SCLERAL FIXATION OF POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTS COMBINED WITH VITRECTOMY* BY David K. Berler, MD, AND (BY INVITATION)
Mark A. Friedberg, MD INTRODUCTION
INTRAOCULAR LENSES (IOLs) HAVE NOT BEEN WIDELY USED IN CONJUNC-
tion with pars plana vitrectomy-lensectomy, even though IOLs are accepted as the standard of care for the safe and efficacious rehabilitation of aphakia. Selection of a particular IOL remains variable. Anterior chamber lenses have been de-emphasized due to complications of earlier models,1-6 although newer anterior chamber implants may be safer.7-10 The presumed advantages of posterior chamber lens implants are such that they are recommended by many investigators, even when capsular and zonular support are lacking. 11-14 Most reports of suture-fixated posterior chamber IOLs concern their use in penetrating keratoplasty. Implantation of posterior chamber IOLs at the time of pars plana vitrectomy has been reported,15-17 but these cases depended on capsular support. We sutured posterior chamber IOLs to sclera at the time of vitrectomy when the lens and lens capsule were sacrificed. Our suture technique is a direct modification of a technique elaborated by J. Lewis (oral communication) but never published, and it also owes much to descriptions by others. 11,18-21 Our modifications were designed to avoid the complications of lens displacement, suture erosion, and endophthalmitis that have been noted in association with scleral fixation of posterior chamber IOLs. 21-23 SURGICAL TECHNIQUE
Patients were prepared and draped in the routine way for pars plana vitrectomy. A 2700 conjunctival peritomy was made sparing the inferior *From the Retina Service, Department of Ophthalmology, Washington Washington, DC. TR. AM. OPHTH. SOC. VOl. LXXXIX, 1991
Hospital Center,
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FIGURE 1
A: Deep scleral grooves 0.75 mm posterior to surgical limbus in oblique meridians. B: Straight needle with Prolene suture (straight arrow) about to engage 27-gauge needle (curved arrow). C: Needle and Prolene suture withdrawn. D: Suture spans posterior chamber.
area between the 4- and 7-o'clock positions. Three standard sclerotomies, each 3.0 mm posterior to the limbus, were made using an MVR blade, and then lensectomy and vitrectomy were performed in the usual manner. Attempts were made to remove all peripheral cortical and capsular lens remnants to avoid any mechanical interference with subsequent IOL placement. The irrigating cannula was left in place at the conclusion of the vitrectomy, and the sclerotomy sites were plugged for temporary closure. In the middle of the superior-temporal quadrant (approximately at the 1:30-o'clock position, using the left eye as an example), 0.75 mm posterior to the posterior surgical limbus, a deep 3.0-mm limbal parallel groove was created (Fig 1A). An identical incision was made in the middle of the inferior nasal quadrant (at the 7:30-o'clock position, using the left eye as an example). A 27-gauge needle was passed into the vitreous cavity through the upper end of the 1:30-o'clock groove and directed into the
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pupillary space, just posterior to the iris. In the upper end of the 7:30o'clock groove, 1800 away, a straight needle (Ethicon STC-6 Plus) attached to a 10-0 Prolene suture was similarly placed and directed into the lumen of the 27-gauge needle, where it was lodged (Fig 1B). The 27-gauge needle was withdrawn, pulling the straight needle and attached 10-0 Prolene suture with it (Fig 1C). A Prolene suture now spanned the posterior chamber, exiting near the upper end of each groove (Fig 1D). Identical maneuvers were performed through the lower ends of the same grooves (Fig 2A), resulting in two parallel Prolene sutures spanning the posterior chamber (Fig 2B). The needles attached to the 10-0 Prolene were removed. A 2. 0-mm limbal-parallel incision was made at the surgical limbus into the anterior chamber at the 12-o'clock position, and a Sinsky hook was inserted through this incision to withdraw the more superior Prolene suture from the eye (Fig 2C). The externalized suture was cut, and each end was sutured to the appropriate haptic of the selected posterior chamber IOL (Fig 2D).
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FIGURE 2
A: Straight needle lodged in lumen of27-gauge needle using lower aspects of scleral grooves. B: Two parallel sutures span posterior chamber. C: Superior suture extracted through 2.0mm limbal opening. D: Superior suture tied to IOL haptics.
