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Intraoperative fracture of AMO Clariflex silicone posterior chamber IOL
CORRESPONDENCE
accurate measurements. Intraoperative retinoscopy slightly increases the time of surgery. COSTAS SARINAS, MD Athens, Greece
References 1. Craig EA, Hanna IT, McGilvray S, et al. Nurse or doctor: biometry for intraocular lens power calculation; who should measure? Health Bull 1995; 53:105–109 2. Olsen T, Olesen H. IOL power mislabeling. Acta Ophthalmol Scand 1993; 71:99–102 3. Choyce P. Intra-ocular Lenses and Implants. London, HK Lewis & Co Ltd, 1964 4. Duke-Elder WS. The Practice of Refraction, 9th ed. London, Churchill Livingstone, 1978 5. Clayman HM. The Surgeon’s Guide to Intraocular Lens Implantation. Thorofare, NJ, Slack, 1985 6. Aramberri J. Intraocular lens power calculation after corneal refractive surgery: double-K method. J Refract Surg 2003; 29:2063–2068 7. Koch D, Wang L. Calculating IOL power in eyes that have had refractive surgery. J Cataract Refract Surg 2003; 29: 2039–2042 8. Hoffer KJ. Calculating intraocular lens power after refractive corneal surgery. Arch Ophthalmol 2002; 120: 500–501 9. Olsen T. Calculating axial length in aphakic and the pseudophakic eye. J Cataract Refract Surg 1988; 14:413– 416
Intraoperative fracture of AMO Clariflex silicone posterior chamber IOL
A
73-year-old woman was admitted for right eye phacoemulsification with intraocular lens (IOL) implantation under local anesthesia. She had no previous eye problems. The AMO Clariflex silicone posterior chamber IOL was chosen for implantation. Routine phacoemulsification with IOL implantation was carried out by an experienced surgeon. The IOL injector (Allergan Unfolder model PSHST) was used to inject the IOL. A fracture in the IOL optic adjacent to the haptic (Figure 1) was noted after implantation. The IOL was not exchanged as the fracture was in the optic periphery and the IOL’s position in the capsular bag was satisfactory. The operation was otherwise uneventful.
1260
Figure 1. The photograph shows a fracture in the IOL optic adjacent to the haptic.
One day postoperatively, the patients’ visual acuity was 6/9 and examination of the eye was satisfactory. The subsequent follow-ups until 3 months postoperatively were satisfactory, with the uncorrected visual acuity of 6/9, improving to 6/6 with spectacle correction. The patient remained asymptomatic and pleased with the visual improvement. Discussion The Clariflex model CLRFLXB silicone posterior chamber IOL is available with a biconvex optic with the square OptiEdge design. It is intended to be implanted in the ciliary sulcus or capsular bag following extracapsular cataract extraction or phacoemulsification. The optic has the ability to be folded before insertion, allowing the IOL to be inserted through an incision of 3.0 mm. Fracture of implanted anterior chamber and posterior chamber poly(methyl methacrylate) IOLs has been reported.1–5 To our knowledge, this is the first report of an intraoperative fracture of a silicone Clariflex IOL since its introduction. The cause of the fracture in this case could be the shearing force applied to the IOL as it worked its way out of the injector. The injector was checked and found to have no defect. Before implantation, there was no obvious sign of a preexisting IOL imperfection microscopically. From this case, it is clear that under certain circumstances, the optic of the Clariflex IOL can fracture and appropriate care should be taken when using an
J CATARACT REFRACT SURG—VOL 31, JUNE 2005
CORRESPONDENCE
injector with this IOL. This case also illustrates that there are no ill effects of a fracture in the optic periphery in an otherwise uneventful operation, at least in the short term. J.L. CHUAH, MB CHB C.V. RAJESH, FRCS Liverpool, United Kingdom Figure 1. Bilateral endophthalmitis in both eyes at presentation. Note the hypopyon and corneal edema (more severe in the right eye).
References 1. Weickert C, Fuhrmann G, Bleckmann H. Spontaneous fracture of an implanted anterior chamber lens. Ophthalmologe 1992; 346–348 2. Capoferri C, Vacchi S, Tafi A, et al. Traumatic fracture of flexible anterior chamber intraocular lenses. J Cataract Refract Surg 1997; 23:1418–1420 3. Eleftheriadis H, Sahu DN, Willekens B, et al. Corneal decompensation and graft failure secondary to a broken posterior chamber poly(methyl methacrylate) intraocular lens haptic. J Cataract Refract Surg 2001; 27:2047– 2050 4. Kirkpatrick JNP, Cook SD. Broken intraocular lens during cataract surgery. Br J Ophthalmol 1992; 76:509 5. Apple DJ, Mamalis N, Lotfield K, et al. Complications of intraocular lenses. Surv Ophthalmol 1984; 29:1–54
Bilateral endophthalmitis after simultaneous bilateral cataract surgery
S
imultaneous bilateral cataract surgery (SBCS) is widely reported, and most authors emphasize the safety of the procedure.1–3 The risk for bilateral sightthreatening complications such as bilateral endophthalmitis makes some surgeons reluctant to perform SBCS. We report a case of bilateral endophthalmitis following SBCS.
