Long-term outcomes of combined penetrating keratoplasty with iris-sutured intraocular lens implantation

Long-term Outcomes After Lamellar Endothelial Keratoplasty Compared With Penetrating Keratoplasty for Corneal Endothelial Dysfunction: A Systematic Review

PURPOSE

The purpose of this study is to evaluate long-term outcomes of endothelial keratoplasty (EK) compared with penetrating keratoplasty (PK) for corneal endothelial dysfunction [Fuchs endothelial corneal dystrophy (FECD) and bullous keratopathy (BK)].

METHODS

In this systematic review, we searched PubMed, the Cochrane Library, and Embase up to May 2022 and considered all types of studies addressing our objective. Graft survival at 5, 10, and 15 years was the main outcome.

RESULTS

Fifty cohort studies were included. At 5 years, in FECD and BK, graft survival seemed higher after EK than PK. Two comparative studies showed either a higher 5-year graft survival after EK than PK or no significant differences. Including noncomparative studies, in FECD, the 5-year graft survival ranged from 0.69 to 0.98 for PK, from 0.93 to 1.00 for DSEK, and from 0.93 to 0.99 for Descemet membrane endothelial keratoplasty (DMEK). In BK, the 5-year graft survival ranged from 0.39 to 0.91 for PK, from 0.65 to 0.89 for DSEK, and from 0.84 to 0.95 for DMEK. The 10-year graft survival ranged from 0.20 to 0.90 for PK and from 0.62 to 0.92 for EK. The mean 5-year best spectacle-corrected visual acuity ranged from 0.73 to 0.43 LogMAR for PK, from 0.61 to 0.09 for DSEK, and from 0.31 to 0.05 for DMEK. The 5-year rejection rate ranged from 11.0% to 28.7% for PK, from 5.0% to 7.9% for DSEK, and from 1.7% to 2.6% for DMEK.

CONCLUSIONS

These results suggest a higher 5-year graft survival and better secondary outcomes after EK. Nevertheless, the level of evidence was low.

PROSPERO REGISTRATION

CRD42021260614.

Trans-Scleral Plugs Fixated FIL SSF IOL: A Review of the Literature and Comparison with Other Secondary IOL Implants

Purpose. To revise the current literature on FIL SSF (Carlevale) intraocular lens, previously known as Carlevale lens, and to compare their outcomes with those from other secondary IOL implants. Methods. We performed a peer review of the literature regarding FIL SSF IOLs until April 2021 and analyzed the results only of articles with a minimum of 25 cases and a follow-up of at least 6 months. The searches yielded 36 citations, 11 of which were abstracts of meeting presentations that were not included in the analysis because of their limited data. The authors reviewed 25 abstracts and selected six articles of possible clinical relevance to review in full text. Of these, four were considered to be sufficiently clinically relevant. Particularly, we extrapolated data regarding the pre- and postoperative best corrected visual acuities (BCVA) and the complications related to the procedure. The complication rates were then compared with those from a recently published Ophthalmic Technology Assessment by the American Academy of Ophthalmology (AAO) on secondary IOL implants. Results. Four studies with a total of 333 cases were included for results analysis. The BCVA improved in all cases after surgery, as expected. Cystoid macular edema (CME) and increased intraocular pressure were the most common complications, with an incidence of up to 7.4% and 16.5%, respectively. Other IOL types from the AAO report included anterior chamber IOLs, iris fixation IOLs, sutured iris fixation IOLs, sutured scleral fixation IOLs, and sutureless scleral fixation IOLs. There was no statistically significant difference in the rates of postoperative CME (p = 0.20), and vitreous hemorrhage (p = 0.89) between other secondary implants and the FIL SSF IOL, whereas the rate of retinal detachment was significantly less with FIL SSF IOLs (p = 0.04). Conclusion. The results of our study suggest the implantation of FIL SSF IOLs is an effective and safe surgical strategy in cases where there is a lack of capsular support. In fact, their outcomes seem to be comparable to those obtained with the other available secondary IOL implants. According to published literature, the FIL SSF (Carlevale) IOL provides favorable functional results with a low rate of postoperative complications.

Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens

Purpose

To assess the incidence of glaucoma after combined Descemet's stripping endothelial keratoplasty (DSEK) and retropupillary fixated iris-claw intraocular lens (IOL) implantation in the patients with bullous keratopathy (BK) who required secondary IOL or IOL exchange.

Methods

In this retrospective case series, medical records of 22 patients who underwent combined DSEK and retropupillary fixated iris-claw IOL implantation were evaluated. Preoperative vision, intraocular pressure (IOP), postoperative IOP at different time periods, and intraoperative and postoperative complications were analyzed.

Results

A total of 22 eyes of 22 patients (7 females and 15 males) were analyzed. The median age was 62 years, and the median duration of the postoperative follow-up was 106.5 days. The corrected distance visual acuity improved from a median of 1.85 logMAR to 1.68 logMAR. None of the patients had intraoperative complications. Three patients (13.6%) had dislocation of the donor tissue on the 1^st postoperative day and were successfully rebubbled. Six eyes (27.3%) had graft failure and required penetrating keratoplasty. Eleven eyes (50%) had a sustained rise in the IOP, of which 2 (9.09%) had ocular hypertension and 9 eyes (40.9%) progressed to glaucoma.

Conclusions

DSEK combined with retropupillary fixated iris-claw lens is a good surgical option for the management of aphakic/pseudophakic BK in patients who require secondary IOL or IOL exchange. Regular IOP monitoring after the surgery is an essential, as there is a risk of IOP rise and glaucoma in the postoperative period. Clinicians should be vigilant and control the IOP to prevent glaucoma progression.

Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the visual acuity results and complications of different surgical techniques for intraocular lens (IOL) implantation in the absence of zonular support.

METHODS

Peer-reviewed literature searches were conducted last in PubMed and the Cochrane Library in July 2019. The searches yielded 734 citations of articles published in English. The panel reviewed the abstracts of these mostly retrospective case series studies, and 45 were determined to be relevant to the assessment objectives. Three articles were rated as level II evidence, and 42 articles were rated as level III evidence.

RESULTS

Eight different types of IOL fixation techniques with at least 6-month follow-up were evaluated: anterior chamber IOL (ACIOL), iris-claw IOL, retropupillary iris-claw IOL, 10-0 polypropylene iris-sutured posterior chamber IOL (PCIOL), 10-0 polypropylene scleral-sutured PCIOL, 8-0 polypropylene scleral-sutured PCIOL, CV-8 polytetrafluoroethylene, and intrascleral haptic fixation (ISHF). Eight articles reported data comparing 2 techniques. The 45 studies had insufficient statistical power to compare the techniques conclusively. A qualitative analysis of similar types showed that trends in visual acuity outcomes were not inferior to those of ACIOL implantation, but the severity of preoperative pathologic features was not controlled for. Compared with ACIOL, complications of cystoid macular edema were higher in 10-0 polypropylene iris-sutured PCIOL and 8-0 polypropylene scleral-sutured PCIOL. Non-anterior chamber IOL techniques were less likely to report chronic uveitis. Chronic glaucoma was highest in the 8-0 polypropylene scleral-sutured PCIOL group. Although retinal detachment was infrequent overall, it was twice as common in both iris- and scleral-sutured PCIOLs (except CV-8 polytetrafluoroethylene suture) compared with nonsutured methods: ACIOL, iris-clipped IOL, and ISHF PCIOL.

CONCLUSIONS

The evidence reviewed shows no superiority of any single IOL implantation technique in the absence of zonular support. The various techniques seem to have equivalent visual acuity outcomes and safety profiles. Each technique has its own profile of inherent risk of postoperative complications. Surgeons must educate patients on the importance of close, long-term follow-up as a result of the uncertain nature of these techniques. Large prospective studies are needed to confirm the long-term complication profiles of these various IOL implantation techniques.