The remaining posterior chamber suture was similarly retrieved, cut, and tied to the haptics of the IOL. Care was taken to ensure that the more superior suture on each haptic matched the suture exiting the superior aspect of the corresponding groove and that the more inferior haptic sutures likewise related to those sutures exiting the more inferior aspects of the grooves (Fig 3A). If the selected IOL had Prolene haptics, each haptic end was enlarged to a bulbous tip by heating with a hand-held cautery to prevent the knots from slipping off, as described by Cowden and Hu. 11. 8 Sodium hyaluronate (Healon) was injected into the anterior chamber for corneal protection, and the limbal wound was enlarged to the diameter of the selected IOL. The lens was placed in the eye posterior to the iris and centered (Fig 3B and C). The two sutures exiting the 7:30 o'clock groove were tied to each other, and the knot buried itself in the groove. The sutures at 1:30-o'clock were tied in the same manner (Fig 3D). The eyes were then examined by indirect ophthalmoscopy, and
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scleral depression and sclerotomies, grooves, and peritomies were sutured closed. The grooves themselves may be sutured or left open if not gaping. PATIENTS
The following six patients all underwent pars plana vitrectomy-lensectomy, membrane peeling if indicated, and four-point scleral fixation of a posterior chamber IOL using the techniques just described. Patient 1 was a 39-year-old man who had traumatic hyphema, secondary glaucoma, dislocated lens, and vitreous hemorrhage. The hyphema progressed to 100% with no visualization of ocular contents. Twelve days after injury, surgery was performed. Patient 2 was a 27-year-old man who presented with a dislocated cataract and vitreous opacities resulting from blunt trauma. Surgery was performed 3 months after injury. Patient 3 was a 44-year-old man who had a subluxed lens and vitreous hemorrhage resulting from blunt trauma. Surgery was performed 3 months after injury. Patient 4 was a 55year-old man with proliferative diabetic retinopathy and cataract. Surgery
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FIGURE
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A: Two sutures attached to each haptic. B and C: IOL inserted into posterior chamber and centered. D: Knots buried in grooves.
included membrane peeling. Patient 5 was a 28-year-old woman who had long-standing dense cataract and vitreous membrane of unknown cause and a history of strabismus and amblyopia. Patient 6 was a 42-year-old man who had suffered a penetrating injury from a nail after removing his safety glasses while hammering. The cornea was repaired initially, and later lensectomy-vitrectomy was performed for dense cataract, organized vitreous, and hemorrhage (Fig 4). RESULTS
All patients experienced significant visual improvement (Table I). Patient 1 improved from preoperative acuity of hand motions to 20/20 after surgery. Patient 2 improved from hand motions preoperatively to 20/400 postoperatively. A choroidal rupture at the fovea was considered responsible for reduced acuity. Patient 3 improved from counting finger vision preoperatively to 20/40 after surgery. Patient 4 had counting finger acuity preoperatively and 20/40 after surgery. Patient 5 had counting finger
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vision preoperatively and 20/100 postoperatively. Amblyopia exanopsia explained the final acuity. Patient 6 improved from hand motion pre-
operatively to 20/20 after surgery. Patient ages ranged from 27 to 55 years. Follow-up varied from 4 months to 10 months (average, 7 months). No operative or postoperative complications were associated with scleral fixation of posterior chamber IOLs in our patients. Specifically, problems such as suture exposure, lens rotation or displacement, infection, hemorrhage, or chronic iritis and discomfort were not observed. TABLE I: RESULTS PATIENT NO.
AGE
PREOPERATIVE VISION*
POSTOPERATIVE VISION
1 2 3 4 5 6
39 27 44 55 28 42
HM HM CF CF CF HM
20/20 20/400t 20/40 20/40 20/100t 20/40
*HM, hand motion; CF, counting fingers. tTrauma-incuded subfoveal choroidal rupture.
tAmblyopia exanopsia.
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FIGURE 4
Patient 6, with penetrating injury and anterior segment distortion. A: After initial corneal repair. B: After pars plana vitrectomy-lensectomy and scleral fixation of posterior chamber IOL. Suture knots are not visible.
