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Photocoagulation of Retinal, Vascular, and Macular Diseases through Intraocular Lenses
Photocoagulation of Retinal, Vascular, and Macular Diseases through Intraocular Lenses ARNALL PATZ, MD
Abstract: A survey of physicians in several retinal centers in this country provided information on more than 500 patients who underwent photocoagulation treatment primarily for retinal, vascular, and macular diseases, and in some instances, for retinal breaks. One hundred fortytwo physicians responded to a questionnaire providing a broader experience on this type of photocoagulation. Seventy-eight of the physicians had not performed photocoagulation through an intraocular lens (IOL) and 64 had treated one or more patients. In view of the essentially satisfactory fundus lesions obtained by photocoagulation through IOLs, one can consider this as an acceptable form of treatment recognizing the problem of visualization in certain patients. If photocoagulation is anticipated at some time after the implantation of an IOL, the technique used should permit safe dilatation of the pupil. The special situation for IOLs in patients with diabetes and macular degeneration is discussed. [Key words: diabetic retinopathy, intraocular lens, macular degeneration, photocoagulation.] Ophthalmology 88:398-406, 1981
Intraocular lenses (IOLs) have been used in this country with steadily increasing frequency in recent years. 1- 5 Yet because of the relatively short period of use, no one ophthalmic center has accumulated a large number of cases of photocoagulation for macular, retinal, and vascular disorders in patients with IOLs. A questionnaire was developed and mailed to physicians in many of the retinal centers in this country to gain more knowledge about other physicians' experiences with these lenses. One hundred seventy-eight questionnaires were mailed and 142 physicians replied, providing information on 587 patients who had received photocoagulation treatment through IOLs. Information gained from this survey documents the feasibility of photocoagulation performed through intraocular lenses, recognizing that there are some limFrom the Wilmer Ophthalmological Institute, Baltimore. Presented at the Eighty-Fifth Annual Meeting of the American Academy of Ophthalmology, Chicago, November 2-7, 1980. Reprint requests to Dr. Patz, The Wilmer Ophthalmological Institute, Johns Hopkins Hospital, Baltimore, MD 21205.
398
itations in the visualization caused primarily by the inability to dilate the pupils adequately in certain patients.
RESULTS OF THE SURVEY The questions asked in the survey are listed in Table 1 and the responses are tabulated in Tables 2 and 3. The additional reflections from the surfaces of the IOL or from the posterior capsule were frequent inconveniences and required some manipulation of the Goldmann lens but were not a major problem in most cases (Fig 1A -C). Although pigment particles on the lens can cause scattering of the laser beam, no evidence of the pigment absorbing the thermal energy and damaging the lens was noted. The presence of pigment particles was listed as a minor inconvenience in visualizing and scattering the laser beam. In two instances, inflammatory deposits (KP-like deposits) obscured the initial view of the fundus but these KP-like deposits 0161-6420/81/0500/0398/$00.95
© American Academy of Ophthalmology
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Table 1. Questionnaire 1. Have you performed photocoagulation through an implanted intraocular lens? Yes _ _ No _ _ If NO, stop here 2. If YES, number of patients treated? _ _ 3. Types of treatment: Diabetic retinopathy PRP _ __ Focal mac Rx for edema _ __ Branch vein occlusion Quadrantic scatter Rx _ __ Focal Rx for mac edema _ __ Macular degeneration Subretinal neovasc _ __ R.P.E. detach _ __ Presumed histo subretinal neovasc _ __ OTHER (please list): _ _ _ __
DISCUSSION
4. Problems or complications: Poor visualization _ __ Difficulty treating periphery in PRP _ __ Pigment on lens scattering laser beam _ __ OTHER: _ _ _ __
Table 2. Results of the Survey Number Questionnaires mailed Physicians who responded Physicians who treated one or more patients Total cases treated Diabetic Retinopathy Physicians who performed PRP* Physicians who treated macular edema Branch Vein Occlusion (BVO) Physicians who used scatter Rx for BVO Physicians who used focal Rx for macular edema Macular Degeneration Physicians treating subretinal degenerations retinal pigment epithelial detachments presumed ocular histoplasmosis (subretinal neovascularization) Miscellaneous Physicians treating peripheral retinal tears augmenting retinal buckles
178 142 64 587 39 9
5 3 10 1 1
8 4
* Twenty-six of these physicians had difficulty with visualizing and treating the mid-periphery.
