ARTICLE
Retinal detachment surgery in eyes with iris-fixated phakic intraocular lenses: Short-term clinical results Yong Joon Kim, MD, Jin Kwon Chung, MD, Sung Jin Lee, MD
PURPOSE: To evaluate the safety of retinal detachment (RD) surgery in eyes with iris-fixated phakic intraocular lenses (pIOLs) and the efficacy of the pIOLs in correcting myopia after RD surgery. SETTING: Single university-based tertiary referral center. DESIGN: Retrospective case series. METHODS: Eyes that had RD surgery (RD group) and healthy fellow eyes (control group) of the same patients were evaluated over 1 year. Surgical success, corrected distance visual acuity (CDVA), anterior chamber depth (ACD), endothelial cell density (ECD), and intraocular pressure (IOP) were assessed preoperatively and postoperatively to evaluate the safety of the surgery. The uncorrected distance visual acuity (UDVA) and spherical equivalent were assessed to evaluate the efficacy of the pIOL after RD surgery. RESULTS: Twenty-two eyes of 11 patients were assessed. Reattachment was achieved in 10 eyes (90.9%) with the first intervention. After 1 year, the mean UDVA was 0.16 G 0.15 logMAR (SD) in the RD group and 0.09 G 0.12 logMAR in the control group (PZ.332). The mean CDVA was 0.03 G 0.07 logMAR in the RD group. The differences in the mean postoperative ACD and ECD between the 2 groups were not significant (PZ.088 and PZ.270, respectively). The mean IOP in the RD group was significantly higher than in the control group up to 1 month postoperatively; thereafter, the difference was not significant. CONCLUSIONS: Preservation of a pIOL during RD surgery did not diminish the safety of the surgery. The efficacy of the pIOL in correcting myopia was not markedly compromised. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:2025–2030 Q 2014 ASCRS and ESCRS
Although the safety and efficacy of corneal refractive surgery have been widely reported, postoperative problems, such as unexpected corneal ectasia and myopic regression, have also been reported.1–3 In addition, highly myopic patients are usually not appropriate candidates for corneal refractive surgery.2,4 Some surgeons have performed refractive lens exchange to correct high myopia; however, the loss of accommodation after surgery remains an inevitable shortcoming.5–7 The development of the phakic intraocular lens (pIOL) has enabled effective correction of high myopia without the loss of accommodation.8–10 Patients who have pIOL implantation usually have highly myopic eyes with a long axial length (AL). Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
Thus, they have a high risk for developing retinal detachment (RD).11,12 Studies13,14 have reported the characteristics of RD in eyes with a pIOL and a favorable retinal reattachment rate after pIOL-sparing RD surgery. However, these studies did not describe other important aspects of surgery, such as the postoperative corrected distance visual acuity (CDVA), anterior chamber depth (ACD), endothelial cell density (ECD), or intraocular pressure (IOP), all of which are factors determining the safety of the surgery. If preservation of the pIOL during after RD surgery would result in a significantly reduced ACD, considerable loss of endothelial cells, or prolonged IOP elevation postoperatively, the pIOL should be extracted during surgery. http://dx.doi.org/10.1016/j.jcrs.2014.03.029 0886-3350
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Considering the purpose of pIOL implantation, the postoperative uncorrected distance visual acuity (UDVA) and refractive error are also important issues related to pIOL-sparing RD surgery. In this study, we assessed the success rate and aforementioned concerns to evaluate the safety and efficacy of pIOL-sparing RD surgery. We also describe the presenting features of RD after iris-fixated pIOL implantation. PATIENTS AND METHODS The medical records of consecutive patients who had pIOLsparing RD surgery by the same experienced retinal specialist (S.J.L.) between May 2008 and June 2012 were reviewed retrospectively. All patients had bilateral pIOL implantation previously and presented with unilateral RD. This study adhered to the tenets of the Declaration of Helsinki. The Institutional Review Board, Soonchunhyang University Seoul Hospital, approved the retrospective study (SCHUH 2013-09-005), and all patients provided informed consent before RD surgery. The eyes were divided into 2 groups. The RD group consisted of eyes with RD that had pIOL-sparing RD surgery. The control group comprised fellow eyes of the same patients.
Surgical Technique The surgeon decided on the surgical procedures for pIOLsparing RD surgery according to the results of dilated fundus examinations. Scleral buckling or encircling was performed under general anesthesia depending on the number, size, and position of the retinal breaks. External subretinal fluid drainage and cryopexy were performed after a conjunctival peritomy was created. A 4.0 mm silicone sponge was placed and fixated on the sclera with 5.0 polyethylene terephthalate (Dacron) sutures depending on the size and position of the retinal breaks. In eyes with a giant retinal tear, grade C proliferative vitreoretinopathy (PVR), or significant vitreous hemorrhage, a 20-gauge pars plana vitrectomy was performed using conventional 3-port sclerotomies combined with scleral surgery. Fluid–air exchange, internal subretinal fluid drainage, endolaser photocoagulation for the retinal break, and intravitreal gas tamponade (sulfur hexafluoride or perfluoropropane) were also performed during vitrectomy. Patients were instructed to assume the appropriate head position.
Submitted: December 23, 2013. Final revision submitted: March 3, 2014. Accepted: March 13, 2014. From the Department of Ophthalmology, Soonchunhyang University College of Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea. Supported by the Soonchunhyang University Research Fund. Corresponding author: Sung Jin Lee, MD, Department of Ophthalmology, Soonchunhyang University Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul, South Korea. E-mail: [email protected].
Preoperative and Postoperative Examinations All patients had a complete ophthalmic examination preoperatively, including UDVA, CDVA, slitlamp biomicroscopy, tonometry, ECD measurement, keratometry, and biometry to measure AL and ACD. A dilated fundus examination with an indirect ophthalmoscope and a Goldmann 3-mirror contact lens was performed before RD surgery. Routine postoperative examinations were scheduled for 1 day, 1 week, and 1, 3, and 6 months. All patients had another complete ophthalmic examination 1 year after surgery.