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Remarkable visual improvement is possible with current vitrectomy techniques, yet vitreous surgeons have been slow to embrace the use of lens implants. Encouraging results have been reported using posterior chamber IOLs at the time of pars plana vitrectomy,15-17 but these surgeons utilized capsular support, not scleral fixation. We sutured posterior chamber IOLs to sclera when pars plana vitrectomy-lensectomy destroyed all capsular support. Lakenpal and Dogra have fixed posterior chamber IOLs to sclera at the time of pars plana vitrectomy, but this technique has not been published. We did not try to place anterior chamber implants, and occasionally anterior segment damage may preclude such placement, as in patient 6 (Fig 4A). Corneal surgeons have led the way in establishing the safety and efficacy of suture fixation of posterior chamber IOLs in complicated cases of aphakia by reporting large series of successes at the time ofpenetrating keratoplasty.5,12"19,20,23 Scleral fixation enjoys a slight preference over iris fixation at this time.24 Scleral fixation of a posterior chamber IOL is not a new procedure, and Girard25 reported fixation of a haptic into the sclera in 1981. Most investigators prefer ciliary sulcus fixation but Apple and associates26 have shown that posterior chamber IOL haptics often miss the sulcus and that the sulcus diameter is only 11.0 to 11.5 mm, less than most surgeons think. Duffey and associates27 used needles perpendicular to the sclera to demonstrate scleral relationships to the ciliary sulcus and found that the sulcus lies only 1.0 mm posterior to the posterior surgical limbus in the vertical meridians and barely 0.5 mm behind the limbus in the horizontal meridians. In view of this, we placed sutures 0.75 mm posterior to the limbus in the oblique meridians. Careful scleral location of needle entries maximized our chances for ciliary sulcus fixation, reducing the risk of bleeding from inadvertent perforation of the major arterial circle of the iris, which is located in the anterior ciliary body. Our technique was further modified to minimize reported complications of suture exposure, lens rotation, and endophthalmitis.22,23,28 A deep groove allowed for easy concealment of knots, and four-point fixation was used for both stability and for simplicity of knot tying. The two sutures that exited from each groove (Fig 3D) were tied to each other, and the resulting knot was buried and unlikely to erode, reducing the risks of discomfort and infection (Fig 4B). These modifications directly derived from the technique of James and Lewis but also owe much to the methods of Cowden and Hu," Girard,13 Hu and associates,18 Shin,20 and Spigelman and associates.21 The only negative features of these maneuvers may be some initial
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confusion by the surgeon when four sutures are seen exiting from the limbal wound at the 12-o'clock position (Fig 3A), but this is easily adjusted to after the first operation. The visual results in our small patient population were very satisfying (Table I), but attention is called to the young age-range involved, 27 to 55 years. Two patients had a final acuity of less than 20/40 owing to maculopathy in one and preexisting amblyopia in the other. Follow-up has been relatively brief (average, 7 months), but the smooth course of all patients and analysis of extensive posterior chamber IOL experienced by others in the literature suggests that no special complications need be anticipated. Posterior chamber IOLs are safe and useful. We encourage the appropriate use of IOLs with vitrectomy surgery, and we offer an implantation technique that my prove helpful. REFERENCES 1. Kraff MC, Sanders DR, Lieberman HL: Monitoring for continuing endothelial cell loss with cataract extraction and intraocular lens implantation. Ophthalmology 1982; 89:3034. 2. Smith PW, Wong SK, Stark WJ, et al: Complications of semiflexible, closed-loop anterior chamber intraocular lenses. Arch Ophthalmol 1987; 105:52-57. 3. Speaker MG, Lugo M, Laibson PR: Penetrating keratoplasty for pseudophakic bullous keratopathy. Ophthalmology 1988; 95:1260-1268. 4. Stark WJ, Cowen CL, Worthen DM, et al: Complications of flexible and semiflexible anterior chamber lenses. Arch Ophthalmol 1987; 105:20-21. 5. Stark WJ, Gottsch JD, Goodman DF, et al: Posterior chamber lens implantation in the absence of capsular support. Arch Ophthalmol 1989; 107:1078-1083. 6. Apple DJ, Olson RJ: Closed loop anterior chamber lenses. Arch Ophthalmol 1987; 105:19-20. 7. Kraff MC, Lieberman HL, Sandlers DR: Secondary intraocular lens implantation: Rigid/semirigid versus flexible lenses. J Cataract Refract Surg 1987; 13:21-26. 8. Lindstrom RL, Harris WS: Secondary anterior chamber lens implantation. CLAO J 1986; 10:133-136. 9. Wong SK, Koch DD, Emery JM: Secondary intraocular lens implantation. J Cataract Refract Surg 1987; 13:17-20. 10. Lim ES, Apple DJ, Tsai JC: An analysis of flexible anterior chamber lenses with special reference to the normalized rate of lens explantation. Ophthalmology 1991; 98:243-246. 11. Cowden JW, Hu BV: A new surgical technique for posterior chamber lens fixation during penetrating keratoplasty in the absence of capsular or zonular support. Cornea 1988; 7:231-235. 12. Gaster RN, Troutman RC, Aspasia D: Combined penetrating keratoplasty and posterior chamber lens implantation in pseudophakic keratopathy. Trans Am Ophthalmol Soc 1990; 88:326-342. 13. Girard L: PC-IOL implantation in the absence ofposterior capsule support. Ophthalmic Surg 1988; 19:680-682. 14. Pannu JS: A new suturing technique for ciliary sulcus fixation in the absence of posterior capsule. Ophthalmic Surg 1988; 19:751-754. 15. Koenig SB, Han DP, Mieler WF, et al: Combined phakoemulsification and pars plana vitrectomy. Arch Ophthalmol 1990; 108:362-364.
