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Simultaneous closed vitrectomy and secondary intraocular lens implantation
Simultaneous closed vitrectomy and secondary intraocular lens implantation Richard J. Mackool, M. D. New Y ork, New York ABSTRACT Thirty consecutive patients undergoing extensive closed vitrectomy and secondary implantation of a Binkhorst iris clip lens maintained their best corrected preoperative visual acuity over a mean follow-up period of 16 months. Complications were limited to one case of transient cystoid macular ede ma and two cases with minor complications from excessive lens motion. Key words: secondary intraocular lens implantation , vitrectomy, cystoid macular edema, Binkhorst iris clip intraocular lens A number of serious complications have been reported after secondary implantation of an intraocular lens (IOL).1-5 In 1975, Darin 6 surveyed 21 experienced lens implant surgeons in the United States and found that many would not do a secondary lens implantation in an eye which had vitreous in the anterior chamber. More recently, Cozean 5 reported an increased rate of complications after secondary IOL insertion if intraoperative vitreous loss had occurred. The purpose of this report is to present the author's t echniques and results for simultaneous closed vitrectomy and secondary intraocular lens implantation (CV-SI) in 30 consecutive aphakic eyes. Six of these patients have b een previously described. 7
SUBJECTS AND METHODS
Thirty consecutive patients (30 eyes) underwent closed vitrectomy during secondary IOL implantation to remove vitreous which was present in the anterior segment. All patients were monocular aphakes who could not successfully wear a contact lens. All had undergone intracapsular cataract extraction (ICCE) from 13 months to eight years before CV-SI and 14 eyes had sector iridectomies. Preoperative ocular abnormalities were otherwise limited to senile macular degeneration (4 patients) and ischemic optic neuropathy (one patient). All patients received Binkhorst 4-loop iris clip lenses, manufactured by IOLAB , during secondary surgery. These lenses have polypropylene (Prolene) haptics. Following CV-SI, all patients were examined at least monthly for six months, and every two to four months thereafter. The follow-up periods ranged from six to 36 months, with an average of 16 months. Fluorescein angiography was performed whenever best corrected postoperative visual acuity fell below preoperative acuity.
Postoperatively, all patients were treated every two hours with a 1% solution of topical prednisolone acetate; this was gradually reduced to once daily by three months, and continued at that level unless the steroid solution increased intraocular pressure.
SURGICAL TECHNIQUE Following pupillary dilatation with a 1% solution of topical tropic-amide (Mydriacyl), a scleral support ring was sutured to the globe. Closed vitrectomy was then performed through the superior limbus prior to IOL insertion. One of the vitrectomy handpieces of the Heslin/Mackool Ocusystem 8 was used in all cases. When one vitrectomy handpiece was used for both infusion and aspiration , it was inserted through a limbal opening made with an IS-gauge needle. When infusion was introduced through a separate 25-gauge cannula, a smaller vitrectomy handpiece was inserted through a limbal tract made with a 21-gauge needle. The vitrectomies performed were intentionally extensive, and all vitreous visible within the red reflex (using coaxial illumination) was removed. This usually included removal of the posterior hyaloid (Fig. 1,2), since posterior vitreous detachment was present in most eyes . Following vitrectomy (which generally required 5 to 10 minutes of operating time), a microspatula was used to excise vitreous strands incarcerated in the small superior incision through which the vitrectomy instrument had passed. The microspatula was inserted through a small puncture in a horizontallimbal meridian (Fig. 3,4). Intracameral acetylcholine injection, enlargement of the corneoscleral incision to 6 mm, sector iridectomy repair (14 eyes), and IOL insertion were then performed. In 29 eyes the IOL was sutured to the iris with 10-0 polypropylene: the suture was placed in the supe rior iris,
Presented at the Fourth u.s. Intraocular Lens Symposium, Los Angeles, California , March 28, 1981 . Reprint requests to Dr. Ma ckool, New York Eye and Ear Infirmary, 310 East 14th Street, New York , NY 10003. AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
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Fig. l(Mackool). Vitreous strands (arrow) are incarcerated in the smalllimbal incision. Vitreous has been removed from the anterior chamber and posterior vitreous detachment is present. Infusion is being delivered by a separate cannula.