Iris suture fixation of subluxated intraocular lenses

PURPOSE

To assess the results of iris suture fixation of subluxated intraocular lenses.

DESIGN

Retrospective study.

METHODS

This was a nonrandomized chart review of eyes with subluxated intraocular lenses that underwent iris suture fixation at an academic institutional care center. Seventy-two eyes of 67 consecutive patients were included. The following cases were excluded: posterior dislocations necessitating pars plana vitrectomy; secondary implantations for aphakia; and iris suture fixation at primary cataract extraction. Main outcome measures included visual acuity improvement, surgically induced astigmatism, and postsurgical complications.

RESULTS

The mean follow-up duration was 16.64 ± 24.37 months (median = 4.03 months). All patients had preoperative monocular diplopia or unstable vision attributable to the subluxated intraocular lenses, and 40.3% of them required aphakic correction. There was an overall improvement in best-corrected visual acuity from a mean preoperative logMAR 0.35 ± 0.32 (Snellen equivalent∼20/45) to logMAR 0.21 ± 0.25 (20/32, P = .001). There was no significant change in astigmatism secondary to the surgery. The mean difference in preoperative keratometry readings was 1.6 ± 1.07 diopter (D), whereas the mean postoperative manifest refraction astigmatic error (vertexed to the corneal surface) was 1.29 ± 0.92 D (P < .02). Re-subluxations occurred in 7 eyes during follow-up; the majority of these eyes underwent repeat fixation. Most (93.55%) intraocular lenses were stable and centered at the final follow-up. Glaucoma developed in 2 eyes postoperatively.

CONCLUSIONS

Iris suture fixation of subluxated intraocular lenses was efficacious for the eyes included in this study, and it led to long-term stability of the intraocular lenses in 93.55% of cases.

Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty

BACKGROUND

To evaluate the indication, visual outcome, and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL) during penetrating keratoplasty.

METHODS

This retrospective study comprised 23 eyes (23 patients) without adequate capsule support undergoing posterior iris-claw aphakic IOL implantation (Verisyse/Artisan) during penetrating keratoplasty between 2005 and 2010. Mean follow-up was 18 months (range from 12 to 37 months).

RESULTS

The IOLs were inserted during an IOL exchange in 17 eyes and as a secondary procedure in six aphakic eyes. Pseudophakic bullous keratopathy with corneal scar after anterior chamber intraocular lens (ACIOL) was the main indication for penetrating keratoplasty in 16 eyes (69.6 %). The final corrected distance visual acuity (CDVA) in logMAR (mean 1.0 ± 0.46) improved significantly (p < 0.05) compared to the preoperative CDVA (mean 1.8 ± 0.73). Twenty eyes (86.9 %) had a final visual acuity in logMAR better than the pre-operative CDVA. The mean postoperative IOP 16.3 mmHg ± 4.0 was not significantly (p > 0.05) higher compared to the preoperative IOP 15.6 mmHg ± 5.1. Complications included slight temporary pupil ovalization in three eyes (13.0 %) and iris-claw IOL sublocation in three eyes (13.0 %); all IOLs could be easily repositioned. Cystoid macular edema occured in one eye (4.3 %) 8 weeks after primary surgery. All grafts remained clear without any sign of graft rejection.

CONCLUSIONS

Retropupillar iris-claw IOL during penetrating keratoplasty provides good visual outcomes with a favorable complication rate, and can be used for a wide range of indications in eyes without adequate capsule support.

Ultrasound biomicroscopic analysis of iris-sutured foldable posterior chamber intraocular lenses

PURPOSE

To report ultrasound biomicroscopic (UBM) findings of iris-sutured foldable posterior chamber intraocular lenses (PCIOLs).

