Long-Term Outcomes of Iris-sutured Posterior Chamber Intraocular Lenses in Children

PURPOSE

To report the long-term outcomes and complications of iris-sutured posterior chamber intraocular lenses (PCIOLs) in the pediatric population.

DESIGN

Retrospective interventional case study.

METHODS

This study involved 12 consecutive pediatric patients (17 eyes) who underwent placement of foldable iris-sutured PCIOLs between September 2004 and September 2007. Outcome measures included change in visual acuity and complications.

RESULTS

Of the 17 eyes were reviewed, 6 (35%) had hereditary or idiopathic ectopia lentis, 5 (29%) had Marfan syndrome, 2 (12%) were aphakic after pars plana vitrectomy and 4 (24%) were aphakic after surgical intervention for trauma. Average follow-up was 4.69 ± 3.21 years and mean age of surgery was 7.21 ± 3.78 years. Seven eyes suffered dislocation of the PCIOL an average of 12.11 ± 11.97 months after surgery, with 2 patients undergoing dislocation a second time. There was a higher rate of dislocation in patients with a history of ectopia lentis due to Marfan syndrome, idiopathic causes, or hereditary causes than in patients being treated for aphakia resulting from other causes (71% vs 29%). Mean visual acuity improved in 12 of 17 patients (71%), from 0.80 ± 0.6 logMAR preoperatively to 0.35 ± 0.5 logMAR at most recent visit, P = .009. One eye of a Marfan patient sustained a retinal detachment 8 months after dislocation of the PCIOL, and 1 patient experienced iris capture of the PCIOL after surgery.

CONCLUSIONS

Iris-sutured intraocular lenses have been used as an alternative to transsclerally sutured intraocular lenses to correct aphakia in pediatric patients. Dislocation of the intraocular lenses can occur frequently, however. The procedure should be considered with caution in pediatric patients.

Scleral-fixated capsular tension rings and segments for ectopia lentis in children

PURPOSE

To report the short-term outcomes and complications of implantation of scleral-fixated capsular tension rings and/or capsular tension segments with intraocular lenses (IOL) in pediatric patients with ectopia lentis.

DESIGN

Retrospective, observational case series.

METHODS

Thirteen consecutive pediatric patients (19 eyes) underwent placement of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring between January 1, 2009 and March 30, 2013 by 3 anterior segment surgeons at a single academic center. The scleral fixation suture was 9-0 polypropylene in 16 eyes and CV-8 Gore-Tex (expanded polytetrafluoroethylene) in 3 eyes. Outcome measures included change in corrected distance visual acuity (CDVA) and complications.

RESULTS

The mean age was 10.2 years ± 4.8 (SD) and the median follow-up, 23.4 months. A Cionni modified capsular tension ring was implanted in 5 eyes and a capsular tension segment with an unsutured capsular tension ring was implanted in 12 eyes. In 2 eyes, capsular tension segment alone was placed. The mean CDVA at the final follow-up (0.10 ± 0.11 logMAR, 18 eyes) was significantly better than preoperatively (0.58 ± 0.26 logMAR, 15 eyes) (P < .001). The CDVA at the final follow-up was 20/40 or better in 18 eyes (94.7%). All IOLs were well centered. Posterior capsule opacification developed in 11 eyes (57.9%), 9 eyes (47.4%) required neodymium-yttrium-aluminum-garnet capsulotomy, and 3 eyes (15.8%) required pars plana vitrectomy and posterior capsulotomy. Other complications included broken suture (5.3%) (9-0 polypropylene at CTR eyelet, repaired with CV-8 Gore-Tex), conjunctival dehiscence (5.3%), suture exposure (5.3%) (trans-scleral 9-0 polypropylene), and vitreous strand at inferior paracentesis (5.3%).

CONCLUSIONS

Implantation of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring appears to be a safe and effective technique for visual rehabilitation in pediatric ectopia lentis.