Fig. 3(Mackool). Spatula has been inserted over superior iris and beneath vitrectomy instrument. The pupil is peaked by incarcerated vitreous strands. 234
Fig.2(Mackool). Central posterior hyaloid has been removed, and only peripheral anterior vitreous remains in vitreous cavity. Vitreous strands remain incarcerated in small limbal incision.
Fig. 4(Mackool). Spatula has been swept into pupillary zone to increase accessibility of the vitreous strands to the cutting port. Pupil is no longer peaked.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
passed through the anterior superior IOL haptic before lens insertion, and tied after the lens was in position.
RESULTS All 30 patients undergoing CV-SI essentially maintained their best preoperative visual acuity as measured at the time of last examination. Complications are summarized in Table 1. One patient experienced a drop of visual acuity from a preoperative level of20/30, to 20/70 one month following CV-SI. Fluorescein angiography demonstrated cystoid macular edema (CME), which cleared spontaneously by the second post-operative month, with visual acuity improving to 20/30. No other patient demonstrated a reduction of acuity, and therefore no other fluorescein angiographic studies were performed. No patient displayed corneal edema in either the immediate or late postoperative periods. No · patient developed chronic glaucoma following CV-SI. Tensions in the immediate postoperative period occasionally rose to between 25 and 35 mm Hg but did not present management problems. Five patients developed steroid-induced elevations of intraocular pressure, requiring reduction or elimination of topical steroid use. One patient developed iritis five months after CVSI. This eye had active pupillary responses and excessive IOL motion in spite of sector iridectomy repair; no iris fixation suture had been placed. Topically applied steroids and miotics added one week later to reduce IOL motion eliminated these episodes for 13 months. A second patient developed a microscopic bleed into the anterior chamber four months after CVSI. This patient also had brisk pupillary responses and
Table 1. Complications in 30 cases of closed vitrectomy and secondary implantation.
Complication Reduced final acuity* Transient CME Corneal edema Glaucoma Late iridocyclitis Late microhyphema
*As compared to preoperative acuity
No. of Eyes
o 1
o o 1 1
excessive IOL motion: bleeding was presum ed to be secondary to continuous pupillary margin trauma. Miotic therapy eliminated the problem for nine months. Several other patients displayed brisk pupillary responses and excessive IOL motion without complications. These patients are now routinely maintained on miotic therapy.
DISCUSSION Following secondary IOL implantation, reduced visual acuity from CME has been reported in 1.5% to 4% of eyes receiving Choyce-style lenses,2,4,5 in 3% of eyes with Medallion lenses,3 and in 7.1% of eyes with Binkhorst iris clip lenses. 1 Vitreous loss has been reported to increase the risk of secondary implantation, 5 and this procedure has been considered to be contraindicated in eyes containing vitreous in the anterior chamber. 6 In this series of 30 consecutive patients, CV -SI with a Binkhorst iris clip lens produced extremely favorable results. CME and corneal edema were essentially nonexistent. Several factors may be responsible for this. First, no secondary procedure was performed within a year of cataract extraction, thus allowing time for the vitreous changes which have been proposed to follow intracapsular cataract extraction. 