Scleral fixation of posterior chamber intraocular lenses using fascia lata to cover the knots

BACKGROUND AND OBJECTIVE: To describe the use of fascia lata to cover the polypropylene knots of scleral fixated posterior chamber intraocular lenses (PCIOL). PATIENTS AND METHODS: Fascia lata was used to cover the knots of scleral fixated PCIOL in 5 eyes with significant scleral thinning. Four of the 5 eyes had the PCIOL insertion and the fascia lata patching in the same setting. The fifth eye previously had scleral fixated PCIOL with late suture erosion through a partial thickness scleral flap. RESULTS: There was no suture exposure or graft thinning throughout a follow-up period of 8 to 16 months. The eyes tolerated the fascia lata well with no early or late postoperative complications. CONCLUSION: Fascia lata provides an effective means to cover the knots of scleral fixated PCIOL, especially in aphakic patients with significant scleral thinning.     

Defect closure with scleral grafts

BACKGROUND: Excessively draining fistulas may lead to enucleation when primary suture closure is not effective. In these cases preserved cadaver tissues such as sclera, fascia lata, dura mater and peritoneum have been used for patch graft repair with variable results. In this study, the clinical outcomes after transplantation of scleral patch grafts have been investigated. METHOD: Twenty-eight eyes of twenty-seven patients underwent surgery with homologous scleral patch grafts for repair of excessively draining scleral fistulas after cataract surgery (n = 2), leaking filtering blebs following full-thickness filtration surgery (n = 7), large scleral perforations due to trauma (n = 7), corneo-scleral ulcerations due to severe eye burns (n = 9) or after radiotherapy of malignant melanoma (n = 3). The mean size of the rectangular grafts was 8.6 x 6.7 mm (+/- 2.8/3.1 mm). Clinical follow-up was up to 73 months (median 30 months). RESULTS: Twenty-three of 28 eyes (82.1 %) showed functional closure after initial surgery without any wound complication such as patch retraction or leakage and without evidence of inflammation. In five eyes surgical revision was necessary. Two of these eyes had to be enucleated due to uncontrollable dehiscence after the second operation. Two eyes were enucleated at the patient's demand due to pain. The fifth eye showed effective closure after the second operation. CONCLUSION: In our study scleral patch grafts were useful in adequately closing large corneo-scleral defects in 24 of 28 eyes (85.7 %). The antigen load and, therefore, the rejection of the scleral grafts is minimized due to the denaturation of proteins during the alcohol treatment before storage.     

Use of split-thickness dermal grafts to repair corneal and scleral defects--a study of 10 patients.

The use of split-thickness dermal grafts for successful repair of corneal and scleral defects is reported in 10 patients (11 eyes) who had non-infectious, impending, or overt ocular perforation. In all patients, traditional methods of reconstruction were deemed inappropriate or had already failed. Corneo-scleral defects occurred after various operations: pterygium excision, retinal detachment repair, insertion of a keratoprosthesis (Cardona implant) into an opaque, vascularised cornea, and penetrating keratoplasty. Other causes of corneoscleral defects were scleromalacia perforans, idiopathic systemic vasculitis, alkali burn, ocular cicatricial pemphigoid, and band keratopathy with recurrent erosion following intraocular metallic foreign body. We propose the use of split-thickness grafts: (1) when adjacent conjunctiva is inadequate to cover a corneoscleral defect owing to its large size or great depth or to conjunctival scarring from previous operations, injury, or ocular cicatricial pemphigoid; or (2) as an alternative to autogenous grafts such as conjunctiva, cartilage, fascia lata, tibial periosteum, or mucous membrane as well as to homologous scleral and lamellar grafts. Dermal grafts are advantageous in that they are autogenous, non-antigenic, survive on avascular surfaces, and self-epithelialise and, thus, need not be covered by conjunctiva. Furthermore, they are pliable, have excellent tensile strength, provide ample tectile support, and are abundantly available. Dermal grafts are harvested from the dermal bed of the thigh after an epidermal flap is hinged at one end.     

