ARTICLE
Implantation of glued intraocular lenses in eyes with microcornea Dhivya Ashok Kumar, MD, FICO, Amar Agarwal, MS, FRCS, FRCOphth, Soundari Sivangnanam, FRCS, Radika Chandrasekar, BSc, Athiya Agarwal, MD, DO
PURPOSE: To evaluate the intraoperative modifications for and vision outcomes after implantation of glued intraocular lenses (IOLs) in eyes with microcornea. SETTING: Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. DESIGN: Prospective case series. METHODS: Eyes with a horizontal cornea of 10.0 mm or less were evaluated for intraoperative modifications and postoperative vision after implantation of a glued IOL. The type of surgery, type of IOL, incision and optic sizes, haptic length modifications, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and postoperative complications were analyzed. RESULTS: A glued IOL was implanted in 15 eyes to treat subluxated cataract (9 eyes), aphakia (5), and intraoperative capsule loss (1). In cases involving a subluxated cataract, implantation of the glued IOL was followed by lensectomy (7 eyes) or intracapsular cataract extraction (2 eyes). The mean follow-up was 22.4 months G 17.2 (SD). The mean horizontal corneal diameter and axial length were 8.0 G 0.6 mm and 21.0 G 2.4 mm, respectively. The mean amount of IOL haptic trimmed intraoperatively was 1.54 G 0.33 mm. There was significant correlation between the horizontal corneal diameter and the amount of haptic trimmed (P Z .000). The mean size of the main incision was 3.70 G 0.98 mm. Three-piece foldable IOLs with a 6.0 mm optic were used. There were no cases of haptic extrusion or subconjunctival haptic placement. There was statistically significant improvement in CDVA (P Z .032) and UDVA (P Z .012) after surgery. CONCLUSION: Glued IOLs were safely implanted in eyes with microcornea using modifications such as custom haptic trimming and 6.0 mm optic foldable IOLs. Financial Disclosure: Dr. Amar Agarwal is a paid consultant to Staar Surgical Co. No other author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2015; 41:327–333 Q 2015 ASCRS and ESCRS
Human cornea size has great significance anatomically and surgically. Cataract removal procedures are often modified for eyes with microcornea, a congenital condition in which the horizontal cornea is less than 10.0 mm. Microcornea is commonly associated with congenital cataract and makes the eye more prone to cataractous change in early adulthood.1–4 The size of the surgical incision, mode of lens removal, type of intraocular lens (IOL) used, and method used to determine IOL power are modified for eyes with microcornea.5,6 Microcornea can present alone or with syndromes, eg, microphthalmia (often) and macrophthalmia (rarely).5–7 It might also be associated with developmental deformity in ciliary zonular fibers, which can cause lens subluxation and Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
intraoperative zonular dialysis during cataract extraction. Under such circumstances, IOL placement in the normal capsular bag might not be possible. Transscleral IOL fixation is 1 option in such clinical scenarios. Here, we discuss our experience with glued transscleral posterior chamber IOL (PC IOL) fixation in eyes with microcornea and the modified technique compared with normal eyes.8,9 PATIENTS AND METHODS This prospective case series involved eyes with microcornea in which glued intrascleral PC IOL fixation surgery was performed from January 1, 2008, to January 1, 2012. Patients http://dx.doi.org/10.1016/j.jcrs.2014.05.039 0886-3350
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who were uncooperative and who were lost to follow-up were excluded. Preoperatively, Snellen visual acuity testing, retinoscopy, keratometry (Bausch & Lomb), noncontact tonometry, partial coherence interferometry (PCI) biometry (IOLMaster, Carl Zeiss Meditec AG), slitlamp biomicroscopy, ultrasound B-scan, and a fundus examination with dilation were performed preoperatively. The SRK II formula10 (for normal axial length [AL]) and SRK/T formula11 (for ALs shorter than 20.0 mm) were used for power calculations with PCI. The efficacy index was calculated by dividing the mean postoperative UDVA by the mean preoperative CDVA. The safety index was determined by dividing the mean postoperative CDVA by the mean preoperative CDVA. A severe complication was defined as a postoperative ocular condition that caused a loss of CDVA. Repeat surgery was defined as a procedure performed in the operating room after the primary glued-IOL procedure.
