Endothelial keratoplasty with anterior chamber intraocular lens versus secondary posterior chamber intraocular lens

Indications and Outcomes of Intraocular Lens Explantation in a Tertiary Eyecare Center in Hungary between 2006 and 2020

Purpose

Our study aimed to evaluate the indications and outcomes of intraocular lens (IOL) explantation surgeries in a tertiary eyecare center in Hungary.

Materials and Methods

This retrospective study included all IOL explantation surgeries performed between 2006 and 2020 at the Department of Ophthalmology of Semmelweis University, Budapest, Hungary. There were no exclusion criteria for this study. For each patient, the demographics, clinical history, preoperative status, indications for IOL explantation, and operative and postoperative details were reviewed. Primary outcomes included explantation indications and the type of secondary implanted IOL.

Results

A total of 161 eyes from 153 patients were included (96 males; 62.7%); age at the time of the IOL explantation was 65.0 ± 17.4 years. The mean time between primary cataract surgery and IOL explantation was 8.5 ± 7.7 years. In total, 139 (86.3%) PCIOLs and 22 (13.7%) ACIOLs were explanted. The main indications for IOL explantation were dislocation (n = 133; 95.7%) and refractive cause (n = 2; 1.4%) in the PCIOL group. Among ACIOL explantations, the main reasons were pseudophakic bullous keratopathy (n = 14; 63.6%), dislocation (n = 4; 18.2%), and refractive cause (n = 2; 9.1%). In the PCIOL group, 115 (82.7%) primary IOLs were implanted in the capsular bag, 16 (11.5%) were sulcus fixated, and 8 (5.8%) were scleral fixated. The most frequent ocular comorbidities were previous vitrectomy (n = 50, 31.1%), previous ocular trauma (n = 45, 28.0%), glaucoma (n = 16, 9.9%), pseudoexfoliation syndrome (n = 15, 9.3%), and high axial myopia (n = 14, 8.7%). The most commonly used secondary IOL implant was the prepupillary iris-claw IOL (n = 115, 73.7%), followed by the retropupillary iris-claw IOL (n = 32, 20.5%). Uncorrected visual acuity (UCVA) was significantly better following IOL exchange in the entire sample (1.57 ± 0.61 (range: 2.40-0.05) vs. 0.77 ± 0.56 (range: 2.40-0.00); p < 0.001). Best-corrected visual acuity (BCVA) was maintained or improved in 80.7% of cases after IOL explantation.

Conclusions

The most common indication for IOL explantation at a tertiary eyecare center in Hungary is IOL dislocation, followed by pseudophakic bullous keratopathy. Prepupillary and retropupillary iris-claw IOL are the most frequently used secondary implants and their use resulted in a significant UCVA improvement following IOL exchange.

Clinical Outcomes of Transscleral-Sutured Intraocular Lens Combined With Descemet Membrane Endothelial Keratoplasty

PURPOSE

The aim of the study was to report clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) combined with transscleral-sutured intraocular lens (IOL) compared with DMEK combined with phacoemulsification and posterior chamber IOL (Phaco-DMEK).

METHODS

A retrospective chart review of all patients who underwent DMEK combined with transscleral-sutured intraocular lens fixation or combined with phacoemulsification for Fuchs endothelial corneal dystrophy from 2016 to 2021 at the Toronto Western Hospital or the Kensington Eye Institute (Toronto, ON, Canada) and had at least 18 months of follow-up was performed. Main outcomes were postoperative distance-corrected visual acuity, rebubbling rate, graft survival rate, and complications.

RESULTS

Twenty-one cases of DMEK combined with transscleral-sutured IOL (DMEK-TSS-IOL) and 44 cases of Phaco-DMEK were evaluated. Twelve eyes (57.15%) had a foldable acrylic 3-piece IOL (AR40E) and 9 (42.85%) had a single-piece polymethylmethacrylate (PMMA) IOL (CZ70BD). LogMAR distance-corrected visual acuity improved significantly from 1.48 ± 0.62 (SD) to 0.86 ± 0.82 ( P = 0.01) 12 months after DMEK-TSS-IOL and from 0.41 ± 0.29 logMAR to 0.11 ± 0.11 logMAR ( P < 0.0001) after Phaco-DMEK. No statistically significant differences were observed in donor ( P = 0.97) or 1-year postoperative endothelial cell density ( P = 0.11) between the groups. Rebubbling was necessary in 33.33% of eyes in DMEK-TSS-IOL compared with 25% of Phaco-DMEK eyes ( P = 0.55). Graft survival rate was 76.19% in the DMEK-TSS-IOL group compared with 90.90% in the Phaco-DMEK group ( P = 0.13).

