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May consultation #2
CONSULTATION SECTION
Cataract Surgical Problem Edited by Rupert M. Menapace, MD
A 42-year-old woman presents with the following history: At 18 years, the right eye had surgery for congenital cataract with relatively good vision but disturbing glare and poor contrast. Intracapsular cryoextraction of the cataractous lens was performed, and an intraocular lens (IOL) was implanted. Over the last years, her vision was reported to have been fairly good. During the past year, however, the patient has had episodes of blurred vision, especially in the morning. In addition, she reports bothersome tenderness of the globe on palpation. Ophthalmic findings are as follows: The right eye is irritation free, with no Tyndall detected on biomicroscopy. An angle-supported Kelman-style multiflex open-loop anterior chamber (AC) IOL is seen. The pupil is stretched and ovally distorted along the IOL axis. Ectropium uveae and stromal atrophy are found inferiorly (Figure 1). On gonioscopy, the elbow of the inferior haptic loop is seen to entangle the iris base, while the apical eyelet located in the chamber angle is encased in a fibrotic cocoon. The elbow of the superior haptic loop is properly residing in the chamber angle, while the loop end is deeply buried in the ciliary body with the eyelet not visible (Figure 2). The intraocular pressure (IOP) is 20 mm Hg in the right eye and 10 mm Hg in the left eye. The cornea appears clear in both eyes. Refraction in the right eye is 2.50 +2.00 50. In the right eye, the decimal corrected distance visual acuity is 0.4 and the corrected near visual acuity is J4, reflecting mild amblyopia. However, the
Figure 1. Angle-supported Kelman-style multiflex open-loop AC IOL. The pupil is stretched and ovally distorted along the IOL axis, with ectropium uveae and stromal atrophy inferiorly.
810
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
endothelial cell count (ECC) is 2770 cells/mm2 in the left eye but only 830 cells/mm2 in the right eye. Corneal pachymetry readings are 540 mm in the left eye and 620 mm in the right eye. Fundoscopy shows no abnormalities. Given the low ECC in the right eye with obvious signs of imminent corneal endothelial decompensation and the bothersome tenderness, what would be your approach to remedy the situation in view of the massive incarceration of the IOL loop ends in a fibrotic cocoon and in the ciliary tissue, respectively?
- This 42-year-old woman presents with fluctuating, worsening vision from a failing right cornea due to a poorly fitting (loose) AC IOL implanted 24 years ago during surgery for congenital cataract. She is
Figure 2. Gonioscopic view shows the elbow of the inferior haptic loop entangles the iris base, while the apical eyelet in the chamber angle is encased in a fibrotic cocoon. The elbow of superior haptic loop properly resides in chamber angle; however, the loop end is deeply buried in ciliary body and the eyelet is not visible. 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.02.025
CONSULTATION SECTION
symptomatic, and something must be done. This includes removal of the AC IOL and a decision regarding the optimum choice for visual rehabilitation. Although any surgical intervention carries a fairly high risk for further corneal decompensation (ECC only 830 cells/mm2), doing nothing will inevitably lead to the same result. At present, the cornea remains optically clear, so it would make good sense to remove the AC IOL sooner rather than later while visibility is good. This will be technically difficult due to fibrotic incarceration of the peripheral arms of the IOL haptics. There are few techniques for removing such an IOL. Guillotining the haptics would be difficult to achieve with a rigid poly(methyl methacrylate) (PMMA) AC IOL and would be undesirable because the mobilized haptic remnants would likely cause further endothelial trauma, cell loss, and pigment release. Trying to pull out the entrapped haptics is likely to be disastrous, and I would strongly advise against this. Surgery under direct gonioscopy would be difficult due to the complex manipulations required to release the haptics. My preferred option would be to cut down directly onto the haptics at the scleral–limbal junction via a 7.0 mm wound to gain direct exposure, starting inferiorly because this haptic appears more accessible on the gonioscopy photographs. Copious use of a dispersive ophthalmic viscosurgical device (OVD) to protect the damaged endothelium would be advisable, combined with a cohesive OVD to maintain the chamber depth throughout IOL manipulation and explantation. The instruments would be disposable curved retinal scissors and a straight retinal forceps, together with a retinal membrane pick to aid with dissection of the haptics. Once both haptics were free, I would refill with OVD and slide the IOL out, tilted more down toward the iris than the cornea, and maybe use a Sheets glide above it to avoid wiping against the endothelium. The wounds would be closed securely with interrupted 10-0 nylon. The oval pupil distortion is likely to be permanent due to cicatricial shortening of the anterior iris surface. Deciding on the best option for visual rehabilitation is difficult. Initially, I would leave the eye aphakic to see how the endothelium reacts to the initial surgery. The probability of needing a Descemet-stripping automated endothelial keratoplasty (DSAEK) is high and would debatably best be performed before secondary IOL implantation. For visual rehabilitation, I would use the same IOL as the one removed but carefully and correctly sized (ie, horizontal white to white [WTW] diameter C 1.0 mm for an angle-supported AC IOL) and implanted via a temporal 7.0 mm frown-incision scleral tunnel. This whole problem could likely have been avoided if the original AC IOL had been
