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Phacoprosthesis in Unusual Cases
phacoprosthesis in unusual 'cases Louis]. Girard, MD, FACS Rowland Hawkins, MD and Ted Baroda/sky, MD From the Institute of Ophthalmology and Twelve Oaks Hospital, Houston, Texas The purpose of this paper is to update and expand my original survey. The surgeons are listed in chronological order as to the year in which they began intraocular lens surgery. The following satistics are current as of Sept. 1976. Phacoprosthesis (intraocular lenses) may be a valuable adjunct to the prevention of amblyopia in cases of traumatic corneal opacification and cataract. In such cases conservative treatment such as initial repair followed by later cataract extraction and penetrating keratoplasty, followed still later by the use of a contact lens may take so long that irreparable amblyopia develops. It is vital to the prevention of amblyopia to regain useful vision as quickly as possible. The use of a phacoprosthesis is the quickest way to obtain vision in such cases and it is felt by the authors, that it is thoroughly justified. Five cases will be reported in which these lenses have been used. Case Studies: Case 1. A five year old white female had suffered a penetrating injury to her left eye on 6/18174 resulting in corneal opacification, cataract formation, and anterior synechiae. On 10/31174 the patient underwent a penetrating keratoplasty, removal of lens remnants, vitrectomy with ultrasonic fragmentation (Fig 1 A, B, & C) and synechialysis. A Binkhorst, four loop, intraocular lens was implanted at the same time. The postoperative course was uneventful, and the patient's vision improved to 20/50.
Figure 1-B, C. Postoperatively after reconstruction of anterior segment, extraction of lens remnants, implantation of intraocular lens and penetrating keratoplasty. Vision, LE 20/50.
Case 2. A four year old white male sustained a laceration of his left eye with corneal opacification and cataract formation on 1125175. When first examined, the patient's vision in this eye was light perception and projection (Fig 2-A). On 111617 5 the patient underwent a rotating autograft, iridectomy,
Figure 2-A Case 2. Adherent leukoma, cataract remnants, and traumatic iridectomy.
Figure 1-A Case 1. A five year old white female had suffered a penetrating injury to the left eye resulting in corneal opacifica-' tion, cataract and anterior synechiae. Appearance at surgery with scleral expander in place. 28
and removal of lens remnants by ultrasonic fragmentation and placement of a phacoprosthesis. The postoperative course was uneventful. When last exa~ mined on 4127176, the vision could be improved to 20/100. The patient is undergoing amblyopia treatment (Fig 2-B).
IrrIgation. The VISIOn improved to 201200 with a contact lens. The patient refused to wear the contact lens and the vision fell to 41200. In addition, the patient developed vitreous membranes. On 8/26176 the patient underwent removal of the lens remnants by vitrectomy with USF and implantation of a phacoprosthesis. During the procedure a retinal tear was discovered and treated with cryoretinopexy. The postoperative course has been uneventful (Fig 3-A, B, C, D).
Figure 2-B. Treated by reconstruction of anterior segment, excision of lens remnants, implantation of phacoprosthesis and rotating autokeratoplasty.
Case 3. In 1974 a six year old white male was struck by a bottle and sustained a laceration of the cornea and cataract in the left eye. On 1117174 the patient underwent an autograft, reconstruction of the anterior segment, and implantation of an intraocular lens. The postoperative course was uneventful and the patient's vision improved to 20/40. Case 4. An eight year old white male who had a laceration of his right eye in 1965. The best vision was light perception and projection. On 1117174 a rotating autograft was performed along with reconstruction of the anterior segment, synechialysis and insertion of a Federov intraocular lens. The postoperative course was uneventful, but the best corrected visual acuity was 4/200 due to macular scars. Case 5. At the age of six this patient sustained a penetrating injury to his right eye. A traumatic cataract developed and was treated by aspiration and
Figure 3-B. Retinal tear being treated by cryoretinopexy.
Figure 3-C. Cryoretinopexy thawing.
Figure 3-ACase S. Traumatic cataract and vitreous membranes, removal of lens remnants produced a retinal tear which was treated by cryoretinopexy. Beginning of procedure.