A prospective multicenter clinical trial to evaluate the safety and effectiveness of the implantable miniature telescope

PURPOSE

To evaluate the safety and preliminary efficacy of a novel visual prosthetic device, the Implantable Miniature Telescope, IMT (by Dr Isaac Lipshitz) (IMT), in a phase I trial in patients with significant bilateral central vision impairment from late-stage age-related macular degeneration (AMD). The IMT is designed to reduce the relative size of the scotoma by rendering enlarged (threefold) central visual field images over the central and peripheral retina.

DESIGN

Prospective, multicenter, open-label clinical trial.

METHODS

In this prospective, multicenter phase I trial, 14 patients aged 60 or older with bilateral geographic atrophy or disciform scar AMD, cataract, and best-corrected visual acuity (BCVA) between 20/80 and 20/400 had an IMT implanted in one eye. Distance and near BCVA, endothelial cell density, and quality of life, measured as activities of daily life (ADL), were evaluated preoperatively and postoperatively.

RESULTS

At 12 months, 10 (77%) of 13 patients gained 2 more lines of either distance or near BCVA, and eight (62%) of 13 patients gained 3 or more lines in either distance or near BCVA. Mean endothelial cell density decreased by 13%. All adverse events resolved without sequelae. ADL scores improved in the majority of patients.

CONCLUSION

The results of this phase I trial support further evaluation of the IMT in a larger study population with late-stage AMD. A phase II/III trial is in progress.

Pediatric cataracts

There have been major changes over the past 5 to 10 years in our understanding of both the chemical basis for and the surgical treatment of cataract in infants and children. Important questions that remain to be answered include the appropriate power and design selection criteria for intraocular lens implantation, as well as management of the posterior capsule and long-term refractive sequelae. In the past 10 years, there have been radical changes in the management of visually significant cataract in the infant and child. Whereas lens removal, subtotal posterior capsulectomy, vitrectomy, and aphakia were once the standard of care, many physicians now feel that small incisions, phacoemulsification technology, and intraocular lenses (IOLs) are best for these patients. Work is continuing to accumulate a significant body of evidence to evaluate results of these changes in technique and to develop optimal IOL designs and selection criteria for these specialized cataract patients.

Acquired supranuclear ocular motor paresis following cardiovascular surgery

Acquired supranuclear ocular motor paresis is a rare disorder characterized by impaired saccadic and smooth pursuit eye movements in one or more directions of gaze. Vestibularly induced eye movements, however, are preserved. Six adult patients developed an acquired supranuclear ocular motor paresis following cardiopulmonary bypass surgery. Neuroimaging studies were normal in two patients and were consistent with small vessel ischemia in four patients. The mean cardiopulmonary bypass time was 132.3 min, and mean circulatory arrest time was 38.7 min; these were not outside established norms for this type of surgery. Patients undergoing cardiopulmonary bypass procedures with deep hypothermia are at risk for acquired supranuclear ocular motor paresis, but the development of this syndrome may not be predictable by duration of circulatory arrest or cardiopulmonary bypass times.

Varicella disciform stromal keratitis

We treated five patients, aged 26, 4, 6, 13, and 7 years, who developed disciform stromal keratitis one, four, four, eight, and ten weeks, respectively, after the onset of the acute vesicular exanthema. Serologic testing confirmed recent varicella and excluded other infectious causes in two cases. After initial improvement with a topical corticosteroid, three patients developed recurrent corneal inflammation resembling zoster keratitis. These cases and previous reports indicate that varicella-zoster virus is a cause of disciform stromal keratitis that may occur and recur several weeks or months after the primary skin rash has resolved.

The evaluation and management of corneal lacerations

Corneal lacerations represent a significant portion of ocular trauma. Effective management of this type of injury involves a thorough evaluation to assess the severity of the injury and the development of a logical management plan. Minor corneal trauma may be handled on an out-patient basis with the use of contact lenses and tissue adhesives. Severe injuries generally require admission and surgical intervention. Utilizing kerato-refractive principles and new suture techniques, post-operative astigmatism can be minimized at the time of primary closure.