Case Report A 70-year-old, otherwise healthy man who had SBCS under general anesthesia at another clinic was referred to our clinic with the diagnosis of early bilateral endophthalmitis. Both eyes were reported to have had uneventful phacoemulsification and implantation of a foldable acrylic intraocular lens. The second eye was operated on after a new drape had been placed but the same fluids as in the first eye were used; the same instruments were used after sterilization with flash autoclave.
On the second postoperative day, the visual acuity in both eyes was hand motions. Slitlamp examination revealed bilateral purulent secretion, ciliary injection, corneal edema, hypopyon, and C4 cells in the anterior chamber (Figure 1). Mild vitreous opacity was detected with B-mode ultrasonography. The patient was hospitalized, and intravitreal vancomycin (1 mg/0.1 mL), cefazolin (2.25 mg/0.1 mL), and dexamethasone (4 mg/0.1 mL) injections were administered after a vitreous tap. Oral ciprofloxacin and topical fortified vancomycin (50 mg/mL), fortified sefazolin (50 mg/mL), and dexamethasone drops were then ordered. Although the vitreous cultures and gram stains were negative, the clinical picture began to improve daily and the hypopyon resolved completely by the end of the first week of treatment. Both eyes were fairly quiet at the 1-month follow-up examination; the best corrected visual acuity had improved to 20/50 in the right eye and 20/40 in the left eye.
Discussion Simulataneous bilateral cataract surgery has potential advantages such as clinical and economic benefits to the patient, hospital, and society.4 Nevertheless, currently the main indication for bilateral surgery is elective choice of the patient and surgeon without specific indications. The critical question is whether the benefits of bilateral surgery justify the risk for simultaneous bilateral complications, especially endophthalmitis. The reported rates of endophthalmitis per operated eye are similar to those of unilateral surgery. This is because strict rules of surgical asepsis are being applied in bilateral surgery. Only 1 case of bilateral endophthalmitis has been reported after bilateral intracapsular surgery.5 To our knowledge, we report the first case of bilateral endophthalmitis after SBCS with phacoemulsification. We suggest that the surgeon think twice before making the decision for SBCS, after
J CATARACT REFRACT SURG—VOL 31, JUNE 2005
1261
accurate measurements. Intraoperative retinoscopy slightly increases the time of surgery. COSTAS SARINAS, MD Athens, Greece
References 1. Craig EA, Hanna IT, McGilvray S, et al. Nurse or doctor: biometry for intraocular lens power calculation; who should measure? Health Bull 1995; 53:105–109 2. Olsen T, Olesen H. IOL power mislabeling. Acta Ophthalmol Scand 1993; 71:99–102 3. Choyce P. Intra-ocular Lenses and Implants. London, HK Lewis & Co Ltd, 1964 4. Duke-Elder WS. The Practice of Refraction, 9th ed. London, Churchill Livingstone, 1978 5. Clayman HM. The Surgeon’s Guide to Intraocular Lens Implantation. Thorofare, NJ, Slack, 1985 6. Aramberri J. Intraocular lens power calculation after corneal refractive surgery: double-K method. J Refract Surg 2003; 29:2063–2068 7. Koch D, Wang L. Calculating IOL power in eyes that have had refractive surgery. J Cataract Refract Surg 2003; 29: 2039–2042 8. Hoffer KJ. Calculating intraocular lens power after refractive corneal surgery. Arch Ophthalmol 2002; 120: 500–501 9. Olsen T. Calculating axial length in aphakic and the pseudophakic eye. J Cataract Refract Surg 1988; 14:413– 416
Intraoperative fracture of AMO Clariflex silicone posterior chamber IOL
A
73-year-old woman was admitted for right eye phacoemulsification with intraocular lens (IOL) implantation under local anesthesia. She had no previous eye problems. The AMO Clariflex silicone posterior chamber IOL was chosen for implantation. Routine phacoemulsification with IOL implantation was carried out by an experienced surgeon. The IOL injector (Allergan Unfolder model PSHST) was used to inject the IOL. A fracture in the IOL optic adjacent to the haptic (Figure 1) was noted after implantation. The IOL was not exchanged as the fracture was in the optic periphery and the IOL’s position in the capsular bag was satisfactory. The operation was otherwise uneventful.
1260
Figure 1. The photograph shows a fracture in the IOL optic adjacent to the haptic.