Figure 3-D. Phacoprosthesis implanted. 29
Discussion: Because of danger to the endothelium by the presence of an intraocular lens, most surgeons have hesitated to implant intraocular lenses into children or young adults. There are, however, cases in which the authors feel an intraocular lens is justified. In young children who have sustained injuries and require cataract extraction and penetrating keratoplasty it requires too much time to perform keratoplasty and cataract extraction and then wait to fit the patient with a contact lens. The patient can become amblyopic in a very short time. In such cases the use of an autograft when possible, or a penetrating homograft keratoplasty and an intraocular lens can restore vision as quickly as possible and prevent intractable amblyopia. Summary: Intraocular lenses may be a valuable adjunct to the prevention of amblyopia in cases of tramatic corneal opacification and cataract in young individuals. In such cases conservative treatment such as initial repair followed by later cataract extraction and penetrating keratoplasty, followed still later by the use of a contact lens may take so long that irreparable amblyopia develops. It is vital to the prevention of amblyopia to regain useful vision as quickly as possible. The use of a phacoprosthesis is the quickest way to obtain vision in these cases. It is felt by the authors that it is thoroughly justified in children when amblyopia is threatening. Five unusual cases are reported in which these lenses have been used.
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Figure 1-B, C. Postoperatively after reconstruction of anterior segment, extraction of lens remnants, implantation of intraocular lens and penetrating keratoplasty. Vision, LE 20/50.
Case 2. A four year old white male sustained a laceration of his left eye with corneal opacification and cataract formation on 1125175. When first examined, the patient's vision in this eye was light perception and projection (Fig 2-A). On 111617 5 the patient underwent a rotating autograft, iridectomy,
Figure 2-A Case 2. Adherent leukoma, cataract remnants, and traumatic iridectomy.
Figure 1-A Case 1. A five year old white female had suffered a penetrating injury to the left eye resulting in corneal opacifica-' tion, cataract and anterior synechiae. Appearance at surgery with scleral expander in place. 28
and removal of lens remnants by ultrasonic fragmentation and placement of a phacoprosthesis. The postoperative course was uneventful. When last exa~ mined on 4127176, the vision could be improved to 20/100. The patient is undergoing amblyopia treatment (Fig 2-B).
IrrIgation. The VISIOn improved to 201200 with a contact lens. The patient refused to wear the contact lens and the vision fell to 41200. In addition, the patient developed vitreous membranes. On 8/26176 the patient underwent removal of the lens remnants by vitrectomy with USF and implantation of a phacoprosthesis. During the procedure a retinal tear was discovered and treated with cryoretinopexy. The postoperative course has been uneventful (Fig 3-A, B, C, D).
Figure 2-B. Treated by reconstruction of anterior segment, excision of lens remnants, implantation of phacoprosthesis and rotating autokeratoplasty.
Case 3. In 1974 a six year old white male was struck by a bottle and sustained a laceration of the cornea and cataract in the left eye. On 1117174 the patient underwent an autograft, reconstruction of the anterior segment, and implantation of an intraocular lens. The postoperative course was uneventful and the patient's vision improved to 20/40. Case 4. An eight year old white male who had a laceration of his right eye in 1965. The best vision was light perception and projection. On 1117174 a rotating autograft was performed along with reconstruction of the anterior segment, synechialysis and insertion of a Federov intraocular lens. The postoperative course was uneventful, but the best corrected visual acuity was 4/200 due to macular scars. Case 5. At the age of six this patient sustained a penetrating injury to his right eye. A traumatic cataract developed and was treated by aspiration and
Figure 3-B. Retinal tear being treated by cryoretinopexy.
Figure 3-C. Cryoretinopexy thawing.
Figure 3-ACase S. Traumatic cataract and vitreous membranes, removal of lens remnants produced a retinal tear which was treated by cryoretinopexy. Beginning of procedure.
Figure 3-D. Phacoprosthesis implanted. 29
Discussion: Because of danger to the endothelium by the presence of an intraocular lens, most surgeons have hesitated to implant intraocular lenses into children or young adults. There are, however, cases in which the authors feel an intraocular lens is justified. In young children who have sustained injuries and require cataract extraction and penetrating keratoplasty it requires too much time to perform keratoplasty and cataract extraction and then wait to fit the patient with a contact lens. The patient can become amblyopic in a very short time. In such cases the use of an autograft when possible, or a penetrating homograft keratoplasty and an intraocular lens can restore vision as quickly as possible and prevent intractable amblyopia. Summary: Intraocular lenses may be a valuable adjunct to the prevention of amblyopia in cases of tramatic corneal opacification and cataract in young individuals. In such cases conservative treatment such as initial repair followed by later cataract extraction and penetrating keratoplasty, followed still later by the use of a contact lens may take so long that irreparable amblyopia develops. It is vital to the prevention of amblyopia to regain useful vision as quickly as possible. The use of a phacoprosthesis is the quickest way to obtain vision in these cases. It is felt by the authors that it is thoroughly justified in children when amblyopia is threatening. Five unusual cases are reported in which these lenses have been used.
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