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The results of posterior chamber lens implantation
The results of posterior chamber lens implantation Manus C. Kraff, M.D. Donald R. Sanders, M.D. Howard L. Lieberman, M.D. Chicago, Illinois
ABSTRACT We studied 1,216 consecutive cases where the surgeon's intent was to implant a posterior chamber lens. In 37 cases, the surgeon elected to put in an anterior chamber lens because of events occurring at the time of surgery. In no instance was the intraocular lens procedure aborted and a lens not implanted. In the 37 cases implanted with anterior chamber lenses, 76% had a final visual acuity of 20/40 or better. In the 1,179 cases that had posterior chamber lenses implanted, 90% had visual acuity of 20/40 or better, and only 1% had worse than 20/400 vision. Senile macular degeneration accounted for over one-half of the 104 patients with a visual acuity of 20/40 or worse. Visual results appeared to be age related; 96% of patients who were less than 75-years-old achieved an acuity of 20/40 or better, whereas only 80% of those over 75 years achieved this level. Our results suggest that extracapsular extraction with posterior chamber lens implantation is safe and provides good visual results. Key Words: anterior chamber lens, posterior chamber lens, pseudophakia, vitreous loss
It was projected that 400,000 cataract extractions would be performed in 1982. Fifty percent of those procedures would be combined with intraocular lens (IOL) implantation, and half of the IOL implantations would involve posterior chamber lenses. Because the total number and proportion of cases with posterior chamber lens implantation is expected to increase, in this paper we report the results of 1,216 consecutive cataract extractions where posterior chamber lens implantation was intended.
MATERIALS AND METHODS One thousand two hundred sixteen consecutive primary intraocular lens implantation cases, all operated on by the same surgeon (MCK) between November 3, 1978, and March 31, 1981, are included in the study. In all cases, the surgeon intended to implant a posterior chamber lens. Preoperative, intraoperative
and postoperative data for each patient were collected in a prospective manner, entered into an IBM 3031 computer and analyzed using the Statistical Package for the Social Sciences (SPSS).l The details of our methods of computerization and the full extent of our data base are given elsewhere. 2, 3 Refraction and best-corrected visual acuity measurements were recorded three to four months postoperatively and at each subsequent visit. Any two-line change in visual acuity was updated, so the listed visual acuity reflects the most recent measurement. Postoperative complications were added to the data base as they occurred. During the latter part of this series, fluorescein angiography was routinely performed at 3 to 6 months postoperatively, and all angiograms were evaluated by a retinal specialist who was unaware of the patient's clinical status.
From the Department of Ophthalmology, Abraham Lincoln School of Medicine, University of Illinois at the Medical Center. Supported in part by core grant lP30EY01792!rom the National Institute ofHealth, Bethesda, Maryland; and Veterans Administration Merit Review Grant. Reprint requests to Manus C. Krajj, M.D., 5600 West Addison Street, Chicago, Illinois 60634. 148
AM INTRA-OCULAR IMPLANT SOC J-VOL 9, SPRING 1983
RESULTS Of the 1,216 consecutive patients studied, 1,179 had posterior chamber lenses implanted and primary posterior capsulotomies: 551 underwent planned extracapsular extraction, 621 underwent phacoemulsification, and seven were converted from phacoemulsification to planned extracapsular extraction. In 37 patients, the surgeon elected to implant an anterior chamber lens because of intraoperative events: 6 had vitreous loss and 31 had posterior capsule rupture without vitreous loss. In no case was the intraocular lens procedure aborted and a lens not implanted. In the 37 patients in whom there was a change of intent, 28 (76%) had a final visual acuity of 20/40 or better, 8 (22%) had worse than 20/40, and one patient (3%) died of natural nonsurgically related causes before a postoperative refraction could be obtained. The mean age of the 1,179 patients undergoing posterior chamber implantation was 69 years, with a range of 32-97 years. Of these, 42% were male and 58% were female. Ninety percent of the patients with posterior chamber lenses had 20/40 vision or better; only 1% had worse than 20/400 vision (Table 1). Over one-half of the 104 patients with worse than 20/40 vision had senile macular degeneration, which is not a complication related to the surgical procedure itself (Table 2). Six patients with less than 20/40 vision had cystoid macular edema (CME). If we define clinical CME as being present only in vision less than 20/40, then only 6 of 1,179 cases (0.5%) had clinically apparent CME. Visual results appeared to be age related. Of the 820 patients who were less than 75-years-old, 786 (96%) achieved a visual result of20/40 or better, whereas 273 (80%) of the 343 patients over 75-years-old attained an acuity of 20/40 or better. Surgical complications included two cases (0.2%) with vitreous loss, distinct from the six cases with vitreous loss that had anterior chamber lens implantation.