Surgical Technique Localized peritomy at the site of exit of the IOL haptics was performed under sterile conditions and using peribulbar anesthesia. Two limbal-based partial-thickness scleral flaps measuring 2.5 mm 2.5 mm were created 180 degrees diagonally apart (using a scleral marker). An infusion cannula (23-gauge trocar infusion system) in the pars plana approximately 3.0 mm from the limbus or an anterior chamber maintainer was used for infusion. A keratome was used to create a superior limbal scleral tunnel incision, and two 20-gauge straight sclerotomies were made under the existing flaps 1.0 to 1.5 mm from the limbus (Figure 1, A and B). When the cataractous lens was membranous or nuclear sclerosis (NS) was grade 1 or 2, a lensectomy (vitrectomy probe, Accurus Surgical System, Alcon Laboratories, Inc.) was performed through the limbal incision. However, when the cataract was NS 3 or 4, intracapsular cataract extraction (ICCE) was performed. In ICCE, a corneoscleral incision of approximately 5.0 mm was made using the keratome, and the entire lens and the capsule were extracted through the main scleral wound using a vectis. The hard cataractous lens was delivered by depressing the posterior lip of the main incision using a vectis and applying counterpressure on the cornea. Immediately after lens removal, 10-0 monofilament sutures were placed in the main wound. Closed-chamber anterior vitrectomy (Accurus Surgical System, Alcon Laboratories, Inc.) was performed to remove the vitreous that entered the anterior chamber with the lens (Figure 1, C). A minimal vitrectomy was also performed through the sclerotomy to remove the vitreous traction. An injector was used to introduce a 3-piece foldable IOL with 6.0 mm optic diameter poly(methyl
Submitted: December 12, 2013. Final revision submitted: April 10, 2014. Accepted: May 5, 2014. From Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Corresponding author: Amar Agarwal, MS, FRCS, FRCOpth, Dr. Agarwal’s Eye Hospital and Eye Research Centre, 19 Cathedral Road, Chennai-600 086, India. E-mail: [email protected].
methacrylate) haptics through the superior main scleral tunnel wound (Figure 1, D to F). The glued IOL forceps was passed through 1 of the sclerotomies, and the tip of the leading haptic was grasped and externalized. The haptic was held by an assistant or by silicone “tires”12 (stoppers). The second haptic then was flexed into the anterior chamber and pulled through the opposite sclerotomy using the glued-IOL forceps and the handshake technique.13 When both haptics were externalized under the flaps, the IOL haptic was trimmed (Figure 2, A and B) using Vannas scissors (AAT 4255 model, Appasamy Associates) or tenotomy scissors (AA 4155, Appasamy Associates). How much haptic was trimmed depended on the corneal diameter. Trimmed haptics without sharp edges were tucked into the limbus-parallel intralamellar Scharioth scleral tunnels made at the point of haptic externalization using a 26-gauge needle. The main wound was closed with 10-0 monofilament nylon, and the trocar infusion was removed. Air was injected into the anterior chamber, reconstituted fibrin glue was injected under the scleral flaps, and local pressure was applied for 10 seconds (Figure 1, F). Finally, the conjunctiva was closed using fibrin glue.
Statistical Analysis Data were entered using Excel software (Microsoft Corp.) and analyzed using SPSS software (version 16.1, SPSS, Inc.). Continuous variables are expressed as means G SD, and categorical variables are expressed as individual counts. The Pearson bivariate correlation was used for correlation evaluation. Differences were considered statistically significant when the P value was less than 0.05.
RESULTS The surgery was performed in 15 eyes (10 patients) (Table 1). The age of the patients ranged from 1 to 54 years. The mean follow-up was 22.4 months G 17.2 (range 48 to 8 months). The lensectomy was followed by implantation of a glued IOL in 7 eyes and by ICCE in 2 eyes. Five eyes with postsurgical aphakia had a secondary PC IOL implantation using a glued IOL. In 1 eye, a glued IOL was implanted after an intraoperative posterior capsule tear. A foldable 3piece IOL (Sofport, Bausch & Lomb) was implanted in 9 eyes, and an AR40e Sensar IOL (Abbott Medical Optics, Inc.) was implanted in 6 eyes. The overall IOL diameter was 13.0 mm and the optic, 6.0 mm. The mean horizontal corneal diameter was 8.0 G 0.6 mm (Table 2), and the mean AL was 21.0 G 2.4 mm. Six eyes had an AL shorter than 20.0 mm at the time of surgery. The mean preoperative UDVA was 0.04 G 0.06, and the mean postoperative UDVA was 0.12 G 0.11. The mean CDVA was 0.13 G 0.07 preoperatively and 0.25 G 0.2 postoperatively. The improvements in CDVA (P Z .002) and UDVA were statistically significant (P Z .011). There was no significant correlation between the horizontal corneal
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Figure 1. A: Vernier calipers are used to measure corneal diameter in an eye with microcornea and aphakia. B: Partial-thickness scleral flaps are created, and a 23-gauge trocar infusion is placed. C: A vitrectomy is performed in the pupillary region and behind it. D: A 3-piece foldable PC IOL is injected and the haptic externalized through the sclerotomy. E: An intralamellar scleral tunnel is made using a 26-gauge needle at the externalization point. F: The haptics are inserted, and the anterior chamber is formed with air.
diameter and the postoperative UDVA (Figure 3). The unimproved CDVA was attributable to preexisting conditions such as nystagmus in 12 eyes (80%), choroidal coloboma in 6 eyes (40%), and associated amblyopia. There was no statistically significant difference between the potential visual acuity measured using a retinal acuity meter and the postoperative CDVA (P Z .967, Mann-Whitney U test). There was no loss of CDVA in any eye. The postoperative safety index and efficacy index were 1.92 and
0.92, respectively. There were no severe postoperative complications during the follow-up. Intraoperative haptic trimming was performed in all eyes. The mean amount of IOL haptic trimmed was 1.54 G 0.33 mm. There was significant correlation between the corneal diameter and the quantity of haptic trimmed (P Z .000, r Z 0.916). The smaller the cornea, the more the haptic was trimmed. No intraoperative haptic damage was noted. The mean size of the main incision was
Figure 2. Intraoperatively, the haptic is trimmed using scissors (A) and is inserted in the scleral tunnel (B).
