- Email: [email protected]
Endothelial Cell Loss With the Choyce Anterior Chamber Lens
endothelial cell loss with the choyce anterior chamber lens Charles H. Cozean, Jr., M.D. Stephen R. Waltman, M.D. Cape Girardeau, Missouri
Previous studies have shown that intracapsular cataract extraction and intraocular lens implantation cause mild to severe corneal endothelial cell 10ss.1-3 The loss occurs intraoperatively with little additional cell loss postoperatively. The degree of cell loss, which is variable,4 depends on the amount of intraoperative endothelial trauma. Many patients have minimal cell loss, but in others over 70% of the central corneal endothelium may be lost during intraocular lens placement. Our study documents the endothelial cell loss that occurs with intracapsular cataract extraction and insertion of a Choyce anterior chamber lens. The average endothelial cell loss in our series was 20%, half that reported in some pre~ious stud.ies. 4.5 !urt~erm~re, endothelial cell loss IS very umform m thIS senes, with no cases of massive cell loss. METHODS Twenty-seven patients, ages 53 to 93, had intracapsular cataract extractions with Choyce intraocular lens implantation in one eye and no surgery in the other eye. Lenses manufactured by Coburn Optical Industries or by McGhan Medical ~orpora tion were used. The average age of the patIents was 74.1 years. Coburn lenses were used in 19 patients and MeG han lenses in eight patients. All surgery was performed by the same surgeon and represents his early experience. No implant procedure was cancelled because of a shallow anterior chamber or vitreous pressure. Corneal specular photomicroscopy was performed six to 18 months postoperatively. The central corneal area was photographed by a single observer. A computerized program was then used to det~rmine endothelial cell densities in both eyes. 5 ThIS was done by a technician who was unaware-of which eye had had surgery. The patients represent a consecutive series except when non ophthalmologic factors prevented the patient from returning for endothelial photographs on the scheduled date. RESULTS There were no surgical or postoperative anterior segment complications and no evidence of corneal decom pensation.
The average endothelial cell count was 2150 (±135) cells/mm2 for the operated eyes and 2780 (±121) cells/mm 2 for the unoperated eyes. This represents an average cell loss of 22.5% (±2.82%). The average cell loss was 20% (±3%) with the Cobur.n lenses and 27% (±6.3%) with the McGhan lenses. ThIS was not significantly different. The cell loss was greater in left vs. right eyes (28% vs. 18%). Over half of the patients had less than a 20% cell loss, and only one (4%) patient had more than a 50% cell loss. No patient had more than a 60% cell loss. DISCUSSION All intraocular lens surgery results in some endothelial cell loss, which is usually not clinically significant. Following intracapsular extraction, when the anterior chamber is deep and the vitreous face is back, an iris-supported lens may be inserted with the knowledge that endothelial cell loss will not be severe. 3. 4 Using iris-supported lenses, Binkhorst 6 reported a cell loss of less than 10% following ex~ra capsular extraction, and a cell loss of 40% followmg intracapsular surgery.5 When the vitreous face is bulging and intraocular lens placement is difficult, however, more than 60% cell destruction can occur. 4 In these difficult cases, the surgeon must decide whether to risk substantial endothelial cell loss and possible future corneal decompensati~n by in~ra ocular lens insertion. Furthermore, dunng sutunng of the corneal wound or tying of the iris suture, collapse o( the anterior chamber will result in additional endothelial cell loss.7 The Choyce intraocular lens may be a use(ul alternative. Because it can be inserted through a small incision with a constant air bubble in the anterior chamber, endothelial cell trauma may be reduced despite a bulging vitreous face. The patients in our study represent a consecutive series, and no cases were cancelled because of vitreous pressure. Despite this, the majority of patients had less than a 20% cell loss. The decision to perform intraocular lens implantation and the choice of lens style depend on many (actors, with possible endothelial cell loss being one of them. REFERENCES 1. Bourne WM, Kaufman HE: Endothelial damage associated with intraocular lenses. Am ] Ophthalmol 81:482, 1976 2. Forstadt SL, Blackwell WL, Jaffe NS et al: Effect of intraocular lens implantation on corneal endothelium. Trans Am Acad Ophthalmol Otolaryngol 83:195, 1977 3. Hirst LW, Snip RC, Stark WJ et al: Qu~ntitative .comeal endothelial evaluation in intraocular lens lmplantatton and cataract surgery. Am] Ophthalmol 84:775, 1977
AM INfRA-OCULAR IMPLANr SOC J-VOL. V, JANUARY 1979
13
4. Drews RC, Wallman SR: Endothelial cell loss in intraocular lens placement. Am Intra-Ocular Implant Soc J 4(2):14,1978 5. Wallman SR: Corneal endothelial changes with long-term topical epinephrine. Arch OphthalmoI95:1357, 1977 6. Binkhorst CD, Nygaard p, Loones LH: Specular microscopy of the corneal endothelium and lens implant surgery. Am J OphthalmoI85:597, 1978 7. Sugar J: Endothelial trauma and cell I~~~ from intraocular lens insertion. Arch Ophthalmol 96:449, 1977 <~.