Statistical Analysis To assess the safety of the pIOL-sparing RD surgery, the mean CDVA, ACD, and ECD in the RD group were compared with those in the control group preoperatively and 1-year postoperatively. At 1 day, 1 week, 1, 3, and 6 months, only the difference in IOP between groups was assessed. To evaluate the efficacy of the pIOL after RD surgery, the UDVA and spherical equivalent (SE) in the RD group were compared with those in the control group preoperatively and 1 year postoperatively. The change in AL was also assessed to clarify the cause of any change in SE. All statistical analyses were performed with SPSS software (version 19.0, SPSS, Inc.). Preoperative and postoperative values in the same group were compared with the Wilcoxon signed-rank test. The Mann-Whitney U test was used for comparisons between the 2 groups. All tests were 2 tailed; a P value less than 0.05 was considered significant.
RESULTS The RD group and control group each comprised 11 eyes of 11 patients (7 men, 4 women). During the 1 year after surgery, no patient missed a follow-up visit. Table 1 shows the clinical features in both groups before pIOL-sparing RD surgery. Presenting Features of Retinal Detachment and Surgical Procedures The mean time between pIOL implantation and the RD was 27.2 months G 11.8 (SD). No trauma occurred in any eye before RD developed. All eyes had multiple retinal breaks. Three eyes had 2 retinal breaks, and 7 eyes had 3 or more retinal breaks. The RD in 1 eye was associated with a retinal dialysis, a large retinal tear, and 3 retinal holes. Seven eyes had macula-sparing RD, and 4 eyes had RD involving the macula. All patients had RD surgery within 2 days of diagnosis. Table 2 shows the surgical procedures for pIOL-sparing RD surgery by individual patient. Surgical Success Retinal reattachment was achieved in 10 (90.9%) of 11 eyes after the first surgical intervention. Because the pupil could be sufficiently dilated in all cases,
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The mean preoperative ACD was not significantly different between the 2 groups. Although the difference in the mean postoperative ACD between the 2 groups showed borderline significance (PZ.088), the mean ACD decreased significantly (0.09 mm) after surgery in the RD group (PZ.035). The mean preoperative and postoperative ECD values were not significantly different between the 2 groups. However, at 1 year, the mean endothelial cell loss was 6.64% G 9.30% in the RD group and 2.25% G 7.40% in the control group (PZ.562). Table 3 shows the ACD and ECD changes. The mean preoperative IOP was 12.9 G 1.3 mm Hg in the RD group and 14.0 G 2.3 mm Hg in the control group (PZ.075). The mean IOP was 18.2 G 2.4 mm Hg, 18.8 G 3.3 mm Hg, 15.5 G 3.4 mm Hg, and 13.9 G 3.3 mm Hg 1 day, 1 week, 1 month, and 3 months postoperatively, respectively, in the RD group and 14.6 G 1.9 mm Hg, 14.7 G 2.5 mm Hg, 14.7 G 2.3 mm Hg, and 14.2 G 2.7 mm Hg, respectively, in the control group. The mean IOP was statistically significantly higher in the RD group than in the control group at 1 day (PZ.003) and 1 week (PZ.005). Thereafter, the mean IOP was not significantly different between the 2 groups. Figure 1 shows the IOP changes over time by group. No eye developed secondary glaucoma during the follow-up.
Table 1. Patient characteristics before RD surgery. Mean G SD Control Group
P Value
Parameter
RD Group
Age (y) SE pre pIOL implantation (D) Preop SE (D) Preop UDVA (logMAR) Preop CDVA (logMAR) Axial length (mm) ACD (mm) ECD (cells/mm2) Time between pIOL/RD (mo)
30.7 G 6.1 8.98 G 3.01
30.7 G 6.1 9.27 G 2.77
d .748
0.22 G 0.39 0.51 G 0.80 0.46 G 0.83 28.13 G 1.63 3.59 G 0.22 2736 G 358 27.2 G 11.8
0.27 G 0.28 0.07 G 0.10 0.00 G 0.00 28.26 G 1.51 3.64 G 0.22 2870 G 259 d
.652 .300 .300 .797 .401 .243 d
ACD Z anterior chamber depth; CDVA Z corrected distance visual acuity; ECD Z endothelial cell density; pIOL Z phakic intraocular lens; RD Z retinal detachment; SE Z spherical equivalent; UDVA Z uncorrected distance visual acuity
visualization of the peripheral retina was never significantly hindered. No intraoperative complications occurred. One eye with a retinal dialysis and a large retinal tear developed a new RD and PVR 3 months after the first intervention. Safety All eyes in the control group had a CDVA of 20/20 before and after surgery. The mean CDVA in the RD group was 0.46 G 0.83 logMAR preoperatively and 0.03 G 0.07 logMAR 1 year postoperatively (PZ.300 and PZ.478, respectively, between groups). The postoperative CDVA was 20/40 or better in all eyes and 20/20 in 9 eyes (81.8%) in the RD group.
Phakic Intraocular Lens Correction of Myopia After Retinal Detachment Surgery The mean UDVA in the RD group was 0.51 G 0.80 logMAR preoperatively and 0.16 G 0.15 logMAR 1 year postoperatively. The mean postoperative UDVA was better in the control group (0.09 G 0.12) than in the RD group, although the difference between
Table 2. Clinical course in RD group.