811
accurately fitted. There is no endothelial threat inherent in these modern AC IOLs as long as they are not loose and mobile. If they are, progressive endothelial cell loss is slow but relentless and takes place over many years, as witnessed here. Brian Little, BSc, MA, FHEA, FRCS, FRCOphth London, United Kingdom
- Over the past years, I have seen several cases of late complications after AC IOL implantation. Most cases developed corneal decompensation; however, some also showed AC IOL dislocation, chronic inflammation, ectropium uveae, or even loop perforation through the sclera. I treated all these cases with AC IOL explantation, secondary posterior chamber (PC) IOL implantation and, if required, corneal transplantation. In the present case, I would plan the same. After peritomy of the conjunctiva, I would place a 25-gauge pars plana infusion and perform 2 vertical sclerotomies through the sulcus with a 23-gauge needle 1.5 to 2.0 mm posterior to the limbus and exactly 180 degrees apart. Starting from these sclerotomies, I would prepare tangential intrascleral tunnels counterclockwise with a bent 23-gauge needle parallel to the limbus. Starting with these preparations is preferable because when the main incision is already created, the eye usually becomes soft, making further manipulations more difficult. Then, I would create a 2-step limbal incision of approximately 5.5 mm width located superior nasally according to the corneal astigmatism, provided the eye is not set too deeply. I would also create 2 side-port incisions. With the help of a reverse Sinskey hook and a Scharioth forceps (DORC), I would try to mobilize the AC IOL. First, I would luxate the superior haptic and externalize it through the main incision. At this point, it is usually possible to rotate the inferior haptic out of the tissue. If this seems too traumatic, the inferior haptic could be cut with a 20-gauge endoscissors. This will release the pressure on the uveal tissue and relieve the pain. Then, I would perform a deep anterior vitrectomy followed by implantation of a standard 3-piece PC IOL using an intrascleral haptic fixation technique.1,A I prefer this technique over others (eg, retropupillary iris-claw IOL) because it will result in the most stable iris–lens diaphragm for possible later surgical reinterventions. In some cases, I have seen some recovery of the cornea with no need for corneal transplantation. But due to the patient’s young age and the low ECC, corneal transplantation will most likely be needed in the future. If so, I would perform endothelial transplantation (Descemet membrane endothelial keratoplasty) because only the corneal endothelium is diseased.
J CATARACT REFRACT SURG - VOL 39, MAY 2013
Cataract Surgical Problem Edited by Rupert M. Menapace, MD
A 42-year-old woman presents with the following history: At 18 years, the right eye had surgery for congenital cataract with relatively good vision but disturbing glare and poor contrast. Intracapsular cryoextraction of the cataractous lens was performed, and an intraocular lens (IOL) was implanted. Over the last years, her vision was reported to have been fairly good. During the past year, however, the patient has had episodes of blurred vision, especially in the morning. In addition, she reports bothersome tenderness of the globe on palpation. Ophthalmic findings are as follows: The right eye is irritation free, with no Tyndall detected on biomicroscopy. An angle-supported Kelman-style multiflex open-loop anterior chamber (AC) IOL is seen. The pupil is stretched and ovally distorted along the IOL axis. Ectropium uveae and stromal atrophy are found inferiorly (Figure 1). On gonioscopy, the elbow of the inferior haptic loop is seen to entangle the iris base, while the apical eyelet located in the chamber angle is encased in a fibrotic cocoon. The elbow of the superior haptic loop is properly residing in the chamber angle, while the loop end is deeply buried in the ciliary body with the eyelet not visible (Figure 2). The intraocular pressure (IOP) is 20 mm Hg in the right eye and 10 mm Hg in the left eye. The cornea appears clear in both eyes. Refraction in the right eye is 2.50 +2.00 50. In the right eye, the decimal corrected distance visual acuity is 0.4 and the corrected near visual acuity is J4, reflecting mild amblyopia. However, the
Figure 1. Angle-supported Kelman-style multiflex open-loop AC IOL. The pupil is stretched and ovally distorted along the IOL axis, with ectropium uveae and stromal atrophy inferiorly.
810
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
endothelial cell count (ECC) is 2770 cells/mm2 in the left eye but only 830 cells/mm2 in the right eye. Corneal pachymetry readings are 540 mm in the left eye and 620 mm in the right eye. Fundoscopy shows no abnormalities. Given the low ECC in the right eye with obvious signs of imminent corneal endothelial decompensation and the bothersome tenderness, what would be your approach to remedy the situation in view of the massive incarceration of the IOL loop ends in a fibrotic cocoon and in the ciliary tissue, respectively?
