Penetrating Keratoplasty and Transscleral Fixation of Posterior Chamber Lens Edward J. Holland, M.D., Sheraz M. Daya, M . D . , A n t h o n y Evangelista, B.A., Jeffrey M. Ketcham, B.S., A n t h o n y J. L u b n i e w s k i , M . D . , D o n a l d J. D o u g h m a n , M.D., and S t e p h e n S. Lane, M . D .
We reviewed the outcome in 115 patients who underwent penetrating keratoplasty and transscleral fixation of a posterior chamber lens. One patient died soon after surgical procedures, and nine patients were lost to follow-up, leaving a cohort of 105 patients. Mean follow-up time was 26.8 months (range, six to 43 months). Visual acuity of 20/40 or better was found in 29 patients (27.6%) and 20/50 to 20/200 in 37 patients (35.2%). Reasons for poor visual outcome included cystoid macular edema in ten patients (9.5%), age-related macular degeneration in six patients (5.7%), and retinal detachment in four patients (3.8%). None of the patients developed lens decentration. There were no instances of hyphema and only one patient had a perioperative limited suprachoroidal hemorrhage. New-onset increase in intraocular pressure developed in 20 of 66 patients (30.3%). Analysis of the 39 patients with preoperative increase in intraocular pressure that required medical treatment demonstrated an improvement in 13 patients (33.3%), worsening in 12 patients (30.8%), and unchanged status in 14 patients (35.9%). The exposed haptic suture was covered by using one of the following three alternative methods: a conjunctival flap, a scierai flap, or a corneal tissue button. Exposure of the haptic suture through the conjunctiva was a complication in 21 patients (20%). Of these, 16 (76.1%) occurred in the group with a conjunctival
Accepted for publication May 6, 1992. From the Cornea and External Disease Service, De partment of Ophthalmology, University of Minnesota, Minneapolis, Minnesota. This study was presented in part at the 17th annual meeting of the Castroviejo Society, Oct. 12, 1991, Anaheim, California. Reprint requests to Edward J. Holland, M.D., Universi ty of Minnesota, Department of Ophthalmology, Box 493 UMHC, 516 Delaware St. S.E., Minneapolis, MN 55455-0501.
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covering, five (23.8%) occurred in the group with a scierai flap, and none occurred in the corneal tissue button group. This study demonstrated that transscleral fixation of a posterior chamber lens is a viable option in the treatment of patients undergoing penetrating keratoplasty and intraocular lens implantation with absent capsular support. INTRAOCULAR
LENS
implantation
has now
become the expected standard of care in the treatment of aphakia. In the absence of cap sular support, anterior chamber lenses have been widely used. Unfortunately these lenses, closed-loop lenses in particular, have been fraught with complications such as trabecular meshwork damage, prolonged inflammation, and corneal decompensation. 1 5 Corneal decom pensation in the presence of an anterior cham ber lens is one of the leading indications for penetrating keratoplasty and intraocular lens removal and exchange. There has been considerable interest in de veloping new techniques for implantation of posterior chamber lenses in the absence of capsular support. One alternative has been to fixate the lens to the iris by using the position ing holes of the lens. 6 · 7 Another has been to fixate the lens by passing a polypropylene su ture attached to the lens haptic through the sulcus transsclerally to the exterior. 8 · 9 Placement of a posterior chamber lens in the ciliary sulcus is anatomically more similar to. that of the crystalline lens than anterior cham ber or iris-supported lenses, and should theoretically reduce some of the problems as sociated with these lenses. This method of implantation has some theoretical advantages including decreased endothelial cell trauma and reduced trabecular meshwork damage from placement in a more correct anatomic location. Furthermore, the lens is fixed by the haptics to
©AMERICAN JOURNAL OF OPHTHALMOLOGY 114:182-187, AUGUST, 1992
Vol. 114, No. 2
Penetrating Keratoplasty and Posterior Chamber Lens
the ciliary sulcus, thereby limiting pseudophacodonesis. To evaluate the clinical outcomes of this pro cedure, we reviewed records of all patients who underwent this procedure at the University of Minnesota in a three-year period.