Pt
Sex/Age (Y)
Macula Sparing
1 2 3 4 5 6 7 8 9 10 11
F/26 F/26 F/27 F/39 M/28 M/33 M/38 M/36 M/19 M/33 M/33
Yes No No No Yes Yes Yes No Yes Yes Yes
Preop
1 Year Postop
UDVA
CDVA
UDVA
CDVA
RD Surgery
Surgical Success After 1st Surgery
0.00 0.10 1.10 2.00 0.10 0.00 0.00 2.00 0.00 0.10 0.22
0.00 0.00 1.10 2.00 0.00 0.00 0.00 2.00 0.00 0.00 0.00
0.00 0.22 0.00 0.30 0.10 0.30 0.00 0.30 0.00 0.10 0.40
0.00 0.00 0.00 0.22 0.00 0.00 0.00 0.10 0.00 0.00 0.00
Scleral buckling Scleral buckling Scleral buckling Vitrectomy C scleral buckling C SF6 Scleral buckling Scleral encircling Scleral buckling Vitrectomy C scleral encircling C SF6 Scleral buckling Vitrectomy C scleral encircling C C3F8 Vitrectomy C scleral encircling C C3F8
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No
C3F8 Z perfluoropropane; CDVA Z corrected distance visual acuity (logMAR); Pt Z patient; RD Z retinal detachment; SF6 Z sulfur hexafluoride; UDVA Z uncorrected distance visual acuity (logMAR)
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Table 3. Changes in ACD and ECD after pIOL-sparing RD surgery. Parameter ACD (mm) RD group Mean G SD Range Control group Mean G SD Range P value ECD (cells/mm2) RD group Mean G SD Range Control group Mean G SD Range P value
Preop
1 Year Postop
P Value
3.58 G 0.22 3.29, 3.87
3.49 G 0.20 3.15, 3.69
.035
3.64 G 0.22 3.29, 3.95 .243
3.62 G 0.20 3.12, 3.81 .088
.685
2736 G 358 2178, 3514
2562 G 491 1388, 3311
.123
2870 G 259 2506, 3266 .151
2794 G 181 2577, 3157 .270
.102
ACD Z anterior chamber depth; ECD Z endothelial cell density
the groups was not significant (PZ.332). The UDVA was 20/40 or better in 10 eyes (90.9%) in the RD group. Table 2 shows the UDVA by individual patient. The mean postoperative SE was more myopic in the RD group ( 0.47 G 0.48 D) than in the control group ( 0.20 G 0.25 D), and the difference was borderline significant (PZ.088). The change in SE after surgery was statistically significant in the RD group (PZ.027) but not in the control group (PZ.531). The mean postoperative AL was 28.14 G 1.71 mm in the RD group and 28.23 G 1.47 mm in the control group (PZ.847). The change in the mean AL postoperatively was not statistically significant in either group (PZ.478).
Figure 1. Measurements of the IOP in the RD and control groups. The linear regression line shows a trend in the RD group (* Z P!.05, Mann-Whitney U test; RD Z retinal detachment).
DISCUSSION Several studies report favorable outcomes after pIOLsparing RD surgery. Jiang et al.13 report a favorable reattachment rate and visual prognosis in 8 eyes of 7 patients. Ruiz-Moreno et al.14 also report good surgical outcomes in 8 eyes of 8 patients. The success rate of pIOL-sparing RD surgery in the present study was similar to those results. Retinal reattachment was achieved in 10 (90.9%) of 11 eyes after the first intervention. Only 1 eye required a second intervention; the eye developed a new RD and a PVR. The eye was treated with pIOL extraction, phacoemulsification, and silicone oil tamponade. The retina was reattached and the visual outcome was good after silicone oil removal and implantation of a foldable acrylic single-piece IOL (Superflex 620H, Rayner Intraocular Lenses Ltd.). The final CDVA in the RD group in the present study was better than that in previous studies. Several factors explain the better visual outcomes in our study. Seven of the 11 eyes had an extramacular RD and good initial visual acuity. Moreover, all patients had RD surgery within 2 days of diagnosis. Improved instrumentation and surgical techniques may also have contributed to better visual outcomes. We believe that these were factors in the good results, even in eyes with RD involving the macula. Although retinal reattachment and CDVA are the most important components of RD surgery, the postoperative UDVA and changes in ACD, ECD, AL, and SE are also important, particularly in eyes with a pIOL. In previous studies,15–17 scleral surgery for RD resulted in an increased AL and a decreased ACD. In the present study, the ALs did not increase significantly after pIOL-sparing RD surgery. This can be explained as follows: First, 7 of the 11 patients had scleral buckling and only 4 patients had scleral encircling. The AL is more elongated with scleral encircling than with scleral segmental buckling.18 The small number of encircling patients may have contributed to this result. Second, the surgeon or variations in surgical technique can affect the AL. A change in AL may be caused by the tightness of the buckling element. Various changes in the AL have been reported after scleral surgery.15–17 Third, eyes with high myopia have long ALs and usually have thin choroids and scleras.19,20 Thus, low tension of the encircling element can be sufficient to cause an appropriate buckling effect in eyes with axial myopia. Although there was no significant change in AL, the ACD decreased significantly after surgery in the RD group. Reduced uveal circulation after scleral surgery causes ciliary body edema,15,21,22 which in turn causes forward rotation of the ciliary body and anterior shift
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of the iris–lens diaphragm. Kawana et al.21 found that eyes treated with encircling surgery had greater ciliary body edema and a shallower ACD than eyes treated with segmental buckling surgery. A decreased ACD associated with an anterior shift of the iris–lens diaphragm can affect the SE and UDVA after RD surgery. In this study, the myopic shift in the SE in the RD group may have been related to a decreased ACD. An anterior shift of the iris–lens diaphragm affects the ECD as well. Endothelial cell loss is negatively correlated with ACD in eyes with pIOLs.23 Previous studies15,24 report a mean reduction in ACD of 0.34 to 0.44 mm 1 week after scleral surgery. In a study by Goezinne et al.,15 the ACD decreased significantly up to 9 months after scleral surgery in phakic eyes. A reduced ACD may cause a high rate of endothelial cell loss, in particular during the early postoperative period. Although not significant, an increased rate of endothelial cell loss was observed in the RD group, whereas the endothelial cell loss in the control group was comparable with published results with the Artisan IOLs and Artiflex IOLs (both Ophtec BV) 2 years after surgery.10,25 Because the ACD was greatly reduced and gradually returned to the preoperative value after surgery, we think most of the endothelial cell loss occurred during surgery and the early postoperative period.15 Surgeons should strive to prevent endothelial cell loss during pIOL-sparing RD surgery. Scleral indentation to localize retinal breaks and performing external drainage of subretinal fluid can cause a transient reduction in ACD. The iris-fixated pIOL can touch the corneal endothelium during the procedures and accelerate endothelial cell loss. Indenting the sclera with minimal tension to examine the peripheral retina may help decrease intraoperative endothelial cell loss. Injecting ophthalmic viscoelastic devices into the anterior chamber can help prevent endothelial touch in patients with a shallow anterior chamber.26 The last concern about pIOL-sparing RD surgery is the IOP. Fiore and Newton24 found a change in the chamber angle in the quadrant directly anterior to the intrascleral implant. Angle-closure glaucoma can also develop after scleral surgery.27,A Moreover, elevated IOP has been reported as a complication of pIOL implantation.28 In the present study, the mean postoperative IOP was significantly higher in the RD group than in the control group up to 1 month after surgery; thereafter, the difference was not significant. Several studies15,28,29 report that elevated IOP was uncommon 3 months after pIOL implantation or RD surgery. In addition, surgeons generally perform a laser iridotomy before pIOL implantation. Therefore, we speculate that a prolonged increase in IOP is not common after pIOL-sparing RD surgery.