Table 3. Problems and Complications Poor visualization: 50 of 64 physicians using Rx Difficulty treating periphery with PRP: 26 of 39 physicians who performed PRP Pigment on lens scattering laser beam: 18 of 64 physicians using Rx* *
Most indicated this was not a significant problem.
cleared with steroid medication, permitting adequate visualization and photocoagulation. The majority of physicians who performed panretinal photocoagulation for proliferative diabetic retinopathy reported problems in visualizing and treating the midperiphery of the fundus.
Poole and Galin4 investigated the effects of argon laser and xenon arc photocoagulation on the plastic materials contained in intraocular lenses. These investigators found no apparent toxic products liberated following photocoagulation as a result of photothermal decomposition. Poole and Galin also found no alteration in cell growth indicating toxicity to rabbit kidney tissue culture from the irradiated lenses. Furthermore, these investigators demonstrated the feasibility of photocoagulating the cat retina through implanted intraocular lenses, producing satisfactory burns in the retina in the experimental animal model with no adverse anterior segment reaction. They reported favorably on argon laser photocoagulation through intraocular lenses on several patients with retinal tears. Diabetic retinopathy. Panretinal photocoagulation done with the argon laser presented a major problem in visualizing and treating the midperiphery for 26 of the 39 physicians who had performed panretinal treatment for diabetic retinopathy. Two of the 26 physicians preferred the xenon arc for the panretinal photocoagulation. The logical question to be asked is, ''Should intraocular lenses be used in diabetic patients because of the likelihood that diabetic patients will develop proliferative retinopathy requiring panretinal photocoagulation?" Certainly from the experiences reported in this survey and the logical interpretation of the findings, one should deliberately avoid an in-· traocular lens procedure in diabetics that will make adequate dilatation of the pupil unsafe. At the Wilmer Institute, Dr. Walter R. Stark6 cited the criteria used by Dr. A. Edward Maumenee and himself for diabetic patients: In general, we try to avoid putting intraocular lenses in patients with diabetes unless they are very elderly or unless there are contraindications to the use of a contact lens, such as dry eyes or lid abnormalities. If the diabetic patient is elderly and has dry eyes with no evidence of diabetic retinopathy, then we would consider an IOL but we would not consider an IOL in a younger diabetic patient, or even one in the 60s with diabetes, because he or she may live long enough to develop retinopathy.
Macular degeneration. Patients with extensive macular degenerative changes rely considerably upon their peripheral visual field and usually do poorly with spectacles after cataract extractions. The use of an IOL is a logical step for these individuals as the IOL provides a more efficient optical system than spectacles. 399
Fig lA. Diagrammatic representation of reflexes from the anterior surface of the intraocular lens.
400
Fig lB. Reflexes from posterior surface of intraocular lens.
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Fig lC. Reflexes from the lens capsule.
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OPHTHALMOLOGY • MAY 1981 • VOLUME 88 • NUMBER 5
Fig 2A. Extensive disciform scar in the right macular area as a result of a previous subretinal neovascular membrane with hemorrhage. The patient's vision was reduced to 5/200 with eccentric fixation.
Fig 28. Left eye of patient in Fig 2A with extensive disciform scar from previous subrefinal neovascular membrane and hemorrhage. Vision 5/200 with eccentric fixation.
402
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Fig 3. A 63-year-old patient with history of disciform scar in fellow eye as part of senile macular degeneration. Left eye shows multiple confluent drusen with vision 20/40.