Patients and Methods From July 1987 to October 1990, 115 patients (115 eyes) underwent penetrating keratoplasty with transscleral fixation of a posterior cham ber lens. Ten patients could not be examined, as one had died and nine were lost to follow-up. The patients selected in the first year of the study were those who were considered to be at risk for complications associated with anterior chamber lens implantation. These included pa tients with glaucoma, peripheral anterior synechiae, and surgical or traumatic aniridia. These early patients did not demonstrate any marked complications and therefore transscler al fixation of posterior chamber lens was used almost exclusively thereafter in all patients un dergoing penetrating keratoplasty and intraoc ular lens implantation in the absence of capsular support. The charts of 105 patients were reviewed to assess visual outcomes, graft survival, glauco ma, and any complications, especially those that may be related to lens implantation. The mean follow-up time was 26.8 months (range, six to 43 months). Average age was 74.1 years (range, 21 to 95 years) and women constituted 64.8% of the group (68 of 105 patients). The leading indication for penetrating keratoplasty with transscleral suture fixation of a posterior chamber lens was pseudophakic bullous keratopathy in 71 patients (67.6%). Other indica tions were aphakic bullous keratopathy in 13 patients (12.4%) and trauma in three patients (2.9%). The remainder consisted of aphakic eyes with previously failed corneal grafts and corneal scars secondary to infectious keratitis and ocular surface disorders. Visual acuity was the last recorded visual acuity at chart review. The term new-onset increase in intraocular pressure was attributed to those patients without a history of preopera tive glaucoma who subsequently required glau coma medications postoperatively for control of increased intraocular pressure. Worsening of intraocular pressure control was attributed to those patients who had a history of preopera tive glaucoma who then required more medica
183
tions or a surgical procedure to control in creased postoperative intraocular pressure. Surgical method—The posterior chamber lenses used were one-piece, 7-mm, biconvex polymethylmethacrylate lenses. The length of the lenses ranged from 13.5 to 14.0 mm. A three-piece polymethylmethacrylate, 14.0-mm lens used in one patient was the only exception. A polypropylene suture was tied to each haptic of the posterior chamber lens at the point of greatest haptic spread. Conjunctival peritomy and scierai flap, when performed, were performed at the site of suture fixation. After the host cornea button was trephined and cut, an anterior chamber lens (if present) was then carefully removed. Anterior vitrectomy was performed by using an automated vitrectomy instrument and a light pipe to delineate the vitreous. Goniosynechialysis and iris recon struction were performed in those cases in which they were warranted. The needle of each polypropylene suture was then passed transsclerally, exiting the eye 0.75 mm posterior to the corneoscleral limbus. The lens was then placed in the posterior chamber with the haptics in the sulcus. In most cases, the lens haptics were placed in an oblique meridian (usually at the 1:30 and 7:30 o'clock meridians) to mini mize involvement of the long posterior ciliary arteries and nerves. After we ensured the pos terior chamber lens was adequately positioned, the suture was pulled taut and a superficial scierai bite was made on the exterior surface. The suture was then tied to itself. The polypropylene suture was cut short and then covered by one of the following three methods: (1) conjunctival flap in 67 patients (63.8%), (2) scierai flap in 34 patients (32.4%), or (3) a 2.5-mm corneal button was taken from the excised cornea 10 in four patients (3.8%). The donor cornea in most cases was sutured to the recipient cornea by using either 16 interrupted or 12 interrupted sutures combined with a 12bite continuous suture.