One day postoperatively, the patients’ visual acuity was 6/9 and examination of the eye was satisfactory. The subsequent follow-ups until 3 months postoperatively were satisfactory, with the uncorrected visual acuity of 6/9, improving to 6/6 with spectacle correction. The patient remained asymptomatic and pleased with the visual improvement. Discussion The Clariflex model CLRFLXB silicone posterior chamber IOL is available with a biconvex optic with the square OptiEdge design. It is intended to be implanted in the ciliary sulcus or capsular bag following extracapsular cataract extraction or phacoemulsification. The optic has the ability to be folded before insertion, allowing the IOL to be inserted through an incision of 3.0 mm. Fracture of implanted anterior chamber and posterior chamber poly(methyl methacrylate) IOLs has been reported.1–5 To our knowledge, this is the first report of an intraoperative fracture of a silicone Clariflex IOL since its introduction. The cause of the fracture in this case could be the shearing force applied to the IOL as it worked its way out of the injector. The injector was checked and found to have no defect. Before implantation, there was no obvious sign of a preexisting IOL imperfection microscopically. From this case, it is clear that under certain circumstances, the optic of the Clariflex IOL can fracture and appropriate care should be taken when using an
J CATARACT REFRACT SURG—VOL 31, JUNE 2005
CORRESPONDENCE
injector with this IOL. This case also illustrates that there are no ill effects of a fracture in the optic periphery in an otherwise uneventful operation, at least in the short term. J.L. CHUAH, MB CHB C.V. RAJESH, FRCS Liverpool, United Kingdom Figure 1. Bilateral endophthalmitis in both eyes at presentation. Note the hypopyon and corneal edema (more severe in the right eye).
References 1. Weickert C, Fuhrmann G, Bleckmann H. Spontaneous fracture of an implanted anterior chamber lens. Ophthalmologe 1992; 346–348 2. Capoferri C, Vacchi S, Tafi A, et al. Traumatic fracture of flexible anterior chamber intraocular lenses. J Cataract Refract Surg 1997; 23:1418–1420 3. Eleftheriadis H, Sahu DN, Willekens B, et al. Corneal decompensation and graft failure secondary to a broken posterior chamber poly(methyl methacrylate) intraocular lens haptic. J Cataract Refract Surg 2001; 27:2047– 2050 4. Kirkpatrick JNP, Cook SD. Broken intraocular lens during cataract surgery. Br J Ophthalmol 1992; 76:509 5. Apple DJ, Mamalis N, Lotfield K, et al. Complications of intraocular lenses. Surv Ophthalmol 1984; 29:1–54
Bilateral endophthalmitis after simultaneous bilateral cataract surgery
S
imultaneous bilateral cataract surgery (SBCS) is widely reported, and most authors emphasize the safety of the procedure.1–3 The risk for bilateral sightthreatening complications such as bilateral endophthalmitis makes some surgeons reluctant to perform SBCS. We report a case of bilateral endophthalmitis following SBCS.
Case Report A 70-year-old, otherwise healthy man who had SBCS under general anesthesia at another clinic was referred to our clinic with the diagnosis of early bilateral endophthalmitis. Both eyes were reported to have had uneventful phacoemulsification and implantation of a foldable acrylic intraocular lens. The second eye was operated on after a new drape had been placed but the same fluids as in the first eye were used; the same instruments were used after sterilization with flash autoclave.
On the second postoperative day, the visual acuity in both eyes was hand motions. Slitlamp examination revealed bilateral purulent secretion, ciliary injection, corneal edema, hypopyon, and C4 cells in the anterior chamber (Figure 1). Mild vitreous opacity was detected with B-mode ultrasonography. The patient was hospitalized, and intravitreal vancomycin (1 mg/0.1 mL), cefazolin (2.25 mg/0.1 mL), and dexamethasone (4 mg/0.1 mL) injections were administered after a vitreous tap. Oral ciprofloxacin and topical fortified vancomycin (50 mg/mL), fortified sefazolin (50 mg/mL), and dexamethasone drops were then ordered. Although the vitreous cultures and gram stains were negative, the clinical picture began to improve daily and the hypopyon resolved completely by the end of the first week of treatment. Both eyes were fairly quiet at the 1-month follow-up examination; the best corrected visual acuity had improved to 20/50 in the right eye and 20/40 in the left eye.
Discussion Simulataneous bilateral cataract surgery has potential advantages such as clinical and economic benefits to the patient, hospital, and society.4 Nevertheless, currently the main indication for bilateral surgery is elective choice of the patient and surgeon without specific indications. The critical question is whether the benefits of bilateral surgery justify the risk for simultaneous bilateral complications, especially endophthalmitis. The reported rates of endophthalmitis per operated eye are similar to those of unilateral surgery. This is because strict rules of surgical asepsis are being applied in bilateral surgery. Only 1 case of bilateral endophthalmitis has been reported after bilateral intracapsular surgery.5 To our knowledge, we report the first case of bilateral endophthalmitis after SBCS with phacoemulsification. We suggest that the surgeon think twice before making the decision for SBCS, after
J CATARACT REFRACT SURG—VOL 31, JUNE 2005
1261