Processed fascia lata as an alternative implant material in evisceration

PURPOSE: To examine the use of processed fascia lata strips as an implant material in evisceration. METHODS: This is a prospective, interventional, noncomparative case series. Eight patients underwent standard evisceration of an eye with subsequent primary insertion of processed fascia lata strips in the scleral shell. They were clinically examined at regular postoperative intervals (up to 20 months) and had computed tomography and magnetic resonance imaging scans of the orbits at the 12-month interval. The development of vascularity of the scleral shell contents was assessed with the intravenous administration of a contrast-enhancing agent. RESULTS: The fascia lata strips were incorporated without significant complications in all cases. The maintenance of adequate volume and position of the eviscerated globe was confirmed by both computed tomography and magnetic resonance imaging scans. T1-weighted magnetic resonance imaging studies with intravenous administration of contrast-enhancing agent and fat-saturation sequences revealed the development of vascularity of the scleral shell contents. CONCLUSIONS: Processed fascia lata may be a useful alternative implant material in evisceration. Possible advantages of its use may include protection against extrusion, custom volume selection and easy intraoperative manipulation.     

Use of autologous fascia lata as a natural biomaterial for tectonic support in surgically induced necrotizing scleritis

Background

Surgically induced scleral necrosis (SINS) is a severe form of scleritis threatening both vision and integrity of the eye. SINS is a rare sequel of ocular surgery and has been described after cataract extraction, trabeculectomy, strabismus, retinal detachment surgery including parsplana vitrectomy, penetrating keratoplasty, pterygium excision, and diode cyclophotocoagulation.

Materials and methods

To report on the application of autologous fascia lata as a readily available natural biomaterial for ocular tectonic support in SINS, we performed this retrospective chart review including two eyes of two patients; one case following both repaired rupture globe, parsplana vitrectomy, and diode laser transscleral cyclophotocoagulation and one case following pterygium surgical excision.

Results

Successful coverage of the area of scleral thinning with autologous fascia lata was achieved in both cases with overlying healthy vascularized conjunctiva and resolution of the ocular inflammation.

Conclusion

The fascia lata transplant combined with systemic immunosuppression was successful in providing adequate tectonic support and controlling the progression of scleral melt for two cases with SINS.     

Autogenous versus allograft fascia lata in frontal sling surgery --long-term results

PURPOSE: Either autogenous or allograft fascia lata frontal sling procedures can be used for the treatment of severe ptosis. We retrospectively evaluated the late outcomes of both approaches. METHODS: Medical records of patients who underwent frontal sling ptosis surgery between 1978 and 2000, with a follow-up of one year or more were included in the study. Success rates and the complications of the surgery for autogenous and allograft fascia lata were recorded. The results were compared statistically. RESULTS: Surgeries were performed with 82 autogenous or 43 allograft fascia lata. At last follow-up there were 71 eyes (86.6%) with good, 8 eyes (9.7%) with moderate, 3 eyes (3.7%) with poor results after autogenous fascia lata and 35 (81.4%), 3 (7%) and 5 (11.6%) after the allograft fascia lata frontal sling procedure. There was no significant difference between the two groups. Repeat surgery was carried out on three patients after autogenous and five after allograft fascia lata surgery. Two cases of preseptal cellulitis were observed, one abscess after autogenous and one lagophthalmus after allograft fascia lata sling surgery. All patients had slight edema early after surgery which resolved in a few days. Only one patient developed a hematoma at the site of the leg incision. CONCLUSIONS: Although the long-term success rate with the autogenous fascia lata is slightly higher and this remains the first choice, allograft fascia lata is a good alternative in patients in whom fascia could not be harvested.     

Use of conjunctiva-Müller muscle pedicle flap in surgical treatment of necrotizing scleritis

PURPOSE: To describe a new surgical technique for scleral repair in eyes with necrotizing scleritis. METHODS: The surgical technique involved placing an autologous fascia lata graft over the scleral defect and covering the graft with an inferiorly based conjunctiva-Müller muscle pedicle flap from the upper eyelid. The flap pedicle was divided 2 months after the initial procedure. The medical records of 2 patients (2 eyes) who underwent a scleral repair with this technique were reviewed. RESULTS: Both patients had progressive, diffuse scleral necrosis secondary to rheumatoid arthritis, and were receiving immunosupressive therapy. One patient had previously undergone unsuccessful scleral reconstructions with patch grafting. In both cases, the eye integrity was preserved after repair with conjunctiva-Müller muscle flap, and postoperative visual acuity improved. No complication developed during follow-up periods of 28 and 54 months. CONCLUSION: Conjunctiva-Müller muscle pedicle flap may provide efficient and safe scleral repair in eyes with necrotizing scleritis.     