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The limitations of this study are the small number of patients and the short follow-up. However, this is the first study evaluating the safety of preserving a pIOL during RD surgery in eyes with iris-fixated pIOLs. Phakic IOL-sparing RD surgery did not markedly compromise the safety of the RD surgery or the efficacy of the implanted pIOL. To strengthen our results, a large prospective study with a subgroup analysis of the different types of RD surgery and pIOLs should be performed. In conclusion, our results indicate that pIOL-sparing RD surgery is safe and effective in treating RD in eyes with previous pIOL implantation. Removal of the pIOL is not necessary at the initial intervention. WHAT WAS KNOWN Phakic IOL implantation to correct high myopia is followed by a 1.5% to 4.8% incidence of RD. Phakic IOL-sparing RD surgery yields a high reattachment rate and favorable visual prognosis. WHAT THIS PAPER ADDS Findings indicate that preserving the pIOL does not compromise the safety of RD surgery in terms of the postoperative CDVA, ACD, ECD, or IOP. The efficacy of iris-fixated pIOL in correcting myopia was not markedly compromised in terms of UDVA and SE after RD surgery in highly myopic patients.
REFERENCES 1. Pallikaris IG, Kymionis GD, Astyrakakis NI. Corneal ectasia induced by laser in situ keratomileusis. J Cataract Refract Surg 2001; 27:1796–1802 2. Randleman JB, Russell B, Ward MA, Thompson KP, Stulting RD. Risk factors and prognosis for corneal ectasia after LASIK. Ophthalmology 2003; 110:267–275 3. Yuen LH, Chan WK, Koh J, Mehta JS, Tan DT; for the SingLasik Resarch Group. A 10-year prospective audit of LASIK outcomes for myopia in 37,932 eyes at a single institution in Asia. Ophthalmology 2010; 117:1236–1244.e1 4. Binder PS. Ectasia after laser in situ keratomileusis. J Cataract Refract Surg 2003; 29:2419–2429 5. Goldberg MF. Clear lens extraction for axial myopia; an appraisal. Ophthalmology 1987; 94:571–582 6. Lyle WA, Jin GJC. Phacoemulsification with intraocular lens implantation in high myopia. J Cataract Refract Surg 1996; 22:238–242 ndez-Vega L, Alfonso JF, Villacampa T. Clear lens extrac7. Ferna tion for the correction of high myopia. Ophthalmology 2003; 110:2349–2354 8. The Implantable Contact Lens in Treatment of Myopia (ITM) Study Group. U.S. Food and Drug Administration clinical trial of the Implantable Contact Lens for moderate to high myopia. Ophthalmology 2003; 110:255–266. Available at:
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http://old.iloveeye.com/pds/FDA.pdf. Accessed August 30, 2014 Ruckhofer J, Seyeddain O, Dexl AK, Grabner G, Stoiber J. Correction of myopic astigmatism with a foldable iris-claw toric phakic intraocular lens: short-term follow-up. J Cataract Refract Surg 2012; 38:582–588 € ell JL, Marinho AAP, Dick HB, Budo C, Malecaze F, Gu Nuijts RMMA, Luyten GPM, Menezo JL, Kohnen T. Foldable Artiflex phakic intraocular lens for the correction of myopia; two-year follow-up results of a prospective European multicenter study. Ophthalmology 2009; 116:671–677 Schepens CL, Marden D. Data on the natural history of retinal detachment; further characterization of certain unilateral nontraumatic cases. Am J Ophthalmol 1966; 61:213–226 The Eye Disease Case-Control Study Group. Risk factors for idiopathic rhegmatogenous retinal detachment. The Eye Disease Case-Control Study Group. Am J Epidemiol 1993; 137:749–757 Jiang T, Chang Q, Wang X, Huang X. Retinal detachment after phakic intraocular lens implantation in severe myopic eyes. Graefes Arch Clin Exp Ophthalmol 2012; 250:1725–1730 JL, Pe rez-Santonja JJ, de la Hoz F. Ruiz-Moreno JM, Alio Retinal detachment in phakic eyes with anterior chamber intraocular lenses to correct severe myopia. Am J Ophthalmol 1999; 127:270–275 Goezinne F, La Heij EC, Berendschot TTJM, Tahzib NG, Cals DWKJ, Liem ATA, Lundqvist IJ, Hendrikse F. Anterior chamber depth is significantly decreased after scleral buckling surgery. Ophthalmology 2010; 117:79–85 Smiddy WE, Loupe DN, Michels RG, Enger C, Glaser BM, deBustros S. Refractive changes after scleral buckling surgery. Arch Ophthalmol 1989; 107:1469–1471 Burton TC, Herron BE, Ossoinig KC. Axial length changes after retinal detachment surgery. Am J Ophthalmol 1977; 83:59–62 Hayashi H, Hayashi K, Nakao F, Hayashi F. [Changes in axial length after scleral buckling surgery] [Japanese]. Nihon Ganka Gakkai Zasshi 1996; 100:302–306 Flores-Moreno I, Lugo F, Duker JS, Ruiz-Moreno JM. The relationship between axial length and choroidal thickness in eyes with high myopia. Am J Ophthalmol 2013; 155:314–319 Grossniklaus HE, Green WR. Pathologic findings in pathologic myopia. Retina 1992; 12:127–133 Kawana K, Okamoto F, Hiraoka T, Oshika T. Ciliary body edema after scleral buckling surgery for rhegmatogenous retinal detachment. Ophthalmology 2006; 113:36–41 Berler DK, Goldstein B. Scleral buckles and rotation of the ciliary body. Arch Ophthalmol 1979; 97:1518–1521
23. Saxena R, Boekhoorn SS, Mulder PGH, Noordzij B, van Rij G, Luyten GPM. Long-term follow-up of endothelial cell change after Artisan phakic intraocular lens implantation. Ophthalmology 2008; 115:608–613 24. Fiore JV Jr, Newton JC. Anterior segment changes following the scleral buckling procedure. Arch Ophthalmol 1970; 84:284–287 25. Pop M, Payette Y. Initial results of endothelial cell counts after Artisan lens for phakic eyes; an evaluation of the United States Food and Drug Administration Ophtec Study. Ophthalmology 2004; 111:309–317. Available at: http://www.leeeye.kr/popup/ non/Artisan2.pdf. Accessed August 30, 2014 26. van der Meulen I, Gunning F, Henry Y, de Vries-Knoppert W, Gortzak-Moorstein N, de Smet MD. Management of retinal detachments in pseudophakic patients with Artisan lenses. J Cataract Refract Surg 2002; 28:1804–1808 27. Perez RN, Phelps CD, Burton TC. Angle-closure glaucoma following scleral buckling operations. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol 1976; 81:247–252 28. Huang D, Schallhorn SC, Sugar A, Farjo AA, Majmudar PA, Trattler WB, Tanzer DJ. Phakic intraocular lens implantation for the correction of myopia; a report by the American Academy of Ophthalmology (Ophthalmic Technology Assessment). Ophthalmology 2009; 116:2244–2258. Available at: http://www.brighton visioncenter.com/Research/Phakic_IOLs_for_Correction_of_My opia_2009.pdf. Accessed August 30, 2014 -Pe rez A, Alonso-Mun ~ oz L, Casa29. Aguilar-Valenzuela L, Lleo rez-Molto FJ, Rahhad MS. Intraocular presnova-Izquierdo J, Pe sure in myopic patients after Worst-Fechner anterior chamber phakic intraocular lens implantation. J Refract Surg 2003; 19:131–136
