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Management of an extruded footplate of an anterior chamber lens with the Nd:YAG laser
In summary, laser-induced IOL opacities may cause glare and image degradation sufficient to reduce visual acuity as exemplified in this case report. The presence of IOL opacities may complicate subsequent laser surgery. Thus, increased and potentially significant IOL damage must be included in the risk/benefit analysis accompanying the judgment to perform a second laser posterior capsulotomy. REFERENCES 1. Stark WJ, Worthen D, Holladay JT, Murray G: Neodymium:YAG lasers; an FDA report. Ophthalmology 92:209212, 1985 2. Manenkov J: Analysis of a mechanism of laser damage to transparent polymers associated with their viscoelastic properties. Soc] Quantum Electronics 11:502-505, 1981 3. Bath PE, Fridge DL, Robinson K, McCord RC: Photometric evaluation of YAG-induced polymethylmethacrylate damage in a keratoprosthesis. Am Intra-Ocular Implant Soc] 11:253256, 1985 4. Bath PE, Romberger A, Brown P, Quon D: Quantitative concepts in avoiding intraocular lens damage from the Nd:YAG laser in posterior capsulotomy. ] Cataract Refract Surg 12:262-266, 1986
Management of an extruded footplate of an anterior chamber lens with the N d: YAG laser Howard Charles, M.D. Gholam A. Peyman, M.D. M. Pierre Pang, M. D. Chicago, Illinois
ABSTRACT A footplate of an anterior chamber lens that extruded through clear cornea was treated by severing the protruding haptic with the Nd:YAG laser and removing it surgically. During the procedure , the remainder of the implant was repositioned and vitreous traction was relieved by pars plana vitrectomy. This technique appeared less injurious to the eye than attempting to cut all four flbrosed haptics and remove the entire implant. Key Words: ante rior chamber l e ns, co mplication , dislocation , intraocular l ens implant , d ;YAG laser, vitr ctom y
The dislocation of intraocular lenses has been reported with anterior chamber, posterior chamber, irisfixed, and iridocapsular styles. 1-6 The selection of surgical treatment depends on the location of the lens implant (i.e., partially or totally extruded from the eye, dislocated posteriorly into the vitreous) and the extent of the ocular injury (i.e., iris and vitreous incarcerated in the wound, intraocular hemorrhage, vitreous fibrosis, corneal decompensation).3,6 We treated a dislocated anterior chamber lens (Shepard style) that had a footplate extruding through clear cornea. CASE REPORT A 69-year-old man had intracapsular cataract extraction in the left eye with the insertion of an anterior chamber intraocular lens (IOL) (Shepard style) in From the Department of Ophthalmology, Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago. Supported in part by a grant from Research to Prevent Blindness, Inc., New York City, and by training grant EY7038 and core grant EY1792 from the National Eye Institute, Bethesda, Maryland. Reprint requests to Gholam A. Peyman, M.D., 1855 W Taylor Street, Chicago, Illinois 60612.
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March 1984 in Bombay. Postoperatively, his visual acuity was reportedly 20/20. In December 1985, he had an uneventful extracapsular cataract extraction with a posterior chamber lens implantation in his right eye. Several weeks later, he noted a sudden sharp drop in vision in the left eye unaccompanied by pain, tenderness, photophobia, photopsia, or swelling of the eyelid. On slitlamp examination, a loop of the implanted lens was found protruding through otherwise intact peripheral cornea. The patient was referred to us for evaluation and treatment. The patient denied ocular trauma. His best corrected visual acuity was lOnO in the right eye with - 5.00 + 2.00 X 7° and 20/200 at two feet in the left eye with - 8.75 + 5.25 X 179°. Slitlamp examination of the right eye showed a clear cornea, deep anterior chamber, normal pupillary light reflexes, and a posterior chamber IOL. Examination of the left eye revealed mild ptosis, superior limbal conjunctival hyperemia, clear cornea (except for a few central keratic precipitates), and mild anterior chamber flare and cells. The superotemporal foot of the anterior chamber lens was protruding through clear cornea 1 mm from the limbus in the 1:00 meridian (Figure 1). The corneoscleral incision from previous surgery was undisturbed. A significant amount of vitreous fibrosis surrounded the protruding foot. The pupil was elongated vertically. Intraocular pressures were 19 mm Hg in the right eye and 18 mm Hg in the left eye. Ophthalmoscopic examination of the right eye disclosed a normal optic disc and retinal blood vessels . There was macular mottling consistent with agerelated macular degeneration . The left fundus was obscured by dense white fibrotic debris in the vitreous and surrounding the IOL, but the retina was attached. We directed 18 bursts (4 pulses/burst, 8 millijoules) of Nd:YAG laser energy toward the section of the
superotemporal footplate lying within the anterior chamber and severed it without incident. The patient was then brought to the operating room and general anesthesia was administered. After a peritomy was made and the rectus muscles were isolated, an infusion cannula was inserted 3 mm posterior to the limbus at the 3:00 meridian. The severed footplate was gently removed and the corneal tunnel was closed with two 9-0 nylon sutures. Sodium hyaluronate (Healon®) was injected into the anterior chamber and the implant was repositioned. Two sclerotomies were made superonasally and superotemporally, and a complete vitrectomy was performed. No retinal tears were found; however, the substantial vitreous traction on the peripheral retina was relieved. There were no immediate postoperative complications, and the patient's visual acuity improved to 20/400 after two months. The anterior chamber lens was in good position and the media were clear (Figure 2). The visual acuity was consistent with cystoid macular edema observed by fluorescein angiography.