- This 42-year-old woman presents with fluctuating, worsening vision from a failing right cornea due to a poorly fitting (loose) AC IOL implanted 24 years ago during surgery for congenital cataract. She is
Figure 2. Gonioscopic view shows the elbow of the inferior haptic loop entangles the iris base, while the apical eyelet in the chamber angle is encased in a fibrotic cocoon. The elbow of superior haptic loop properly resides in chamber angle; however, the loop end is deeply buried in ciliary body and the eyelet is not visible. 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.02.025
CONSULTATION SECTION
symptomatic, and something must be done. This includes removal of the AC IOL and a decision regarding the optimum choice for visual rehabilitation. Although any surgical intervention carries a fairly high risk for further corneal decompensation (ECC only 830 cells/mm2), doing nothing will inevitably lead to the same result. At present, the cornea remains optically clear, so it would make good sense to remove the AC IOL sooner rather than later while visibility is good. This will be technically difficult due to fibrotic incarceration of the peripheral arms of the IOL haptics. There are few techniques for removing such an IOL. Guillotining the haptics would be difficult to achieve with a rigid poly(methyl methacrylate) (PMMA) AC IOL and would be undesirable because the mobilized haptic remnants would likely cause further endothelial trauma, cell loss, and pigment release. Trying to pull out the entrapped haptics is likely to be disastrous, and I would strongly advise against this. Surgery under direct gonioscopy would be difficult due to the complex manipulations required to release the haptics. My preferred option would be to cut down directly onto the haptics at the scleral–limbal junction via a 7.0 mm wound to gain direct exposure, starting inferiorly because this haptic appears more accessible on the gonioscopy photographs. Copious use of a dispersive ophthalmic viscosurgical device (OVD) to protect the damaged endothelium would be advisable, combined with a cohesive OVD to maintain the chamber depth throughout IOL manipulation and explantation. The instruments would be disposable curved retinal scissors and a straight retinal forceps, together with a retinal membrane pick to aid with dissection of the haptics. Once both haptics were free, I would refill with OVD and slide the IOL out, tilted more down toward the iris than the cornea, and maybe use a Sheets glide above it to avoid wiping against the endothelium. The wounds would be closed securely with interrupted 10-0 nylon. The oval pupil distortion is likely to be permanent due to cicatricial shortening of the anterior iris surface. Deciding on the best option for visual rehabilitation is difficult. Initially, I would leave the eye aphakic to see how the endothelium reacts to the initial surgery. The probability of needing a Descemet-stripping automated endothelial keratoplasty (DSAEK) is high and would debatably best be performed before secondary IOL implantation. For visual rehabilitation, I would use the same IOL as the one removed but carefully and correctly sized (ie, horizontal white to white [WTW] diameter C 1.0 mm for an angle-supported AC IOL) and implanted via a temporal 7.0 mm frown-incision scleral tunnel. This whole problem could likely have been avoided if the original AC IOL had been
811
accurately fitted. There is no endothelial threat inherent in these modern AC IOLs as long as they are not loose and mobile. If they are, progressive endothelial cell loss is slow but relentless and takes place over many years, as witnessed here. Brian Little, BSc, MA, FHEA, FRCS, FRCOphth London, United Kingdom
- Over the past years, I have seen several cases of late complications after AC IOL implantation. Most cases developed corneal decompensation; however, some also showed AC IOL dislocation, chronic inflammation, ectropium uveae, or even loop perforation through the sclera. I treated all these cases with AC IOL explantation, secondary posterior chamber (PC) IOL implantation and, if required, corneal transplantation. In the present case, I would plan the same. After peritomy of the conjunctiva, I would place a 25-gauge pars plana infusion and perform 2 vertical sclerotomies through the sulcus with a 23-gauge needle 1.5 to 2.0 mm posterior to the limbus and exactly 180 degrees apart. Starting from these sclerotomies, I would prepare tangential intrascleral tunnels counterclockwise with a bent 23-gauge needle parallel to the limbus. Starting with these preparations is preferable because when the main incision is already created, the eye usually becomes soft, making further manipulations more difficult. Then, I would create a 2-step limbal incision of approximately 5.5 mm width located superior nasally according to the corneal astigmatism, provided the eye is not set too deeply. I would also create 2 side-port incisions. With the help of a reverse Sinskey hook and a Scharioth forceps (DORC), I would try to mobilize the AC IOL. First, I would luxate the superior haptic and externalize it through the main incision. At this point, it is usually possible to rotate the inferior haptic out of the tissue. If this seems too traumatic, the inferior haptic could be cut with a 20-gauge endoscissors. This will release the pressure on the uveal tissue and relieve the pain. Then, I would perform a deep anterior vitrectomy followed by implantation of a standard 3-piece PC IOL using an intrascleral haptic fixation technique.1,A I prefer this technique over others (eg, retropupillary iris-claw IOL) because it will result in the most stable iris–lens diaphragm for possible later surgical reinterventions. In some cases, I have seen some recovery of the cornea with no need for corneal transplantation. But due to the patient’s young age and the low ECC, corneal transplantation will most likely be needed in the future. If so, I would perform endothelial transplantation (Descemet membrane endothelial keratoplasty) because only the corneal endothelium is diseased.
J CATARACT REFRACT SURG - VOL 39, MAY 2013