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Posterior Chamber Intraocular Lens Insertion During Pars Plana Lensectomy and Vitrectomy for Complications of Proliferative Diabetic Retinopathy
AMERICAN
JOURNAL
OF
OPHTHALMOLOGY®
NUMBER 1
VOLUME 108
JULY, 1989
Posterior Chamber Intraocular Lens Insertion During Pars Plana Lensectomy and Vitrectomy for Complications of Proliferative Diabetic Retinopathy George W. Blankenship, M.D., Harry W. Flynn, Jr., M.D., and Gregg T. Kokame, M.D. We inserted posterior chamber lenses into 21 eyes with complications of diabetic retinopathy upon completion of pars plana lensectomy and vitrectomy in a single session. After the original surgery, two eyes developed retinal detachments and underwent vitrectomy revisions with scleral buckling, one eye had a fluid-gas exchange for residual vitreous cavity blood, one eye had supplemental laser treatment, and one eye had intraocular antibiotics for endophthalmitis. Six months later, postoperative vision was better in 16 of the 21 eyes (76%), the same in four eyes (19%), and worse in one eye (5%). In 16 eyes visual acuity was 20/200 or better, and in six eyes it was 20/40 or better postoperatively. Decreased vision was caused by preexisting macular disease; two eyes had corneal edema with iris neovascularization associated with residual retinal detachment. The procedure and lenses were well tolerated and provided good pseudophakic vision.
is often removed during pars plana vitrectomy for complications of diabetic retinopathy to permit an adequate fundus view for detailed proliferative membrane THE CRYSTALLINE LENS
Accepted for publication March 21, 1989., From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida. This study was supported in part by Research to Prevent Blindness, Inc., Florida Lions Eye Bank Laboratory, and the Brenn Green Diabetic Retinopathy Fund, Miami, Florida. Reprint requests to George W. Blankenship, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101.
©AMERICAN JOURNAL OF OPHTHALMOLOGY
108:1-5,
JULY,
dissection, to improve postoperative visual function, and to eliminate the need for subsequent cataract surgery. However, visual rehabilitation of these aphakic eyes is often difficult. We developed a technique, similar to that described by Girard;' of inserting posterior chamber lenses in the ciliary sulcus at the end of the surgical procedure. Material and Methods Between February 1987 and May 1988, we conducted a study to evaluate the efficacy of posterior chamber intraocular lens insertion after completion of pars plana lensectomy and vitrectomy for complications of diabetic retinopathy. To be eligible for participation, patients who gave informed consent had to have well-documented diabetes, be available for six months after surgery for follow-up examinations, and be willing to participate in a prospective study. The ocular eligibility criteria consisted of normal intraocular pressure, absence of iris or angle neovascularization, the presence of lens opacities that would prevent an adequate surgical view, vitreous or preretinal hemorrhages ofat least three months' duration that obscured the macula and adjacent posterior fundus from binocular indirect ophthalmoscopic visualization, or traction macular detachment. We did not insert intraocular lenses and the eyes were excluded from the study if extensive bleeding or extensive retinal holes and detachment occurred during surgery, or if the goals of vitrectomy to remove media opaci1989
1
2
AMERICAN JOURNAL OF OPHTHALMOLOGY
ties, release traction, and to obtain hemostasis were not accomplished. Twenty-one eyes of 19 patients fulfilled the above criteria, underwent surgery with posterior chamber lens insertion in the ciliary sulcus, and were followed up for at least six months. Before surgery, we recorded information regarding the patient's sex, age, duration of diabetes, and visual acuity. Recorded ocular data included best-corrected visual acuity, intraocular pressure, extent of cataract, extent of vitreous and preretinal hemorrhage, presence and extent of retinal detachment, and extent of previous photocoagulation treatment. When media opacities prevented complete preoperative evaluation, these findings were supplied from observations made during surgery. We also noted occurrences of intraoperative complications. We performed postoperative examinations at varying intervals as indicated by the needs of each case. The occurrence of additional ocular surgery and complications were recorded. Six months after surgery, we examined each patient and information identical to that gathered preoperatively was recorded. Surgical technique-Before surgery, the pupil was dilated widely with repeated drops of 10% phenylephrine and 1% cyclopentolate. Additional mydriasis was obtained by adding 1 ml of nonpreserved epinephrine hydrochloride (1:1,000 solution) to a I-liter bottle of intraocular infusion fluid. After anesthesia and akinesia with a 4-ml 0.5% bupivacaine retrobulbar injection, and sterile cleansing of the surgical field, we made preparations for a three-port pars plana vitrectomy with pars plana sclerotomies 3 mm from the corneosclerallimbus in the superotemporal and superonasal quadrants with a 4-mm pars plana infusion port inserted into the vitreous cavity through a similar inferotemporal sclerotomy. We aspirated the cataract with or without fragmentation through a 19-9auge needle inserted into the lens through the superotemporal sclerotomy while additional infusion was supplied into the lens with a separate 19-9auge needle inserted through the superonasal sclerotomy (Fig. 1).2 We left the anterior lens capsule and zonules intact. We replaced the lens removal needles with fiber optic illumination and vitrectomy instruments which we then used to remove the remaining lens material, posterior lens capsule, vitreous opacities, anterior to posterior vitreous traction, and epiretinal membranes, and to
July, 1989
Fig. 1 (Blankenship, Flynn, and Kokame). Two 19-9auge needles are inserted through pars plana sclerotomies into the lens for infusion and aspiration with or without fragmentation and emulsification. The anterior lens capsule and zonular support are left intact.
