Spontaneous iris retraction occurring after extracapsular cataract extraction and posterior lens implantation in patients with glaucoma

Incidence, causes, and neodymium:YAG laser treatment of pupillary capture

OBJECTIVE

To report the incidence of and factors associated with pupillary capture after cataract surgery and evaluate the outcomes of treatment with the neodymium:YAG (Nd:YAG) laser.

SETTING

Unit of Ophthalmology, University of Edinburgh, and Royal Infirmary of Edinburgh Trust Hospital, Edinburgh, United Kingdom.

METHODS

This prospective study comprised 792 consecutive patients having cataract extraction by one surgeon from 1989 to 1993. Outcome measures were incidence of pupillary capture associated with eye disease and treatment, surgical technique, and intraocular lens (IOL) placement and style; postoperative progress; and results of Nd:YAG treatment.

RESULTS

Pupillary capture developed in 30 of the 764 patients (3.9%) having implantation of a posterior chamber IOL a mean of 14 weeks postoperatively (range 2 to 44 weeks). The incidence was significantly higher in eyes with angle-closure glaucoma, combined glaucoma and cataract surgery, can-opener capsulotomy, manual extraction, sulcus IOL implantation, large-optic IOLs, and one-piece IOLs. Neodymium:YAG laser treatment was successful in 8 of 12 eyes.

CONCLUSION

Pupiliary capture may be anticipated and when recognized at an early stage, treated successfully with an Nd:YAG laser in most cases.

Results of cataract surgery and implantation of a compressible disc lens in patients with glaucoma

We studied the efficacy and postoperative behavior of a compressible disc posterior chamber intraocular lens in 40 eyes of 33 glaucoma patients. They had a mean follow-up of 12.8 months. Postoperatively, 38 eyes (95%) had a best corrected visual acuity of 20/40 or better. Minor decentration occurred in one case. Early posterior capsule fibrosis (40%) was 50% less than in earlier reports on the rigid Galand disc IOL. Posterior synechias were present in 35% of eyes. Postoperative complications such as pupil capture (0%) and significant posterior capsule opacification (12.5%) were minimized by using this IOL. Closed-loop circular lenses are an attractive alternative to open-loop-supported IOLs in patients with glaucoma.

Iris modifications following extracapsular cataract extraction with posterior chamber lens implantation

We prospectively examined 94 eyes of 93 consecutive patients who had planned extracapsular cataract extraction or phacoemulsification with posterior chamber intraocular lens (IOL) implantation. The observed postoperative iris biomicroscopic modifications are described and classified. Iris synechial formation was more frequently observed in eyes with pseudoexfoliation syndrome, when an irregular anterior capsulotomy was performed, when the IOL was other than in the bag, and in cases of postoperative fibrinous exudation. Synechias occurred more frequently in intraoperatively injured iris areas. Pupil capture was the only postoperative iris modification that was observed to affect visual acuity. The maximal postoperative dilation was greater and the pupillary photic reaction was significantly less modified postoperatively (P = .0058) when the IOL was fixated within the capsular bag.

Posterior chamber intraocular lens dislocations and malpositions

Decentration and malposition of posterior chamber intraocular lenses (PC IOL) accounts for one of the remaining and unresolved conditions associated with the implantation of these lenses. This condition assumes importance since in approximately 50% of cases where a PC IOL is removed there is an aspect of improper positioning. The common types of malpositions are: pupil capture; sunset syndrome; sunrise syndrome; horizontal decentration; and the windshield wiper syndrome. This paper will explore the causes and management of these conditions and discuss the virtues of capsular bag implantation.

Glaucoma and its relationship to intraocular lens implantation

The management of glaucoma and cataract is a complex subject that has remained controversial until recently. Extracapsular cataract surgery with posterior chamber lens implantation has made the procedure safe to perform in most eyes with glaucoma controlled medically, by laser trabeculoplasty or after filtering surgery. This paper will review the literature to establish rational guidelines for this particular group of patients.

Glaucoma and intraocular lens implantation

Extracapsular cataract extraction with posterior chamber intraocular lens implantation is a viable method to rehabilitate the glaucoma patient with a cataract effectively. The success with this procedure in uncomplicated cases is translated into excellent results in the glaucomatous eye. This paper reports the results of extracapsular cataract extraction with posterior chamber intraocular lens implantation in four groups of glaucoma patients: (1) chronic open-angle glaucoma; (2) angle-closure glaucoma; (3) after argon laser trabeculoplasty; (4) after filtering procedures. The visual acuity after this surgical procedure improved to 20/40 or better in 86% of patients. Intraocular pressure was controlled in all groups at a level approaching the preoperative value. Ninety percent were controlled with equal or less medication than that used preoperatively. There has been no significant progression of optic nerve cupping or visual field loss.

Combined cataract extraction and guarded sclerectomy. Reevaluation in the extracapsular era

Thirty-four eyes of 25 patients underwent a guarded sclerectomy in combination with either an intracapsular or extracapsular cataract extraction. The intraocular pressure was well-controlled in the early postoperative period in all but one case, and only one eye developed a flat anterior chamber that required surgical reformation. However, there was a high incidence of intraoperative and postoperative complications in both the intracapsular and extracapsular groups. These observations, as well as experience with extracapsular cataract extraction and posterior chamber lens implantation alone in glaucomatous eyes, have led to a reevaluation of the criteria for combined cataract and glaucoma surgery.

Malpositioned posterior chamber lenses: etiology, prevention, and management

The various types of posterior chamber intraocular lens malpositions, in increasing degrees of severity, are described. These include pupillary capture, optic decentration, malpositioned loop, windshield wiper, sunrise, sunset and lost lens syndromes. The etiologies, management, and prevention of these complications are discussed.

Complications of intraocular lenses. A historical and histopathological review

Recent improvements in intraocular lens (IOL) design, manufacturing techniques, and surgical techniques have greatly reduced the incidence of complications following implantation, and many authors now consider IOL implantation to be among the most safe and effective major surgical procedures. However, adverse reactions are still seen--some as late sequelae of earlier IOL designs and implantation techniques and some as sequelae of more recent implantations using "state-of-the-art" lenses and surgical techniques. Complications may be due to various factors, including surgical technique, IOL design, or the inability of some eyes with preexisting disease to tolerate an implant. The authors trace the evolution of IOLs since Ridley's first implant, summarizing the modifications in lenses and surgical techniques that were made as complications were recognized. They then review the clinical and histopathological features of selected cases from more than 200 IOLs and/or globes removed due to IOL-related complications and studied in the University of Utah Ocular Pathology Laboratory. It is hoped that this review will provide insights into the pathogenesis of IOL complications, enhancing the current success of implant procedures and stimulating further basic and clinical research in this area.