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Phacoemulsification cataract surgery in vitrectomized eyes
LETTERS 2. Keskinbora K. Simultaneous bilateral PEKKE-IOL implantation. "loft Gaz 1994; 24:165-167 3. Fenton PJ, Gardner ID. Simultaneous bilateral intrancular surgery. Tram Ophthalmol Soc UK 1982; 102:298-301 4. Payne JV, Kameen AJ, Jensen AD, Christy NE. Expulsive hemorrhage: its incidence in cataract surgery and a report of four bilateral cas~. Trans Am Ophthalmol 1985; 83:181-204
Phacoemulsification Cataract Surgery in VitrectomiTed Eyes n the article by Lacalle et al.,' underlying vitreoretinal pathology in 2 eyes that had pars plana vitrectomy was stated to be an intraocular foreign body. However, location of the penetrating wound and associated lens or zonular pathology was not clearly described. In eyes with corneal penetration and an intraocular foreign body, we expect capsular or cortical defects in the lens. This type of defect (tear) can increase during phacoemulsification, resulting in luxation of cortical materials into the vitreous cavity. In this type of eye, a larger capsulorhexis and prolapsing the nucleus into the anterior chamber and performing phacoemulsification there can decrease complications. On the other hand, penetrating injury associated with a corneal or limbal entrance can cause some degree of zonular loss, which can result in posterior capsule tears. Unless an endocapsular ring is used to manage zonular dialysis in such eyes, we think in-the-bag implantation of an intraocular lens (IOL) is impossible and sulcus implantation very hard. Lack of vitreous support and abnormal anterior chamber depth alterations as in vitrectomized eyes can cause further loss of zonules, resulting in failure of IOL implantation. In eyes with penetrating trauma and an intraocular foreign. body, detailed examination of the lens capsule and zonules is especially important to eliminate future complications. The authors mention a tear in the posterior capsule in 2 eyes intraoperatively. One of these eyes was stated to require anterior vitrectomy and presented some lens cortical material luxation into the vitreous cavity. Laser capsulotomy was performed at least I year after surgery in all cases. In eyes with a posterior capsule defect, posterior capsulorhexis could prevent tear enlargement, allowing in-the-bag or sulcus IOL fixation. In this case, there would be no need to perform a laser capsulotomy. On the contrary, if the tear v'as too large, whether an
I
IOL was implanted, the authors should describe the reason for the laser capsulotomy. One reason for the high incidence of asymmetric in-the-bag sulcus fixation in the study was identified as small pupil. We suggest using flexible iris hooks in eyes with small pupil. This device allows examination of the status of the capsule and zonules during phacoemulsification and also ensures symmetric in-the-bag or sulcus IOL fixation. They may also be useful for facilitating probable vitreous surgery in case of cortical material luxation into the vitreous during phacoemulsification in eyes with previous vitreoretinal pathology. OSMAN ~EK|(~, MD
Mala~ya, Turkey CO~AR BATMAN,MD
Ankara, Turkey Rcfcrellce 1. Lacalle VD, Garate FJO, Alday NM, et al. Phacoemulsification cataract surgery in vitrectomlzed eyes. J Cataract Refract Surg 1998; 24:806-809
Proper Orientation fter reading the case report by Nagamoto and coauthors, I it occurred to me that they may have inserted the intraocular lens (IOL) backward; i.e., with the angulated loops pushing 'the optic forward in the bag. This would certainly account for the myopic shift they noted and also for the ability of the lens to slip forward. I have seen this with earlier models of the Allergan silicone IOL. In fact, I reported this at the 1992 Symposium on Cataract, IOL and Refractive Surgery, where I demonstrated that the flexibility of the loop-optic junction in these lenses causes them to shift forward; in my.case experience, this happens particularly in short eyes. I have also had several patients with pupiUary capture with the silicone IOL. I have implanted hundreds of AcrySof lenses and have found the IOL calculations to be particularly accurate; therefore, I think the authors should check the angulation of the loops and curve of the haptics to determine whether the lens was accidentally put in backward.