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Table 1. Demographics of the eyes. Preop
Age Preop Eye (Yrs) Sex Lens 1 2 3 4 5 6 7 8 9 10 11 12 13
6 6 1 1 4 4 3 3 6 6 24 54 25
F F F F F F F F M M F F F
A A SC SC SC SC SC SC A A A SC PCR
14 15
32 28
F F
SC SC
Comorbidity
Surgery
Nystagmus Nystagmus Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus Nystagmus, glaucoma Nystagmus Nystagmus d
Anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL ICCE, anterior vitrectomy, glued IOL Phacoemulsification, anterior vitrectomy, glued IOL ICCE, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL
Corneal opacity Glaucoma, aniridia
6-Mo Postop
UDVA CDVA UDVA CDVA 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.05 0.05 0.25
0.33 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.05 0.10 0.10 0.10 0.25
0.25 0.17 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.10 0.17 0.17 0.33
0.5 0.17 0.17 0.17 0.10 0.10 0.17 0.10 0.17 0.17 0.17 0.17 0.66
0.02 0.02
0.25 0.17
0.33 0.17
0.66 0.33
A Z aphakia; CDVA Z corrected distance visual acuity; ICCE Z intracapsular cataract extraction; IOL Z intraocular lens; PCR Z posterior capsule rupture; SC Z subluxated cataract; UDVA Z uncorrected distance visual acuity
3.7 G 0.98 mm (range 3.2 to 6.0 mm). In all eyes, the main wound was sutured using 10-0 monofilament nylon. No postoperative IOL decentration or tilt was seen clinically or using anterior segment optical coherence tomography. Postoperative glaucoma was seen in 1 eye; the IOP was controlled with 2 antiglaucoma medications. The mean postoperative IOP was 12.6 G 1.0 mm Hg.
There was no correlation between the corneal diameter and the postoperative IOP (Figure 4). There was no haptic extrusion or subconjunctival haptic in any of the 15 eyes during the follow-up. DISCUSSION Ocular associations with microcornea include openangle and closed-angle glaucoma, congenital cataract,
Table 2. Biometry and IOL characteristics. Corneal Axial Intraocular Lens Horizontal Length Eye Diameter (mm) (mm) K1 (D) K2 (D) Total Size (mm) Optic Size (mm) Haptic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
8.0 8.1 8.2 8.0 7.0 7.2 9.0 9.0 8.0 8.0 7.5 7.0 8.4 8.2 8.5
23.09 22.96 17.20 17.60 19.50 19.30 19.60 18.80 20.42 20.69 23.62 23.98 22.20 21.50 25.28
42.19 43.27 42.30 42.10 42.10 41.40 43.20 42.10 42.20 42.40 41.61 42.14 42.30 43.20 37.58
44.82 45.73 43.20 43.20 41.20 41.80 43.20 42.20 42.20 42.80 40.49 41.98 42.10 42.00 41.21
13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0
6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0
Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA
IOL Z intraocular lens; K1 Z flat keratometry; K2 Z steep keratometry; PMMA Z poly(methyl methacrylate)
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Figure 3. Correlation between corneal diameter and postoperative UDVA (UDVA Z uncorrected distance visual acuity).
Figure 4. Correlation between corneal diameter and postoperative IOP (IOP Z intraocular pressure).