obtain hemostasis. We then performed panretinal endophotocoagulation throughout the midperipheral and peripheral fundus unless there had been adequate previous treatment. Anterior lens capsular opacities were eliminated by either aspirating the epithelial cells, or creating a small central capsulotomy with the vitrecto my instrument. We removed the vitrectomy instruments and temporarily closed the sclerotomy sites with sutures. Infusion was stopped, but we left the inferotemporal pars plana infusion port in place. We opened the anterior chamber with a limbal incision, and inserted the preselected posterior chamber lens in the ciliary sulcus in front of the anterior lens capsule (Fig. 2). We closed the limbal incision with sutures. We restarted the intraocular infusion, and reinserted the vitrectomy instrument into the anterior vitreous cavity behind the anterior lens capsule and the optical component of the intraocular lens. We then removed the central anterior lens capsule from behind the optical component leaving a peripheral rim to support the haptics (Fig. 3), after which we removed the instrument and temporarily closed the sclerotomy site. We reexamined the fundus with indirect ophthalmoscopy and if found to be acceptable, we permanently closed the sclerotomies, removed the infusion port, and closed its sclerotomy. Conjunctiva and Tenon's capsule were then closed, subconjunctival antibiotics and
Vol. 108, No. 1
Lens Insertion During Lensectomy and Vitrectomy
Fig. 2 (Blankenship, Flynn, and Kokame). The vitrectomy instruments are removed, the sclerotomies are closed, and a posterior chamber lens is inserted through a limbal incision into the ciliary sulcus anterior to the intact anterior lens capsule and zonules.
corticosteroids were injected, and a sterile protective bandage was applied. Results Ten men and nine women who ranged in age from 35 to 79 years (median, 63 years) were included. The patients had known of their diabetes from five to 34 years (mean, 19 years).
Fig. 3 (Blankenship, Flynn, and Kokame). After the limbal incision has been closed, one of the superior sclerotomies is reopened and the vitrectomy instrument inserted into the vitreous cavityand used to remove the anterior lens capsule from behind the lens optical component.
3
The age at which diabetes had been diagnosed ranged from 8 to 50 years (mean, 26 years). Fourteen patients used insulin and in five the disease was controlled by diet. Three required hemodialysis. The left eye was involved in 12 cases and the right in nine cases. Vitreeto my was performed for nonclearing opaque vitreous hemorrhage in 19 eyes with decreased vision of three to 24 months' duration (mean, ten months). Two eyes had vitrectomy for traction macular detachments with decreased vision for one and three months. During surgery, two eyes had minor intraoperative bleeding for which transvitreal bipolar diathermy successfully obtained hemostasis, and two developed posterior retinal holes after which all epiretinal membranes and traction were removed and air-fluid exchanges with transvitreal laser treatment were performed after lens implantation. Two of the intraocular lenses were poorly supported because of zonular dialysis: lens repositioning provided adequate support in one case, and excessive removal of the peripheral anterior lens capsule for which scleral suturing in the ciliary sulcus area was required in the other case. Intraocular lens insertion was planned but not performed in an additional three eyes. In two eyes iatrogenic retinal holes occurred with residual epiretinal proliferative membranes and traction that could not be removed. Persistent bleeding from the disk and retinal surface despite extensive efforts to obtain hemostasis occurred in the other eye. These three eyes were excluded from the study. Panretinal photocoagulation using an endolaser system was performed in three eyes that had not received any previous photocoagulation, and to supplement previous panretinal photocoagulation in 14 additional eyes. The remaining four eyes did not receive panretinal photocoagulation because the extent of previous treatment was thought to be adequate. During the first postoperative week, one eye developed a moderate vitreous cavity hemorrhage that cleared spontaneously during the next two weeks, and one developed Staphylococcus aureus endophthalmitis that was treated with intravitreal and intravenous antibiotics. During the remaining first postoperative month, the two eyes with iatrogenic posterior retinal holes had additional detachments and pars plana vitrectomies with scleral buckling procedures and fluid-gas exchanges were performed. One eye had additional scatter laser
4