2 A recent report14 demonstrated an increased complication rate when a secondary procedure was performed within one year after cataract extraction. Second all closed vitrectomies were intentionally extensive: and all vitreous strands to the wound were excised. While the role of the vitreous in CME is Poorly understood , the resolution of CME following 7-12 vitrectomy has been frequently reported. The large vitrectomies performed (the posterior hyaloid was usually removed) may thus have minimized the incidence of CME in these patients. Third, advanced vitrectomy instrumentationS greatly simplifies the procedure and reduces vitreous traction. The precisely regulated flow process significantly reduces the total fluid exchange required for vitrectomy, and this is reflected in the absence of corneal complications. Finally, a scleral support ring was used in all eyes. Following vitrectomy, enlarging the wound for secondary implantation can result in globe collapse during IOL insertion, and corneal endothelial trauma may readily result. The scleral support ring maintains the anterior segment and makes atraumatic IOL insertion quite simple.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
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REFERENCES
1. Binkhorst CD, Leonard PAM: Results in 208 iris-clip pseudophakos implantations. Am] Ophthalmol 64:947, 1967 2. Choyce DP: The latest facts and figures on anterior chamber lens implants. Contact and Intraocular Lens MedJ 2:60, 1976 3. Shammas HJF, Milkie CF: Secondary lens implantation in aphakia: visual results and complications. Am Intra-Ocular Implant Soc] 4:180, 1978 4. Shammas HJF, Milkie CF: Primary vs. secondary insertion of anterior chamber lenses. Am Intra-Ocular Implant Soc] 5:141, 1979 5. Cozean CH Jr: A longer view of secondary intraocular lens implantation with special emphasis on the role of the vitreous. Am Intra-Ocular Implant Soc] 6:361, 1980 6. Darin JJ: Survey of secondary lens implantation. Am IntraOcular Implant Soc] 1(2):32, 1975 7. Mackool RJ: Closed vitrectomy and the intraocular implant. Ophthalmol 88:414, 1981 8. Mackool RJ, Heslin KB, Banko A: Combined phacoemulsification and pars plana vitrectomy capability in a single compu-
236
9. 10. 11.
12. 13. 14.
terized instrument. Am Intra-Ocular Implant Soc] 6:377, 1980 Michels RG, Machemer R,Muelier-Jensen K: Vitreous surgery: history and current concepts. Ophthalmic Surg 5:13, 1974 Michels RS, Stark WJ: Vitrectomy techniques in anterior segment surgery. Trans Am Acad Ophthalmol Otolaryngol 810P:382, 1976 Aaberg TM: Pars plana vitrectomy for persistent aphakic cystoid macular edema secondary to vitreous incarceration in the cataract wound, in McPherson A(ed): New and Controversial Aspects ofVitreo-retinal Surgery. St Louis, CV Mosby, 1977, pp 230-233 Taylor RT, Michels RG, Stark WJ: Vitrectomy methods in anterior segment surgery. Ophthalmic Surg 10(10):25, 1979 Federman JL, Annesley WH Jr, Sarin L, Remer P: Vitrectomy and cystoid macular edema. Ophthalmol87:622, 1980 Shammas HJF, Milkie CF: Cystoid macular edema following secondary lens implantation. Am Intra-Ocular Implant Soc] 7:40, 1981
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
SUBJECTS AND METHODS
Thirty consecutive patients (30 eyes) underwent closed vitrectomy during secondary IOL implantation to remove vitreous which was present in the anterior segment. All patients were monocular aphakes who could not successfully wear a contact lens. All had undergone intracapsular cataract extraction (ICCE) from 13 months to eight years before CV-SI and 14 eyes had sector iridectomies. Preoperative ocular abnormalities were otherwise limited to senile macular degeneration (4 patients) and ischemic optic neuropathy (one patient). All patients received Binkhorst 4-loop iris clip lenses, manufactured by IOLAB , during secondary surgery. These lenses have polypropylene (Prolene) haptics. Following CV-SI, all patients were examined at least monthly for six months, and every two to four months thereafter. The follow-up periods ranged from six to 36 months, with an average of 16 months. Fluorescein angiography was performed whenever best corrected postoperative visual acuity fell below preoperative acuity.
Postoperatively, all patients were treated every two hours with a 1% solution of topical prednisolone acetate; this was gradually reduced to once daily by three months, and continued at that level unless the steroid solution increased intraocular pressure.