A
CAROL BOERNER, MD
Brookline, Massachusetts, USA Reference
1. Nagamoto S, KohzukaT, NagamotoT. PupiUaryblock after pupillary capture of an Ar.rySofintrancular lens. J Cataract Refract Surg 1998; 24:1271-1274
j CATARACTREFRACTSUKG--VOL25,MARCH1999
305
Phacoemulsification Cataract Surgery in VitrectomiTed Eyes n the article by Lacalle et al.,' underlying vitreoretinal pathology in 2 eyes that had pars plana vitrectomy was stated to be an intraocular foreign body. However, location of the penetrating wound and associated lens or zonular pathology was not clearly described. In eyes with corneal penetration and an intraocular foreign body, we expect capsular or cortical defects in the lens. This type of defect (tear) can increase during phacoemulsification, resulting in luxation of cortical materials into the vitreous cavity. In this type of eye, a larger capsulorhexis and prolapsing the nucleus into the anterior chamber and performing phacoemulsification there can decrease complications. On the other hand, penetrating injury associated with a corneal or limbal entrance can cause some degree of zonular loss, which can result in posterior capsule tears. Unless an endocapsular ring is used to manage zonular dialysis in such eyes, we think in-the-bag implantation of an intraocular lens (IOL) is impossible and sulcus implantation very hard. Lack of vitreous support and abnormal anterior chamber depth alterations as in vitrectomized eyes can cause further loss of zonules, resulting in failure of IOL implantation. In eyes with penetrating trauma and an intraocular foreign. body, detailed examination of the lens capsule and zonules is especially important to eliminate future complications. The authors mention a tear in the posterior capsule in 2 eyes intraoperatively. One of these eyes was stated to require anterior vitrectomy and presented some lens cortical material luxation into the vitreous cavity. Laser capsulotomy was performed at least I year after surgery in all cases. In eyes with a posterior capsule defect, posterior capsulorhexis could prevent tear enlargement, allowing in-the-bag or sulcus IOL fixation. In this case, there would be no need to perform a laser capsulotomy. On the contrary, if the tear v'as too large, whether an
I
IOL was implanted, the authors should describe the reason for the laser capsulotomy. One reason for the high incidence of asymmetric in-the-bag sulcus fixation in the study was identified as small pupil. We suggest using flexible iris hooks in eyes with small pupil. This device allows examination of the status of the capsule and zonules during phacoemulsification and also ensures symmetric in-the-bag or sulcus IOL fixation. They may also be useful for facilitating probable vitreous surgery in case of cortical material luxation into the vitreous during phacoemulsification in eyes with previous vitreoretinal pathology. OSMAN ~EK|(~, MD
Mala~ya, Turkey CO~AR BATMAN,MD
Ankara, Turkey Rcfcrellce 1. Lacalle VD, Garate FJO, Alday NM, et al. Phacoemulsification cataract surgery in vitrectomlzed eyes. J Cataract Refract Surg 1998; 24:806-809
Proper Orientation fter reading the case report by Nagamoto and coauthors, I it occurred to me that they may have inserted the intraocular lens (IOL) backward; i.e., with the angulated loops pushing 'the optic forward in the bag. This would certainly account for the myopic shift they noted and also for the ability of the lens to slip forward. I have seen this with earlier models of the Allergan silicone IOL. In fact, I reported this at the 1992 Symposium on Cataract, IOL and Refractive Surgery, where I demonstrated that the flexibility of the loop-optic junction in these lenses causes them to shift forward; in my.case experience, this happens particularly in short eyes. I have also had several patients with pupiUary capture with the silicone IOL. I have implanted hundreds of AcrySof lenses and have found the IOL calculations to be particularly accurate; therefore, I think the authors should check the angulation of the loops and curve of the haptics to determine whether the lens was accidentally put in backward.
A
CAROL BOERNER, MD
Brookline, Massachusetts, USA Reference
1. Nagamoto S, KohzukaT, NagamotoT. PupiUaryblock after pupillary capture of an Ar.rySofintrancular lens. J Cataract Refract Surg 1998; 24:1271-1274
j CATARACTREFRACTSUKG--VOL25,MARCH1999
305