corneal opacity, microphthalmos, optic nerve hypoplasia, microphakia, and cornea plana. Iris coloboma is often present as a keyhole defect of the iris caused by defective closure of embryonic fissure, and it might be associated with choroidal coloboma. Surgical management of eyes with an abnormally small corneal diameter and cataract is complex. In cataract removal in eyes with microcornea, the usual intraoperative problem, especially with hard nuclei, is the need for a large incision, sometimes extending approximately 180 degrees (up to one half the width of the cornea). A wound that large can cause sudden globe decompression, which can induce intraoperative suprachoroidal hemorrhage or decompression retinopathy, although this rarely occurs. However, when the cataract is membranous or less dense, lensectomy is beneficial. Open-globe manipulation is always highly risky in such eyes. However, this risk can be managed by creating a scleral tunnel incision rather than a straight incision and by preplacing sutures with which to close the globe rapidly if suprachoroidal hemorrhage develops. Microcornea can be associated with zonular dialysis and subluxated cataract, which prevent implantation of an IOL in the capsular bag. Sutured scleral-fixated IOLs, one of the conventional methods of IOL placement in such situations, might be risky in eyes with microcornea that have preexisting retinal conditions such as choroidal coloboma. Although coloboma itself does not prevent the placement of a scleral-fixated IOL, that type of IOL might be too difficult for optimum placement and the scleral suturing technique could be risky under such a clinical scenario. However, hooks and capsular tension rings can be used.14
Anterior chamber IOLs are not recommended in these eyes because of the risk for endothelial damage caused by a shallow anterior chamber and difficult IOL sizing in the anterior chamber. Glued-IOL implantation is preferred because it has less pseudophacodonesis, good IOL stability, and no polypropylene (Prolene) suture-related complications.15,16 Glued PC IOLs can be placed in these eyes with less difficulty by following certain intraoperative modifications (eg, customizing haptic trimming, using IOLs with 6.0 mm optic diameters, using foldable IOLs, and maintaining intraoperative closed-globe manipulation). Because a 6.0 mm optic covers almost the entire pupillary zone, the chances of decentration are smaller. With use of a foldable glued IOL and a scleral tunnel incision, suture-induced astigmatism is often minimized. Haptic trimming has helped in proper positioning of the IOL, and the trimmed edge might strengthen adhesion along with glue. Another intraoperative problem in eyes with microcornea is the nondilating pupil with iris coloboma. Retracting the iris with iris hooks might help with phacoemulsification and visualization. A large iris colobomatous defect can be corrected by performing iridoplasty using a modified McCannel suture.17 Patients with microcornea are often hyperopic and have shallow anterior chambers. Use of gas-forced infusion during phacoemulsification deepens the chamber and prevents endothelial damage.18 There are few reports of cataract surgery in eyes with microcornea, and there are no studies of the use of transscleral-fixated PC IOLs in eyes with zonular dialysis.5,6,19–28 Gimbel et al.19 reported inserting PC IOLs in bilateral microcorneas with corneal diameters of 9.43 mm and 9.61 mm and ALs of 19.29 mm and
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19.23 mm to obtain a postoperative bilateral CDVA of 20/20. Dahan20 reported that with unilateral congenital and developmental cataracts, a pediatric PC IOL can be inserted in the capsular bag unless the corneal diameter is less than 9.5 mm. Sinskey et al.21 report inserting a secondary PC IOL in aphakic eyes with microphthalmos. There are reports of placing posterior chamber piggyback IOLs in small eyes22,23; however, the piggyback IOL cannot be placed in cases of capsule deficiency. Potential postoperative complications of congenital cataract include the formation of a secondary membrane, glaucoma, and retinal detachment.24 The possibility of such complications is greater when congenital cataracts are accompanied by microphthalmos or microcornea.25,26 In our study, 1 eye developed secondary glaucoma and no eye developed no retinal detachment or a pupillary membrane during the follow-up. Postoperative CDVA in our study was influenced by such factors as age, preexisting retinal conditions, presence of amblyopia, and the power of the IOL implanted. Comorbid illness in these patients is a common cause of reduced improvement in visual acuity. Preexisting nystagmus, choroidal coloboma, corneal opacity, glaucoma, and amblyopia affect the final vision outcome. Achieving emmetropia in eyes with microphthalmos is challenging because of the difficulty of calculating the correct IOL power. Several third-generation IOL power formulas have been used to try to achieve the target refraction. Inatomi et al.27 reported the most accurately predicted refraction using the SRK/T formula for microphthalmos and ALs of less than 19.0 mm. Bartke et al.28 used modified biometric formulas for cataract with microphthalmos in adulthood. Accurate IOL power calculation in complicated eyes with microcornea has not been studied in detail. Sutureless scleral-fixated IOLs have shown satisfactory results in normal-sized corneas in the recent past.8,9,12,13,15–17,29,30 The limitations of our study included the small number of patients, the limited follow-up, and the broad age range of the patients at the time of surgery. Also, the study group comprised patients with normal ALs and patients with small ALs. Although there were no potential haptic-related complications such as haptic breakage in this study, long-term analysis of haptic status in such eyes is recommended. In addition, the results in adult eyes will differ from those in pediatric eyes. Therefore, longer follow-up is needed in these patients to confirm the functional stability. Nevertheless, our data provide interim results with no severe complications and suggest that glued transscleral PC IOL implantation is an excellent cataract surgery alternative for eyes with microcornea that lack capsule support.
WHAT WAS KNOWN Posterior chamber IOLs can be placed in eyes with microcornea after cataract removal. Glued transscleral fixation can be performed in eyes with deficient capsule support. WHAT THIS PAPER ADDS Glued IOLs were inserted safely in eyes with microcornea that lack capsule support. Intraoperative modifications, such as customized haptic trimming, 6.0 mm optic IOLs, and closed-globe manipulation, will improve the success rate of implanting glued IOLs in eyes with microcornea.