treatment for residual untreated ischemic peripheral retina, and one had additional vitreous cavity hemorrhage for which a vitreous cavity fluid-air exchange was performed on an outpatient basis. Preoperatively, best-corrected visual acuity was 20/60 to 20/100 in three eyes (14%), counting fingers in nine eyes (43%), and hand motions to light perception in nine eyes (43%) (Fig. 4). Six months after the primary pars plana lensectomy and vitrectomy with posterior chamber lens insertion, 16 eyes (76%) had improved vision, four (19%) had the same vision, and one (5%) had decreased vision. Bestcorrected visual acuity in six eyes (29%) was 20/40 or better, in ten eyes (48%) 20/50 to 20/200, in three eyes (14%) 6/200 or counting fingers, and in two eyes (9%) hand motions to light perception. Anatomically, 19 (90%) of the 21 eyes had clear pseudophakic anterior segments, vitreous cavities, and attached retinas without synechia, glaucoma, corneal edema, or iris or angle neovascularization. Two eyes had corneal edema and iris neovascularization, with one having an opaque vitreous hemorrhage that obscured fundus visualization and the other
HM LP UJ
>
I-
61Z00-FC
a:
UJ
0..
o
July, 1989
AMERICAN JOURNAL OF OPHTHALMOLOGY
20/50-200
••• •• • •• • •• • •• ••
UJ
a: 0..
20/20-40
20/20 20/40
20/50 20/200
61200 FC
HM
NLP
LP
POSTOPERATIVE
Fig. 4 (Blankenship, Flynn, and Kokame). Comparison of best-corrected preoperative with sixmonth postoperative visual acuities. Those above the diagonal line showed improved vision, those along the line had the same level of vision, and those below had poorer vision. HM, hand motions; LP, light perception; NLP, no light perception; FC, counting fingers.
having a peripheral retinal detachment despite previous vitrectomy revision and scleral buckling.
Discussion Visual rehabilitation of aphakic diabetic eyes after pars plana vitrectomy is often difficult even when the anatomic objectives are achieved. Decreased peripheral vision, distortion, and magnification produced with aphakic spectacle lenses are often made worse by diabetic retinal and macular problems. Diabetic corneal epithelial problems often prevent successful use of aphakic contact lenses.v' Intraocular lenses provide more natural and convenient vision, and are successfully used in eyes with inactive diabetic retinopathy.r" Smiddy and associates" and Hutton, Pesicka, and Fuller'' reported good visual and anatomic results with extracapsular cataract surgery and lens implantation in eyes that had previously had successful diabetic vitrectomies. We achieved similar visual and anatomic results, but the time and expense of two operative procedures were avoided by using a combined approach. Properly centered posterior chamber lenses with clear posterior capsules or large central capsulotomies permit adequate fundus visualization for thorough peripheral retinal examinations. Two of the 21 pseudophakic eyes in our series underwent subsequent pars plana vitrectomy revisions with scleral buckling for recurrent retinal detachments, and the posterior chamber intraocular lens did not interfere with the preoperative evaluations, surgeries, or postoperative examinations. The surgical sequence of posterior chamber lens insertion after completion of the vitrectomy component has advantages compared to more conventional extracapsular cataract extraction with lens implantation at the start of the vitrectomy procedure. Deferring the corneal incision until the end of the procedure maintains better corneal transparency and eliminates the risk of corneal incision leakage, especially if increased intraocular pressure is needed for hemostasis. Dispersion of iris pigment into the anterior chamber and on the implant surface that may compromise the view of the posterior segment is also avoided. This sequence permits fundus examination and a better opportunity to predict the prognosis for
Lens Insertion During Lensectomy and Vitrectomy
Vol. 108, No. 1
a successful visual result,":" and the determination and management of vitrectomy complications before a final decision is made about lens implantation. Despite the posterior chamber lens, the large capsulotomy creates a single chambered eye with increased risk of iris neovascularization and neovascular glaucoma. 13.14 Extensive use of endolaser photocoagulation'<" substantially reduces this risk," as does the diagnosis and repair of rhegmatogenous retinal detachments. Most of the operative procedures in this study were performed without complication. Other than the two eyes with poor zonular support of the lens, the complications that occurred were related to the extensive diabetic retinopathy and the vitrectomy component of the surgery. The peripheral rim of remaining anterior capsule and zonules adequately support and help center the implant, but ciliary sulcus fixation sutures are used if needed." Our visual and anatomic results were similar to those of other diabetic vitrectomy series.":" with visual function related to diabetic fundus changes rather than the intraocular lens. However, the advantages and efficacy of this surgical procedure with posterior chamber lens insertion compared to conventional techniques can only be proven with a much larger clinical trial in which the type of procedure is randomly determined. The successful pseudophakic visual and anatomic results obtained with pars plana lensectomy, vitrectomy, and posterior chamber lens insertion indicate that good and more rapid visual rehabilitation are obtained with one procedure in most cases.