OTHER CITED MATERIAL A. Smith TR, “Acute Glaucoma Developing After Scleral Buckling Procedures,” presented at the 491st meeting of the New England Ophthalmological Society, Boston, Massachusetts, USA, November 1966. Abstract available in Am J Ophthalmol 1967; 63:1807–1808
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First author: Yong Joon Kim, MD Department of Ophthalmology, Soonchunhyang University College of Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea
Retinal detachment surgery in eyes with iris-fixated phakic intraocular lenses: Short-term clinical results Yong Joon Kim, MD, Jin Kwon Chung, MD, Sung Jin Lee, MD
PURPOSE: To evaluate the safety of retinal detachment (RD) surgery in eyes with iris-fixated phakic intraocular lenses (pIOLs) and the efficacy of the pIOLs in correcting myopia after RD surgery. SETTING: Single university-based tertiary referral center. DESIGN: Retrospective case series. METHODS: Eyes that had RD surgery (RD group) and healthy fellow eyes (control group) of the same patients were evaluated over 1 year. Surgical success, corrected distance visual acuity (CDVA), anterior chamber depth (ACD), endothelial cell density (ECD), and intraocular pressure (IOP) were assessed preoperatively and postoperatively to evaluate the safety of the surgery. The uncorrected distance visual acuity (UDVA) and spherical equivalent were assessed to evaluate the efficacy of the pIOL after RD surgery. RESULTS: Twenty-two eyes of 11 patients were assessed. Reattachment was achieved in 10 eyes (90.9%) with the first intervention. After 1 year, the mean UDVA was 0.16 G 0.15 logMAR (SD) in the RD group and 0.09 G 0.12 logMAR in the control group (PZ.332). The mean CDVA was 0.03 G 0.07 logMAR in the RD group. The differences in the mean postoperative ACD and ECD between the 2 groups were not significant (PZ.088 and PZ.270, respectively). The mean IOP in the RD group was significantly higher than in the control group up to 1 month postoperatively; thereafter, the difference was not significant. CONCLUSIONS: Preservation of a pIOL during RD surgery did not diminish the safety of the surgery. The efficacy of the pIOL in correcting myopia was not markedly compromised. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:2025–2030 Q 2014 ASCRS and ESCRS
Although the safety and efficacy of corneal refractive surgery have been widely reported, postoperative problems, such as unexpected corneal ectasia and myopic regression, have also been reported.1–3 In addition, highly myopic patients are usually not appropriate candidates for corneal refractive surgery.2,4 Some surgeons have performed refractive lens exchange to correct high myopia; however, the loss of accommodation after surgery remains an inevitable shortcoming.5–7 The development of the phakic intraocular lens (pIOL) has enabled effective correction of high myopia without the loss of accommodation.8–10 Patients who have pIOL implantation usually have highly myopic eyes with a long axial length (AL). Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
Thus, they have a high risk for developing retinal detachment (RD).11,12 Studies13,14 have reported the characteristics of RD in eyes with a pIOL and a favorable retinal reattachment rate after pIOL-sparing RD surgery. However, these studies did not describe other important aspects of surgery, such as the postoperative corrected distance visual acuity (CDVA), anterior chamber depth (ACD), endothelial cell density (ECD), or intraocular pressure (IOP), all of which are factors determining the safety of the surgery. If preservation of the pIOL during after RD surgery would result in a significantly reduced ACD, considerable loss of endothelial cells, or prolonged IOP elevation postoperatively, the pIOL should be extracted during surgery. http://dx.doi.org/10.1016/j.jcrs.2014.03.029 0886-3350
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Considering the purpose of pIOL implantation, the postoperative uncorrected distance visual acuity (UDVA) and refractive error are also important issues related to pIOL-sparing RD surgery. In this study, we assessed the success rate and aforementioned concerns to evaluate the safety and efficacy of pIOL-sparing RD surgery. We also describe the presenting features of RD after iris-fixated pIOL implantation. PATIENTS AND METHODS The medical records of consecutive patients who had pIOLsparing RD surgery by the same experienced retinal specialist (S.J.L.) between May 2008 and June 2012 were reviewed retrospectively. All patients had bilateral pIOL implantation previously and presented with unilateral RD. This study adhered to the tenets of the Declaration of Helsinki. The Institutional Review Board, Soonchunhyang University Seoul Hospital, approved the retrospective study (SCHUH 2013-09-005), and all patients provided informed consent before RD surgery. The eyes were divided into 2 groups. The RD group consisted of eyes with RD that had pIOL-sparing RD surgery. The control group comprised fellow eyes of the same patients.