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First author: Dhivya Ashok Kumar, MD, FICO Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India
Implantation of glued intraocular lenses in eyes with microcornea Dhivya Ashok Kumar, MD, FICO, Amar Agarwal, MS, FRCS, FRCOphth, Soundari Sivangnanam, FRCS, Radika Chandrasekar, BSc, Athiya Agarwal, MD, DO
PURPOSE: To evaluate the intraoperative modifications for and vision outcomes after implantation of glued intraocular lenses (IOLs) in eyes with microcornea. SETTING: Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. DESIGN: Prospective case series. METHODS: Eyes with a horizontal cornea of 10.0 mm or less were evaluated for intraoperative modifications and postoperative vision after implantation of a glued IOL. The type of surgery, type of IOL, incision and optic sizes, haptic length modifications, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and postoperative complications were analyzed. RESULTS: A glued IOL was implanted in 15 eyes to treat subluxated cataract (9 eyes), aphakia (5), and intraoperative capsule loss (1). In cases involving a subluxated cataract, implantation of the glued IOL was followed by lensectomy (7 eyes) or intracapsular cataract extraction (2 eyes). The mean follow-up was 22.4 months G 17.2 (SD). The mean horizontal corneal diameter and axial length were 8.0 G 0.6 mm and 21.0 G 2.4 mm, respectively. The mean amount of IOL haptic trimmed intraoperatively was 1.54 G 0.33 mm. There was significant correlation between the horizontal corneal diameter and the amount of haptic trimmed (P Z .000). The mean size of the main incision was 3.70 G 0.98 mm. Three-piece foldable IOLs with a 6.0 mm optic were used. There were no cases of haptic extrusion or subconjunctival haptic placement. There was statistically significant improvement in CDVA (P Z .032) and UDVA (P Z .012) after surgery. CONCLUSION: Glued IOLs were safely implanted in eyes with microcornea using modifications such as custom haptic trimming and 6.0 mm optic foldable IOLs. Financial Disclosure: Dr. Amar Agarwal is a paid consultant to Staar Surgical Co. No other author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2015; 41:327–333 Q 2015 ASCRS and ESCRS
Human cornea size has great significance anatomically and surgically. Cataract removal procedures are often modified for eyes with microcornea, a congenital condition in which the horizontal cornea is less than 10.0 mm. Microcornea is commonly associated with congenital cataract and makes the eye more prone to cataractous change in early adulthood.1–4 The size of the surgical incision, mode of lens removal, type of intraocular lens (IOL) used, and method used to determine IOL power are modified for eyes with microcornea.5,6 Microcornea can present alone or with syndromes, eg, microphthalmia (often) and macrophthalmia (rarely).5–7 It might also be associated with developmental deformity in ciliary zonular fibers, which can cause lens subluxation and Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
intraoperative zonular dialysis during cataract extraction. Under such circumstances, IOL placement in the normal capsular bag might not be possible. Transscleral IOL fixation is 1 option in such clinical scenarios. Here, we discuss our experience with glued transscleral posterior chamber IOL (PC IOL) fixation in eyes with microcornea and the modified technique compared with normal eyes.8,9 PATIENTS AND METHODS This prospective case series involved eyes with microcornea in which glued intrascleral PC IOL fixation surgery was performed from January 1, 2008, to January 1, 2012. Patients http://dx.doi.org/10.1016/j.jcrs.2014.05.039 0886-3350
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who were uncooperative and who were lost to follow-up were excluded. Preoperatively, Snellen visual acuity testing, retinoscopy, keratometry (Bausch & Lomb), noncontact tonometry, partial coherence interferometry (PCI) biometry (IOLMaster, Carl Zeiss Meditec AG), slitlamp biomicroscopy, ultrasound B-scan, and a fundus examination with dilation were performed preoperatively. The SRK II formula10 (for normal axial length [AL]) and SRK/T formula11 (for ALs shorter than 20.0 mm) were used for power calculations with PCI. The efficacy index was calculated by dividing the mean postoperative UDVA by the mean preoperative CDVA. The safety index was determined by dividing the mean postoperative CDVA by the mean preoperative CDVA. A severe complication was defined as a postoperative ocular condition that caused a loss of CDVA. Repeat surgery was defined as a procedure performed in the operating room after the primary glued-IOL procedure.