Long-term persistence of fascia lata patch graft in glaucoma drainage device surgery

PURPOSE: Conjunctival erosion in glaucoma drainage device surgery can be prevented by the use of patch grafts to cover the extraocular portion of the tube. Several materials can be used, among them human preserved fascia lata. METHODS: The authors present a case of a failed Ahmed glaucoma valve due to encapsulation of the bleb, in which the fascia lata patch placed to cover the tube was removed 32 months later, during the implantation of a second glaucoma drainage device. RESULTS: Histopathologic examination of the fascia lata patch demonstrated its persistence, without degradation or cellular infiltration. CONCLUSIONS: Human preserved fascia lata is a suitable material for tube covering in glaucoma drainage device surgery, with long-term survival.     

A modified iris repair technique and capsular tension ring insertion in a patient with coloboma with cataracts

PURPOSE: We describe our successful experience using a capsular tension ring (CTR) and iris repair during cataract surgery in a patient with bilateral coloboma. METHODS: A 67-year-old woman had no history of trauma, but had zonular deficiency and inferonasal iris defects in both eyes. An extracapsular cataract extraction and intraocular lens (IOL) scleral fixation was performed in the left eye. A CTR was implanted in the right eye through a sclerocorneal incision. After the IOL was placed centrally in the capsular bag, two paracenteses were made at the limbus (5 o'clock and 7 o'clock). A long, straight needle was passed through the 7 o'clock paracentesis site into a angled, blunt tipped 27 gauge needle inserted from the 5 o'clock paracentesis. The two needles were pulled out at 5 o'clock. After inserting the long needle into the blunt tipped needle at 7 o'clock, both were passed back through the 7 o'clock paracentesis site. The needles were pulled out again at the 5 o'clock paracentesis site tied. Equal tension was used to tie both sides. RESULTS: Visual acuity improved to 20/20 in the right eye. CONCLUSIONS: Both capsular tension ring implantation and iris repair was successfully performed at the time of cataract surgery in a coloboma patient, which resulted in improvements in visual function and cosmesis.     

The use of the scleral "B"-shaped embedding method for intraocular lens suspension surgery

Objective To explore the use of the scleral "B"-shaped embedding method for intraocular lens suspension surgery.Methods Twenty-five patients (27 eyes) with aphakia or lens subluxation were selected for this prospective case series study.Intraocular lens suspension surgery was performed on all eyes.The "B"-shaped embedding method was used to fixate the loop of the intraocular lens instead of using the traditional intraocular lens loop fixation under the scleral flap.The intraocular lenses included the suspension type (23 eyes) and the iris diaphragm suspension type.The eyes with pupil deformation and iris disarticulation were handled during the surgery.Results Visual acuity and photophobia symptoms improved after surgery.Visual acuity after surgery was between 0.05 and 0.6.Ciliary body bleeding during surgery occurred in 1 eye.The bleeding was resolved by increasing intraocular pressure,replacing the incision and vitreous cavity lavage hemorrhage.All patients were followed up for 6-12 months.There was no infection or uncomfortable symptoms caused by exposure of the scleral line knot and conjunctival hyperemia during the follow-up period.The position of the intraocular lens was normal without ectopic or oblique placement.Conclusion The traditional intraocular lens loop fixation under the scleral flap was improved.The use of the scleral "B"-shaped embedding method is worth promoting to widen its acceptance.     