Surgical Technique The surgeon decided on the surgical procedures for pIOLsparing RD surgery according to the results of dilated fundus examinations. Scleral buckling or encircling was performed under general anesthesia depending on the number, size, and position of the retinal breaks. External subretinal fluid drainage and cryopexy were performed after a conjunctival peritomy was created. A 4.0 mm silicone sponge was placed and fixated on the sclera with 5.0 polyethylene terephthalate (Dacron) sutures depending on the size and position of the retinal breaks. In eyes with a giant retinal tear, grade C proliferative vitreoretinopathy (PVR), or significant vitreous hemorrhage, a 20-gauge pars plana vitrectomy was performed using conventional 3-port sclerotomies combined with scleral surgery. Fluid–air exchange, internal subretinal fluid drainage, endolaser photocoagulation for the retinal break, and intravitreal gas tamponade (sulfur hexafluoride or perfluoropropane) were also performed during vitrectomy. Patients were instructed to assume the appropriate head position.
Submitted: December 23, 2013. Final revision submitted: March 3, 2014. Accepted: March 13, 2014. From the Department of Ophthalmology, Soonchunhyang University College of Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea. Supported by the Soonchunhyang University Research Fund. Corresponding author: Sung Jin Lee, MD, Department of Ophthalmology, Soonchunhyang University Hospital, 59, Daesagwan-ro, Yongsan-gu, Seoul, South Korea. E-mail: [email protected].
Preoperative and Postoperative Examinations All patients had a complete ophthalmic examination preoperatively, including UDVA, CDVA, slitlamp biomicroscopy, tonometry, ECD measurement, keratometry, and biometry to measure AL and ACD. A dilated fundus examination with an indirect ophthalmoscope and a Goldmann 3-mirror contact lens was performed before RD surgery. Routine postoperative examinations were scheduled for 1 day, 1 week, and 1, 3, and 6 months. All patients had another complete ophthalmic examination 1 year after surgery.
Statistical Analysis To assess the safety of the pIOL-sparing RD surgery, the mean CDVA, ACD, and ECD in the RD group were compared with those in the control group preoperatively and 1-year postoperatively. At 1 day, 1 week, 1, 3, and 6 months, only the difference in IOP between groups was assessed. To evaluate the efficacy of the pIOL after RD surgery, the UDVA and spherical equivalent (SE) in the RD group were compared with those in the control group preoperatively and 1 year postoperatively. The change in AL was also assessed to clarify the cause of any change in SE. All statistical analyses were performed with SPSS software (version 19.0, SPSS, Inc.). Preoperative and postoperative values in the same group were compared with the Wilcoxon signed-rank test. The Mann-Whitney U test was used for comparisons between the 2 groups. All tests were 2 tailed; a P value less than 0.05 was considered significant.
RESULTS The RD group and control group each comprised 11 eyes of 11 patients (7 men, 4 women). During the 1 year after surgery, no patient missed a follow-up visit. Table 1 shows the clinical features in both groups before pIOL-sparing RD surgery. Presenting Features of Retinal Detachment and Surgical Procedures The mean time between pIOL implantation and the RD was 27.2 months G 11.8 (SD). No trauma occurred in any eye before RD developed. All eyes had multiple retinal breaks. Three eyes had 2 retinal breaks, and 7 eyes had 3 or more retinal breaks. The RD in 1 eye was associated with a retinal dialysis, a large retinal tear, and 3 retinal holes. Seven eyes had macula-sparing RD, and 4 eyes had RD involving the macula. All patients had RD surgery within 2 days of diagnosis. Table 2 shows the surgical procedures for pIOL-sparing RD surgery by individual patient. Surgical Success Retinal reattachment was achieved in 10 (90.9%) of 11 eyes after the first surgical intervention. Because the pupil could be sufficiently dilated in all cases,
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The mean preoperative ACD was not significantly different between the 2 groups. Although the difference in the mean postoperative ACD between the 2 groups showed borderline significance (PZ.088), the mean ACD decreased significantly (0.09 mm) after surgery in the RD group (PZ.035). The mean preoperative and postoperative ECD values were not significantly different between the 2 groups. However, at 1 year, the mean endothelial cell loss was 6.64% G 9.30% in the RD group and 2.25% G 7.40% in the control group (PZ.562). Table 3 shows the ACD and ECD changes. The mean preoperative IOP was 12.9 G 1.3 mm Hg in the RD group and 14.0 G 2.3 mm Hg in the control group (PZ.075). The mean IOP was 18.2 G 2.4 mm Hg, 18.8 G 3.3 mm Hg, 15.5 G 3.4 mm Hg, and 13.9 G 3.3 mm Hg 1 day, 1 week, 1 month, and 3 months postoperatively, respectively, in the RD group and 14.6 G 1.9 mm Hg, 14.7 G 2.5 mm Hg, 14.7 G 2.3 mm Hg, and 14.2 G 2.7 mm Hg, respectively, in the control group. The mean IOP was statistically significantly higher in the RD group than in the control group at 1 day (PZ.003) and 1 week (PZ.005). Thereafter, the mean IOP was not significantly different between the 2 groups. Figure 1 shows the IOP changes over time by group. No eye developed secondary glaucoma during the follow-up.