References 1. Girard, L. J.: Posterior chamber implant after pars plana lensectomy. In Emery, J. M., and Jacobson, A. C. (eds.): Current Concepts in Cataract Surgery. Selected Proceedings of the EIghth Biannual Cataract Surgical Congress. New York, AppletonCentury-Crofts, 1984, p. 71. 2. Benson, W. E., Blankenship, G. W., and Machemer, R.: Pars plana lens removal with vitrectomy. Am. J. Ophthalmol. 84:150, 1977. 3. Kenyon, K. R.: Recurrent corneal erosion. Pathogenesis and therapy. Int. Ophthalmol. Clin. 19:169, 1979.
4. Schultz, R. 0., Van Horn, D. L., Peters, M. A., Klewin, K. M., and Schutten, W. H.: Diabetic keratopathy. Trans. Am. Ophthalmol. Soc. 79:180, 1981.
5
5. Straatsma, B. R., Pettit, T. H., Wheeler, N., and Miyamasu, W.: Diabetes mellitus and intraocular lens implantation. Ophthalmology 90:336, 1983. 6. Murphy, R. P., and Patz, A.: Diabetic retinopathy and intraocular lenses. In Stark, W. J., Terry, A. c., and Maumenee, A. E. (eds.): Anterior Segment Surgery. 10Ls, Lasers, and Refraction Keratoplasty. Baltimore, Williams & Wilkins, 1987, pp.
277-282.
7. Fung, W. E.: Phacoemulsification and implantation of posterior chamber intraocular lens in eyes with quiescent proliferative diabetic retinopathy. Graefes Arch. Clin. Exp. Ophthalmol. 225:251, 1987. 8. Smiddy, W. E., Stark, W. J., Michels, R. G., Maumenee, A. E., Terry, A. c.. and Glaser, B. M.: Cataract extraction after vitrectomy. Ophthalmology 94:483, 1987.
9. Hutton, W. L., Pesicka, G. A., and Fuller, D. G.: Cataract extraction in the diabetic eye after vitrectomy. Am. J. Ophthalmol. 104:1, 1987. 10_ Blankenship, G. W.: Preoperative prognostic factors in diabetic pars plana vitrectomy. Ophthalmology 89:1246, 1982. 11. Thompson, J. T., Auer, C. L., de Bustros, S., Michels, R. G., Rice, T. A., and Glaser, B. M.: Prognostic indicators of success and failure in vitrectomy for diabetic retinopathy. Ophthalmology 93:290, 1986. 12. Thompson, J. T., de Bustros, S., Michels,
R. G., and Rice, T. A.: Results and prognostic factors in vitrectomy for diabetic vitreous hemorrhage. Arch. Ophthalmol. 105:191, 1987. 13. Blankenship, G. W.: The lens influence on diabetic vitrectomy results. Report of a prospective randomized study. Arch. Ophthalmol. 98:2196, 1980. 14. Rice, T. A., Michels, R. G., Maguire, M. G., and Rice, E. F.: The effect of lensectomy on the incidence of iris neovascularization and neovascular glaucoma after vitrectomy for diabetic retinopathy. Am. J. Ophthalmol. 95:1, 1983. 15. Fleischman, J. A., Swartz, M., and Dixon, J. A.: Argon laser endophotocoagulation. An intraoperative trans-pars plana technique. Arch. Ophthalmol. 99:1610, 1981. 16. Liggett, P. E., Lean, J. S., Barlow, W. E., and Ryan, S. J.: Intraoperative argon endophotocoagulation for recurrent vitreous hemorrhage after vitrectomy for diabetic retinopathy. Am. J. Ophthalmol. 103:146, 1987. 17. Murphy, R. P., and Egbert, P. R.: Regression of iris neovascularization following panretinal photocoagulation. Arch. Ophthalmol. 97:700, 1979. 18. Hu, B. V., Shin, D. H., Gibbs, K. A., and Hong, Y. J.: Implantation of posterior chamber lenses in the absence of capsular and zonular support. Arch. Ophthalmol. 106:416, 1988. 19. Machemer, R., and Blankenship, G.: Vitrectomy for proliferative diabetic retinopathy associated with vitreous hemorrhage. Ophthalmology 88:643, 1981.