Surgical Technique Localized peritomy at the site of exit of the IOL haptics was performed under sterile conditions and using peribulbar anesthesia. Two limbal-based partial-thickness scleral flaps measuring 2.5 mm 2.5 mm were created 180 degrees diagonally apart (using a scleral marker). An infusion cannula (23-gauge trocar infusion system) in the pars plana approximately 3.0 mm from the limbus or an anterior chamber maintainer was used for infusion. A keratome was used to create a superior limbal scleral tunnel incision, and two 20-gauge straight sclerotomies were made under the existing flaps 1.0 to 1.5 mm from the limbus (Figure 1, A and B). When the cataractous lens was membranous or nuclear sclerosis (NS) was grade 1 or 2, a lensectomy (vitrectomy probe, Accurus Surgical System, Alcon Laboratories, Inc.) was performed through the limbal incision. However, when the cataract was NS 3 or 4, intracapsular cataract extraction (ICCE) was performed. In ICCE, a corneoscleral incision of approximately 5.0 mm was made using the keratome, and the entire lens and the capsule were extracted through the main scleral wound using a vectis. The hard cataractous lens was delivered by depressing the posterior lip of the main incision using a vectis and applying counterpressure on the cornea. Immediately after lens removal, 10-0 monofilament sutures were placed in the main wound. Closed-chamber anterior vitrectomy (Accurus Surgical System, Alcon Laboratories, Inc.) was performed to remove the vitreous that entered the anterior chamber with the lens (Figure 1, C). A minimal vitrectomy was also performed through the sclerotomy to remove the vitreous traction. An injector was used to introduce a 3-piece foldable IOL with 6.0 mm optic diameter poly(methyl
Submitted: December 12, 2013. Final revision submitted: April 10, 2014. Accepted: May 5, 2014. From Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, India. Corresponding author: Amar Agarwal, MS, FRCS, FRCOpth, Dr. Agarwal’s Eye Hospital and Eye Research Centre, 19 Cathedral Road, Chennai-600 086, India. E-mail: [email protected].
methacrylate) haptics through the superior main scleral tunnel wound (Figure 1, D to F). The glued IOL forceps was passed through 1 of the sclerotomies, and the tip of the leading haptic was grasped and externalized. The haptic was held by an assistant or by silicone “tires”12 (stoppers). The second haptic then was flexed into the anterior chamber and pulled through the opposite sclerotomy using the glued-IOL forceps and the handshake technique.13 When both haptics were externalized under the flaps, the IOL haptic was trimmed (Figure 2, A and B) using Vannas scissors (AAT 4255 model, Appasamy Associates) or tenotomy scissors (AA 4155, Appasamy Associates). How much haptic was trimmed depended on the corneal diameter. Trimmed haptics without sharp edges were tucked into the limbus-parallel intralamellar Scharioth scleral tunnels made at the point of haptic externalization using a 26-gauge needle. The main wound was closed with 10-0 monofilament nylon, and the trocar infusion was removed. Air was injected into the anterior chamber, reconstituted fibrin glue was injected under the scleral flaps, and local pressure was applied for 10 seconds (Figure 1, F). Finally, the conjunctiva was closed using fibrin glue.
Statistical Analysis Data were entered using Excel software (Microsoft Corp.) and analyzed using SPSS software (version 16.1, SPSS, Inc.). Continuous variables are expressed as means G SD, and categorical variables are expressed as individual counts. The Pearson bivariate correlation was used for correlation evaluation. Differences were considered statistically significant when the P value was less than 0.05.
RESULTS The surgery was performed in 15 eyes (10 patients) (Table 1). The age of the patients ranged from 1 to 54 years. The mean follow-up was 22.4 months G 17.2 (range 48 to 8 months). The lensectomy was followed by implantation of a glued IOL in 7 eyes and by ICCE in 2 eyes. Five eyes with postsurgical aphakia had a secondary PC IOL implantation using a glued IOL. In 1 eye, a glued IOL was implanted after an intraoperative posterior capsule tear. A foldable 3piece IOL (Sofport, Bausch & Lomb) was implanted in 9 eyes, and an AR40e Sensar IOL (Abbott Medical Optics, Inc.) was implanted in 6 eyes. The overall IOL diameter was 13.0 mm and the optic, 6.0 mm. The mean horizontal corneal diameter was 8.0 G 0.6 mm (Table 2), and the mean AL was 21.0 G 2.4 mm. Six eyes had an AL shorter than 20.0 mm at the time of surgery. The mean preoperative UDVA was 0.04 G 0.06, and the mean postoperative UDVA was 0.12 G 0.11. The mean CDVA was 0.13 G 0.07 preoperatively and 0.25 G 0.2 postoperatively. The improvements in CDVA (P Z .002) and UDVA were statistically significant (P Z .011). There was no significant correlation between the horizontal corneal
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Figure 1. A: Vernier calipers are used to measure corneal diameter in an eye with microcornea and aphakia. B: Partial-thickness scleral flaps are created, and a 23-gauge trocar infusion is placed. C: A vitrectomy is performed in the pupillary region and behind it. D: A 3-piece foldable PC IOL is injected and the haptic externalized through the sclerotomy. E: An intralamellar scleral tunnel is made using a 26-gauge needle at the externalization point. F: The haptics are inserted, and the anterior chamber is formed with air.
diameter and the postoperative UDVA (Figure 3). The unimproved CDVA was attributable to preexisting conditions such as nystagmus in 12 eyes (80%), choroidal coloboma in 6 eyes (40%), and associated amblyopia. There was no statistically significant difference between the potential visual acuity measured using a retinal acuity meter and the postoperative CDVA (P Z .967, Mann-Whitney U test). There was no loss of CDVA in any eye. The postoperative safety index and efficacy index were 1.92 and
0.92, respectively. There were no severe postoperative complications during the follow-up. Intraoperative haptic trimming was performed in all eyes. The mean amount of IOL haptic trimmed was 1.54 G 0.33 mm. There was significant correlation between the corneal diameter and the quantity of haptic trimmed (P Z .000, r Z 0.916). The smaller the cornea, the more the haptic was trimmed. No intraoperative haptic damage was noted. The mean size of the main incision was
Figure 2. Intraoperatively, the haptic is trimmed using scissors (A) and is inserted in the scleral tunnel (B).