Patients with advanced drusen who are potential candidates to develop subretinal choroidal neovascularization in subsequent years would also be candidates for the IOL. Should these patients develop a neovascular membrane and a subsequent disciform scar, the IOL would enable them to perform much more efficiently than with spectacles, because of the better optical system of the IOL. The patient shown in Figs 2A and B subsequently developed cataracts that were finally removed when they were almost mature. The patient underwent routine intracapsular cataract extraction with no complications. She was unable to wear contact lenses and was severely incapacitated while wearing spectacles, because her peripheral field which she had relied on prior to the cataract development was markedly distorted through the spectacles. This patient, who was operated upon several years ago, would now be considered a suitable candidate for intraocular lenses. These would enable her to have much better use of the field of vision from the retina surrounding the large macular scars. The patient in Fig 3 with multiple drusen is at risk for developing subretinal neovascularization in subsequent years with hemorrhage and scar formation. He lost vision in the fellow eye from a disciform macular scar. Should this type of patient require cataract surgery, the use of an intraocular lens deserves serious consideration because he is at risk for developing significant macular damage in future years. In that event, ordinary spectacles would compromise his peripheral visual field, which is essential to him. In cataract patients with macular degeneration, it
is important to recognize the amount of visual impairment caused by the macular changes as well as by the cataract. Since the patient's own crystalline lens in place generally provides his best optical system, operation for the cataract is not indicated until the lens opacities are moderately advanced. Indeed, removal of the cataract in an early stage of development is not advocated and would appear contraindicated in patients with significant macular degeneration. Recently, Guyton and Minkowski (personal communication) have developed a "potential acuity meter" to measure visual acuity through partially developed cataracts, providing a more accurate assessment of macular function in these patients. In response to the survey, Dr. William H. Jarrett II of Atlanta kindly submitted excellent quality photographs of a patient with senile macular degeneration. A subretinal neovascular membrane developed after his cataract operation and was treated uneventfully with the argon laser by Dr. Jarrett (Figs 4A- D). One respondent to this survey reported that the lens loop scattered the argon laser beam in one instance. It is of interest that Litwin 7 reported that the loop of a four-loop Binkhorst lens acted as a fiberoptic bundle. The laser beam was carried posteriorly by the loop, then under the iris, around the back into the optical part of the intraocular lens, and then directly into the eye of the observer. Litwin commented that this phenomenon might create a hazard for the observers in the room unless they were protected by laser safety goggles. He commented that the laser manufacturer felt that the orange safety filter in the laser was probably sufficient to protect the surgeon in this circumstance.
403
OPHTHALMOLOGY • MAY 1981 • VOLUME 88 • NUMBER 5
Fig 4A. Anterior segment photograph of IOL with pupil partially cularization (Courtesy of Dr. William H. Jarrett, II, Atlanta).
Fig 48. Pretreatment fundus photograph of patient in Fig 4A. Neovascular membrane with overlying sensory retinal detachment (arrow).
404
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Fig 4C. Immediate post-treatment fundus photograph of lesion in Fig 4B.
Fig 4C. Fundus photograph six weeks after photocoagulation treatment.
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OPHTHALMOLOGY • MAY 1981 • VOLUME 88 • NUMBER 5
REFERENC ES 4. 1. Van Balen AThM, ed. First International Symposium on Artificial Lensimplantation, Utrecht April, 1974. Doc Ophthalmol Proc Ser 1975; Vol 6. 2. Nordlohne ME. The intraocular implant lens development and results with special reference to the Binkhorst lens. 2nd ed. Baltimore: Williams & Wilkins, 1975. 3. Wilensky JT, ed. Intraocular Lenses. Transactions of the Uni-
406
5. 6. 7.
versity of Illinois Symposium on Intraocular Lenses. New York: Appleton-Century Crofts, 1977. Poole TA, Galin MA. Argon laser photocoagulation of the posterior segment in pseudophakia. Am J Ophthalmol 1977; 83:185-7. Jaffe NS, Galin MA, Hirschman H, et al. Pseudophakos. St. Louis, CV Mosby, 1978. Stark WR. Personal communication. Litwin RL. Laser photocoagulation hazards. Letter to the Editor. Am J Ophthalmol 1979; 87:583.