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16. Pang MP, Peyman GA, Minatoya HK: Posterior chamber lens implantation following pars plana lensectomy and vitrectomy in severe proliferative diabetic retinopathy. CanJ Ophthalmol 1989; 24:175-178. 17. Ruiz RS, Saatci OA: Posterior chamber intraocular lens implantation in eyes with inactive and active proliferative diabetic retinopathy. Am J Ophthalmol 1991; 111:158162. 18. Hu BV, Shin DH, Gibbs KA, et al: Implantation of a posterior chamber lens in the absence of capsular and zonular support. Arch Ophthalmol 1988; 106:416-420. 19. Price FW, Whitson WE: Visual results of suture-fixated posterior chamber lenses during penetrating keratoplasty. Ophthalmology 1989; 96:1234-1240. 20. Shin DH: Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens. Ophthalmic Surg 1988; 19:755-756. 21. Spigelman AV, Lindstrom RL, Nichols BD, et al: Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant. Ophthalmic Surg 1988; 19:396-398. 22. Heilskov T, Joondeph BC, Olsen KR, et al: Late endophthalmitis after transcleral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1989; 107:1427. 23. Johnson SM: Results of exchanging anterior chamber lenses with sulcus-fixated posterior chamber IOLs without capsular support in penetrating keratoplasty. Ophthalmic Surg 1989; 20:465-468. 24. Sen HA, Smith PW: Current trends in suture fixation of posterior chamber intraocular lenses. Ophthalmic Surg 1990; 212:689-695. 25. Girard LJ: Pars plana phakoprosthesis (aphakic intraocular implant): A preliminary report. Ophthalmic Surg 1981; 12:19-22. 26. Apple DJ, Price FW, Gwin T, et al: Sutured retropupillary posterior chamber intraocular lenses for exchange or secondary implantation. Ophthalmology 1989; 96:1241-1247. 27. Duffey RJ, Holland EJ, Agapitos PJ, et al: Anatomic study of transsclerally sutured intraocular lens implantation. Am J Ophthalmol 1989; 108:300-309. 28. Lindquist TD, Agapitos PJ, Lindstrom RL, et al: Transcleral fixation of posterior chamber intraocular lenses in the absence of capsular support. Ophthalmic Surg 1989; 20:769-775.
DISCUSSION
DR RICHARD C. TROUTMAN. I am particularly pleased to discuss this paper, not only because it has been presented by Doctor Berler, a new member and longtime friend, but also because Doctor Berler and I shared the same mentor, Doctor McLean, who I am sure would have been most proud to welcome Doctor Berler to join our number. The authors have presented a new approach to the visual rehabilitation of patients undergoing vitreoretinal surgery combined with pars plana total extraction of the lens. They have recognized that successful management of the primary disease is but halfway to a cure. After carefully surveying the literature, they have chosen to use posterior chamber lenses, fixated to the sclera through the scleral sulcus, to avoid the late complications inherent to anterior chamber angle-fixated lenses (eg, Kelman-style lenses), pseudophakic bullous keratopathy, uveitis and glaucoma, and cystoid maculopathy. They have cited in particular the experience of corneal surgeons, such as myself and Gaster, who routinely use posterior chamber lenses in the management of pseudophakic bullous keratopathy. Our pathology differs, however, in that the already-present anterior chamber intraocu-
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lar lens and keratopathy necessitate an anterior approach. This facilitates not only vitrectomy but, in the presence of an intact iris, the alternative use of an irisfixated posterior chamber lens. This approach is preferred in particular over the use of "blind" sulcus fixation as opposed to the technique described by Berler and Friedberg. Their technique, derived from a technique described by Lewis, is particularly effective in the intact globe. As he has illustrated, all needles are inserted from externally, the needle arming the fixating suture as well as the 27gauge needle guiding its exit from the opposite sulcus. This reduces the possibility of hemorrhage and assures accurate sulcus positioning of the lens haptics, and it is my preferred technique in corneal surgery when the iris sphincter is compromised and in an intact globe. One objection to the authors' technique is the necessity to tie the thread to the free end of the haptic, which might become untied or slip off during or following the procedure. Also, there is the unknown toxicity that may be elicited from heating the haptic to prevent slipping. I have found both the iris and sulcus fixation techniques are facilitated by the use of an intraocular lens, the haptics of which have been fitted with fixation holes proximal to the optic (for iris fixation) and at the peripheral curve of the haptic (for sulcus fixation), the "lens for all reasons" (ORC). These allow the suture thread to be fixated in the loop without knotting. For iris fixation, suturing is further facilitated by the use of a doublearmed (BVIOO-4 Ethicon) 2-inch polypropylene thread. Lewis has recently modified his technique