Table 1. Visual results in 1179 posterior chamber lens implantations.
Postoperative Visual Acuity 20/20 - 20/40 20/50 - 20/100 20/200 - 20/400 < 20/400 Missing Total
Number of Cases
Percent
1059 66 28 10 16
90% 6% 2% 1% 1%
1179
100%
Table 2. Causes of visual acuity ofless than 20/40 in patients with posterior chambp-r lens implantation. Number of Cases
Causes Senile macular degeneration Retinal detachment Preoperative corneal disease Cystoid macular edema Miscellaneous (nonsurgical) causes Unknown Total
55 10 8 6 18 7 104
Percent 52% 10% 8% 6% 17% 7% 100%
Small Descemet's detachments were noted in six cases (0.5%) and, as mentioned previously, capsule rupture that precipitated change in intent was noted in 2.5% of the population. Postoperative complications included 19 cases of retinal detachment (l.6%), implant subluxation in 2 cases (0.2%), requiring fixation with McCannel sutures, and one case (0.1%) of pupillary block that was managed medically with dilation and resolved without further therapy. Interpretable angiograms were obtained in 452 cases (38%). Of these, 61 (13.5%) were positive for CME.
DISCUSSION When reporting the results of a consecutive series of posterior chamber lens implantations, surgeons often fail to include those cases where there was a change of intent dictated by a complication occurring at surgery. In our study, 37 cases constitute this ';hidden population" and, of these, vitreous loss occurred in 16%. This finding is significant since only 76% of the patients who had a change of intent had a visual acuity of 20/40 or better as compared with 90% in the group with posterior chamber lens implantation. The change-in-intent group is an important population since it falsely makes posterior chamber lens implantation appear more efficacious, and in this report makes anterior chamber lens implantation appear worse. Our results indicate that the visual acuity with posterior chamber lens implantation is excellent, and the incidence of surgical and postoperative complications is small, despite inclusion of this hidden population. Visual results appear age related with fewer patients over 75 years achieving 20/40 or better. This is most probably related to the increasing incidence of senile macular degeneration4, 5 and CME6 with age.
AM INTRA-OCULAR IMPLANT SOC J-VOL 9, SPRING 1983
149
Analysis of this series of cases suggests that extracapsular extraction with posterior chamber lens implantation is safe and provides good visual results.
ACKNOWLEDGMENT Lee M. Jampol, M.D., read the fluorescein angiograms reported in this paper.