Table 1. Patient characteristics before RD surgery. Mean G SD Control Group
P Value
Parameter
RD Group
Age (y) SE pre pIOL implantation (D) Preop SE (D) Preop UDVA (logMAR) Preop CDVA (logMAR) Axial length (mm) ACD (mm) ECD (cells/mm2) Time between pIOL/RD (mo)
30.7 G 6.1 8.98 G 3.01
30.7 G 6.1 9.27 G 2.77
d .748
0.22 G 0.39 0.51 G 0.80 0.46 G 0.83 28.13 G 1.63 3.59 G 0.22 2736 G 358 27.2 G 11.8
0.27 G 0.28 0.07 G 0.10 0.00 G 0.00 28.26 G 1.51 3.64 G 0.22 2870 G 259 d
.652 .300 .300 .797 .401 .243 d
ACD Z anterior chamber depth; CDVA Z corrected distance visual acuity; ECD Z endothelial cell density; pIOL Z phakic intraocular lens; RD Z retinal detachment; SE Z spherical equivalent; UDVA Z uncorrected distance visual acuity
visualization of the peripheral retina was never significantly hindered. No intraoperative complications occurred. One eye with a retinal dialysis and a large retinal tear developed a new RD and PVR 3 months after the first intervention. Safety All eyes in the control group had a CDVA of 20/20 before and after surgery. The mean CDVA in the RD group was 0.46 G 0.83 logMAR preoperatively and 0.03 G 0.07 logMAR 1 year postoperatively (PZ.300 and PZ.478, respectively, between groups). The postoperative CDVA was 20/40 or better in all eyes and 20/20 in 9 eyes (81.8%) in the RD group.
Phakic Intraocular Lens Correction of Myopia After Retinal Detachment Surgery The mean UDVA in the RD group was 0.51 G 0.80 logMAR preoperatively and 0.16 G 0.15 logMAR 1 year postoperatively. The mean postoperative UDVA was better in the control group (0.09 G 0.12) than in the RD group, although the difference between
Table 2. Clinical course in RD group.
Pt
Sex/Age (Y)
Macula Sparing
1 2 3 4 5 6 7 8 9 10 11
F/26 F/26 F/27 F/39 M/28 M/33 M/38 M/36 M/19 M/33 M/33
Yes No No No Yes Yes Yes No Yes Yes Yes
Preop
1 Year Postop
UDVA
CDVA
UDVA
CDVA
RD Surgery
Surgical Success After 1st Surgery
0.00 0.10 1.10 2.00 0.10 0.00 0.00 2.00 0.00 0.10 0.22
0.00 0.00 1.10 2.00 0.00 0.00 0.00 2.00 0.00 0.00 0.00
0.00 0.22 0.00 0.30 0.10 0.30 0.00 0.30 0.00 0.10 0.40
0.00 0.00 0.00 0.22 0.00 0.00 0.00 0.10 0.00 0.00 0.00
Scleral buckling Scleral buckling Scleral buckling Vitrectomy C scleral buckling C SF6 Scleral buckling Scleral encircling Scleral buckling Vitrectomy C scleral encircling C SF6 Scleral buckling Vitrectomy C scleral encircling C C3F8 Vitrectomy C scleral encircling C C3F8
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No
C3F8 Z perfluoropropane; CDVA Z corrected distance visual acuity (logMAR); Pt Z patient; RD Z retinal detachment; SF6 Z sulfur hexafluoride; UDVA Z uncorrected distance visual acuity (logMAR)
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Table 3. Changes in ACD and ECD after pIOL-sparing RD surgery. Parameter ACD (mm) RD group Mean G SD Range Control group Mean G SD Range P value ECD (cells/mm2) RD group Mean G SD Range Control group Mean G SD Range P value
Preop
1 Year Postop
P Value
3.58 G 0.22 3.29, 3.87
3.49 G 0.20 3.15, 3.69
.035
3.64 G 0.22 3.29, 3.95 .243
3.62 G 0.20 3.12, 3.81 .088
.685
2736 G 358 2178, 3514
2562 G 491 1388, 3311
.123
2870 G 259 2506, 3266 .151
2794 G 181 2577, 3157 .270
.102
ACD Z anterior chamber depth; ECD Z endothelial cell density
the groups was not significant (PZ.332). The UDVA was 20/40 or better in 10 eyes (90.9%) in the RD group. Table 2 shows the UDVA by individual patient. The mean postoperative SE was more myopic in the RD group ( 0.47 G 0.48 D) than in the control group ( 0.20 G 0.25 D), and the difference was borderline significant (PZ.088). The change in SE after surgery was statistically significant in the RD group (PZ.027) but not in the control group (PZ.531). The mean postoperative AL was 28.14 G 1.71 mm in the RD group and 28.23 G 1.47 mm in the control group (PZ.847). The change in the mean AL postoperatively was not statistically significant in either group (PZ.478).
Figure 1. Measurements of the IOP in the RD and control groups. The linear regression line shows a trend in the RD group (* Z P!.05, Mann-Whitney U test; RD Z retinal detachment).