Results Visual acuity—At last follow-up, 102 patients (97.1%) had clear grafts. There were a total of 15 rejections (14.3%), all of which were treated successfully. Three grafts (2.9%) failed, two because of glaucoma and one because of corne al ulcération. Preoperative visual acuity was less than 20/200 in 82 patients (78.1%), 20/50 to 20/200 in 19 patients (18.1%), and 20/40 or
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August, 1992
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■ 20/40 or better ■ 20/50 - 20/200
We reviewed the outcome in 115 patients who underwent penetrating keratoplasty and transscleral fixation of a posterior chamber lens. One patient died soon after surgical procedures, and nine patients were lost to follow-up, leaving a cohort of 105 patients. Mean follow-up time was 26.8 months (range, six to 43 months). Visual acuity of 20/40 or better was found in 29 patients (27.6%) and 20/50 to 20/200 in 37 patients (35.2%). Reasons for poor visual outcome included cystoid macular edema in ten patients (9.5%), age-related macular degeneration in six patients (5.7%), and retinal detachment in four patients (3.8%). None of the patients developed lens decentration. There were no instances of hyphema and only one patient had a perioperative limited suprachoroidal hemorrhage. New-onset increase in intraocular pressure developed in 20 of 66 patients (30.3%). Analysis of the 39 patients with preoperative increase in intraocular pressure that required medical treatment demonstrated an improvement in 13 patients (33.3%), worsening in 12 patients (30.8%), and unchanged status in 14 patients (35.9%). The exposed haptic suture was covered by using one of the following three alternative methods: a conjunctival flap, a scierai flap, or a corneal tissue button. Exposure of the haptic suture through the conjunctiva was a complication in 21 patients (20%). Of these, 16 (76.1%) occurred in the group with a conjunctival
Accepted for publication May 6, 1992. From the Cornea and External Disease Service, De partment of Ophthalmology, University of Minnesota, Minneapolis, Minnesota. This study was presented in part at the 17th annual meeting of the Castroviejo Society, Oct. 12, 1991, Anaheim, California. Reprint requests to Edward J. Holland, M.D., Universi ty of Minnesota, Department of Ophthalmology, Box 493 UMHC, 516 Delaware St. S.E., Minneapolis, MN 55455-0501.
182
covering, five (23.8%) occurred in the group with a scierai flap, and none occurred in the corneal tissue button group. This study demonstrated that transscleral fixation of a posterior chamber lens is a viable option in the treatment of patients undergoing penetrating keratoplasty and intraocular lens implantation with absent capsular support. INTRAOCULAR
LENS
implantation
has now
become the expected standard of care in the treatment of aphakia. In the absence of cap sular support, anterior chamber lenses have been widely used. Unfortunately these lenses, closed-loop lenses in particular, have been fraught with complications such as trabecular meshwork damage, prolonged inflammation, and corneal decompensation. 1 5 Corneal decom pensation in the presence of an anterior cham ber lens is one of the leading indications for penetrating keratoplasty and intraocular lens removal and exchange. There has been considerable interest in de veloping new techniques for implantation of posterior chamber lenses in the absence of capsular support. One alternative has been to fixate the lens to the iris by using the position ing holes of the lens. 6 · 7 Another has been to fixate the lens by passing a polypropylene su ture attached to the lens haptic through the sulcus transsclerally to the exterior. 8 · 9 Placement of a posterior chamber lens in the ciliary sulcus is anatomically more similar to. that of the crystalline lens than anterior cham ber or iris-supported lenses, and should theoretically reduce some of the problems as sociated with these lenses. This method of implantation has some theoretical advantages including decreased endothelial cell trauma and reduced trabecular meshwork damage from placement in a more correct anatomic location. Furthermore, the lens is fixed by the haptics to
©AMERICAN JOURNAL OF OPHTHALMOLOGY 114:182-187, AUGUST, 1992
Vol. 114, No. 2
Penetrating Keratoplasty and Posterior Chamber Lens
the ciliary sulcus, thereby limiting pseudophacodonesis. To evaluate the clinical outcomes of this pro cedure, we reviewed records of all patients who underwent this procedure at the University of Minnesota in a three-year period.