REFERENCES
1. Nie NH, Hull CH, JenkinsJG, etal.: Statistical Package for the
Social Sciences, New York, McGraw Hill Book Company, 1975
150
2. Sanders DR, KraffMC, Lieberman HL, Thompson L: Computerization of intraocular lens data. In: Greenfield RH, Colenbrander A, eds., Computers in Ophthalmology. New York, Institute of Electrical and Electronics Engineers, pp 71-76, 1979 3. Sanders DR, Kraff MC: Computerization of intraocular lens data. Am Intra-Ocular Implant Soc] 6(2):156-159, 1980 4. Kraff MC, Sanders DR, Lieberman HL: The medallion suture lens: Management of complications. Ophthalmology 86:643654, 1979 5. Jaffe NS, Eichenbaum DM, Clayman HM, Light DS: Acomparis on of 500 Binkhorst implants with 500 routine intracapsular cataract extractions. Am] Ophthalmol 85:24-27, 1978 6. Kraff MC, Sanders DR, Jampol LM, et al.: Prophylaxis of pseudophakic cystoid macular edema with topical indomethacin. Ophthalmology 89:885-890, 1982
AM INTRA-OCULAR IMPLANT SOC J-VOL 9, SPRING 1983
ABSTRACT We studied 1,216 consecutive cases where the surgeon's intent was to implant a posterior chamber lens. In 37 cases, the surgeon elected to put in an anterior chamber lens because of events occurring at the time of surgery. In no instance was the intraocular lens procedure aborted and a lens not implanted. In the 37 cases implanted with anterior chamber lenses, 76% had a final visual acuity of 20/40 or better. In the 1,179 cases that had posterior chamber lenses implanted, 90% had visual acuity of 20/40 or better, and only 1% had worse than 20/400 vision. Senile macular degeneration accounted for over one-half of the 104 patients with a visual acuity of 20/40 or worse. Visual results appeared to be age related; 96% of patients who were less than 75-years-old achieved an acuity of 20/40 or better, whereas only 80% of those over 75 years achieved this level. Our results suggest that extracapsular extraction with posterior chamber lens implantation is safe and provides good visual results. Key Words: anterior chamber lens, posterior chamber lens, pseudophakia, vitreous loss
It was projected that 400,000 cataract extractions would be performed in 1982. Fifty percent of those procedures would be combined with intraocular lens (IOL) implantation, and half of the IOL implantations would involve posterior chamber lenses. Because the total number and proportion of cases with posterior chamber lens implantation is expected to increase, in this paper we report the results of 1,216 consecutive cataract extractions where posterior chamber lens implantation was intended.
MATERIALS AND METHODS One thousand two hundred sixteen consecutive primary intraocular lens implantation cases, all operated on by the same surgeon (MCK) between November 3, 1978, and March 31, 1981, are included in the study. In all cases, the surgeon intended to implant a posterior chamber lens. Preoperative, intraoperative
and postoperative data for each patient were collected in a prospective manner, entered into an IBM 3031 computer and analyzed using the Statistical Package for the Social Sciences (SPSS).l The details of our methods of computerization and the full extent of our data base are given elsewhere. 2, 3 Refraction and best-corrected visual acuity measurements were recorded three to four months postoperatively and at each subsequent visit. Any two-line change in visual acuity was updated, so the listed visual acuity reflects the most recent measurement. Postoperative complications were added to the data base as they occurred. During the latter part of this series, fluorescein angiography was routinely performed at 3 to 6 months postoperatively, and all angiograms were evaluated by a retinal specialist who was unaware of the patient's clinical status.
From the Department of Ophthalmology, Abraham Lincoln School of Medicine, University of Illinois at the Medical Center. Supported in part by core grant lP30EY01792!rom the National Institute ofHealth, Bethesda, Maryland; and Veterans Administration Merit Review Grant. Reprint requests to Manus C. Krajj, M.D., 5600 West Addison Street, Chicago, Illinois 60634. 148
AM INTRA-OCULAR IMPLANT SOC J-VOL 9, SPRING 1983
RESULTS Of the 1,216 consecutive patients studied, 1,179 had posterior chamber lenses implanted and primary posterior capsulotomies: 551 underwent planned extracapsular extraction, 621 underwent phacoemulsification, and seven were converted from phacoemulsification to planned extracapsular extraction. In 37 patients, the surgeon elected to implant an anterior chamber lens because of intraoperative events: 6 had vitreous loss and 31 had posterior capsule rupture without vitreous loss. In no case was the intraocular lens procedure aborted and a lens not implanted. In the 37 patients in whom there was a change of intent, 28 (76%) had a final visual acuity of 20/40 or better, 8 (22%) had worse than 20/40, and one patient (3%) died of natural nonsurgically related causes before a postoperative refraction could be obtained. The mean age of the 1,179 patients undergoing posterior chamber implantation was 69 years, with a range of 32-97 years. Of these, 42% were male and 58% were female. Ninety percent of the patients with posterior chamber lenses had 20/40 vision or better; only 1% had worse than 20/400 vision (Table 1). Over one-half of the 104 patients with worse than 20/40 vision had senile macular degeneration, which is not a complication related to the surgical procedure itself (Table 2). Six patients with less than 20/40 vision had cystoid macular edema (CME). If we define clinical CME as being present only in vision less than 20/40, then only 6 of 1,179 cases (0.5%) had clinically apparent CME. Visual results appeared to be age related. Of the 820 patients who were less than 75-years-old, 786 (96%) achieved a visual result of20/40 or better, whereas 273 (80%) of the 343 patients over 75-years-old attained an acuity of 20/40 or better. Surgical complications included two cases (0.2%) with vitreous loss, distinct from the six cases with vitreous loss that had anterior chamber lens implantation.