巩膜“B”形埋线法在人工晶状体悬吊术中的应用

目的 探讨巩膜“B”形埋线法在人工晶状体悬吊术中应用.方法 前瞻性系列病例研究.选择无晶状体或晶状体半脱位患者25例(27眼),对常规巩膜瓣下人工晶状体袢固定的方法进行改良,行“B”形埋线法固定人工晶状体袢,其中悬吊型人工晶状体23眼,带虹膜隔悬吊型人工晶状体4眼,有瞳孔变形、虹膜离断同时进行瞳孔缝合及根部离断修复.术后观察视力、畏光状况、有无缝线暴露、长充血等刺激症状、人工晶状体位置等.结果 全部患者术后视力或畏光症状均有所改善.术后视力:0.05～0.6.术中睫状体出血1例,经升高眼内压止血,更换切口,玻璃体腔灌洗积血,之后手术顺利.所有病例观察6～12个月.随访期内无巩膜线结暴露、结膜充血等刺激症状,无感染.临床观察人工晶状体固定位置良好,无人工晶状体移位、倾斜现象.结论 采用巩膜“B”形埋线法对传统人工晶状体悬吊术巩膜瓣下的晶状体袢固定切口进行改良,安全有效.     

玻璃体切割术联合人工晶状体巩膜固定术治疗眼外伤的疗效

目的：探讨玻璃体切割术(pars plana vitrectomy,PPV)联合人工晶状体(intraocular lens,IOL)巩膜固定术治疗眼外伤的疗效。 方法：系列病例回顾性分析。将马来西亚大学医学中心接受PPV联合IOL巩膜固定术的8例连续性病例纳入研究,其中1例患者双眼均受伤,共有9眼。对现阶段视力,手术技巧,并发症及术后疗效进行分析。 结果：9眼中有8眼（89%）视力提高。术后主要并发症是眼压升高,无缝线破裂。 结论：PPV联合IOL巩膜固定术对有眼外伤病史的患者有非常好的疗效。     

Rescue of exposed scleral buckles with cadaveric pericardial patch grafts

PURPOSE: To describe a new method for salvaging externally exposed silicone scleral exoplants (buckles) to avoid removal and the consequent risk of retinal redetachment. DESIGN: A retrospective, noncomparative, interventional case series. PARTICIPANTS: Four patients with exposed, clinically uninfected scleral buckles after initial surgery for the treatment of rhegmatogenous retinal detachment. INTERVENTION: Processed human donor pericardium patch grafts (Tutoplast; Innovative Ophthalmic Products, INC:, Costa Mesa, CA) were used to cover exposed areas of scleral buckles in concert with conjunctivoplasty. MAIN OUTCOME MEASURES: Scleral buckle preservation was the goal of this new treatment strategy. RESULTS: In four eyes treated with pericardial patch grafts to cover segments of exposed scleral buckles, three (75%) were managed successfully with one surgery. One eye (25%) had this treatment method fail and required scleral buckle removal. CONCLUSIONS: Processed human donor pericardium patch grafting is one useful way to avoid removing exposed scleral buckles, and consequently, sparing patients the risk of recurrent retinal detachment.     

小梁切除联合巩膜瓣下羊膜植入治疗难治性青光眼

目的观察小梁切除术联合巩膜瓣下羊膜植入治疗难治性青光眼的疗效。方法对28例（35眼）难治性青光眼患者行小梁切除联合巩膜瓣下羊膜植入,观察术后滤过泡的形成、眼压变化、手术成功率和并发症的发生率。结果术后随访12～24个月。滤过泡形成情况：I型滤过泡21眼．Ⅱ型滤过泡9眼,Ⅲ型滤过泡2眼和Ⅳ型滤过泡3眼;其中,功能型滤过泡占85．7％（30／35）,非功能型滤过泡占14．3％（5／35）。眼压情况：术后第3个月,平均眼压（13．1±2．6）mmHg;术后第12个月,平均眼压（15．4±3．1）mmHg。手术总有效率为94．3％（33／35）,主要并发症为前房渗出性反应5眼,前房有少量积血1眼（为新生血管性青光眼）,均在1周内消退。结论小梁切除联合巩膜瓣下羊膜植入术能有效提高难治性青光眼的手术成功率。     