SURGICAL TECHNIQUE Following pupillary dilatation with a 1% solution of topical tropic-amide (Mydriacyl), a scleral support ring was sutured to the globe. Closed vitrectomy was then performed through the superior limbus prior to IOL insertion. One of the vitrectomy handpieces of the Heslin/Mackool Ocusystem 8 was used in all cases. When one vitrectomy handpiece was used for both infusion and aspiration , it was inserted through a limbal opening made with an IS-gauge needle. When infusion was introduced through a separate 25-gauge cannula, a smaller vitrectomy handpiece was inserted through a limbal tract made with a 21-gauge needle. The vitrectomies performed were intentionally extensive, and all vitreous visible within the red reflex (using coaxial illumination) was removed. This usually included removal of the posterior hyaloid (Fig. 1,2), since posterior vitreous detachment was present in most eyes . Following vitrectomy (which generally required 5 to 10 minutes of operating time), a microspatula was used to excise vitreous strands incarcerated in the small superior incision through which the vitrectomy instrument had passed. The microspatula was inserted through a small puncture in a horizontallimbal meridian (Fig. 3,4). Intracameral acetylcholine injection, enlargement of the corneoscleral incision to 6 mm, sector iridectomy repair (14 eyes), and IOL insertion were then performed. In 29 eyes the IOL was sutured to the iris with 10-0 polypropylene: the suture was placed in the supe rior iris,
Presented at the Fourth u.s. Intraocular Lens Symposium, Los Angeles, California , March 28, 1981 . Reprint requests to Dr. Ma ckool, New York Eye and Ear Infirmary, 310 East 14th Street, New York , NY 10003. AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
233
Fig. l(Mackool). Vitreous strands (arrow) are incarcerated in the smalllimbal incision. Vitreous has been removed from the anterior chamber and posterior vitreous detachment is present. Infusion is being delivered by a separate cannula.
Fig. 3(Mackool). Spatula has been inserted over superior iris and beneath vitrectomy instrument. The pupil is peaked by incarcerated vitreous strands. 234
Fig.2(Mackool). Central posterior hyaloid has been removed, and only peripheral anterior vitreous remains in vitreous cavity. Vitreous strands remain incarcerated in small limbal incision.
Fig. 4(Mackool). Spatula has been swept into pupillary zone to increase accessibility of the vitreous strands to the cutting port. Pupil is no longer peaked.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
passed through the anterior superior IOL haptic before lens insertion, and tied after the lens was in position.
RESULTS All 30 patients undergoing CV-SI essentially maintained their best preoperative visual acuity as measured at the time of last examination. Complications are summarized in Table 1. One patient experienced a drop of visual acuity from a preoperative level of20/30, to 20/70 one month following CV-SI. Fluorescein angiography demonstrated cystoid macular edema (CME), which cleared spontaneously by the second post-operative month, with visual acuity improving to 20/30. No other patient demonstrated a reduction of acuity, and therefore no other fluorescein angiographic studies were performed. No patient displayed corneal edema in either the immediate or late postoperative periods. No · patient developed chronic glaucoma following CV-SI. Tensions in the immediate postoperative period occasionally rose to between 25 and 35 mm Hg but did not present management problems. Five patients developed steroid-induced elevations of intraocular pressure, requiring reduction or elimination of topical steroid use. One patient developed iritis five months after CVSI. This eye had active pupillary responses and excessive IOL motion in spite of sector iridectomy repair; no iris fixation suture had been placed. Topically applied steroids and miotics added one week later to reduce IOL motion eliminated these episodes for 13 months. A second patient developed a microscopic bleed into the anterior chamber four months after CVSI. This patient also had brisk pupillary responses and
Table 1. Complications in 30 cases of closed vitrectomy and secondary implantation.
Complication Reduced final acuity* Transient CME Corneal edema Glaucoma Late iridocyclitis Late microhyphema
*As compared to preoperative acuity
No. of Eyes
o 1
o o 1 1
excessive IOL motion: bleeding was presum ed to be secondary to continuous pupillary margin trauma. Miotic therapy eliminated the problem for nine months. Several other patients displayed brisk pupillary responses and excessive IOL motion without complications. These patients are now routinely maintained on miotic therapy.
DISCUSSION Following secondary IOL implantation, reduced visual acuity from CME has been reported in 1.5% to 4% of eyes receiving Choyce-style lenses,2,4,5 in 3% of eyes with Medallion lenses,3 and in 7.1% of eyes with Binkhorst iris clip lenses. 1 Vitreous loss has been reported to increase the risk of secondary implantation, 5 and this procedure has been considered to be contraindicated in eyes containing vitreous in the anterior chamber. 6 In this series of 30 consecutive patients, CV -SI with a Binkhorst iris clip lens produced extremely favorable results. CME and corneal edema were essentially nonexistent. Several factors may be responsible for this. First, no secondary procedure was performed within a year of cataract extraction, thus allowing time for the vitreous changes which have been proposed to follow intracapsular cataract extraction. 2 A recent report14 demonstrated an increased complication rate when a secondary procedure was performed within one year after cataract extraction. Second all closed vitrectomies were intentionally extensive: and all vitreous strands to the wound were excised. While the role of the vitreous in CME is Poorly understood , the resolution of CME following 7-12 vitrectomy has been frequently reported. The large vitrectomies performed (the posterior hyaloid was usually removed) may thus have minimized the incidence of CME in these patients. Third, advanced vitrectomy instrumentationS greatly simplifies the procedure and reduces vitreous traction. The precisely regulated flow process significantly reduces the total fluid exchange required for vitrectomy, and this is reflected in the absence of corneal complications. Finally, a scleral support ring was used in all eyes. Following vitrectomy, enlarging the wound for secondary implantation can result in globe collapse during IOL insertion, and corneal endothelial trauma may readily result. The scleral support ring maintains the anterior segment and makes atraumatic IOL insertion quite simple.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
235
REFERENCES
1. Binkhorst CD, Leonard PAM: Results in 208 iris-clip pseudophakos implantations. Am] Ophthalmol 64:947, 1967 2. Choyce DP: The latest facts and figures on anterior chamber lens implants. Contact and Intraocular Lens MedJ 2:60, 1976 3. Shammas HJF, Milkie CF: Secondary lens implantation in aphakia: visual results and complications. Am Intra-Ocular Implant Soc] 4:180, 1978 4. Shammas HJF, Milkie CF: Primary vs. secondary insertion of anterior chamber lenses. Am Intra-Ocular Implant Soc] 5:141, 1979 5. Cozean CH Jr: A longer view of secondary intraocular lens implantation with special emphasis on the role of the vitreous. Am Intra-Ocular Implant Soc] 6:361, 1980 6. Darin JJ: Survey of secondary lens implantation. Am IntraOcular Implant Soc] 1(2):32, 1975 7. Mackool RJ: Closed vitrectomy and the intraocular implant. Ophthalmol 88:414, 1981 8. Mackool RJ, Heslin KB, Banko A: Combined phacoemulsification and pars plana vitrectomy capability in a single compu-
236
9. 10. 11.
12. 13. 14.
terized instrument. Am Intra-Ocular Implant Soc] 6:377, 1980 Michels RG, Machemer R,Muelier-Jensen K: Vitreous surgery: history and current concepts. Ophthalmic Surg 5:13, 1974 Michels RS, Stark WJ: Vitrectomy techniques in anterior segment surgery. Trans Am Acad Ophthalmol Otolaryngol 810P:382, 1976 Aaberg TM: Pars plana vitrectomy for persistent aphakic cystoid macular edema secondary to vitreous incarceration in the cataract wound, in McPherson A(ed): New and Controversial Aspects ofVitreo-retinal Surgery. St Louis, CV Mosby, 1977, pp 230-233 Taylor RT, Michels RG, Stark WJ: Vitrectomy methods in anterior segment surgery. Ophthalmic Surg 10(10):25, 1979 Federman JL, Annesley WH Jr, Sarin L, Remer P: Vitrectomy and cystoid macular edema. Ophthalmol87:622, 1980 Shammas HJF, Milkie CF: Cystoid macular edema following secondary lens implantation. Am Intra-Ocular Implant Soc] 7:40, 1981
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981