JOURNAL
OF
OPHTHALMOLOGY®
NUMBER 1
VOLUME 108
JULY, 1989
Posterior Chamber Intraocular Lens Insertion During Pars Plana Lensectomy and Vitrectomy for Complications of Proliferative Diabetic Retinopathy George W. Blankenship, M.D., Harry W. Flynn, Jr., M.D., and Gregg T. Kokame, M.D. We inserted posterior chamber lenses into 21 eyes with complications of diabetic retinopathy upon completion of pars plana lensectomy and vitrectomy in a single session. After the original surgery, two eyes developed retinal detachments and underwent vitrectomy revisions with scleral buckling, one eye had a fluid-gas exchange for residual vitreous cavity blood, one eye had supplemental laser treatment, and one eye had intraocular antibiotics for endophthalmitis. Six months later, postoperative vision was better in 16 of the 21 eyes (76%), the same in four eyes (19%), and worse in one eye (5%). In 16 eyes visual acuity was 20/200 or better, and in six eyes it was 20/40 or better postoperatively. Decreased vision was caused by preexisting macular disease; two eyes had corneal edema with iris neovascularization associated with residual retinal detachment. The procedure and lenses were well tolerated and provided good pseudophakic vision.
is often removed during pars plana vitrectomy for complications of diabetic retinopathy to permit an adequate fundus view for detailed proliferative membrane THE CRYSTALLINE LENS
Accepted for publication March 21, 1989., From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida. This study was supported in part by Research to Prevent Blindness, Inc., Florida Lions Eye Bank Laboratory, and the Brenn Green Diabetic Retinopathy Fund, Miami, Florida. Reprint requests to George W. Blankenship, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101.
©AMERICAN JOURNAL OF OPHTHALMOLOGY
108:1-5,
JULY,
dissection, to improve postoperative visual function, and to eliminate the need for subsequent cataract surgery. However, visual rehabilitation of these aphakic eyes is often difficult. We developed a technique, similar to that described by Girard;' of inserting posterior chamber lenses in the ciliary sulcus at the end of the surgical procedure. Material and Methods Between February 1987 and May 1988, we conducted a study to evaluate the efficacy of posterior chamber intraocular lens insertion after completion of pars plana lensectomy and vitrectomy for complications of diabetic retinopathy. To be eligible for participation, patients who gave informed consent had to have well-documented diabetes, be available for six months after surgery for follow-up examinations, and be willing to participate in a prospective study. The ocular eligibility criteria consisted of normal intraocular pressure, absence of iris or angle neovascularization, the presence of lens opacities that would prevent an adequate surgical view, vitreous or preretinal hemorrhages ofat least three months' duration that obscured the macula and adjacent posterior fundus from binocular indirect ophthalmoscopic visualization, or traction macular detachment. We did not insert intraocular lenses and the eyes were excluded from the study if extensive bleeding or extensive retinal holes and detachment occurred during surgery, or if the goals of vitrectomy to remove media opaci1989
1
2
AMERICAN JOURNAL OF OPHTHALMOLOGY
ties, release traction, and to obtain hemostasis were not accomplished. Twenty-one eyes of 19 patients fulfilled the above criteria, underwent surgery with posterior chamber lens insertion in the ciliary sulcus, and were followed up for at least six months. Before surgery, we recorded information regarding the patient's sex, age, duration of diabetes, and visual acuity. Recorded ocular data included best-corrected visual acuity, intraocular pressure, extent of cataract, extent of vitreous and preretinal hemorrhage, presence and extent of retinal detachment, and extent of previous photocoagulation treatment. When media opacities prevented complete preoperative evaluation, these findings were supplied from observations made during surgery. We also noted occurrences of intraoperative complications. We performed postoperative examinations at varying intervals as indicated by the needs of each case. The occurrence of additional ocular surgery and complications were recorded. Six months after surgery, we examined each patient and information identical to that gathered preoperatively was recorded. Surgical technique-Before surgery, the pupil was dilated widely with repeated drops of 10% phenylephrine and 1% cyclopentolate. Additional mydriasis was obtained by adding 1 ml of nonpreserved epinephrine hydrochloride (1:1,000 solution) to a I-liter bottle of intraocular infusion fluid. After anesthesia and akinesia with a 4-ml 0.5% bupivacaine retrobulbar injection, and sterile cleansing of the surgical field, we made preparations for a three-port pars plana vitrectomy with pars plana sclerotomies 3 mm from the corneosclerallimbus in the superotemporal and superonasal quadrants with a 4-mm pars plana infusion port inserted into the vitreous cavity through a similar inferotemporal sclerotomy. We aspirated the cataract with or without fragmentation through a 19-9auge needle inserted into the lens through the superotemporal sclerotomy while additional infusion was supplied into the lens with a separate 19-9auge needle inserted through the superonasal sclerotomy (Fig. 1).2 We left the anterior lens capsule and zonules intact. We replaced the lens removal needles with fiber optic illumination and vitrectomy instruments which we then used to remove the remaining lens material, posterior lens capsule, vitreous opacities, anterior to posterior vitreous traction, and epiretinal membranes, and to
July, 1989
Fig. 1 (Blankenship, Flynn, and Kokame). Two 19-9auge needles are inserted through pars plana sclerotomies into the lens for infusion and aspiration with or without fragmentation and emulsification. The anterior lens capsule and zonular support are left intact.