Abstract: A survey of physicians in several retinal centers in this country provided information on more than 500 patients who underwent photocoagulation treatment primarily for retinal, vascular, and macular diseases, and in some instances, for retinal breaks. One hundred fortytwo physicians responded to a questionnaire providing a broader experience on this type of photocoagulation. Seventy-eight of the physicians had not performed photocoagulation through an intraocular lens (IOL) and 64 had treated one or more patients. In view of the essentially satisfactory fundus lesions obtained by photocoagulation through IOLs, one can consider this as an acceptable form of treatment recognizing the problem of visualization in certain patients. If photocoagulation is anticipated at some time after the implantation of an IOL, the technique used should permit safe dilatation of the pupil. The special situation for IOLs in patients with diabetes and macular degeneration is discussed. [Key words: diabetic retinopathy, intraocular lens, macular degeneration, photocoagulation.] Ophthalmology 88:398-406, 1981
Intraocular lenses (IOLs) have been used in this country with steadily increasing frequency in recent years. 1- 5 Yet because of the relatively short period of use, no one ophthalmic center has accumulated a large number of cases of photocoagulation for macular, retinal, and vascular disorders in patients with IOLs. A questionnaire was developed and mailed to physicians in many of the retinal centers in this country to gain more knowledge about other physicians' experiences with these lenses. One hundred seventy-eight questionnaires were mailed and 142 physicians replied, providing information on 587 patients who had received photocoagulation treatment through IOLs. Information gained from this survey documents the feasibility of photocoagulation performed through intraocular lenses, recognizing that there are some limFrom the Wilmer Ophthalmological Institute, Baltimore. Presented at the Eighty-Fifth Annual Meeting of the American Academy of Ophthalmology, Chicago, November 2-7, 1980. Reprint requests to Dr. Patz, The Wilmer Ophthalmological Institute, Johns Hopkins Hospital, Baltimore, MD 21205.
398
itations in the visualization caused primarily by the inability to dilate the pupils adequately in certain patients.
RESULTS OF THE SURVEY The questions asked in the survey are listed in Table 1 and the responses are tabulated in Tables 2 and 3. The additional reflections from the surfaces of the IOL or from the posterior capsule were frequent inconveniences and required some manipulation of the Goldmann lens but were not a major problem in most cases (Fig 1A -C). Although pigment particles on the lens can cause scattering of the laser beam, no evidence of the pigment absorbing the thermal energy and damaging the lens was noted. The presence of pigment particles was listed as a minor inconvenience in visualizing and scattering the laser beam. In two instances, inflammatory deposits (KP-like deposits) obscured the initial view of the fundus but these KP-like deposits 0161-6420/81/0500/0398/$00.95
© American Academy of Ophthalmology
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Table 1. Questionnaire 1. Have you performed photocoagulation through an implanted intraocular lens? Yes _ _ No _ _ If NO, stop here 2. If YES, number of patients treated? _ _ 3. Types of treatment: Diabetic retinopathy PRP _ __ Focal mac Rx for edema _ __ Branch vein occlusion Quadrantic scatter Rx _ __ Focal Rx for mac edema _ __ Macular degeneration Subretinal neovasc _ __ R.P.E. detach _ __ Presumed histo subretinal neovasc _ __ OTHER (please list): _ _ _ __
DISCUSSION
4. Problems or complications: Poor visualization _ __ Difficulty treating periphery in PRP _ __ Pigment on lens scattering laser beam _ __ OTHER: _ _ _ __
Table 2. Results of the Survey Number Questionnaires mailed Physicians who responded Physicians who treated one or more patients Total cases treated Diabetic Retinopathy Physicians who performed PRP* Physicians who treated macular edema Branch Vein Occlusion (BVO) Physicians who used scatter Rx for BVO Physicians who used focal Rx for macular edema Macular Degeneration Physicians treating subretinal degenerations retinal pigment epithelial detachments presumed ocular histoplasmosis (subretinal neovascularization) Miscellaneous Physicians treating peripheral retinal tears augmenting retinal buckles
178 142 64 587 39 9
5 3 10 1 1
8 4
* Twenty-six of these physicians had difficulty with visualizing and treating the mid-periphery.