Fig. 2.
Fig.!.
314
(Charles) Anterior chambe r lens with extruded footplate. Haptic passes through clear cornea (arrow).
J CATARACT REFRACT
(Charles) One week postoperatively lens is well positioned , with reversed end of haptic in anterior chamber (black arrow). Corneal incision has been closed with three nylon sutures (w hite arrow).
DISCUSSION The dislocation of an IOL is usually caused by trauma. In our patient, the lens was poorly positioned, allowing the initial contact between the haptic and the corneal endothelium. The fibrosed vitreous in the anterior chamber probably caused enough pressure necrosis to tunnel the footplate through the cornea . Previously, Nd:YAG laser energy has been used to sever inferior hap tics that are fibrosed into the angle from fibrous downgrowth or traumatic injury. We are unaware of it being used to cut superiorly dislocated haptics to maintain the implant. Steinert and Puliafit0 7 SURG-VOL 13, MAY 1987
stated that 6 mJ to 12 mJ and 25 to 100 pulses of Nd:YAG energy are usually required to cut polymethyl methacrylate or polypropylene haptics. They observed thinning of the haptics and focal vaporization and cracking from the pressure wave. We used 8 mJ and 72 pulses to sever the footplate completely. No corneal changes, significant anterior chamber inflammation, or increased pressure occurred afterward. Another approach would have been to enter the eye at the limbus, attempt to release the superior haptic from the fibrosed vitreous, cut the other haptics or extricate them out of the angle, and then remove the entire lens. This would have been far more traumatic to the corneal endothelium, would have deprived the patient of pseudophakic vision, and, most importantly, would have greatly increased the risk of retinal tearing by producing tension on the fibrosed vitreous. REFERENCES 1. Chowdhury AM, Bras JF: Posterior dislocation of an intraocular lens implant and its removal. Br J OphthalmoI6l:327-328, 1977 2. Biedner B, RothkoH'L, Blumenthal M: Subconjunctival dislocation of intraocular lens implant. Am J Ophthalmol 84:265-266, 1977 3. Hamburger HA, Lerner L: Surgical treatment of dislocated irisplane intraocular lenses. Ann Ophthalmol 17:434-436, 1985 4. Corboy JM, Ing MR: Traumatic loss of an anterior chamber lens. Am Intra-Ocular Implant Soc J .5:54-55, 1979 5. Bene C, Kranias G: Subconjunctival dislocation of a posterior chamber intraocular lens. Am J Ophthalmol 99:8.5-86, 1985 6. Koch DD, Knauer WJ III, Emery JM: Flexible anterior chamber intraocular lens expulsion. Am Intra-Ocular Implant Soc J 11:286-288, 1985 7. Steinert RF, Puliafito CA: The Nd- YAG Laser in Ophthalmology; Principles and Clinical Applications of Photodisruption. Philadelphia, WB Saunders Co, pp 129-130, 1985
Insertion of a second intraocular lens following traumatic expulsion of a posterior chamber lens John C. Hagan III, M.D. North Kansas City, Missouri
ABSTRACT Traumatic expulsion of an intraocular lens has rarely been reported in the literature. Successful implantation of a second intraocular lens following a traumatic expulsion has not been reported. This paper reports such a case. Key Words: intraocular le ns , traumatic expulsion
Traumatic expulsion of an intraocular lens (IOL) is apparently rare. Eleven cases have been reported in the literature .1-7 In none of these cases was the original or a second new, sterile 10L inserted. I have recently managed two traumatic expulsions. In one case, following anterior chamber reconstruction, I inserted a second 10L. I believe this to be the first such case report. CASE REPORTS
Case 1 The patient, a 70-year-old white female, had controlled open-angle glaucoma and preoperative vision of counting fingers at five feet. On January 29, 1985, I performed an uncomplicated planned extracapsular cataract extraction and inserted a posterior chamber IOL. The implant was 14 mm in length and had polypropylene (Prolene®) loops attached to a 6.5-mm optic. The loops were placed in the capsular bag. A primary capsulotomy was not performed. The incision was lO-mm chord length, biplaned, and closed with six interrupted 10-0 nylon sutures. Four days postoperatively the implant was in position, the wound secure, and visual acuity was 20/50 with a pinhole. Two days later the patient was found unconscious on the bathroom Hoor by her daughter. A Fox shield was still Reprint requests to John C. Hagan III, M.D., 2700 Hospital Drive, Suite 400, North Kansas City, Missouri 64116.