Patients and Methods From July 1987 to October 1990, 115 patients (115 eyes) underwent penetrating keratoplasty with transscleral fixation of a posterior cham ber lens. Ten patients could not be examined, as one had died and nine were lost to follow-up. The patients selected in the first year of the study were those who were considered to be at risk for complications associated with anterior chamber lens implantation. These included pa tients with glaucoma, peripheral anterior synechiae, and surgical or traumatic aniridia. These early patients did not demonstrate any marked complications and therefore transscler al fixation of posterior chamber lens was used almost exclusively thereafter in all patients un dergoing penetrating keratoplasty and intraoc ular lens implantation in the absence of capsular support. The charts of 105 patients were reviewed to assess visual outcomes, graft survival, glauco ma, and any complications, especially those that may be related to lens implantation. The mean follow-up time was 26.8 months (range, six to 43 months). Average age was 74.1 years (range, 21 to 95 years) and women constituted 64.8% of the group (68 of 105 patients). The leading indication for penetrating keratoplasty with transscleral suture fixation of a posterior chamber lens was pseudophakic bullous keratopathy in 71 patients (67.6%). Other indica tions were aphakic bullous keratopathy in 13 patients (12.4%) and trauma in three patients (2.9%). The remainder consisted of aphakic eyes with previously failed corneal grafts and corneal scars secondary to infectious keratitis and ocular surface disorders. Visual acuity was the last recorded visual acuity at chart review. The term new-onset increase in intraocular pressure was attributed to those patients without a history of preopera tive glaucoma who subsequently required glau coma medications postoperatively for control of increased intraocular pressure. Worsening of intraocular pressure control was attributed to those patients who had a history of preopera tive glaucoma who then required more medica
183
tions or a surgical procedure to control in creased postoperative intraocular pressure. Surgical method—The posterior chamber lenses used were one-piece, 7-mm, biconvex polymethylmethacrylate lenses. The length of the lenses ranged from 13.5 to 14.0 mm. A three-piece polymethylmethacrylate, 14.0-mm lens used in one patient was the only exception. A polypropylene suture was tied to each haptic of the posterior chamber lens at the point of greatest haptic spread. Conjunctival peritomy and scierai flap, when performed, were performed at the site of suture fixation. After the host cornea button was trephined and cut, an anterior chamber lens (if present) was then carefully removed. Anterior vitrectomy was performed by using an automated vitrectomy instrument and a light pipe to delineate the vitreous. Goniosynechialysis and iris recon struction were performed in those cases in which they were warranted. The needle of each polypropylene suture was then passed transsclerally, exiting the eye 0.75 mm posterior to the corneoscleral limbus. The lens was then placed in the posterior chamber with the haptics in the sulcus. In most cases, the lens haptics were placed in an oblique meridian (usually at the 1:30 and 7:30 o'clock meridians) to mini mize involvement of the long posterior ciliary arteries and nerves. After we ensured the pos terior chamber lens was adequately positioned, the suture was pulled taut and a superficial scierai bite was made on the exterior surface. The suture was then tied to itself. The polypropylene suture was cut short and then covered by one of the following three methods: (1) conjunctival flap in 67 patients (63.8%), (2) scierai flap in 34 patients (32.4%), or (3) a 2.5-mm corneal button was taken from the excised cornea 10 in four patients (3.8%). The donor cornea in most cases was sutured to the recipient cornea by using either 16 interrupted or 12 interrupted sutures combined with a 12bite continuous suture.
Results Visual acuity—At last follow-up, 102 patients (97.1%) had clear grafts. There were a total of 15 rejections (14.3%), all of which were treated successfully. Three grafts (2.9%) failed, two because of glaucoma and one because of corne al ulcération. Preoperative visual acuity was less than 20/200 in 82 patients (78.1%), 20/50 to 20/200 in 19 patients (18.1%), and 20/40 or
184
August, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
■ 20/40 or better ■ 20/50 - 20/200