Congenital ptosis: results of surgical management

Purpose: To determine the visual and cosmetic outcome following the surgical correction of isolated congenital ptosis. Methods: A retrospective review of the outcome of isolated congenital ptosis corrected under the supervision of one surgeon at The Children's Hospital, Camperdown, between January 1983 and January 1993 was examined. Some 65 patients with 80 involved eyes were identified; 30 eyes underwent a levator resection procedure, 40 eyes underwent a brow suspension using donor stored fascia lata, and in 10 eyes a brow suspension was performed using mersilene mesh. Results: In 78 eyes of 63 patients, a good cosmetic result was achieved. In two patients (two eyes) a poor cosmetic result was achieved. These two patients refused further surgery following an undercorrection of their initial ptosis. The recurrence rates for the primary procedures were 16.7% for levator resection procedures, 35% for brow suspension procedures using donor fascia lata, and 30% for brow suspension surgery using mersilene mesh. Some 35.3% of eyes following mersilene slings required further surgery for granulomas and exposed mersilene mesh compared with 6% having similar complications with stored fascia lata. Nine patients (11.25%) had reduced visual acuity (one line or more on the Snellen chart or its equivalent with the other tests used) on the operated side. Only one patient was found to have significant astigmatism. Conclusions: An acceptable cosmetic result was achieved with one operation in 75.3% of cases. In 20.8% of cases a second operation was required and in 3.9% of cases three or more operations were required. This series supports the view that where possible, levator resection is the preferred form of surgery to correct congenital ptosis. When the levator function is inadequate, brow suspension is performed. The use of donor fascia lata resulted in a good cosmetic appearance with a low occurrence of surgical side effects. Amblyopia, when strictly defined, occurred in 11.25% of eyes despite early surgery for severe cases and intensive amblyopia therapy. Management requires repeated follow up for early detection and introduction of occlusion therapy or surgical ptosis correction.     

Congenital ptosis: results of surgical management

PURPOSE: To determine the visual and cosmetic outcome following the surgical correction of isolated congenital ptosis. METHODS: A retrospective review of the outcome of isolated congenital ptosis corrected under the supervision of one surgeon at The Children's Hospital, Camperdown, between January 1983 and January 1993 was examined. Some 65 patients with 80 involved eyes were identified; 30 eyes underwent a levator resection procedure, 40 eyes underwent a brow suspension using donor stored fascia lata, and in 10 eyes a brow suspension was performed using mersilene mesh. RESULTS: In 78 eyes of 63 patients, a good cosmetic result was achieved. In two patients (two eyes) a poor cosmetic result was achieved. These two patients refused further surgery following an undercorrection of their initial ptosis. The recurrence rates for the primary procedures were 16.7% for levator resection procedures, 35% for brow suspension procedures using donor fascia lata, and 30% for brow suspension surgery using mersilene mesh. Some 35.3% of eyes following mersilene slings required further surgery for granulomas and exposed mersilene mesh compared with 6% having similar complications with stored fascia lata. Nine patients (11.25%) had reduced visual acuity (one line or more on the Snellen chart or its equivalent with the other tests used) on the operated side. Only one patient was found to have significant astigmatism. CONCLUSIONS: An acceptable cosmetic result was achieved with one operation in 75.3% of cases. In 20.8% of cases a second operation was required and in 3.9% of cases three or more operations were required. This series supports the view that where possible, levator resection is the preferred form of surgery to correct congenital ptosis. When the levator function is inadequate, brow suspension is performed. The use of donor fascia lata resulted in a good cosmetic appearance with a low occurrence of surgical side effects. Amblyopia, when strictly defined, occurred in 11.25% of eyes despite early surgery for severe cases and intensive amblyopia therapy. Management requires repeated follow up for early detection and introduction of occlusion therapy or surgical ptosis correction.     