obtain hemostasis. We then performed panretinal endophotocoagulation throughout the midperipheral and peripheral fundus unless there had been adequate previous treatment. Anterior lens capsular opacities were eliminated by either aspirating the epithelial cells, or creating a small central capsulotomy with the vitrecto my instrument. We removed the vitrectomy instruments and temporarily closed the sclerotomy sites with sutures. Infusion was stopped, but we left the inferotemporal pars plana infusion port in place. We opened the anterior chamber with a limbal incision, and inserted the preselected posterior chamber lens in the ciliary sulcus in front of the anterior lens capsule (Fig. 2). We closed the limbal incision with sutures. We restarted the intraocular infusion, and reinserted the vitrectomy instrument into the anterior vitreous cavity behind the anterior lens capsule and the optical component of the intraocular lens. We then removed the central anterior lens capsule from behind the optical component leaving a peripheral rim to support the haptics (Fig. 3), after which we removed the instrument and temporarily closed the sclerotomy site. We reexamined the fundus with indirect ophthalmoscopy and if found to be acceptable, we permanently closed the sclerotomies, removed the infusion port, and closed its sclerotomy. Conjunctiva and Tenon's capsule were then closed, subconjunctival antibiotics and
Vol. 108, No. 1
Lens Insertion During Lensectomy and Vitrectomy
Fig. 2 (Blankenship, Flynn, and Kokame). The vitrectomy instruments are removed, the sclerotomies are closed, and a posterior chamber lens is inserted through a limbal incision into the ciliary sulcus anterior to the intact anterior lens capsule and zonules.
corticosteroids were injected, and a sterile protective bandage was applied. Results Ten men and nine women who ranged in age from 35 to 79 years (median, 63 years) were included. The patients had known of their diabetes from five to 34 years (mean, 19 years).
Fig. 3 (Blankenship, Flynn, and Kokame). After the limbal incision has been closed, one of the superior sclerotomies is reopened and the vitrectomy instrument inserted into the vitreous cavityand used to remove the anterior lens capsule from behind the lens optical component.
3
The age at which diabetes had been diagnosed ranged from 8 to 50 years (mean, 26 years). Fourteen patients used insulin and in five the disease was controlled by diet. Three required hemodialysis. The left eye was involved in 12 cases and the right in nine cases. Vitreeto my was performed for nonclearing opaque vitreous hemorrhage in 19 eyes with decreased vision of three to 24 months' duration (mean, ten months). Two eyes had vitrectomy for traction macular detachments with decreased vision for one and three months. During surgery, two eyes had minor intraoperative bleeding for which transvitreal bipolar diathermy successfully obtained hemostasis, and two developed posterior retinal holes after which all epiretinal membranes and traction were removed and air-fluid exchanges with transvitreal laser treatment were performed after lens implantation. Two of the intraocular lenses were poorly supported because of zonular dialysis: lens repositioning provided adequate support in one case, and excessive removal of the peripheral anterior lens capsule for which scleral suturing in the ciliary sulcus area was required in the other case. Intraocular lens insertion was planned but not performed in an additional three eyes. In two eyes iatrogenic retinal holes occurred with residual epiretinal proliferative membranes and traction that could not be removed. Persistent bleeding from the disk and retinal surface despite extensive efforts to obtain hemostasis occurred in the other eye. These three eyes were excluded from the study. Panretinal photocoagulation using an endolaser system was performed in three eyes that had not received any previous photocoagulation, and to supplement previous panretinal photocoagulation in 14 additional eyes. The remaining four eyes did not receive panretinal photocoagulation because the extent of previous treatment was thought to be adequate. During the first postoperative week, one eye developed a moderate vitreous cavity hemorrhage that cleared spontaneously during the next two weeks, and one developed Staphylococcus aureus endophthalmitis that was treated with intravitreal and intravenous antibiotics. During the remaining first postoperative month, the two eyes with iatrogenic posterior retinal holes had additional detachments and pars plana vitrectomies with scleral buckling procedures and fluid-gas exchanges were performed. One eye had additional scatter laser
4
treatment for residual untreated ischemic peripheral retina, and one had additional vitreous cavity hemorrhage for which a vitreous cavity fluid-air exchange was performed on an outpatient basis. Preoperatively, best-corrected visual acuity was 20/60 to 20/100 in three eyes (14%), counting fingers in nine eyes (43%), and hand motions to light perception in nine eyes (43%) (Fig. 4). Six months after the primary pars plana lensectomy and vitrectomy with posterior chamber lens insertion, 16 eyes (76%) had improved vision, four (19%) had the same vision, and one (5%) had decreased vision. Bestcorrected visual acuity in six eyes (29%) was 20/40 or better, in ten eyes (48%) 20/50 to 20/200, in three eyes (14%) 6/200 or counting fingers, and in two eyes (9%) hand motions to light perception. Anatomically, 19 (90%) of the 21 eyes had clear pseudophakic anterior segments, vitreous cavities, and attached retinas without synechia, glaucoma, corneal edema, or iris or angle neovascularization. Two eyes had corneal edema and iris neovascularization, with one having an opaque vitreous hemorrhage that obscured fundus visualization and the other
HM LP UJ
>
I-
61Z00-FC
a:
UJ
0..