DESIGN

Prospective, noninterventional consecutive case series.

METHODS

Fifteen eyes with foldable acrylic IOL implantation using peripheral iris suture fixation in the absence of capsular support were included. UBM was used to determinate the haptic position in relation to the ciliary sulcus and ciliary body in these eyes. Additionally, anterior chamber depth, lens tilt, site of suture fixation, focal iris or angle abnormalities, and relationship of iris to lens were determined. Main outcome measures were haptic position, anterior chamber depth, and iris anatomic changes.

RESULTS

Of the 30 haptics imaged, 16 (53.3%) were positioned in the ciliary sulcus. Nine (30%) haptics were found over the ciliary processes, and 5 (16.7%) were over pars plana. No patients were found to have peripheral anterior synechiae present at the haptic position. The mean (+/- standard deviation) depth of the anterior chamber was 3.84 +/- 0.36 mm. The iris profile was altered in all patients at the iris-haptic suture fixation site. No angle abnormalities or tilted lenses were found.

CONCLUSIONS

Iris-sutured PCIOL haptics were found to be in the ciliary sulcus or over the ciliary body with no significant tilt on UBM analysis. The procedure respects the angle anatomy, and no evidence of angle closure was found. The anterior chamber was deeper than has been reported previously for scleral sutured PCIOLs and was similar to that of pseudophakic eyes. This may have implications for surgical technique, IOL power calculations, and postoperative complications.

Small-Incision Iris Fixation of Foldable Intraocular Lenses in the Absence of Capsule Support

PURPOSE

To report visual outcomes and complications of modified McCannel iris suture fixation of small-incision foldable acrylic intraocular lenses (IOLs) for aphakia in the absence of capsule support.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Forty-six patients who underwent foldable acrylic IOL implantation using peripheral iris suture fixation for aphakia in the absence of capsule support.

METHODS

Data from 46 patients who underwent iris fixation of a foldable acrylic IOL were retrospectively evaluated for underlying diagnoses, surgical history, clinical results, and complications.

MAIN OUTCOME MEASURES

Postoperative best-corrected visual acuity (BCVA), spherical equivalent, and surgical complications.

RESULTS

Best-corrected visual acuity improved from 20/100 to 20/50 (P = 0.01), with 97% of eyes maintaining or improving BCVA after a mean (+/- standard deviation) follow-up of 24.1+/-12.4 months. Complications included transient low-grade uveitis (3 [6.5%]), transient pigment dispersion (3 [6.5%]), IOL dislocation (2 [4.3%]), elevated intraocular pressure (1 [2.2%]), and retinal detachment (1 [2.2%]). No new cases of cystoid macular edema or worsening of glaucoma occurred.

CONCLUSION

Small-incision peripheral iris fixation of 3-piece acrylic foldable IOLs in the absence of capsule support appears to be an effective technique with few severe adverse events.

Subluxation of suture-fixated posterior chamber intraocular lenses a clinicopathologic study

PURPOSE

To report the occurrence of subluxation of suture-fixated posterior chamber (PC) intraocular lenses (IOL) and elucidate the mechanisms involved.

DESIGN

Prospective clinicopathologic study.

PARTICIPANTS

A single 10-0 Prolene suture explanted from a patient who experienced subluxation of his PC-IOL, 11.5 years after placement. Furthermore, multiple 10-0 Prolene sutures and PC-IOLs used for iris fixation were studied as controls.

METHODS

Scanning electron microscopy (SEM) was used to analyze the surface of the explanted suture. In addition, randomly selected 10-0 Prolene sutures cut with Vannas scissors and cut with the positioning holes of a randomly selected PC-IOL identical to that implanted in the patient's eye were examined as controls. Finally, the positioning holes of several randomly selected, iris-fixated PC-IOLs were studied using SEM with particular attention to surface quality and edge finish.

MAIN OUTCOME MEASURES

Presence of any signs of suture degradation, the character of the cut edge of the suture, as well as the characteristics of the positioning holes of the PC-IOLs.

RESULTS

Scanning electron microscopy of the explanted suture revealed sharply cut edges, without significant degradation of the suture, and no intact loop. Scanning electron microscopy of the control suture cut with a PC-IOL demonstrated a similarly cut edge. The positioning holes of the examined PC-IOLs had a sharp edge, and some also had an imperfect finish.

CONCLUSION

We conclude that the surface properties of the positioning holes lead to cutting of the suture, and subsequent subluxation of the PC-IOL.

Deep Lamellar Endothelial Keratoplasty

PURPOSE

To report the 6-month results for the treatment of endothelial dysfunction in a large, prospective series of deep lamellar endothelial keratoplasty (DLEK) procedures.

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

One hundred eyes of 88 patients with corneal edema from Fuchs' dystrophy and pseudophakia.

METHODS

A limbal, scleral, partial-depth incision provided access for a deep lamellar corneal pocket dissection. Two eyes were converted to penetrating keratoplasty (PK) at the time of DLEK surgery because of poor dissections. Of the 98 eyes that had completed DLEK surgeries, 36 eyes received a large-incision technique (9-mm scleral access incision) and 62 eyes received a small-incision technique (5-mm scleral access incision). A 7.5- to 8.0-mm posterior lamellar disc of recipient tissue then was excised and replaced through the pocket with a similar size donor disc containing healthy endothelium. A temporary air bubble in the anterior chamber was used for donor tissue adherence, and no surface corneal incisions or sutures were necessary.

MAIN OUTCOME MEASURES

Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction (MR) astigmatism, and endothelial cell density (ECD) were evaluated prospectively.

RESULTS

At 6 months after surgery, all 98 DLEK corneas were clear and the grafts were healed in good position. The mean BSCVA was 20/46, with a range between 20/20 and 20/400. The average MR astigmatism was 1.34+/-0.86 diopters (D), representing an average change in astigmatism from before surgery of +0.28+/-1.08 D (P = 0.013). The average ECD at 6 months was 2140+/-427 cells/mm2, representing a mean cell loss from preoperative donor cell measurements of 25%.

CONCLUSIONS

The DLEK procedure, with its absence of corneal surface incisions and sutures, preserves the normal corneal topography, minimizes astigmatism, and provides a healthy donor endothelial cell count and function. The DLEK procedure represents a reasonable alternative to PK, and compared with historical PK data, offers superior refractive outcomes in the treatment of endothelial dysfunction.

Subluxation of Iris-Sutured Intraocular Lenses and Results of a Closed Chamber Technique for Repositioning After Penetrating Keratoplasty

PURPOSE

To describe subluxation of iris-fixated intraocular lenses (IOLs) after penetrating keratoplasty (PK) as a postoperative complication and report the long-term outcomes of a closed-chamber refixation technique used in the management.

METHODS

This was a retrospective, noncomparative interventional case series in which 19 consecutive patient charts with a subluxated iris-fixated IOL after PK were retrospectively reviewed. Fourteen of the patients underwent surgery using a closed-chamber refixation technique. These patients were evaluated for visual outcome and surgical complications associated with the procedure.

RESULTS

In 13 patients, postoperative follow-up was available. In all 13 cases, the fixated IOL appeared stable and remained well positioned during a follow-up period of 56 months (range, 6-122). All patients (100%) achieved improved uncorrected visual acuity. The postoperative visual acuity ranged from 20/20 to 20/100 with a mean of 20/40. Vitreous hemorrhage occurred in 1 patient, and an additional patient required a second surgery using the same technique. Both of these patients did well with a final visual acuity of 20/40 and 20/50, respectively.

CONCLUSIONS

Subluxation of iris-fixated IOL after PK can occur as a postoperative complication. The technique that we herein describe enables secure refixation of subluxated IOLs and yields favorable long-term results.