PPCIOL的设计、手术适应证及禁忌证、手术方法、术后观察、并发症及其防治等方面进行综述,以期为临床应用提供参考.     

Ultrasound biomicroscopy study of the Verisyse aphakic intraocular lens combined with penetrating keratoplasty in pseudophakic bullous keratopathy

PURPOSE: To evaluate anterior segment modifications after penetrating keratoplasty (PKP), previous anterior chamber intraocular lens (IOL) removal, and Verisyse IOL (AMO) implantation over the iris or under the iris for the treatment of pseudophakic bullous keratopathy (PBK) using ultrasound biomicroscopy. SETTING: Department of Ophthalmology, Poitiers University Hospital, Poitiers, France. METHODS: A prospective randomized comparative case series included 27 patients (27 eyes) with PBK who had PKP and implantation of a Verisyse VRSA54 aphakic IOL. The IOL was implanted over the iris in 13 patients (Group A) and under the iris in a reversed position in 14 patients (Group B). Ultrasound biomicroscopy scans 6 months after surgery measured central anterior chamber depth (ACD), iris thickness (IT), distance of the haptics from the corneal endothelium (CED), distance of the haptics from the ciliary body (CBD), angle opening distance (AOD) 500 mum from the scleral spur (AOD500) and the iridocorneal angle theta on the 4 o'clock meridian lines (AOD3; AOD9; AOD12; AOD6/theta12, theta6, theta3, theta9). RESULTS: No significant difference was found in IT, CBD, or AOD12 between Group A and Group B (P >.05). In Group B, the mean ACD was deeper by approximately 55% (P = .008); CED3 was larger by 69% (P = .0162), CED9 by 80% (P = .0128), AOD3 by 57% (P = .0309), AOD9 by 140% (P = .0057), and AOD6 by 44% (P = .0399); and theta3 was wider by 52% (P = .046), theta9 by 123% (P = .0068), theta12 by 50% (P = .0492), and theta6 by 81% (P = .0237). CONCLUSION: Ultrasound biomicroscopy showed that in eyes that had PKP with Verisyse IOL enclavation to the posterior plane of the iris, which involved posterior translation of the iridal plane, the ACD was significantly deeper and the CED and AOD were significantly larger than in eyes with anterior enclavation of the IOL.     

Penetrating keratoplasty for pseudophakic bullous keratopathy associated with closed-loop anterior chamber intraocular lenses

Closed-loop anterior chamber intraocular lenses (AC IOLs) are associated with a high incidence of pseudophakic bullous keratopathy (PBK). The prognosis for recovery of vision with penetrating keratoplasty and the exchange of one type of AC IOL for another remains controversial. A total of 40 consecutive patients with closed-loop AC IOLs and varying degrees of PBK underwent penetrating keratoplasty, explanation of the closed-loop AC IOL, and implantation of a flexible tripod AC IOL--all done with a uniform technique. The average follow-up study was 24 months. Average preoperative visual acuity was 20/170 (range, 20/25-hand motions) and average postoperative visual acuity was 20/44 (range, 20/20-no light perception). A total of 23 eyes (57.5%) achieved a visual acuity of 20/40 or better. Eleven eyes (27.5%) had a visual acuity of 20/200 or worse. Persistent cystoid macular edema was the most frequent cause of poor vision postoperatively (4 eyes), followed by age-related macular degeneration (3 eyes) and graft rejection (2 eyes). This is the first series documenting a good visual outcome for at least 2 years after penetrating keratoplasty and exchange of a closed-loop AC IOL for a single type of flexible tripod AC IOL.     

Secondary posterior chamber intraocular lens implantation in children.

BACKGROUND: Primary intraocular lens (IOL) implantation after cataract aspiration is a widely accepted means of correcting pediatric aphakia. However, little is available in the literature on secondary IOL implantation in children. We present our experience over the past 6 years. METHODS: The charts of 57 aphakic children (61 eyes) who underwent secondary posterior chamber IOL implantation between January 1989 and April 1996 were reviewed. In general, these children were either intolerant of or noncompliant with their contact lenses. An attempt was made to correlate visual outcome with patient variables. Evaluation of the ciliary sulcus structure was made in selected patients by ultrasonographic biomicroscopy to reveal any changes resulting from the presence of the IOL haptic in the sulcus. RESULTS: The age range at the time of surgery was 2 to 16 years (mean 8 y). Mean follow-up was 14 months (range 6 to 48 months). Forty-two percent of the patients had a best-corrected visual acuity of 20/40 or better and 78% saw better than 20/80. Posterior capsular opacification occurred in 10 eyes, 8 of which required neodymium:yttrium-aluminum-garnet laser capsulotomy. No major complications occurred. Ciliary sulcus evaluation by biomicroscopy did not reveal any significant ciliary body or scleral erosion. No changes were noted when the implanted sulcus was compared with the normal contralateral side. CONCLUSION: Although follow-up was short, this review suggests that secondary posterior chamber IOL implantation is a safe alternative when other methods of correcting pediatric aphakia fail.