Phacoemulsification and lens implantation after scleral buckling surgery

PURPOSE:To determine the intraoperative and postoperative complications and best-corrected visual acuity outcomes of eyes undergoing phacoemulsification and intraocular lens implantation after retinal detachment repair by the scleral buckling technique. METHODS:The charts of all patients who underwent phacoemulsification and intraocular lens implantation between July 1991 and May 1998 in two surgical practices were reviewed to identify eyes with a history of retinal detachment repaired by the scleral buckling technique. Eyes with a history of pars plana vitrectomy were excluded. Demographic and surgical data, preoperative and postoperative best-corrected visual acuity, and intraoperative and postoperative complications were recorded.RESULTS:We identified 34 eyes of 32 patients. The mean interval from retinal detachment repair to phacoemulsification was 12.4 years. The mean interval from phacoemulsification to final examination was 20 months. Risk factors for retinal detachment included isolated myopia (82%), myopia with lattice retinal degeneration (5.9%), and myopia with trauma (8.8%). One eye (2.9%) had no identifiable risk factors. Final best-corrected visual acuity of 20/40 or better was attained in 29 (85%) of 34 eyes and 20/20 or better in 18 (53%) of the eyes. Of the five eyes with the lowest best-corrected visual acuity, three had a macula-off retinal detachment; one had a posterior capsule opacity, epiretinal membrane, and corneal edema secondary to ocular ischemia; and one had advanced glaucoma. All five eyes still experienced an improvement in best-corrected visual acuity. With regard to complications, one eye had a posterior capsular tear with vitreous loss and another developed a postoperative retinal tear. Posterior capsule opacification requiring laser capsulotomy developed in 13 eyes (38%). No eye developed a retinal redetachment. CONCLUSION:Phacoemulsification and intraocular lens implantation can be performed safely after scleral buckling surgery and excellent best-corrected visual acuity results can be attained in most eyes. No modification of surgical technique is necessary. No retinal redetachment occurred in this series.     

复杂眼外伤的玻璃体切除联合手术治疗

目的:探讨玻璃体切除联合手术治疗复杂眼外伤的疗效。方法:玻璃体切除联合白内障摘除、人工晶状体Ⅱ期植入、眼内异物摘出、视网膜脱离复位治疗复杂眼外伤26例26眼。结果:术后视力较术前提高者19眼,视力不变者6眼,视力下降者1眼;眼内炎2眼感染控制,眼内异物9眼均一次成功摘出,视网膜脱离成功复位者5眼,眼球萎缩1眼。结论:选择恰当的手术时机,合理的手术方案,对挽救眼球和恢复视功能起着决定性作用。     

Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients

PURPOSE: To review one surgeon's experience with posterior lamellar grafting for lower eyelid elevation over a 15-year period, comparing the success of different posterior lamellar grafts used in 4 etiology groups. METHODS: A retrospective chart review of 400 patients (659 eyelids) was conducted. Patients were grouped into thyroid ophthalmopathy, previous surgery, trauma, and idiopathic causes. Three graft types were used: hard palate mucosa, free tarsoconjunctival, and free scleral. Objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy, and subjective patient symptoms, preoperatively and postoperatively were compared between graft types and etiologic groups. Complications were tabulated and compared between groups, as was any need for further surgery. The mean follow-up interval was 16.5 months. The main outcome measures were objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy. RESULTS: A mean reduction in lagophthalmos ( approximately 0.5 mm), superficial punctate keratopathy (mean score reduction = 0.2, on a scale of 1-3), and scleral show ( approximately 1.3 mm) was demonstrated for all etiology groups and graft types. Furthermore, 90% of patients subjectively reported a reduction of 1 to 3 symptoms. Hard palate mucosa grafts were more likely to be used than tarsoconjunctival grafts in cases with one or more previous surgeries (p < 0.001). Complications were more common with tarsoconjunctival grafts (except for bleeding), but the difference was statistically significant only for wound dehiscence (p = 0.004). CONCLUSIONS: Lower eyelid retraction repair with posterior lamellar grafting and lateral eyelid tightening can be recommended with confidence for eyelid retraction patients because most improved subjectively and by objective examination.     

Transscleral fixation of a black diaphragm intraocular lens in severely traumatized eyes requiring vitreoretinal surgery

The records of 4 eyes of 4 patients who had transscleral fixation of black diaphragm intraocular lenses (IOLs) after vitreoretinal surgery due to complications of severe perforating trauma were retrospectively reviewed. The transscleral fixation was performed 4 to 13 months after the vitreoretinal surgery. All patients reported a subjective decrease in glare and photophobia, with improved visual acuity in 2 eyes during a mean follow-up of 3 years. Cystoid macular edema was noted in 1 eye and transitory intraocular pressure elevation due to intraocular silicone oil in 1 eye. Severe perforating eye injury is frequently associated with extensive iris defects and lenticular and vitreoretinal complications. Although visual acuity may not be the primary concern in these eyes, favorable visual rehabilitation can be achieved following proper management of the retinal complications and transscleral fixation of black diaphragm IOLs to overcome glare and photophobia.