ERRATA
"
Vol. IV, No. <3 July 1978: 1. Page 90: The equation 9t the top of the page' . should read: Rs =
1336 (4r-a) - D(a-d) (4r-d) 1336 [V(4r-a) + O.0032r] - D(a-d) [V(4r-d) + O.003dr]
14
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
Previous studies have shown that intracapsular cataract extraction and intraocular lens implantation cause mild to severe corneal endothelial cell 10ss.1-3 The loss occurs intraoperatively with little additional cell loss postoperatively. The degree of cell loss, which is variable,4 depends on the amount of intraoperative endothelial trauma. Many patients have minimal cell loss, but in others over 70% of the central corneal endothelium may be lost during intraocular lens placement. Our study documents the endothelial cell loss that occurs with intracapsular cataract extraction and insertion of a Choyce anterior chamber lens. The average endothelial cell loss in our series was 20%, half that reported in some pre~ious stud.ies. 4.5 !urt~erm~re, endothelial cell loss IS very umform m thIS senes, with no cases of massive cell loss. METHODS Twenty-seven patients, ages 53 to 93, had intracapsular cataract extractions with Choyce intraocular lens implantation in one eye and no surgery in the other eye. Lenses manufactured by Coburn Optical Industries or by McGhan Medical ~orpora tion were used. The average age of the patIents was 74.1 years. Coburn lenses were used in 19 patients and MeG han lenses in eight patients. All surgery was performed by the same surgeon and represents his early experience. No implant procedure was cancelled because of a shallow anterior chamber or vitreous pressure. Corneal specular photomicroscopy was performed six to 18 months postoperatively. The central corneal area was photographed by a single observer. A computerized program was then used to det~rmine endothelial cell densities in both eyes. 5 ThIS was done by a technician who was unaware-of which eye had had surgery. The patients represent a consecutive series except when non ophthalmologic factors prevented the patient from returning for endothelial photographs on the scheduled date. RESULTS There were no surgical or postoperative anterior segment complications and no evidence of corneal decom pensation.
The average endothelial cell count was 2150 (±135) cells/mm2 for the operated eyes and 2780 (±121) cells/mm 2 for the unoperated eyes. This represents an average cell loss of 22.5% (±2.82%). The average cell loss was 20% (±3%) with the Cobur.n lenses and 27% (±6.3%) with the McGhan lenses. ThIS was not significantly different. The cell loss was greater in left vs. right eyes (28% vs. 18%). Over half of the patients had less than a 20% cell loss, and only one (4%) patient had more than a 50% cell loss. No patient had more than a 60% cell loss. DISCUSSION All intraocular lens surgery results in some endothelial cell loss, which is usually not clinically significant. Following intracapsular extraction, when the anterior chamber is deep and the vitreous face is back, an iris-supported lens may be inserted with the knowledge that endothelial cell loss will not be severe. 3. 4 Using iris-supported lenses, Binkhorst 6 reported a cell loss of less than 10% following ex~ra capsular extraction, and a cell loss of 40% followmg intracapsular surgery.5 When the vitreous face is bulging and intraocular lens placement is difficult, however, more than 60% cell destruction can occur. 4 In these difficult cases, the surgeon must decide whether to risk substantial endothelial cell loss and possible future corneal decompensati~n by in~ra ocular lens insertion. Furthermore, dunng sutunng of the corneal wound or tying of the iris suture, collapse o( the anterior chamber will result in additional endothelial cell loss.7 The Choyce intraocular lens may be a use(ul alternative. Because it can be inserted through a small incision with a constant air bubble in the anterior chamber, endothelial cell trauma may be reduced despite a bulging vitreous face. The patients in our study represent a consecutive series, and no cases were cancelled because of vitreous pressure. Despite this, the majority of patients had less than a 20% cell loss. The decision to perform intraocular lens implantation and the choice of lens style depend on many (actors, with possible endothelial cell loss being one of them. REFERENCES 1. Bourne WM, Kaufman HE: Endothelial damage associated with intraocular lenses. Am ] Ophthalmol 81:482, 1976 2. Forstadt SL, Blackwell WL, Jaffe NS et al: Effect of intraocular lens implantation on corneal endothelium. Trans Am Acad Ophthalmol Otolaryngol 83:195, 1977 3. Hirst LW, Snip RC, Stark WJ et al: Qu~ntitative .comeal endothelial evaluation in intraocular lens lmplantatton and cataract surgery. Am] Ophthalmol 84:775, 1977
AM INfRA-OCULAR IMPLANr SOC J-VOL. V, JANUARY 1979
13
4. Drews RC, Wallman SR: Endothelial cell loss in intraocular lens placement. Am Intra-Ocular Implant Soc J 4(2):14,1978 5. Wallman SR: Corneal endothelial changes with long-term topical epinephrine. Arch OphthalmoI95:1357, 1977 6. Binkhorst CD, Nygaard p, Loones LH: Specular microscopy of the corneal endothelium and lens implant surgery. Am J OphthalmoI85:597, 1978 7. Sugar J: Endothelial trauma and cell I~~~ from intraocular lens insertion. Arch Ophthalmol 96:449, 1977 <~.
ERRATA
"
Vol. IV, No. <3 July 1978: 1. Page 90: The equation 9t the top of the page' . should read: Rs =
1336 (4r-a) - D(a-d) (4r-d) 1336 [V(4r-a) + O.0032r] - D(a-d) [V(4r-d) + O.003dr]
14
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979