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Management of an extruded footplate of an anterior chamber lens with the N d: YAG laser Howard Charles, M.D. Gholam A. Peyman, M.D. M. Pierre Pang, M. D. Chicago, Illinois
ABSTRACT A footplate of an anterior chamber lens that extruded through clear cornea was treated by severing the protruding haptic with the Nd:YAG laser and removing it surgically. During the procedure , the remainder of the implant was repositioned and vitreous traction was relieved by pars plana vitrectomy. This technique appeared less injurious to the eye than attempting to cut all four flbrosed haptics and remove the entire implant. Key Words: ante rior chamber l e ns, co mplication , dislocation , intraocular l ens implant , d ;YAG laser, vitr ctom y
The dislocation of intraocular lenses has been reported with anterior chamber, posterior chamber, irisfixed, and iridocapsular styles. 1-6 The selection of surgical treatment depends on the location of the lens implant (i.e., partially or totally extruded from the eye, dislocated posteriorly into the vitreous) and the extent of the ocular injury (i.e., iris and vitreous incarcerated in the wound, intraocular hemorrhage, vitreous fibrosis, corneal decompensation).3,6 We treated a dislocated anterior chamber lens (Shepard style) that had a footplate extruding through clear cornea. CASE REPORT A 69-year-old man had intracapsular cataract extraction in the left eye with the insertion of an anterior chamber intraocular lens (IOL) (Shepard style) in From the Department of Ophthalmology, Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago. Supported in part by a grant from Research to Prevent Blindness, Inc., New York City, and by training grant EY7038 and core grant EY1792 from the National Eye Institute, Bethesda, Maryland. Reprint requests to Gholam A. Peyman, M.D., 1855 W Taylor Street, Chicago, Illinois 60612.
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March 1984 in Bombay. Postoperatively, his visual acuity was reportedly 20/20. In December 1985, he had an uneventful extracapsular cataract extraction with a posterior chamber lens implantation in his right eye. Several weeks later, he noted a sudden sharp drop in vision in the left eye unaccompanied by pain, tenderness, photophobia, photopsia, or swelling of the eyelid. On slitlamp examination, a loop of the implanted lens was found protruding through otherwise intact peripheral cornea. The patient was referred to us for evaluation and treatment. The patient denied ocular trauma. His best corrected visual acuity was lOnO in the right eye with - 5.00 + 2.00 X 7° and 20/200 at two feet in the left eye with - 8.75 + 5.25 X 179°. Slitlamp examination of the right eye showed a clear cornea, deep anterior chamber, normal pupillary light reflexes, and a posterior chamber IOL. Examination of the left eye revealed mild ptosis, superior limbal conjunctival hyperemia, clear cornea (except for a few central keratic precipitates), and mild anterior chamber flare and cells. The superotemporal foot of the anterior chamber lens was protruding through clear cornea 1 mm from the limbus in the 1:00 meridian (Figure 1). The corneoscleral incision from previous surgery was undisturbed. A significant amount of vitreous fibrosis surrounded the protruding foot. The pupil was elongated vertically. Intraocular pressures were 19 mm Hg in the right eye and 18 mm Hg in the left eye. Ophthalmoscopic examination of the right eye disclosed a normal optic disc and retinal blood vessels . There was macular mottling consistent with agerelated macular degeneration . The left fundus was obscured by dense white fibrotic debris in the vitreous and surrounding the IOL, but the retina was attached. We directed 18 bursts (4 pulses/burst, 8 millijoules) of Nd:YAG laser energy toward the section of the
superotemporal footplate lying within the anterior chamber and severed it without incident. The patient was then brought to the operating room and general anesthesia was administered. After a peritomy was made and the rectus muscles were isolated, an infusion cannula was inserted 3 mm posterior to the limbus at the 3:00 meridian. The severed footplate was gently removed and the corneal tunnel was closed with two 9-0 nylon sutures. Sodium hyaluronate (Healon®) was injected into the anterior chamber and the implant was repositioned. Two sclerotomies were made superonasally and superotemporally, and a complete vitrectomy was performed. No retinal tears were found; however, the substantial vitreous traction on the peripheral retina was relieved. There were no immediate postoperative complications, and the patient's visual acuity improved to 20/400 after two months. The anterior chamber lens was in good position and the media were clear (Figure 2). The visual acuity was consistent with cystoid macular edema observed by fluorescein angiography.