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Table 1. Demographics of the eyes. Preop
Age Preop Eye (Yrs) Sex Lens 1 2 3 4 5 6 7 8 9 10 11 12 13
6 6 1 1 4 4 3 3 6 6 24 54 25
F F F F F F F F M M F F F
A A SC SC SC SC SC SC A A A SC PCR
14 15
32 28
F F
SC SC
Comorbidity
Surgery
Nystagmus Nystagmus Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus, choroidal coloboma Nystagmus Nystagmus, glaucoma Nystagmus Nystagmus d
Anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL Anterior vitrectomy, glued IOL ICCE, anterior vitrectomy, glued IOL Phacoemulsification, anterior vitrectomy, glued IOL ICCE, anterior vitrectomy, glued IOL Lensectomy, anterior vitrectomy, glued IOL
Corneal opacity Glaucoma, aniridia
6-Mo Postop
UDVA CDVA UDVA CDVA 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.05 0.05 0.25
0.33 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.05 0.10 0.10 0.10 0.25
0.25 0.17 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.10 0.17 0.17 0.33
0.5 0.17 0.17 0.17 0.10 0.10 0.17 0.10 0.17 0.17 0.17 0.17 0.66
0.02 0.02
0.25 0.17
0.33 0.17
0.66 0.33
A Z aphakia; CDVA Z corrected distance visual acuity; ICCE Z intracapsular cataract extraction; IOL Z intraocular lens; PCR Z posterior capsule rupture; SC Z subluxated cataract; UDVA Z uncorrected distance visual acuity
3.7 G 0.98 mm (range 3.2 to 6.0 mm). In all eyes, the main wound was sutured using 10-0 monofilament nylon. No postoperative IOL decentration or tilt was seen clinically or using anterior segment optical coherence tomography. Postoperative glaucoma was seen in 1 eye; the IOP was controlled with 2 antiglaucoma medications. The mean postoperative IOP was 12.6 G 1.0 mm Hg.
There was no correlation between the corneal diameter and the postoperative IOP (Figure 4). There was no haptic extrusion or subconjunctival haptic in any of the 15 eyes during the follow-up. DISCUSSION Ocular associations with microcornea include openangle and closed-angle glaucoma, congenital cataract,
Table 2. Biometry and IOL characteristics. Corneal Axial Intraocular Lens Horizontal Length Eye Diameter (mm) (mm) K1 (D) K2 (D) Total Size (mm) Optic Size (mm) Haptic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
8.0 8.1 8.2 8.0 7.0 7.2 9.0 9.0 8.0 8.0 7.5 7.0 8.4 8.2 8.5
23.09 22.96 17.20 17.60 19.50 19.30 19.60 18.80 20.42 20.69 23.62 23.98 22.20 21.50 25.28
42.19 43.27 42.30 42.10 42.10 41.40 43.20 42.10 42.20 42.40 41.61 42.14 42.30 43.20 37.58
44.82 45.73 43.20 43.20 41.20 41.80 43.20 42.20 42.20 42.80 40.49 41.98 42.10 42.00 41.21
13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0 13.0
6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0
Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, violet PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA Modified C, blue PMMA
IOL Z intraocular lens; K1 Z flat keratometry; K2 Z steep keratometry; PMMA Z poly(methyl methacrylate)
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Figure 3. Correlation between corneal diameter and postoperative UDVA (UDVA Z uncorrected distance visual acuity).
Figure 4. Correlation between corneal diameter and postoperative IOP (IOP Z intraocular pressure).