Table 1. Visual results in 1179 posterior chamber lens implantations.
Postoperative Visual Acuity 20/20 - 20/40 20/50 - 20/100 20/200 - 20/400 < 20/400 Missing Total
Number of Cases
Percent
1059 66 28 10 16
90% 6% 2% 1% 1%
1179
100%
Table 2. Causes of visual acuity ofless than 20/40 in patients with posterior chambp-r lens implantation. Number of Cases
Causes Senile macular degeneration Retinal detachment Preoperative corneal disease Cystoid macular edema Miscellaneous (nonsurgical) causes Unknown Total
55 10 8 6 18 7 104
Percent 52% 10% 8% 6% 17% 7% 100%
Small Descemet's detachments were noted in six cases (0.5%) and, as mentioned previously, capsule rupture that precipitated change in intent was noted in 2.5% of the population. Postoperative complications included 19 cases of retinal detachment (l.6%), implant subluxation in 2 cases (0.2%), requiring fixation with McCannel sutures, and one case (0.1%) of pupillary block that was managed medically with dilation and resolved without further therapy. Interpretable angiograms were obtained in 452 cases (38%). Of these, 61 (13.5%) were positive for CME.
DISCUSSION When reporting the results of a consecutive series of posterior chamber lens implantations, surgeons often fail to include those cases where there was a change of intent dictated by a complication occurring at surgery. In our study, 37 cases constitute this ';hidden population" and, of these, vitreous loss occurred in 16%. This finding is significant since only 76% of the patients who had a change of intent had a visual acuity of 20/40 or better as compared with 90% in the group with posterior chamber lens implantation. The change-in-intent group is an important population since it falsely makes posterior chamber lens implantation appear more efficacious, and in this report makes anterior chamber lens implantation appear worse. Our results indicate that the visual acuity with posterior chamber lens implantation is excellent, and the incidence of surgical and postoperative complications is small, despite inclusion of this hidden population. Visual results appear age related with fewer patients over 75 years achieving 20/40 or better. This is most probably related to the increasing incidence of senile macular degeneration4, 5 and CME6 with age.
AM INTRA-OCULAR IMPLANT SOC J-VOL 9, SPRING 1983
149
Analysis of this series of cases suggests that extracapsular extraction with posterior chamber lens implantation is safe and provides good visual results.
ACKNOWLEDGMENT Lee M. Jampol, M.D., read the fluorescein angiograms reported in this paper.
REFERENCES
1. Nie NH, Hull CH, JenkinsJG, etal.: Statistical Package for the
Social Sciences, New York, McGraw Hill Book Company, 1975
150
2. Sanders DR, KraffMC, Lieberman HL, Thompson L: Computerization of intraocular lens data. In: Greenfield RH, Colenbrander A, eds., Computers in Ophthalmology. New York, Institute of Electrical and Electronics Engineers, pp 71-76, 1979 3. Sanders DR, Kraff MC: Computerization of intraocular lens data. Am Intra-Ocular Implant Soc] 6(2):156-159, 1980 4. Kraff MC, Sanders DR, Lieberman HL: The medallion suture lens: Management of complications. Ophthalmology 86:643654, 1979 5. Jaffe NS, Eichenbaum DM, Clayman HM, Light DS: Acomparis on of 500 Binkhorst implants with 500 routine intracapsular cataract extractions. Am] Ophthalmol 85:24-27, 1978 6. Kraff MC, Sanders DR, Jampol LM, et al.: Prophylaxis of pseudophakic cystoid macular edema with topical indomethacin. Ophthalmology 89:885-890, 1982
AM INTRA-OCULAR IMPLANT SOC J-VOL 9, SPRING 1983