Fig. 2.
Fig.!.
314
(Charles) Anterior chambe r lens with extruded footplate. Haptic passes through clear cornea (arrow).
J CATARACT REFRACT
(Charles) One week postoperatively lens is well positioned , with reversed end of haptic in anterior chamber (black arrow). Corneal incision has been closed with three nylon sutures (w hite arrow).
DISCUSSION The dislocation of an IOL is usually caused by trauma. In our patient, the lens was poorly positioned, allowing the initial contact between the haptic and the corneal endothelium. The fibrosed vitreous in the anterior chamber probably caused enough pressure necrosis to tunnel the footplate through the cornea . Previously, Nd:YAG laser energy has been used to sever inferior hap tics that are fibrosed into the angle from fibrous downgrowth or traumatic injury. We are unaware of it being used to cut superiorly dislocated haptics to maintain the implant. Steinert and Puliafit0 7 SURG-VOL 13, MAY 1987
stated that 6 mJ to 12 mJ and 25 to 100 pulses of Nd:YAG energy are usually required to cut polymethyl methacrylate or polypropylene haptics. They observed thinning of the haptics and focal vaporization and cracking from the pressure wave. We used 8 mJ and 72 pulses to sever the footplate completely. No corneal changes, significant anterior chamber inflammation, or increased pressure occurred afterward. Another approach would have been to enter the eye at the limbus, attempt to release the superior haptic from the fibrosed vitreous, cut the other haptics or extricate them out of the angle, and then remove the entire lens. This would have been far more traumatic to the corneal endothelium, would have deprived the patient of pseudophakic vision, and, most importantly, would have greatly increased the risk of retinal tearing by producing tension on the fibrosed vitreous. REFERENCES 1. Chowdhury AM, Bras JF: Posterior dislocation of an intraocular lens implant and its removal. Br J OphthalmoI6l:327-328, 1977 2. Biedner B, RothkoH'L, Blumenthal M: Subconjunctival dislocation of intraocular lens implant. Am J Ophthalmol 84:265-266, 1977 3. Hamburger HA, Lerner L: Surgical treatment of dislocated irisplane intraocular lenses. Ann Ophthalmol 17:434-436, 1985 4. Corboy JM, Ing MR: Traumatic loss of an anterior chamber lens. Am Intra-Ocular Implant Soc J .5:54-55, 1979 5. Bene C, Kranias G: Subconjunctival dislocation of a posterior chamber intraocular lens. Am J Ophthalmol 99:8.5-86, 1985 6. Koch DD, Knauer WJ III, Emery JM: Flexible anterior chamber intraocular lens expulsion. Am Intra-Ocular Implant Soc J 11:286-288, 1985 7. Steinert RF, Puliafito CA: The Nd- YAG Laser in Ophthalmology; Principles and Clinical Applications of Photodisruption. Philadelphia, WB Saunders Co, pp 129-130, 1985
Insertion of a second intraocular lens following traumatic expulsion of a posterior chamber lens John C. Hagan III, M.D. North Kansas City, Missouri
ABSTRACT Traumatic expulsion of an intraocular lens has rarely been reported in the literature. Successful implantation of a second intraocular lens following a traumatic expulsion has not been reported. This paper reports such a case. Key Words: intraocular le ns , traumatic expulsion
Traumatic expulsion of an intraocular lens (IOL) is apparently rare. Eleven cases have been reported in the literature .1-7 In none of these cases was the original or a second new, sterile 10L inserted. I have recently managed two traumatic expulsions. In one case, following anterior chamber reconstruction, I inserted a second 10L. I believe this to be the first such case report. CASE REPORTS
Case 1 The patient, a 70-year-old white female, had controlled open-angle glaucoma and preoperative vision of counting fingers at five feet. On January 29, 1985, I performed an uncomplicated planned extracapsular cataract extraction and inserted a posterior chamber IOL. The implant was 14 mm in length and had polypropylene (Prolene®) loops attached to a 6.5-mm optic. The loops were placed in the capsular bag. A primary capsulotomy was not performed. The incision was lO-mm chord length, biplaned, and closed with six interrupted 10-0 nylon sutures. Four days postoperatively the implant was in position, the wound secure, and visual acuity was 20/50 with a pinhole. Two days later the patient was found unconscious on the bathroom Hoor by her daughter. A Fox shield was still Reprint requests to John C. Hagan III, M.D., 2700 Hospital Drive, Suite 400, North Kansas City, Missouri 64116.
J CATARACT REFRACT
SURG-VOL 13, MAY 1987
315