for use with a similar lens (Cilco, Alcon, CC70BD). This lens has fixation holes only at the peripheral curve of the haptic. His recent technique is designed to use a single suture loop passing freely through the hole in the haptic. This also permits the knot to be rotated into the needle tract, obviating the necessity to create a groove or flap to bury the knot. The double suture is passed as illustrated by Doctor Berler, but after being cut, instead of being tied to the haptic, one cut end is passed through the fixation hole and tied to the cut end exiting from the same side. The knot can then be readily pulled through and externalized and cut off. The thread loop remaining is knotted over the sclera and the free end can be easily rotated and buried in a needle tract. The same maneuver is repeated to the opposite side as the lens is positioned behind the iris. In spite of the small series of six patients and the varied pathology, the authors obtained consistently good functional vision results, limited only by preexisting disease, significantly better than our experience in pseudophakic keratopathy. This may be because of the younger patient group (average age, 37 years) and the relatively short follow-up (7 months). Further, one can anticipate the necessity for secondary retinal surgery because of the severe primary disease. Nevertheless, their experience has shown both the feasibility and efficacy of primary visual rehabilitation, which has until now been largely ignored in the management of such severely damaged eyes. I should like to pose the following questions to the authors: 1. What are your exclusion criteria? 2. How were implant powers and accuracy determined in the absence of a cataract in the fellow eye with a significant refractive error?
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3. Did any patient have compromised binocular vision or diplopia? If so, was it related to posterior disease or to the intraocular lens? 4. What were the preoperative and postoperative specular microscopy findings? 5. In the event of secondary vitreoretinal surgery, how would you handle a dislocated intraocular lens? Remove it? Replace it? DR DANIEL M. TAYLOR. I would like to congratulate Doctor Berler on his presentation. I am very pleased to see that the retinal surgeons are moving into the intraocular lens field. Most corneal surgeons probably began to place posterior chamber sutured-in-lenses some 5 years ago after their disenchantment with anterior chamber lenses in eyes requiring penetrating keratoplasty for corneal decompensation secondary to an iris supported or malpositioned anterior chamber lens in eyes that had received intracapsular cataract extraction. Having been badly burned with iris supported lenses and intracapsular extraction, I elected, from the onset, to avoid fixating the posterior chamber IOL to the iris. We began, as Doctor Berler outlined, by making a double pass through the ciliary sulcus and out through the sclera to provide stable fixation. We did not experience a ciliary body hemorrhage with this technique, but other surgeons have and, on occasion, the bleeding has been significant. For this reason, we felt that a single pass through the ciliary body might be preferable to reduce the chance of inadvertent bleeding by at least 50% and that the fixation would still be reasonably stable. With this change in technique, we continued to avoid intraocular bleeding. On only one occasion did we experience a significant rotation of the lens, but this was easily correctable with a spatula. I have not placed an anterior chamber lens in any eye requiring penetrating keratoplasty for over 4 years, and have used them only on very rare occasions during routine cataract surgery. In the latter instance, we elected to use an anterior chamber lens only when there has been extensive capsular rupture and/or vitreous loss with inadequate capsule remaining in to support the posterior chamber lens. The insertion of a sutured-in posterior chamber lens during cataract surgery is a more formidable procedure than during keratoplasty, and in an eye that has already been surgically traumatized, it seems reasonable to avoid excessive manipulation. From 1975 through 1979, I inserted a fairly large number of iris supported lenses, combined with intracapsular cataract extraction. We subsequently experienced a very high instance of cystoid macular edema that frequently progressed to corneal decompensation. When we performed a penetrating keratoplasty and left the iris supported lens in place, we experienced an extremely high incidence of subsequent graft failure within 1 to 3 years after keratoplasty. The cystoid macular edema, corneal decompensation and subsequent graft failure were all due to the presence of chronic low-grade inflammation secondary to chronic iris irritation. Similar results were reported by others with the utilization of anterior chamber lenses, but my own experience in this area was limited since I converted directly to extracapsular cataract extraction with the utilization of posterior chamber lenses in 1979. This is a problem that has been largely eliminated with the