Table 3. Problems and Complications Poor visualization: 50 of 64 physicians using Rx Difficulty treating periphery with PRP: 26 of 39 physicians who performed PRP Pigment on lens scattering laser beam: 18 of 64 physicians using Rx* *
Most indicated this was not a significant problem.
cleared with steroid medication, permitting adequate visualization and photocoagulation. The majority of physicians who performed panretinal photocoagulation for proliferative diabetic retinopathy reported problems in visualizing and treating the midperiphery of the fundus.
Poole and Galin4 investigated the effects of argon laser and xenon arc photocoagulation on the plastic materials contained in intraocular lenses. These investigators found no apparent toxic products liberated following photocoagulation as a result of photothermal decomposition. Poole and Galin also found no alteration in cell growth indicating toxicity to rabbit kidney tissue culture from the irradiated lenses. Furthermore, these investigators demonstrated the feasibility of photocoagulating the cat retina through implanted intraocular lenses, producing satisfactory burns in the retina in the experimental animal model with no adverse anterior segment reaction. They reported favorably on argon laser photocoagulation through intraocular lenses on several patients with retinal tears. Diabetic retinopathy. Panretinal photocoagulation done with the argon laser presented a major problem in visualizing and treating the midperiphery for 26 of the 39 physicians who had performed panretinal treatment for diabetic retinopathy. Two of the 26 physicians preferred the xenon arc for the panretinal photocoagulation. The logical question to be asked is, ''Should intraocular lenses be used in diabetic patients because of the likelihood that diabetic patients will develop proliferative retinopathy requiring panretinal photocoagulation?" Certainly from the experiences reported in this survey and the logical interpretation of the findings, one should deliberately avoid an in-· traocular lens procedure in diabetics that will make adequate dilatation of the pupil unsafe. At the Wilmer Institute, Dr. Walter R. Stark6 cited the criteria used by Dr. A. Edward Maumenee and himself for diabetic patients: In general, we try to avoid putting intraocular lenses in patients with diabetes unless they are very elderly or unless there are contraindications to the use of a contact lens, such as dry eyes or lid abnormalities. If the diabetic patient is elderly and has dry eyes with no evidence of diabetic retinopathy, then we would consider an IOL but we would not consider an IOL in a younger diabetic patient, or even one in the 60s with diabetes, because he or she may live long enough to develop retinopathy.
Macular degeneration. Patients with extensive macular degenerative changes rely considerably upon their peripheral visual field and usually do poorly with spectacles after cataract extractions. The use of an IOL is a logical step for these individuals as the IOL provides a more efficient optical system than spectacles. 399
Fig lA. Diagrammatic representation of reflexes from the anterior surface of the intraocular lens.
400
Fig lB. Reflexes from posterior surface of intraocular lens.
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Fig lC. Reflexes from the lens capsule.
401
OPHTHALMOLOGY • MAY 1981 • VOLUME 88 • NUMBER 5
Fig 2A. Extensive disciform scar in the right macular area as a result of a previous subretinal neovascular membrane with hemorrhage. The patient's vision was reduced to 5/200 with eccentric fixation.
Fig 28. Left eye of patient in Fig 2A with extensive disciform scar from previous subrefinal neovascular membrane and hemorrhage. Vision 5/200 with eccentric fixation.
402
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Fig 3. A 63-year-old patient with history of disciform scar in fellow eye as part of senile macular degeneration. Left eye shows multiple confluent drusen with vision 20/40.
