kelman anterior chamber lens a preliminary report Lyle Moses, M.D. Cleveland, Ohio At the 7th Annual Alumni meeting of the David Kelman Research Foundation, Dr. Charles Kelman presented his anterior chamber lens. Dr. Kelman and Dr. K. Buol Heslin presented more than one year's experiences with over 100 cases. My own experiences with his lens were discussed with Dr. Kelman, and wi~h his encouragement I am presenting my own senes. During the past one and a half months, I have implanted 20 Kelman lenses. In spite of the short follow-up period, my enthusiasm for the lens has prompted me to present a preliminary report. Continued experience by more surgeons is needed to show the real efficacy of this lens. This paper is not intended to be a "how-to-do-it" manual. It includes a brief outline of the technique, and is not a substitute for the type of course Dr. Kelman offers on the use of his lens. The Kelman anterior chamber lens is made of clinical quality, compression-molded Perspex, PMMA. It is thin (optical zone 0.42 mm; haptic zone 0.2 mm.) and lightweight (2 mgm in aqueous). The lens can be used with intracapsular or extracapsular surgery, phacoemulsification, or as a secondary implant. Surgeons who prefer the phacoemulsification technique will find the Kelman lens especially advantageous because it can be inserted through a 4 mm. incision. Its 3-point widespread fixation affords maximum stability and prevents rotation. When phacoemulsification is used, the usual preoperative medications are prescribed to soften the eye, dilate the pupil, and anesthetize the tissues. A small limbal stab incision is made into the anterior chamber at the 8 o'clock position, through which a chamber-maintaining tube is later inserted. The usual phacoemulsification technique is carried out through a superior 3 mm. incision. After the cortical material is removed, the chamber is opened an additional 1 mm. A fine silicone tube is inserted through the 8 o'clock stab incision. This tube is connected to the Cavitron pump and the chamber is maintained by briefly compressing the foot switch to the number 2 position. Acetylcholine is irrigated into the anterior chamber to constrict the pupil. With the concave surface down, the lens is grasped and the 4 o'clock foot is inserted through the incision (Fig. 1). The lens is rotated slightly and the 8 o'clock foot is
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Fig. 1 (Moses, L.) Initial insertion of Kelman lens.
Fig. 2 (Moses, L.) Insertion of 8 o'clock foot of Kelman lens.
Fig. 3 (Moses, L.) Insertion of lens body.
inserted (Fig. 2). The lens is regrasped and the body is moved to the right and inserted through the wound (Fig. 3). Care is taken to avoid contact with corneal endothelium and iris as the two feet are moved across the chamber to their fixation points behind the scleral spur. The superior scleral lip is retracted with a cystotome or forceps; a Kelman-McPherson forceps or a cyclodialsis spatula is inserted into the hole of the superior haptic and the haptic placed under the scleral shelf (Fig. 4). A peripheral
Fig. 5 (Moses, L.) Kelmanlens four days post-op.
Fig. 4 (Moses, L.) Placement of haptic under scleral shelf.
iridectomy is made adjacent to the superior haptic. The corneal wound is closed with two sutures. The chamber-maintaining tube is removed. If a posterior capsulotomy is desired, a Ziegler knife can easily be inserted behind the lens; air is then placed in the anterior chamber. The usual post-operative steroids, antibiotics, and cycloplegics are prescribed. If an intracapsular extraction is preferred, the chamber-maintainer is omitted, since the irrigation may disturb the hyloid face. After the cataract is removed, the wound is closed sufficiently to hold air, the pupil is constricted, and the lens is inserted while air maintains the chamber. Following an extracapsular extraction, the chamber can be maintained with either the chamber-maintainer or air. If a secondary implant is indicated and planned, there is a distinct advantage in' keeping the wound small. The eye must be soft pre-operatively. If the hyaloid face is exposed, the lens is inserted under air. When the posterior capsule is intact, the chambermaintainer can be used to great advantage. The post-operative course with the Kelman lens after phacoemulsification is amazingly quiet. Figures 5-8 show typical post-operative stages. The eyes are minimally injected and have minimal iritis. Mild corneal edema in three of my patients cleared
Fig. 6 (Moses, L.) Kelman lens ten days post·op.
Fig. 7 (Moses, L.) Kelman lens 20 days post-op.