DISCUSSION Several studies report favorable outcomes after pIOLsparing RD surgery. Jiang et al.13 report a favorable reattachment rate and visual prognosis in 8 eyes of 7 patients. Ruiz-Moreno et al.14 also report good surgical outcomes in 8 eyes of 8 patients. The success rate of pIOL-sparing RD surgery in the present study was similar to those results. Retinal reattachment was achieved in 10 (90.9%) of 11 eyes after the first intervention. Only 1 eye required a second intervention; the eye developed a new RD and a PVR. The eye was treated with pIOL extraction, phacoemulsification, and silicone oil tamponade. The retina was reattached and the visual outcome was good after silicone oil removal and implantation of a foldable acrylic single-piece IOL (Superflex 620H, Rayner Intraocular Lenses Ltd.). The final CDVA in the RD group in the present study was better than that in previous studies. Several factors explain the better visual outcomes in our study. Seven of the 11 eyes had an extramacular RD and good initial visual acuity. Moreover, all patients had RD surgery within 2 days of diagnosis. Improved instrumentation and surgical techniques may also have contributed to better visual outcomes. We believe that these were factors in the good results, even in eyes with RD involving the macula. Although retinal reattachment and CDVA are the most important components of RD surgery, the postoperative UDVA and changes in ACD, ECD, AL, and SE are also important, particularly in eyes with a pIOL. In previous studies,15–17 scleral surgery for RD resulted in an increased AL and a decreased ACD. In the present study, the ALs did not increase significantly after pIOL-sparing RD surgery. This can be explained as follows: First, 7 of the 11 patients had scleral buckling and only 4 patients had scleral encircling. The AL is more elongated with scleral encircling than with scleral segmental buckling.18 The small number of encircling patients may have contributed to this result. Second, the surgeon or variations in surgical technique can affect the AL. A change in AL may be caused by the tightness of the buckling element. Various changes in the AL have been reported after scleral surgery.15–17 Third, eyes with high myopia have long ALs and usually have thin choroids and scleras.19,20 Thus, low tension of the encircling element can be sufficient to cause an appropriate buckling effect in eyes with axial myopia. Although there was no significant change in AL, the ACD decreased significantly after surgery in the RD group. Reduced uveal circulation after scleral surgery causes ciliary body edema,15,21,22 which in turn causes forward rotation of the ciliary body and anterior shift
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of the iris–lens diaphragm. Kawana et al.21 found that eyes treated with encircling surgery had greater ciliary body edema and a shallower ACD than eyes treated with segmental buckling surgery. A decreased ACD associated with an anterior shift of the iris–lens diaphragm can affect the SE and UDVA after RD surgery. In this study, the myopic shift in the SE in the RD group may have been related to a decreased ACD. An anterior shift of the iris–lens diaphragm affects the ECD as well. Endothelial cell loss is negatively correlated with ACD in eyes with pIOLs.23 Previous studies15,24 report a mean reduction in ACD of 0.34 to 0.44 mm 1 week after scleral surgery. In a study by Goezinne et al.,15 the ACD decreased significantly up to 9 months after scleral surgery in phakic eyes. A reduced ACD may cause a high rate of endothelial cell loss, in particular during the early postoperative period. Although not significant, an increased rate of endothelial cell loss was observed in the RD group, whereas the endothelial cell loss in the control group was comparable with published results with the Artisan IOLs and Artiflex IOLs (both Ophtec BV) 2 years after surgery.10,25 Because the ACD was greatly reduced and gradually returned to the preoperative value after surgery, we think most of the endothelial cell loss occurred during surgery and the early postoperative period.15 Surgeons should strive to prevent endothelial cell loss during pIOL-sparing RD surgery. Scleral indentation to localize retinal breaks and performing external drainage of subretinal fluid can cause a transient reduction in ACD. The iris-fixated pIOL can touch the corneal endothelium during the procedures and accelerate endothelial cell loss. Indenting the sclera with minimal tension to examine the peripheral retina may help decrease intraoperative endothelial cell loss. Injecting ophthalmic viscoelastic devices into the anterior chamber can help prevent endothelial touch in patients with a shallow anterior chamber.26 The last concern about pIOL-sparing RD surgery is the IOP. Fiore and Newton24 found a change in the chamber angle in the quadrant directly anterior to the intrascleral implant. Angle-closure glaucoma can also develop after scleral surgery.27,A Moreover, elevated IOP has been reported as a complication of pIOL implantation.28 In the present study, the mean postoperative IOP was significantly higher in the RD group than in the control group up to 1 month after surgery; thereafter, the difference was not significant. Several studies15,28,29 report that elevated IOP was uncommon 3 months after pIOL implantation or RD surgery. In addition, surgeons generally perform a laser iridotomy before pIOL implantation. Therefore, we speculate that a prolonged increase in IOP is not common after pIOL-sparing RD surgery.
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The limitations of this study are the small number of patients and the short follow-up. However, this is the first study evaluating the safety of preserving a pIOL during RD surgery in eyes with iris-fixated pIOLs. Phakic IOL-sparing RD surgery did not markedly compromise the safety of the RD surgery or the efficacy of the implanted pIOL. To strengthen our results, a large prospective study with a subgroup analysis of the different types of RD surgery and pIOLs should be performed. In conclusion, our results indicate that pIOL-sparing RD surgery is safe and effective in treating RD in eyes with previous pIOL implantation. Removal of the pIOL is not necessary at the initial intervention. WHAT WAS KNOWN Phakic IOL implantation to correct high myopia is followed by a 1.5% to 4.8% incidence of RD. Phakic IOL-sparing RD surgery yields a high reattachment rate and favorable visual prognosis. WHAT THIS PAPER ADDS Findings indicate that preserving the pIOL does not compromise the safety of RD surgery in terms of the postoperative CDVA, ACD, ECD, or IOP. The efficacy of iris-fixated pIOL in correcting myopia was not markedly compromised in terms of UDVA and SE after RD surgery in highly myopic patients.
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First author: Yong Joon Kim, MD Department of Ophthalmology, Soonchunhyang University College of Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea
