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Survey on Secondary Lens Implantation
survey on secondary lens implantation John]. Darin, M.D. Westlake Village, California
-articles
Primary Implantation is defined as the implanting of an intraocular lens at the same time of cataract extraction, while a Secondary Implantation (S.I.) is defined as the implanting of an intraocular lens in an eye that has undergone prior cataract extraction. Each year in the United States there are over 400,000 cataract extractions performed, so one can readily see that there are literally millions of of potential aphakic implantations. The purpose of this paper is to present a very conservative appr-oach to secondary lens implantation in the midst of the recent tremendous upsurge of interest in intraocular lens implantation in the United States. I have surveyed many prominent implant surgeons, compiled their statistics, and attempted to obtain their ideas and philosophies regarding secondary lens implantation. TURGUT N. HAMDI, M.D. Philadelphia, Pennsylvania
Started IOL Total IOL S.1. Post I.CCE. Post E.CCE.
32
1953 475 156 (32.8%) 3 153
Dr. Hamdi was the first American to implant an intraocular lens. This was performed in Philadelphia in 1953 using the original Ridley posterior chamber lens. A large percentage of Dr. Hamdi's vast experience with secondary lens implantation took place in the late fifties and sixties when he was using the flexible Leib-Danheim anterior chamber angle supported lens. His routine was to perform a planned extracapsular cataract extraction, and after at least three months had elapsed, to do a planned secondary implantation. Since 1968 Dr. Hamdi has been using the Copeland iris plane intraocular lens as a primary implantation. He is exclusively an extracapsular surgeon when performing intraocular lens implantation. In reviewing Dr. Hamdi's statistics, note that he has performed only three secondary implantations following intracapsular surgery. He will not do a secondary implantation in an eye with vitreous in the anterior chamber.
CLINICAL SITVA nON
00 Mature Cataract OS Aphakia (post I.CCE. with intact vitreous face) A) Patient cannot wear CL. (wearing aphakic spectacle OS)
Would you ever do a 5.1.
as first?
Dr. Hamdi: "I would not recommend doing a 5.1. on the aphakic eye. The patient needs to see, and the chances of him seeing most quickly without complications is to do the right eye. This is, of course, to be decided upon by the patient and is contingent upon his willingness to wear cataract spectacles."
Would you generally do just a cataract extraction aD without IOL? Dr. Hamdi: "If the patient is unable to wear a
CL. and is unwilling to wear cataract 'glasses, I would use an intraocular lens. However, if he is already wearing cataract glasses comfortably, I would push for conventional surgery in the second- eye. If the patient is unhappy with cataract glasses, I would explain that he must decide to use the right eye alone following the intraocular lens."
If the patient is wearing a you do?
c.L.
as
what would
Dr. Hamdi: "I would do an intraocular lens 00." HENRY HIRSCHMAN, MD. Long Beach, California
Started IOL TotailOL S.1. Post I.CCE. Post E.CCE.
1967 1250 40 (3.2%) 30 10
Dr. Hirschman, who has implanted the greatest number of intraocular lenses in the United States, spoke on the topic of secondary lens implantation at the Long Beach Intraocular Lens Implant Conference in November 1974. He stressed a very conservative approach regarding this subject. Dr. Hirschman states that the indication for 5.1. should be sharply limited to a patient with monocular aphakia who absolutely cannot wear a contact lens and has a need for binocularity. Of interest is the fact that Dr. Hirschman did very few secondary implantations early in his career ("two in first one hundred, three-four
in second one hundred, zero in third one hundred"). At present Dr. Hirschman is doing a greater number of secondary implantations because he is performing a greater percentage of extracapsular surgery. It is a well accepted fact that secondary implantation with an intact posterior capsule is a much safer procedure than following intracapsular surgery. Dr. Hirschman's preferred lens for secondary implantation post I.CCE. and post E.C.CE. is the Platinum Clip lens. He also stated that if iridocapsular adhesions are present pre-operatively then the Binkhorst two-loop lens is ideal. CLINICAL SITVA nON
00 Mature Cataract OS Aphakia (post I.CCE. with intact vitreous face) A) Patient cannot wear CL. (wearing aphakic spectacle OS)
Would you ever do a 5.1.
as first?
Dr. Hirschman: "Would much prefer to do a cataract extraction with lens implant 00 and possibly a 5.1. OS one year later if patient's visual requirements needed it."
Would you generally do just a cataract extraction aD without IOL? Dr. Hirschman: "Yes. Depending on patient's occupational and visual requirements."
If the patient is wearing a contact lens would you do?
as
what
Dr. Hirschman: "Then I would do a cataract extraction with lens implant 00 only." NORMAN JAFFE, MD., Miami Beach, Florida
Started IOL TotailOL S.1.
1967 700 1 (0.18%)
CLINICAL SITVAnON
If you "had" to do a 5.1. (60 year old monocular aphakic 00 with 20/20 OS and cannot wear a contact lens and needs binocularity for work).
How would you approach an eye with an intact vitreous face? Dr. Jaffe: "It is unthinkable for me to do a 5.1. in this case. The need for binocularity is overrated. Give a contact lens to pass a job requirement and then abandon the lens if it is uncomfortable. I am philosophically against 5.1. I think we invent too
33
many unreal indications. My greatest fear is to take a 20/20 eye (with contact lens or spectacles) and ruin it with a 5.1. Even if the patient can't use the aphakic eye, it is potentially a good eye if the opposite eye ever has a cystoid macular edema or if the opposite eye is ever lost due to retinal detachment, trauma, central retinal artery thrombosis, etc." MURRY K. WEBER, M.D. Canoga Park, California
Started 10L TotallOL 5.1. Post I.CCE. Post E.CCE.
1968 250 6 (2.4%) 3 3
Dr. Weber, another pioneer in American Implant Surgery, also reflects a very cautious, conservative approach to secondary lens implantation. He will not do a 5.1. in an eye with vitreous in the anterior chamber. CLINICAL SITUAnON
00 Mature Cataract OS Aphakia (post I.CCE. with intact vitreous face.) A) Patient cannot wear CL. (wearing aphakic spectacle OS).
Would you ever do a 5.1. first? Dr. Weber: "I could conceivably do this if the patient not only could not wear contact lens but was adamant about not wanting aphakic glasses, was not young (over 60) and couldn't be talked out of it."
Would you generally do just cataract extraction OD without IOL? Dr. Weber: "YES".
Started 10L TotallOL 5.1.
1968 100
o
Dr. Anderson has not performed any 5.1. but of interest is his reply to the question: Your feelings about 5.1. following E.CCE. with an intactposterior capsule? Dr. Anderson: "Safe, not reluctant to do this in indicated situation." DENNIS SHEPARD, M.D., F.A.C.S., Santa Monica, California
Started 10L TotallOL 5.1. Post I.CCE. Post E.CCE.
1971 436 15 (4.3%) 14 1
Dr. Shepard's statistics again indicate a cautious regard for secondary lens implantation early in his implantation career since he only performed one 5.1. in his first 200 cases of intraocular lenses. Dr. Shepard will generally perform a 5.1. on the aphakic eye and then do a primary implantation on the cataractous eye at a later date. He has had good success with the Medallion suture lenses in aphakic eyes with prior small sector iridectomies.
COMPLICA nONS OF SECONDARY LENS IMPLANT AnON 1. Cystoid Macular Edema
Dr. Hirschman: "Probably at least 10% and that's the biggest risk."
OS what would
Dr. Shepard: "Greatest fear, causes worst visual acuity loss, may not respond to treatmentterrible problem."
Dr. Weber: "Implant 00 as long as patient clearly understands necessity of contact lens OS for binocularity. If 00 with implant is total success for minimum of 6 months I might be convinced to try 5.1. OS, but have talked all patients out of this to date."
Dr. Alpar: "1 believe the greatest fear I have." Dr. Drews: "Cystoid macular edema is certainly one of the concerns with 5.1. especially after intracapsular cataract extraction. This would be much more likely if the vitreous is disturbed."
Dr. Weber's preferred lens for 5.1. is the Binkhorst four-loop lens.
Dr. Gould: "Generally with I.CCE. and implant a dreadful complication."
If the patient is wearing a you do?
34
c.L.
RALPH ANDERSON, M.D., San Diego, California
Dr. Dickerson: "If vitreous is lost, this is a marked problem." 2. Vitreous Loss (Post I.C.C.E.)
Dr. Hirschman: "Frequently encountered." Dr. Cruickshanks: "In general does not seem especially important as long as controllable." Dr. Shepard: "I don't fear it, it happens in 35% of cases of 5.1. in my hands, I expect it." Dr. Hartstein: "I worry about this but so far has worked out okay in my small series." Dr. Micheles: "Even when controlled can be a problem for the retina at a later date. Dr. Sheets: "Vitreous loss in my cases disastrous." Dr. Drews: "I feel very strongly there should not be any vitreous loss during 5.1. If there is, implantation should probably be forgotten. . The idea that one can do an anterior vitrectomy - --and a 5.1. may sound interesting theoretically but will require the accumulation of a large number of independently studied (with Fluorescein angiography) cases to evaluate." 3. Corneal Problems
Dr. Hirschman: states that if one considers to do a 5.1. one naturally should carefully examine the condition of the cornea for degenerative changes but probably just as important is to find out how the cornea tolerated the primary cataract extraction. This requires reviewing your postoperative records or obtaining the records from another surgeon. One should not attempt a 5.1. in an eye with a postoperative history of prolonged cornea edema, for no matter how atraumaticaIIy the 5.1. is performed, one may end up with a permanent corneal dystrophy. Dr. Drews: "5.1. is certainly much more traumatic to the cornea and otherwise than primary implantation. Such patients certainly need a very healthy corneal endothelium preoperatively. With experience the corneal problems decrease." Dr. Gould: "If endothelium is undisturbed, should not be a problem." Dr. Hartstein: "None so far, in fact in my series and others I've spoken to the cornea im-
mediately after surgery is clearer." Dr. Shepard: "No, rare." 4. Vitritis Causing Decreased Vision
Dr. Hirschman: "A definite risk, not always transien t." Dr. Weber: "No." Dr. Shepard: "Yes, maybe long and chronic. Significant cause of visual loss and prolonged red eye." Dr. Alpar: "Usually can be cleared on intensive topical and sometimes systemic steroids." Dr. Micheles: "Great fear, may be 2-3%." Dr. Darr: "Constan.f' Dr. Sheets: "Has occurred."Dr. Drews: "Vitritis (with properly made, pure lenses) should only be seen these days where faulty technique has introduced contamination along with the lens, or where vitreous has been disturbed. Contrary to popular opinion, in ordinary cataract surgery, the vitreous must be respected wheri lens implantation is performed." 5. Intraocular Lens Movement Due to Vitreous
Bands
Dr. Hirschman: "Minimized by extreme care with vitrectomy and suturing. Should be very rare." Dr. Shepard: "I haven't seen this." Dr. Alpar: liMy least worry." Dr. Mich eles: "Rare if surgery done correctly." Dr. Sheets: "Not enough experience to have seen this." Dr. Gould: "Sounds horrible." Dr. Drews: "Vitreous bands coming through the pupil should certainly be an absolute contraindication to 5.1., and must be absolutely avoided after implantation." ADVANTAGES OF SECONDARY LENS IMPLANTATION
If one attempts a 5.1. and if one is fortunate enough to avoid any of the many complications associated
35
with this procedure, and if the visual result is good, then you will have a very appreciative patient. This is due to the fact that these patients have known the optical disadvantages of the world of aphakic vision, and really appreciate the optical advantages of psuedophakia. Patients undergoing primary lens implantation naturally do not experience aphakic vision and therefore have no basis of comparison. CONCLUSIONS OF SURVEY ON SECONDARY LENS IMPLANT A nON
1. Everyone agrees that if a patient is wearing a contact lens the patient should not undergo secondary lens implantation. 2. It is well agreed upon that, all things equal, it
is much safer to perform a secondary lens implantation in an eye with an intact posterior capsule than in an eye which has undergone prior intracapsular surgery.
3. Many, if not most implant surgeons, will not
do a secondary lens implantation in an eye with vitreous in the anterior chamber. Dr. Worst at the November 1974 Long Beach Conference stated "Stay away from secondary lens implantation following intracapsular surgery."
4. Some implant surgeons, judging by their stat-
istics and comments, are strongly opposed to secondary implantation. (Dr. Jaffe, 1 in 700i Dr. Galin 6 in 1000i Dr. Anderson, 0 in 100i Dr. Hertzog, 0 in 80i Dr. Drews, 2 in 101).
5. Extremely wide differences of opinions among
implant surgeons concerning indications, techniques, lenses, and complications.
Dr. Hirschman makes the statement that the word Secondary lens implantation should make the surgeon think twice before attempting this procedure. •
36
TABLE OF SURVEY RESULTS Year Total Started IOL
S.I.
%
HAMDI Philadelphia, Penn.
1953
475
156
32.8
GALIN New York, N.Y.
1959
1,000
6
0.6
GILLS Newport Richey, Fla.
1961
1,100
200
18.2
HIRSCHMAN Long Beach, Calif.
1967
1,250
40
3.2
JAFFE Miami Beach, Fla.
1967
700
1
0.19
CRUICKSHANKS Sarnia, Ontario
1967
230
7
3.0
WEBER Canoga Park, Calif.
1968
250
6
2.4
ANDERSON San Diego, Calif.
1968
100
o
0
SHEPARD Santa Maria, Calif.
1971
436
15
3.4
HARTSTEIN St. Louis, Mo.
1972
200
12
6.0
ALPAR Amarillo, Texas
1972
130
10
7.7
HERTZOG Long Beach, Calif.
1972
80
o
0
MICHELIS Long Beach, Calif.
1973
250
20
8.0
DREWS Clayton, Mo.
1973
101
2
2.0
1973
100
3
3.0
KRATZ Van Nuys, Calif.
1974
300
12
4.0
SHEETS Odessa, Texas
1974
300
9
3.0
COOPERMAN Beverly Hills, Calif.
1974
150
8
5.3
GILMORE Santa Monica, Calif.
1974
83
4
4.8
GOULD White Plains, N.Y.
1974
46
2
4.3
DICKERSON Santa Monica, Calif.
1974
36
2
5.5
7,317
515
7.0
DARR
Indio, Calif.
TOTAL
-articles
Primary Implantation is defined as the implanting of an intraocular lens at the same time of cataract extraction, while a Secondary Implantation (S.I.) is defined as the implanting of an intraocular lens in an eye that has undergone prior cataract extraction. Each year in the United States there are over 400,000 cataract extractions performed, so one can readily see that there are literally millions of of potential aphakic implantations. The purpose of this paper is to present a very conservative appr-oach to secondary lens implantation in the midst of the recent tremendous upsurge of interest in intraocular lens implantation in the United States. I have surveyed many prominent implant surgeons, compiled their statistics, and attempted to obtain their ideas and philosophies regarding secondary lens implantation. TURGUT N. HAMDI, M.D. Philadelphia, Pennsylvania
Started IOL Total IOL S.1. Post I.CCE. Post E.CCE.
32
1953 475 156 (32.8%) 3 153
Dr. Hamdi was the first American to implant an intraocular lens. This was performed in Philadelphia in 1953 using the original Ridley posterior chamber lens. A large percentage of Dr. Hamdi's vast experience with secondary lens implantation took place in the late fifties and sixties when he was using the flexible Leib-Danheim anterior chamber angle supported lens. His routine was to perform a planned extracapsular cataract extraction, and after at least three months had elapsed, to do a planned secondary implantation. Since 1968 Dr. Hamdi has been using the Copeland iris plane intraocular lens as a primary implantation. He is exclusively an extracapsular surgeon when performing intraocular lens implantation. In reviewing Dr. Hamdi's statistics, note that he has performed only three secondary implantations following intracapsular surgery. He will not do a secondary implantation in an eye with vitreous in the anterior chamber.
CLINICAL SITVA nON
00 Mature Cataract OS Aphakia (post I.CCE. with intact vitreous face) A) Patient cannot wear CL. (wearing aphakic spectacle OS)
Would you ever do a 5.1.
as first?
Dr. Hamdi: "I would not recommend doing a 5.1. on the aphakic eye. The patient needs to see, and the chances of him seeing most quickly without complications is to do the right eye. This is, of course, to be decided upon by the patient and is contingent upon his willingness to wear cataract spectacles."
Would you generally do just a cataract extraction aD without IOL? Dr. Hamdi: "If the patient is unable to wear a
CL. and is unwilling to wear cataract 'glasses, I would use an intraocular lens. However, if he is already wearing cataract glasses comfortably, I would push for conventional surgery in the second- eye. If the patient is unhappy with cataract glasses, I would explain that he must decide to use the right eye alone following the intraocular lens."
If the patient is wearing a you do?
c.L.
as
what would
Dr. Hamdi: "I would do an intraocular lens 00." HENRY HIRSCHMAN, MD. Long Beach, California
Started IOL TotailOL S.1. Post I.CCE. Post E.CCE.
1967 1250 40 (3.2%) 30 10
Dr. Hirschman, who has implanted the greatest number of intraocular lenses in the United States, spoke on the topic of secondary lens implantation at the Long Beach Intraocular Lens Implant Conference in November 1974. He stressed a very conservative approach regarding this subject. Dr. Hirschman states that the indication for 5.1. should be sharply limited to a patient with monocular aphakia who absolutely cannot wear a contact lens and has a need for binocularity. Of interest is the fact that Dr. Hirschman did very few secondary implantations early in his career ("two in first one hundred, three-four
in second one hundred, zero in third one hundred"). At present Dr. Hirschman is doing a greater number of secondary implantations because he is performing a greater percentage of extracapsular surgery. It is a well accepted fact that secondary implantation with an intact posterior capsule is a much safer procedure than following intracapsular surgery. Dr. Hirschman's preferred lens for secondary implantation post I.CCE. and post E.C.CE. is the Platinum Clip lens. He also stated that if iridocapsular adhesions are present pre-operatively then the Binkhorst two-loop lens is ideal. CLINICAL SITVA nON
00 Mature Cataract OS Aphakia (post I.CCE. with intact vitreous face) A) Patient cannot wear CL. (wearing aphakic spectacle OS)
Would you ever do a 5.1.
as first?
Dr. Hirschman: "Would much prefer to do a cataract extraction with lens implant 00 and possibly a 5.1. OS one year later if patient's visual requirements needed it."
Would you generally do just a cataract extraction aD without IOL? Dr. Hirschman: "Yes. Depending on patient's occupational and visual requirements."
If the patient is wearing a contact lens would you do?
as
what
Dr. Hirschman: "Then I would do a cataract extraction with lens implant 00 only." NORMAN JAFFE, MD., Miami Beach, Florida
Started IOL TotailOL S.1.
1967 700 1 (0.18%)
CLINICAL SITVAnON
If you "had" to do a 5.1. (60 year old monocular aphakic 00 with 20/20 OS and cannot wear a contact lens and needs binocularity for work).
How would you approach an eye with an intact vitreous face? Dr. Jaffe: "It is unthinkable for me to do a 5.1. in this case. The need for binocularity is overrated. Give a contact lens to pass a job requirement and then abandon the lens if it is uncomfortable. I am philosophically against 5.1. I think we invent too
33
many unreal indications. My greatest fear is to take a 20/20 eye (with contact lens or spectacles) and ruin it with a 5.1. Even if the patient can't use the aphakic eye, it is potentially a good eye if the opposite eye ever has a cystoid macular edema or if the opposite eye is ever lost due to retinal detachment, trauma, central retinal artery thrombosis, etc." MURRY K. WEBER, M.D. Canoga Park, California
Started 10L TotallOL 5.1. Post I.CCE. Post E.CCE.
1968 250 6 (2.4%) 3 3
Dr. Weber, another pioneer in American Implant Surgery, also reflects a very cautious, conservative approach to secondary lens implantation. He will not do a 5.1. in an eye with vitreous in the anterior chamber. CLINICAL SITUAnON
00 Mature Cataract OS Aphakia (post I.CCE. with intact vitreous face.) A) Patient cannot wear CL. (wearing aphakic spectacle OS).
Would you ever do a 5.1. first? Dr. Weber: "I could conceivably do this if the patient not only could not wear contact lens but was adamant about not wanting aphakic glasses, was not young (over 60) and couldn't be talked out of it."
Would you generally do just cataract extraction OD without IOL? Dr. Weber: "YES".
Started 10L TotallOL 5.1.
1968 100
o
Dr. Anderson has not performed any 5.1. but of interest is his reply to the question: Your feelings about 5.1. following E.CCE. with an intactposterior capsule? Dr. Anderson: "Safe, not reluctant to do this in indicated situation." DENNIS SHEPARD, M.D., F.A.C.S., Santa Monica, California
Started 10L TotallOL 5.1. Post I.CCE. Post E.CCE.
1971 436 15 (4.3%) 14 1
Dr. Shepard's statistics again indicate a cautious regard for secondary lens implantation early in his implantation career since he only performed one 5.1. in his first 200 cases of intraocular lenses. Dr. Shepard will generally perform a 5.1. on the aphakic eye and then do a primary implantation on the cataractous eye at a later date. He has had good success with the Medallion suture lenses in aphakic eyes with prior small sector iridectomies.
COMPLICA nONS OF SECONDARY LENS IMPLANT AnON 1. Cystoid Macular Edema
Dr. Hirschman: "Probably at least 10% and that's the biggest risk."
OS what would
Dr. Shepard: "Greatest fear, causes worst visual acuity loss, may not respond to treatmentterrible problem."
Dr. Weber: "Implant 00 as long as patient clearly understands necessity of contact lens OS for binocularity. If 00 with implant is total success for minimum of 6 months I might be convinced to try 5.1. OS, but have talked all patients out of this to date."
Dr. Alpar: "1 believe the greatest fear I have." Dr. Drews: "Cystoid macular edema is certainly one of the concerns with 5.1. especially after intracapsular cataract extraction. This would be much more likely if the vitreous is disturbed."
Dr. Weber's preferred lens for 5.1. is the Binkhorst four-loop lens.
Dr. Gould: "Generally with I.CCE. and implant a dreadful complication."
If the patient is wearing a you do?
34
c.L.
RALPH ANDERSON, M.D., San Diego, California
Dr. Dickerson: "If vitreous is lost, this is a marked problem." 2. Vitreous Loss (Post I.C.C.E.)
Dr. Hirschman: "Frequently encountered." Dr. Cruickshanks: "In general does not seem especially important as long as controllable." Dr. Shepard: "I don't fear it, it happens in 35% of cases of 5.1. in my hands, I expect it." Dr. Hartstein: "I worry about this but so far has worked out okay in my small series." Dr. Micheles: "Even when controlled can be a problem for the retina at a later date. Dr. Sheets: "Vitreous loss in my cases disastrous." Dr. Drews: "I feel very strongly there should not be any vitreous loss during 5.1. If there is, implantation should probably be forgotten. . The idea that one can do an anterior vitrectomy - --and a 5.1. may sound interesting theoretically but will require the accumulation of a large number of independently studied (with Fluorescein angiography) cases to evaluate." 3. Corneal Problems
Dr. Hirschman: states that if one considers to do a 5.1. one naturally should carefully examine the condition of the cornea for degenerative changes but probably just as important is to find out how the cornea tolerated the primary cataract extraction. This requires reviewing your postoperative records or obtaining the records from another surgeon. One should not attempt a 5.1. in an eye with a postoperative history of prolonged cornea edema, for no matter how atraumaticaIIy the 5.1. is performed, one may end up with a permanent corneal dystrophy. Dr. Drews: "5.1. is certainly much more traumatic to the cornea and otherwise than primary implantation. Such patients certainly need a very healthy corneal endothelium preoperatively. With experience the corneal problems decrease." Dr. Gould: "If endothelium is undisturbed, should not be a problem." Dr. Hartstein: "None so far, in fact in my series and others I've spoken to the cornea im-
mediately after surgery is clearer." Dr. Shepard: "No, rare." 4. Vitritis Causing Decreased Vision
Dr. Hirschman: "A definite risk, not always transien t." Dr. Weber: "No." Dr. Shepard: "Yes, maybe long and chronic. Significant cause of visual loss and prolonged red eye." Dr. Alpar: "Usually can be cleared on intensive topical and sometimes systemic steroids." Dr. Micheles: "Great fear, may be 2-3%." Dr. Darr: "Constan.f' Dr. Sheets: "Has occurred."Dr. Drews: "Vitritis (with properly made, pure lenses) should only be seen these days where faulty technique has introduced contamination along with the lens, or where vitreous has been disturbed. Contrary to popular opinion, in ordinary cataract surgery, the vitreous must be respected wheri lens implantation is performed." 5. Intraocular Lens Movement Due to Vitreous
Bands
Dr. Hirschman: "Minimized by extreme care with vitrectomy and suturing. Should be very rare." Dr. Shepard: "I haven't seen this." Dr. Alpar: liMy least worry." Dr. Mich eles: "Rare if surgery done correctly." Dr. Sheets: "Not enough experience to have seen this." Dr. Gould: "Sounds horrible." Dr. Drews: "Vitreous bands coming through the pupil should certainly be an absolute contraindication to 5.1., and must be absolutely avoided after implantation." ADVANTAGES OF SECONDARY LENS IMPLANTATION
If one attempts a 5.1. and if one is fortunate enough to avoid any of the many complications associated
35
with this procedure, and if the visual result is good, then you will have a very appreciative patient. This is due to the fact that these patients have known the optical disadvantages of the world of aphakic vision, and really appreciate the optical advantages of psuedophakia. Patients undergoing primary lens implantation naturally do not experience aphakic vision and therefore have no basis of comparison. CONCLUSIONS OF SURVEY ON SECONDARY LENS IMPLANT A nON
1. Everyone agrees that if a patient is wearing a contact lens the patient should not undergo secondary lens implantation. 2. It is well agreed upon that, all things equal, it
is much safer to perform a secondary lens implantation in an eye with an intact posterior capsule than in an eye which has undergone prior intracapsular surgery.
3. Many, if not most implant surgeons, will not
do a secondary lens implantation in an eye with vitreous in the anterior chamber. Dr. Worst at the November 1974 Long Beach Conference stated "Stay away from secondary lens implantation following intracapsular surgery."
4. Some implant surgeons, judging by their stat-
istics and comments, are strongly opposed to secondary implantation. (Dr. Jaffe, 1 in 700i Dr. Galin 6 in 1000i Dr. Anderson, 0 in 100i Dr. Hertzog, 0 in 80i Dr. Drews, 2 in 101).
5. Extremely wide differences of opinions among
implant surgeons concerning indications, techniques, lenses, and complications.
Dr. Hirschman makes the statement that the word Secondary lens implantation should make the surgeon think twice before attempting this procedure. •
36
TABLE OF SURVEY RESULTS Year Total Started IOL
S.I.
%
HAMDI Philadelphia, Penn.
1953
475
156
32.8
GALIN New York, N.Y.
1959
1,000
6
0.6
GILLS Newport Richey, Fla.
1961
1,100
200
18.2
HIRSCHMAN Long Beach, Calif.
1967
1,250
40
3.2
JAFFE Miami Beach, Fla.
1967
700
1
0.19
CRUICKSHANKS Sarnia, Ontario
1967
230
7
3.0
WEBER Canoga Park, Calif.
1968
250
6
2.4
ANDERSON San Diego, Calif.
1968
100
o
0
SHEPARD Santa Maria, Calif.
1971
436
15
3.4
HARTSTEIN St. Louis, Mo.
1972
200
12
6.0
ALPAR Amarillo, Texas
1972
130
10
7.7
HERTZOG Long Beach, Calif.
1972
80
o
0
MICHELIS Long Beach, Calif.
1973
250
20
8.0
DREWS Clayton, Mo.
1973
101
2
2.0
1973
100
3
3.0
KRATZ Van Nuys, Calif.
1974
300
12
4.0
SHEETS Odessa, Texas
1974
300
9
3.0
COOPERMAN Beverly Hills, Calif.
1974
150
8
5.3
GILMORE Santa Monica, Calif.
1974
83
4
4.8
GOULD White Plains, N.Y.
1974
46
2
4.3
DICKERSON Santa Monica, Calif.
1974
36
2
5.5
7,317
515
7.0
DARR
Indio, Calif.
TOTAL