Fig. 8 (Moses, L.) Kelman lens 35 days post-op.
within one week. Most patients are off cycloplegics withi~ ten days, and off steroid drops within three or four weeks. Because of the small incision, the refraction is usually stable enough to prescribe glasses within three to five weeks after surgery. There have been no instances of hyphe~a or elevated intraocular pressure. Ocular tenderness associated with other anterior chamber lenses is absent. It is too early to evaluate the incidence of cystoid macular edema (none has· occurred to date), but I see no reason why it should vary from this author's prior experience of 1.69%.1 The ages of my patients with the Kelman lens ranged from 47 to 89 (mean: 69.06). Resulting visual acuity averaged 20120-20125; one patient, 20/30; one 20/40, and one 20150 (the latter two had pre-operatively-diagnosed senile chorodial macular degeneration). Summary The Kelman anterior chamber lens is thin and lightweight. Its design is unique for introduction through a small limbal incision following phacoemulsification or as a secondary implant. It can be used easily in conjunction with intracapsular or extracapsular surgery. The postoperative course is quiet and short, and the patient has rapid visual rehabilitation with a comfortable eye. Reference 1. Moses, L.: Incidence of cystoid macular edema following cataract extraction with pseudophakos implantation: Intracapsular vs. Extracapsular vs. Phacoemulsification. American Intra-ocular Implant Society Journal; to be published.
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Fig. 1 (Moses, L.) Initial insertion of Kelman lens.
Fig. 2 (Moses, L.) Insertion of 8 o'clock foot of Kelman lens.
Fig. 3 (Moses, L.) Insertion of lens body.
inserted (Fig. 2). The lens is regrasped and the body is moved to the right and inserted through the wound (Fig. 3). Care is taken to avoid contact with corneal endothelium and iris as the two feet are moved across the chamber to their fixation points behind the scleral spur. The superior scleral lip is retracted with a cystotome or forceps; a Kelman-McPherson forceps or a cyclodialsis spatula is inserted into the hole of the superior haptic and the haptic placed under the scleral shelf (Fig. 4). A peripheral
Fig. 5 (Moses, L.) Kelmanlens four days post-op.
Fig. 4 (Moses, L.) Placement of haptic under scleral shelf.
iridectomy is made adjacent to the superior haptic. The corneal wound is closed with two sutures. The chamber-maintaining tube is removed. If a posterior capsulotomy is desired, a Ziegler knife can easily be inserted behind the lens; air is then placed in the anterior chamber. The usual post-operative steroids, antibiotics, and cycloplegics are prescribed. If an intracapsular extraction is preferred, the chamber-maintainer is omitted, since the irrigation may disturb the hyloid face. After the cataract is removed, the wound is closed sufficiently to hold air, the pupil is constricted, and the lens is inserted while air maintains the chamber. Following an extracapsular extraction, the chamber can be maintained with either the chamber-maintainer or air. If a secondary implant is indicated and planned, there is a distinct advantage in' keeping the wound small. The eye must be soft pre-operatively. If the hyaloid face is exposed, the lens is inserted under air. When the posterior capsule is intact, the chambermaintainer can be used to great advantage. The post-operative course with the Kelman lens after phacoemulsification is amazingly quiet. Figures 5-8 show typical post-operative stages. The eyes are minimally injected and have minimal iritis. Mild corneal edema in three of my patients cleared
Fig. 6 (Moses, L.) Kelman lens ten days post·op.
Fig. 7 (Moses, L.) Kelman lens 20 days post-op.
Fig. 8 (Moses, L.) Kelman lens 35 days post-op.
within one week. Most patients are off cycloplegics withi~ ten days, and off steroid drops within three or four weeks. Because of the small incision, the refraction is usually stable enough to prescribe glasses within three to five weeks after surgery. There have been no instances of hyphe~a or elevated intraocular pressure. Ocular tenderness associated with other anterior chamber lenses is absent. It is too early to evaluate the incidence of cystoid macular edema (none has· occurred to date), but I see no reason why it should vary from this author's prior experience of 1.69%.1 The ages of my patients with the Kelman lens ranged from 47 to 89 (mean: 69.06). Resulting visual acuity averaged 20120-20125; one patient, 20/30; one 20/40, and one 20150 (the latter two had pre-operatively-diagnosed senile chorodial macular degeneration). Summary The Kelman anterior chamber lens is thin and lightweight. Its design is unique for introduction through a small limbal incision following phacoemulsification or as a secondary implant. It can be used easily in conjunction with intracapsular or extracapsular surgery. The postoperative course is quiet and short, and the patient has rapid visual rehabilitation with a comfortable eye. Reference 1. Moses, L.: Incidence of cystoid macular edema following cataract extraction with pseudophakos implantation: Intracapsular vs. Extracapsular vs. Phacoemulsification. American Intra-ocular Implant Society Journal; to be published.
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