CONCLUSIONS

Transscleral-sutured IOL combined with DMEK is an option for the management of endothelial diseases in aphakic eyes or those which require IOL exchange for the experienced surgeon. However, when compared with routine Phaco-DMEK, there are higher complication and lower survival rates at 18 months.

Efficacy and safety of UT-DSAEK combined with Carlevale's sutureless scleral fixation IOL

PURPOSE

To evaluate a novel surgical combination of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and sutureless scleral fixation for Carlevale intraocular lens (SSF-Carlevale IOL) implantation to manage corneal endothelial decompensation when there is a concomitant need for secondary IOL fixation.

METHODS

Clinical data collected from 10 eyes of 9 patients with bullous keratopathy (BK) who underwent combined UT-DSAEK and SSF-Carlevale IOL implantation in a single procedure were retrospectively analyzed. Anterior chamber IOL (4 cases), aphakia (4 cases, 1 of which associated with PEX), and previous trauma (2 cases) were the conditions responsible for BK. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell density (ECD), central corneal thickness (CCT), graft thickness (GT) and complications were recorded over a 12-month follow-up period.

RESULTS

In 90% (9/10) of eyes graft clarity was maintained during follow-up. The mean CDVA improved significantly (p < 0.0001) from 1.78 ± 0.76 logMAR preoperatively to 0.53 ± 0.3 logMAR at 12 months. ECD on average decreased from 2575 ± 125.3 cells/mm2 (donor tissue) to 1697 ± 133.3 cells/mm2 in 12 months. The mean CCT decreased from 870 ± 200 µm to 650 µm ± 9 at 12 months (ANOVA, p = 0.0005).

CONCLUSIONS

Combined UT-DSAEK and SSF-Carlevale IOL implantation was associated with good corneal graft survival and IOP control, with few complications. These findings suggest that this surgical approach is a practical option for patients requiring both treatment for corneal endothelial dysfunction and secondary IOL implantation.

Outcomes of Secondary Intraocular Lens Implantation and Descemet Stripping Endothelial Keratoplasty-Comparing Staged Versus Combined Surgical Approach

PURPOSE

The aim of this study was to compare the outcomes of staged versus combined surgical approach for secondary intraocular lens (IOL) implantation and Descemet stripping endothelial keratoplasty (DSEK).

METHODS

This is a retrospective review of 124 eyes from 124 patients who underwent either staged or combined secondary IOL implantation in addition to DSEK over a 5-year period at 2 academic tertiary referral centers, between January 1, 2014, and October 1, 2019. Corrected distance visual acuity (CDVA), presence of graft detachment, primary graft failure (PGF), and cystoid macular edema were documented and analyzed.

RESULTS

The CDVA for the 1- to 2- month follow-up period was significantly better in the staged group compared with the combined group ( P = 0.011). By the postoperative 6- to 9-month follow-up period, there was no significant difference in the CDVA between the groups ( P = 0.591). There was no significant difference in the incidence of PGF or graft detachment between the 2 groups ( P > 0.05). In addition, there was no significant difference in the CDVA or rate of postoperative complications between the different methods of IOL fixation.

CONCLUSIONS

The short-term visual outcomes were significantly better in eyes that underwent staged secondary IOL implantation and DSEK versus the combined surgical approach, although the difference was no longer present at 6 to 9 months. There was no difference in the rate of PGF or graft detachment between the 2 groups.

The Descemet Membrane Endothelial Keratoplasty (DMEK) "Wave Maneuver"

A novel technique for Descemet membrane endothelial keratoplasty (DMEK) graft handling and centration without the endothelium touching the posterior part of the anterior chamber (AC), is presented here. It is particularly suitable for vitrectomized eyes, deep AC, and AC intraocular lenses (ACIOLs), potentially reducing surgery time and endothelial cell loss during surgery. This retrospective interventional case series includes 27 eyes with complex ocular pathology. All utilized a “Wave maneuver” to center an early elevated graft without completing graft centration on the bottom of the AC. Successful graft attachment and centration were evaluated intra and post-operatively. Best-corrected visual acuity (BCVA), central corneal thickness (CCT), and donor endothelial cell density (ECD) were measured pre-operatively, and three and six months post-operatively. DMEK grafts were successfully attached and centered in all cases. No maneuver-related complications were observed intraoperatively. BCVA improved from a pre-operative 0.2 ± 0.63, to 0.43 ± 0.49 and 0.76 ± 0.51 at the three- and six-month follow-ups, respectively (p < 0.01). CCT decreased from a pre-operative 742 ± 118, to 546 ± 87 and 512 ± 67 at three and six months, respectively (p < 0.01). ECD decreased from 2878 ± 419 cells/mm2 to 1153 ± 466 cells/mm2 at three and six months, respectively (p < 0.01). The “Wave maneuver” may be very beneficial in DMEK cases where the AC is either very deep or the bottom of the AC is compromised. The “Wave maneuver” learning curve was brief.

Impact of vaccination on keratoplasty

PURPOSE OF REVIEW

Corneal graft rejection has been reported after coronavirus disease 2019 (COVID-19) vaccination. The purpose of this review is to evaluate the literature regarding corneal graft rejection after vaccination, including rejection rates and risk factors. We aim to create a framework to identify patients who are at higher risk for graft rejection and may warrant consideration of prophylactic interventions.

RECENT FINDINGS

Graft rejection has been reported following administration of mRNA, viral vector, and inactivated whole-virion COVID-19 vaccines. Most cases had additional risk factors associated with rejection. Vaccination increases circulation of proinflammatory cytokines, CD4+ and CD8+ T-cell responses, and antispike neutralizing antibody, all of which may contribute to graft rejection. Two prospective studies have found no relationship between recent vaccination and rejection but 20% of cornea specialists report to have seen a vaccine-associated rejection and 22% recommend delaying vaccination in certain circumstances. Many specialists recommend prophylactic topical corticosteroids before and after vaccination to mitigate rejection risk but there is no evidence to support this practice on a wider scale.

SUMMARY

Our framework identified 96.8% of penetrating keratoplasty patients with vaccine-associated rejection as higher risk. Further research is needed in order to develop evidence-based guidelines.

"Air-Assisted" Donor Lenticule Insertion in Descemet Stripping Endothelial Keratoplasty in Aphakia With Large Iris Defect and Without Posterior Capsular Support

PURPOSE

The purpose of this study was to report a novel technique of donor lenticule insertion in Descemet stripping endothelial keratoplasty (DSEK) in aphakic corneal edema with large iris defect and without any posterior capsular support.

METHODS

This was a retrospective consecutive interventional case series. Clinical records of ten 1-eyed aphakic patients with corneal edema with large iris defect and no capsular support who underwent air-assisted donor lenticule insertion in DSEK were evaluated. After making 6.0- to 6.5-mm sclerocorneal tunnel and 2 side ports, limited anterior vitrectomy was performed if required. Then, Descemetorhexis was performed under air through side ports. Manually dissected donor lenticule was inserted into the anterior chamber under full-chamber air by a 30-G needle push-in technique. Further air tamponade was given if necessary. No fluid-air exchange was performed. The patient was kept on the same operating table for at least 1 hour and then shifted. Graft attachments in early postoperative period, corrected distant visual acuity, and endothelial cell density after 3, 6, and 12 months were analyzed.

RESULTS

The mean postoperative follow-up period was 19.2 ± 6.7 months. There was no donor dislocation in this small group. All patients achieved a corrected distant visual acuity of 0.70 (20/100) after 3 months and maintained until 12 months. The endothelial cell density at 3 months (n = 8) was 2028 ± 151/mm 2 , at 6 months (n = 7) 1776 ± 198/mm 2 , and at 12 months (n = 7) 1721 ± 172/mm 2 . The corresponding endothelial cell loss was 25.8% ± 5.6%, 34.4% ± 5.1%, and 37.8% ± 7.1%, respectively. One graft failed after 15 months.

CONCLUSIONS

"Air-assisted" donor lenticule insertion in DSEK is a safe surgical technique in aphakic patients with corneal edema with large iris defect and no capsular support.

Implantation of retropupillary iris-claw lenses: A review on surgical management and outcomes

Iris-claw lenses have gained increasing popularity over the last years and are by many surgeons regarded as viable options in eyes with insufficient capsular or zonular support. The iris-claw lens has two haptics with fine fissures for folding (enclavating) the mid-peripheral part of the iris stroma and can either be placed in front of or posterior to the iris. In particular, the retropupillary implantation has been increasingly chosen probably due to having an anatomical position similar to that of the crystalline lens. The present review is based on a literature review and also on the authors' clinical experience with this lens, and it focuses on surgical techniques and outcomes especially related to the characteristics of this lens, having haptics with claws that fixate the lens to the posterior iris. Implanting retropupillary iris-claw lenses has a relatively short learning curve, and there are only few complications reported during surgery. Retropupillary iris-claw lenses have demonstrated generally favourable efficiency and safety. However, the outcomes are probably more influenced by the reason for surgery and eye comorbidity than the lens itself. Albeit seldom reported, the postoperative complications have mostly been related to atrophy of the iris at the site of the haptics, or IOL decentration or disenclavation of one of the haptics. To date, however, there are few randomized clinical trials comparing this lens to other lens alternatives in eyes exhibiting insufficient capsular or zonular support for placing the lens in the ciliary sulcus. In the future, prospective studies with large samples should be performed to gain insights into the long-term safety of retropupillary placed iris-claw lenses, and for comparisons with the various other techniques of lens fixation.

Descemet membrane endothelial keratoplasty in a patient with iris-fixated intraocular lens and prior radial keratotomy: a case report

Background

Anterior segment surgeries such as cataract surgery, intraocular lens (IOL) repositioning, and radial keratotomy (RK) may hasten endothelial dysfunction, particularly in the context of pre-existing Fuchs dystrophy, necessitating future corneal transplantation.

Case presentation

A 68-year-old woman with a history of RK with associated irregular astigmatism in both eyes and iris-fixated intraocular lens (IF-IOL) in the left eye presented with six months of decreased vision in the left eye. She was found to have Fuchs dystrophy and underwent DMEK surgery. She had an uncomplicated postoperative course, with uncorrected visual acuity improving to 20/20 three months after surgery.

Conclusion

To our knowledge, this is the first reported case of a highly successful DMEK surgery in a patient with prior RK and IF-IOL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02103-1.

Retropupillary Iris-Claw Intraocular Lenses: A Literature Review

Retropupillary iris-claw intraocular lenses (ICIOLs) have been increasingly chosen by surgeons nowadays as a primary or secondary procedure of IOL implantation in eyes with insufficient capsular or zonular support. They have gained popularity due to their simple fast technique, favourable functional outcomes, and safety. The transition in the ICIOL fixation from prepupillary to a more biologically appropriate retropupillary position and change in the optic design from biconvex to convex-concave have provided better visual outcomes and improved safety. A peer-reviewed literature search was conducted in Medline (PubMed), Embase, and Cochrane Library using the keywords "retropupillary iris claw" and "iris claw". The search yielded 310 articles that were screened. Forty-three articles on retropupillary ICIOLs were finally found to be relevant and reviewed in full-text versions. The functional outcomes following retropupillary implantation of ICIOLs have been acceptable in eyes with no ocular co-morbidities otherwise. However, the indications for surgery may affect the outcomes. The major postoperative complications directly associated with ICIOLs include pupil ovalization and redislocation. Nevertheless, the rate of disenclavation depends on the experience and skill of the surgeon. This review is based on a literature review, and it focuses on the preoperative evaluation, surgical technique, postoperative outcomes, and associated complications. Prospective randomized trials with a larger sample size and longer follow-up are needed for comparison with other techniques of IOL fixation and confirmation of long-term safety profile.