o
July, 1989
AMERICAN JOURNAL OF OPHTHALMOLOGY
20/50-200
••• •• • •• • •• • •• ••
UJ
a: 0..
20/20-40
20/20 20/40
20/50 20/200
61200 FC
HM
NLP
LP
POSTOPERATIVE
Fig. 4 (Blankenship, Flynn, and Kokame). Comparison of best-corrected preoperative with sixmonth postoperative visual acuities. Those above the diagonal line showed improved vision, those along the line had the same level of vision, and those below had poorer vision. HM, hand motions; LP, light perception; NLP, no light perception; FC, counting fingers.
having a peripheral retinal detachment despite previous vitrectomy revision and scleral buckling.
Discussion Visual rehabilitation of aphakic diabetic eyes after pars plana vitrectomy is often difficult even when the anatomic objectives are achieved. Decreased peripheral vision, distortion, and magnification produced with aphakic spectacle lenses are often made worse by diabetic retinal and macular problems. Diabetic corneal epithelial problems often prevent successful use of aphakic contact lenses.v' Intraocular lenses provide more natural and convenient vision, and are successfully used in eyes with inactive diabetic retinopathy.r" Smiddy and associates" and Hutton, Pesicka, and Fuller'' reported good visual and anatomic results with extracapsular cataract surgery and lens implantation in eyes that had previously had successful diabetic vitrectomies. We achieved similar visual and anatomic results, but the time and expense of two operative procedures were avoided by using a combined approach. Properly centered posterior chamber lenses with clear posterior capsules or large central capsulotomies permit adequate fundus visualization for thorough peripheral retinal examinations. Two of the 21 pseudophakic eyes in our series underwent subsequent pars plana vitrectomy revisions with scleral buckling for recurrent retinal detachments, and the posterior chamber intraocular lens did not interfere with the preoperative evaluations, surgeries, or postoperative examinations. The surgical sequence of posterior chamber lens insertion after completion of the vitrectomy component has advantages compared to more conventional extracapsular cataract extraction with lens implantation at the start of the vitrectomy procedure. Deferring the corneal incision until the end of the procedure maintains better corneal transparency and eliminates the risk of corneal incision leakage, especially if increased intraocular pressure is needed for hemostasis. Dispersion of iris pigment into the anterior chamber and on the implant surface that may compromise the view of the posterior segment is also avoided. This sequence permits fundus examination and a better opportunity to predict the prognosis for
Lens Insertion During Lensectomy and Vitrectomy
Vol. 108, No. 1
a successful visual result,":" and the determination and management of vitrectomy complications before a final decision is made about lens implantation. Despite the posterior chamber lens, the large capsulotomy creates a single chambered eye with increased risk of iris neovascularization and neovascular glaucoma. 13.14 Extensive use of endolaser photocoagulation'<" substantially reduces this risk," as does the diagnosis and repair of rhegmatogenous retinal detachments. Most of the operative procedures in this study were performed without complication. Other than the two eyes with poor zonular support of the lens, the complications that occurred were related to the extensive diabetic retinopathy and the vitrectomy component of the surgery. The peripheral rim of remaining anterior capsule and zonules adequately support and help center the implant, but ciliary sulcus fixation sutures are used if needed." Our visual and anatomic results were similar to those of other diabetic vitrectomy series.":" with visual function related to diabetic fundus changes rather than the intraocular lens. However, the advantages and efficacy of this surgical procedure with posterior chamber lens insertion compared to conventional techniques can only be proven with a much larger clinical trial in which the type of procedure is randomly determined. The successful pseudophakic visual and anatomic results obtained with pars plana lensectomy, vitrectomy, and posterior chamber lens insertion indicate that good and more rapid visual rehabilitation are obtained with one procedure in most cases.
References 1. Girard, L. J.: Posterior chamber implant after pars plana lensectomy. In Emery, J. M., and Jacobson, A. C. (eds.): Current Concepts in Cataract Surgery. Selected Proceedings of the EIghth Biannual Cataract Surgical Congress. New York, AppletonCentury-Crofts, 1984, p. 71. 2. Benson, W. E., Blankenship, G. W., and Machemer, R.: Pars plana lens removal with vitrectomy. Am. J. Ophthalmol. 84:150, 1977. 3. Kenyon, K. R.: Recurrent corneal erosion. Pathogenesis and therapy. Int. Ophthalmol. Clin. 19:169, 1979.
4. Schultz, R. 0., Van Horn, D. L., Peters, M. A., Klewin, K. M., and Schutten, W. H.: Diabetic keratopathy. Trans. Am. Ophthalmol. Soc. 79:180, 1981.
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5. Straatsma, B. R., Pettit, T. H., Wheeler, N., and Miyamasu, W.: Diabetes mellitus and intraocular lens implantation. Ophthalmology 90:336, 1983. 6. Murphy, R. P., and Patz, A.: Diabetic retinopathy and intraocular lenses. In Stark, W. J., Terry, A. c., and Maumenee, A. E. (eds.): Anterior Segment Surgery. 10Ls, Lasers, and Refraction Keratoplasty. Baltimore, Williams & Wilkins, 1987, pp.
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7. Fung, W. E.: Phacoemulsification and implantation of posterior chamber intraocular lens in eyes with quiescent proliferative diabetic retinopathy. Graefes Arch. Clin. Exp. Ophthalmol. 225:251, 1987. 8. Smiddy, W. E., Stark, W. J., Michels, R. G., Maumenee, A. E., Terry, A. c.. and Glaser, B. M.: Cataract extraction after vitrectomy. Ophthalmology 94:483, 1987.
9. Hutton, W. L., Pesicka, G. A., and Fuller, D. G.: Cataract extraction in the diabetic eye after vitrectomy. Am. J. Ophthalmol. 104:1, 1987. 10_ Blankenship, G. W.: Preoperative prognostic factors in diabetic pars plana vitrectomy. Ophthalmology 89:1246, 1982. 11. Thompson, J. T., Auer, C. L., de Bustros, S., Michels, R. G., Rice, T. A., and Glaser, B. M.: Prognostic indicators of success and failure in vitrectomy for diabetic retinopathy. Ophthalmology 93:290, 1986. 12. Thompson, J. T., de Bustros, S., Michels,
R. G., and Rice, T. A.: Results and prognostic factors in vitrectomy for diabetic vitreous hemorrhage. Arch. Ophthalmol. 105:191, 1987. 13. Blankenship, G. W.: The lens influence on diabetic vitrectomy results. Report of a prospective randomized study. Arch. Ophthalmol. 98:2196, 1980. 14. Rice, T. A., Michels, R. G., Maguire, M. G., and Rice, E. F.: The effect of lensectomy on the incidence of iris neovascularization and neovascular glaucoma after vitrectomy for diabetic retinopathy. Am. J. Ophthalmol. 95:1, 1983. 15. Fleischman, J. A., Swartz, M., and Dixon, J. A.: Argon laser endophotocoagulation. An intraoperative trans-pars plana technique. Arch. Ophthalmol. 99:1610, 1981. 16. Liggett, P. E., Lean, J. S., Barlow, W. E., and Ryan, S. J.: Intraoperative argon endophotocoagulation for recurrent vitreous hemorrhage after vitrectomy for diabetic retinopathy. Am. J. Ophthalmol. 103:146, 1987. 17. Murphy, R. P., and Egbert, P. R.: Regression of iris neovascularization following panretinal photocoagulation. Arch. Ophthalmol. 97:700, 1979. 18. Hu, B. V., Shin, D. H., Gibbs, K. A., and Hong, Y. J.: Implantation of posterior chamber lenses in the absence of capsular and zonular support. Arch. Ophthalmol. 106:416, 1988. 19. Machemer, R., and Blankenship, G.: Vitrectomy for proliferative diabetic retinopathy associated with vitreous hemorrhage. Ophthalmology 88:643, 1981.