Bacterial keratitis after radial keratotomy

The authors identified nine patients with culture-proven keratitis after radial keratotomy (RK). Three patients became infected in the immediate post-operative period, and six patients had delayed-onset keratitis. Gram-negative rods were the predominant pathogens in late-onset keratitis (4 of 6 infections). Gram-positive cocci were implicated in all three postoperative infections. The inferior corneal quadrants were involved in seven of nine patients. Two episodes of late-onset keratitis were associated with contact lens wear. Five of these patients had transverse incisions or greater than eight radial cuts. All six patients regained visual acuity of 20/40 or better. Two additional cases of early-onset and six cases of late-onset keratitis with many features similar to these cases have been reported previously.

Fungal keratitis in contact lens wearers

In a retrospective review from 1972 through 1987 of patients with microbial keratitis, fungal infection occurred in four (4%) of 90 cosmetic or aphakic contact lens wearers and in four (27%) of 15 patients using a therapeutic soft contact lens. Predisposing factors included improper lens care by the refractive lens wearers and a chronic epithelial defect with topical corticosteroid use among the therapeutic lens wearers. The responsible organisms in the refractive lens group were Fusarium solani (two patients) and Cephalosporium and Paecilomyces (one patient each), and in the therapeutic lens group Candida (three patients) and Aspergillus (one patient). Filamentous fungi were more likely to be associated with cosmetic or aphakic lens wear, whereas yeasts were more frequently found with therapeutic lens use.

Post-traumatic subgaleal hematoma with subperiosteal orbital extension

Delayed, progressive proptosis is rare following mild head trauma. We describe a case of subperiosteal orbital extension of a subgaleal hematoma and review ten cases from the literature of solitary subperiosteal hematoma and one of subgaleal hematoma with orbital extension. A patient profile, mode of clinical presentation, management options, and an algorithm for management are presented.

Experimental evaluation of chlorhexidine gluconate for ocular antisepsis

Chlorhexidine gluconate is a bisguanide germicide currently available with 70% isopropanol (Hibistat, Hibitane) or a detergent (Hibiclens, Hibiscrub) for preoperative skin preparation. As these solvents are toxic to the cornea, we investigated the safety and efficacy of aqueous chlorhexidine solutions for ophthalmic use. Chlorhexidine in Tris-glycine buffer was evaluated for retardation of epithelial regeneration after experimental corneal abrasion in rabbits. Irrigant concentrations of 2.0 and 4.0% chlorhexidine significantly slowed the healing rate (0.546 and 0.076 mm/h, respectively) compared with saline controls (0.938 mm/h). Irrigant concentrations of less than or equal to 1% did not statistically delay healing (P greater than 0.4). In a separate group of animals, the right conjunctivae of pigmented rabbits were inoculated with Staphylococcus epidermidis (approximately 10(7) organisms per eye) and irrigated with 40 microliters of aqueous chlorhexidine in concentrations of 0.1, 0.5, and 1.0%; the left eyes were irrigated with saline or left untreated. Quantitative conjunctival cultures were obtained, and the total number of organisms recovered per eye was calculated. All chlorhexidine-treated eyes showed significant reduction in organisms compared with either untreated or saline-irrigated control eyes (P less than 0.001). In vitro antimicrobial susceptibility testing demonstrated chlorhexidine in concentrations of 0.1 to 4% to be highly active against a variety of gram-positive and gram-negative bacterial pathogens by disk diffusion and broth diffusion assays. Topical aqueous chlorhexidine may be an alternate agent for preoperative conjunctival antisepsis.

Transdermal scopolamine delivery system (TRANSDERM-V) and acute angle-closure glaucoma

A 58-year-old woman developed unilateral acute angle-closure glaucoma four days after the application of a patch of transdermal scopolamine delivery system (TRANSDERM-V).