Episcleritis and secondary glaucoma after transscleral fixation of a posterior chamber intraocular lens

Sulcus Fixated Posterior Chamber Lenses with and without Suture in Cases Lacking Capsular Support

In a prospective study ten commercially available anterior chamber lenses with S-shaped haptics and multipoint support were implanted into the posterior chamber in cases of secondary lens implantation after intracapsular cataract operation. The lenses were trans-sclerally fixed by two sutures through the ciliary sulcus. They showed more immediate stability than ten C-loop posterior chamber lenses of a control group and remained firmly fixed without complications during a follow-up of up to 54 months. To overcome the disadvantages of suture fixation a sutureless sulcus self-fixation PCL was developed and implanted into six eyes with special indications. After more than one year of follow-up no late adverse reaction was noted.

Cauterization technique for suture erosion in transscleral fixation of intraocular lenses

Transscleral suturing is a commonly applied technique to fix intraocular implants in the sulcus. A major problem after transscleral implantation is suture erosion that normally happens in the late post-surgery period and may result in an increased incidence of endophthalmitis. Here we describe an original cauterization method by using a glass rod to melt the exposed suture end without damaging the suture knot in the sclera to avoid suture exposure in sclera-fixed IOL implantation. This is a simple, quick and effective technique that can be performed without conjunctiva incisions and will help to reduce suture erosion related complications.

Ab externo 4-point scleral fixation of posterior chamber intraocular lenses

PURPOSE

To evaluate the results of ab externo 4-point scleral fixation of posterior chamber intraocular lenses (PC IOLs) as a primary or secondary procedure.

SETTING

Aravind Eye Hospital, Madurai, India.

METHODS

This retrospective study comprised 25 patients: 17 aphakic and 8 with traumatic subluxated lenses. The subluxated cataracts were removed intracapsularly. All patients had ab externo 4-point flapless scleral fixation of a PC IOL. Preoperative status, intraoperative details, and postoperative outcome were analyzed.

RESULTS

Mean follow-up was 8.02 months (range 6 to 26 months). The preoperative findings included sector iridectomy (n = 6), peripheral anterior synechias (n = 5), corneal scar (n = 2), vitreous hemorrhage (n = 2), traumatic angle recession (n = 1), retinitis pigmentosa (n = 1), primary open-angle glaucoma (n = 1), and macular pigmentary mottling (n = 1). There were no intraoperative problems related to scleral fixation. Postoperative complications and findings included cystoid macular edema (CME) (n = 2), uveitis (n = 1), and a healed macular choroidal tear (n = 1). No patient had suture exposure, IOL tilt/decentration, or infection. Twenty-two patients (88.0%) had a visual acuity of 6/12 or better at final follow-up. The cause of poor visual recovery in 3 patients included pre-existing macular degeneration, healed macular choroidal tear, and CME in 1 patient each.

CONCLUSION

Four-point scleral fixation is a simple technique that in this series of 25 patients was not associated with major intraoperative or postoperative complications and gave satisfactory visual results.

Glaucoma associated with uveitis

Raised intraocular pressure is a common and frequently serious complication of anterior uveitis. The milieu of inflammatory cells, the mediators they release, and the corticosteroid therapy used to treat the uveitis can participate in the pathogenesis of uveitic glaucoma. These factors alter the normal anatomic structure of the anterior chamber and angle, influencing aqueous production and outflow. These changes act to disrupt the homeostatic mechanisms of intraocular pressure control. Structural changes in the angle can be acute, such as in secondary angle closure with pupillary block glaucoma, or chronic, such as combined steroid-induced and secondary open angle glaucoma. Management of uveitic glaucoma may be difficult because of the numerous mechanisms involved in its pathogenesis. Diagnostic and therapeutic decisions are guided by careful delineation of the pathophysiology of each individual case. The goal of treatment is to minimize permanent structural alteration of aqueous outflow and to prevent damage to the optic nerve head. This article reviews the pathogenesis of uveitic glaucoma, with specific attention to etiology. Medical and surgical therapies are also discussed, with emphasis on the more recent developments in each category.

Long-term results using scleral-fixated posterior chamber intraocular lenses

Transscleral ciliary sulcus fixation of a posterior chamber intraocular lens (IOL) is a technique for managing complicated cataract surgery, secondary IOL implantation, and IOL exchange. We performed a retrospective review of 32 patients who had a minimum of six months and a mean of 13.3 months follow-up after transscleral ciliary sulcus fixation of a posterior chamber IOL. In 30 patients, vision was maintained or improved following surgery. Complications were not uncommon; they were visually significant in three patients and necessitated a reoperation for late subluxation of the IOL in one other patient. Although the long-term visual results are encouraging, the postoperative complication rate of scleral-fixated posterior chamber IOLs is between that of posterior chamber IOLs inserted when the posterior capsule is intact and that of closed-loop anterior chamber IOLs.

Intraocular lens exchange for anterior chamber intraocular lens-induced corneal endothelial damage

BACKGROUND

Anterior chamber and iris-plane intraocular lenses (IOLs) have been implicated in causing corneal endothelial damage and progression to pseudophakic bullous keratopathy.

METHODS

The authors performed IOL exchanges on 102 eyes with signs of early corneal decompensation or progressive endothelial cell loss associated with these anterior chamber or iris-plane IOLs. Replacement IOLs were posterior chamber lenses sutured to the iris (87 eyes), sutured to the sclera (3 eyes), or placed in the ciliary sulcus (12 eyes).

RESULTS

Seventy-two eyes (71%) had the same or improved vision after a mean follow-up period of 18.6 months (range, 6 to 60 months). Only 24 eyes (23.5%) progressed to corneal decompensation. Of the eyes that decompensated, 75% had preoperative endothelial cell counts of 500 cells/mm2 or less (P < 0.0001), and 83% had preoperative signs of early corneal decompensation (P < 0.001). Biomicroscopic signs of early corneal decompensation seen preoperatively in 50 eyes resolved in 17 eyes (34%) and remained unchanged in 12 eyes (24%) at the last postoperative follow-up visit.

CONCLUSION

Removal of anterior chamber and iris-plane intraocular lenses in eyes showing signs of endothelial damage may prevent progression to pseudophakic bullous keratopathy if performed before a critical degree of endothelial cell loss or dysfunction has developed.