Patients with advanced drusen who are potential candidates to develop subretinal choroidal neovascularization in subsequent years would also be candidates for the IOL. Should these patients develop a neovascular membrane and a subsequent disciform scar, the IOL would enable them to perform much more efficiently than with spectacles, because of the better optical system of the IOL. The patient shown in Figs 2A and B subsequently developed cataracts that were finally removed when they were almost mature. The patient underwent routine intracapsular cataract extraction with no complications. She was unable to wear contact lenses and was severely incapacitated while wearing spectacles, because her peripheral field which she had relied on prior to the cataract development was markedly distorted through the spectacles. This patient, who was operated upon several years ago, would now be considered a suitable candidate for intraocular lenses. These would enable her to have much better use of the field of vision from the retina surrounding the large macular scars. The patient in Fig 3 with multiple drusen is at risk for developing subretinal neovascularization in subsequent years with hemorrhage and scar formation. He lost vision in the fellow eye from a disciform macular scar. Should this type of patient require cataract surgery, the use of an intraocular lens deserves serious consideration because he is at risk for developing significant macular damage in future years. In that event, ordinary spectacles would compromise his peripheral visual field, which is essential to him. In cataract patients with macular degeneration, it
is important to recognize the amount of visual impairment caused by the macular changes as well as by the cataract. Since the patient's own crystalline lens in place generally provides his best optical system, operation for the cataract is not indicated until the lens opacities are moderately advanced. Indeed, removal of the cataract in an early stage of development is not advocated and would appear contraindicated in patients with significant macular degeneration. Recently, Guyton and Minkowski (personal communication) have developed a "potential acuity meter" to measure visual acuity through partially developed cataracts, providing a more accurate assessment of macular function in these patients. In response to the survey, Dr. William H. Jarrett II of Atlanta kindly submitted excellent quality photographs of a patient with senile macular degeneration. A subretinal neovascular membrane developed after his cataract operation and was treated uneventfully with the argon laser by Dr. Jarrett (Figs 4A- D). One respondent to this survey reported that the lens loop scattered the argon laser beam in one instance. It is of interest that Litwin 7 reported that the loop of a four-loop Binkhorst lens acted as a fiberoptic bundle. The laser beam was carried posteriorly by the loop, then under the iris, around the back into the optical part of the intraocular lens, and then directly into the eye of the observer. Litwin commented that this phenomenon might create a hazard for the observers in the room unless they were protected by laser safety goggles. He commented that the laser manufacturer felt that the orange safety filter in the laser was probably sufficient to protect the surgeon in this circumstance.
403
OPHTHALMOLOGY • MAY 1981 • VOLUME 88 • NUMBER 5
Fig 4A. Anterior segment photograph of IOL with pupil partially cularization (Courtesy of Dr. William H. Jarrett, II, Atlanta).
Fig 48. Pretreatment fundus photograph of patient in Fig 4A. Neovascular membrane with overlying sensory retinal detachment (arrow).
404
PATZ • PHOTOCOAGULATION THROUGH INTRAOCULAR LENSES
Fig 4C. Immediate post-treatment fundus photograph of lesion in Fig 4B.
Fig 4C. Fundus photograph six weeks after photocoagulation treatment.
405
OPHTHALMOLOGY • MAY 1981 • VOLUME 88 • NUMBER 5
REFERENC ES 4. 1. Van Balen AThM, ed. First International Symposium on Artificial Lensimplantation, Utrecht April, 1974. Doc Ophthalmol Proc Ser 1975; Vol 6. 2. Nordlohne ME. The intraocular implant lens development and results with special reference to the Binkhorst lens. 2nd ed. Baltimore: Williams & Wilkins, 1975. 3. Wilensky JT, ed. Intraocular Lenses. Transactions of the Uni-
406
5. 6. 7.
versity of Illinois Symposium on Intraocular Lenses. New York: Appleton-Century Crofts, 1977. Poole TA, Galin MA. Argon laser photocoagulation of the posterior segment in pseudophakia. Am J Ophthalmol 1977; 83:185-7. Jaffe NS, Galin MA, Hirschman H, et al. Pseudophakos. St. Louis, CV Mosby, 1978. Stark WR. Personal communication. Litwin RL. Laser photocoagulation hazards. Letter to the Editor. Am J Ophthalmol 1979; 87:583.