corneal opacity, microphthalmos, optic nerve hypoplasia, microphakia, and cornea plana. Iris coloboma is often present as a keyhole defect of the iris caused by defective closure of embryonic fissure, and it might be associated with choroidal coloboma. Surgical management of eyes with an abnormally small corneal diameter and cataract is complex. In cataract removal in eyes with microcornea, the usual intraoperative problem, especially with hard nuclei, is the need for a large incision, sometimes extending approximately 180 degrees (up to one half the width of the cornea). A wound that large can cause sudden globe decompression, which can induce intraoperative suprachoroidal hemorrhage or decompression retinopathy, although this rarely occurs. However, when the cataract is membranous or less dense, lensectomy is beneficial. Open-globe manipulation is always highly risky in such eyes. However, this risk can be managed by creating a scleral tunnel incision rather than a straight incision and by preplacing sutures with which to close the globe rapidly if suprachoroidal hemorrhage develops. Microcornea can be associated with zonular dialysis and subluxated cataract, which prevent implantation of an IOL in the capsular bag. Sutured scleral-fixated IOLs, one of the conventional methods of IOL placement in such situations, might be risky in eyes with microcornea that have preexisting retinal conditions such as choroidal coloboma. Although coloboma itself does not prevent the placement of a scleral-fixated IOL, that type of IOL might be too difficult for optimum placement and the scleral suturing technique could be risky under such a clinical scenario. However, hooks and capsular tension rings can be used.14
Anterior chamber IOLs are not recommended in these eyes because of the risk for endothelial damage caused by a shallow anterior chamber and difficult IOL sizing in the anterior chamber. Glued-IOL implantation is preferred because it has less pseudophacodonesis, good IOL stability, and no polypropylene (Prolene) suture-related complications.15,16 Glued PC IOLs can be placed in these eyes with less difficulty by following certain intraoperative modifications (eg, customizing haptic trimming, using IOLs with 6.0 mm optic diameters, using foldable IOLs, and maintaining intraoperative closed-globe manipulation). Because a 6.0 mm optic covers almost the entire pupillary zone, the chances of decentration are smaller. With use of a foldable glued IOL and a scleral tunnel incision, suture-induced astigmatism is often minimized. Haptic trimming has helped in proper positioning of the IOL, and the trimmed edge might strengthen adhesion along with glue. Another intraoperative problem in eyes with microcornea is the nondilating pupil with iris coloboma. Retracting the iris with iris hooks might help with phacoemulsification and visualization. A large iris colobomatous defect can be corrected by performing iridoplasty using a modified McCannel suture.17 Patients with microcornea are often hyperopic and have shallow anterior chambers. Use of gas-forced infusion during phacoemulsification deepens the chamber and prevents endothelial damage.18 There are few reports of cataract surgery in eyes with microcornea, and there are no studies of the use of transscleral-fixated PC IOLs in eyes with zonular dialysis.5,6,19–28 Gimbel et al.19 reported inserting PC IOLs in bilateral microcorneas with corneal diameters of 9.43 mm and 9.61 mm and ALs of 19.29 mm and
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19.23 mm to obtain a postoperative bilateral CDVA of 20/20. Dahan20 reported that with unilateral congenital and developmental cataracts, a pediatric PC IOL can be inserted in the capsular bag unless the corneal diameter is less than 9.5 mm. Sinskey et al.21 report inserting a secondary PC IOL in aphakic eyes with microphthalmos. There are reports of placing posterior chamber piggyback IOLs in small eyes22,23; however, the piggyback IOL cannot be placed in cases of capsule deficiency. Potential postoperative complications of congenital cataract include the formation of a secondary membrane, glaucoma, and retinal detachment.24 The possibility of such complications is greater when congenital cataracts are accompanied by microphthalmos or microcornea.25,26 In our study, 1 eye developed secondary glaucoma and no eye developed no retinal detachment or a pupillary membrane during the follow-up. Postoperative CDVA in our study was influenced by such factors as age, preexisting retinal conditions, presence of amblyopia, and the power of the IOL implanted. Comorbid illness in these patients is a common cause of reduced improvement in visual acuity. Preexisting nystagmus, choroidal coloboma, corneal opacity, glaucoma, and amblyopia affect the final vision outcome. Achieving emmetropia in eyes with microphthalmos is challenging because of the difficulty of calculating the correct IOL power. Several third-generation IOL power formulas have been used to try to achieve the target refraction. Inatomi et al.27 reported the most accurately predicted refraction using the SRK/T formula for microphthalmos and ALs of less than 19.0 mm. Bartke et al.28 used modified biometric formulas for cataract with microphthalmos in adulthood. Accurate IOL power calculation in complicated eyes with microcornea has not been studied in detail. Sutureless scleral-fixated IOLs have shown satisfactory results in normal-sized corneas in the recent past.8,9,12,13,15–17,29,30 The limitations of our study included the small number of patients, the limited follow-up, and the broad age range of the patients at the time of surgery. Also, the study group comprised patients with normal ALs and patients with small ALs. Although there were no potential haptic-related complications such as haptic breakage in this study, long-term analysis of haptic status in such eyes is recommended. In addition, the results in adult eyes will differ from those in pediatric eyes. Therefore, longer follow-up is needed in these patients to confirm the functional stability. Nevertheless, our data provide interim results with no severe complications and suggest that glued transscleral PC IOL implantation is an excellent cataract surgery alternative for eyes with microcornea that lack capsule support.
WHAT WAS KNOWN Posterior chamber IOLs can be placed in eyes with microcornea after cataract removal. Glued transscleral fixation can be performed in eyes with deficient capsule support. WHAT THIS PAPER ADDS Glued IOLs were inserted safely in eyes with microcornea that lack capsule support. Intraoperative modifications, such as customized haptic trimming, 6.0 mm optic IOLs, and closed-globe manipulation, will improve the success rate of implanting glued IOLs in eyes with microcornea.
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First author: Dhivya Ashok Kumar, MD, FICO Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India