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adoption of extracapsular surgery and posterior chamber lens insertion by almost all surgeons. In the past, a number of our patients who had experienced the above sequence of events developed permanent visual loss secondary to macular degenerative changes caused by the persistent cystoid macular edema. In some of our patients who have received a penetrating keratoplasty, anterior vitrectomy and sutured-in posterior chamber lens, for what we perceived to be permanent loss of macular function and corneal decompensation due to the presence of an iris fixated or anterior chamber lens, we have actually noticed a resolution of the cystoid macular edema and an improvement in visual acuity to the 20/60 to 20/40 range. This is a bit anecdotal and will require carefully controlled studies, but it seems to be a vast improvement over the hopelessly burned out maculas that we have dealt with in the past where the vision was permanently reduced to the 20/200 to 20/400 range. I would like to suggest again to Doctor Berler that he consider converting to the single suture scleral fixation technique since the fixation appears to be adequate and reduces the change of intraocular hemorrhage by at least 50% over the double fixation technique. We really have not had any problems with knots or loss of lenses into the vitreous or late intraocular infection. In essence, we have had no complications from this procedure and believe it has a distinct advantage over the anterior chamber lens technique. Again, my congratulations to Doctor Berler for his excellent presentation. DR RICHARD LINDSTROM. Thank you for an excellent paper. I now have a retinal surgeon in my association who is also doing this. The retinal surgeons are moving into intraocular lenses. It is quite interesting. I think after traveling around the world and being interested in this now for several years, there are several people that deserve some credit. They include Strampelli, Epstein from South Africa who is not commonly mentioned but did this in the middle of the 1970s, Louis Girard and Enrique Malbran. In many of the publications they have not all been credited. Two-point fixation or four-point fixation, both work. In addition, I would like to mention that I think it works equally well if you pass the needle inside out as it does from outside in. It is crucial, however, to bury the sutures. The question I have, is have you had any hemorrhage? In the several hundred cases that we have done we have seen hemorrhages. We have found that we can always control it, sometimes, with irrigation of thrombin, 100 U/ml. I think in particular one should watch for the anticoagulated patient who consumes a lot of aspirin or Coumadin. This may carry some extra risk. Did you have any hemorrhage at all and since you deal with a lot of hemorrhage, as a retinal surgeon, what would you recommend to manage it? In addition, I would like to ask again if you think it is better in a complicated situation, such as you deal with, to do it in one stage or two stages? I would think intraocular lens power calculation in these complex cases might be quite difficult. Some of the retinal surgeons that I work with prefer the two stage procedure. They will simply reconstruct the eye as a
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retinal surgeon and have the implant placed later. Have you done any as a second stage and what would be your recommendation? DR ROBERT C. DREWS. It is interesting to see the variation in techniques for fixating these lenses. We even had one retinal surgeon in St Louis who did a series of about 20 cases where he placed the loops in the ciliary sulcus under direct visualization without sutures. He just left them there. That was a little scary, but these patients did well. A few thoughts. When you heat Prolene you have to be a little careful. If you heat it lightly it is easy to form a mushroom cap on the end of the Prolene. The edges of that cap are quite sharp and may lead to late tissue erosion and irritation. In trauma cases especially, I think it is important to do a pupil-plasty to repair iris defects to improve the patient's visual function. Because of the few cases of endophthalmitis that are reported, I think it is important in all of these cases to instruct the patient on the early signs of irritation of a suture end sticking up and of endophthalmitis, so hopefully they will come before infection occurs. The question is not whether complications occur, the question is how often? DR THOMAS 0. WOOD. Historically, I would like to mention that Doctor Muenzler in Oklahoma City, is the guy that got us all suturing in posterior chamber intraocular lenses in corneal transplant patients about 1979 or 1980. Doctor Gettelfinger, in Memphis, was right on his heels. Doctor Troutman, this was an elegant presentation on the use of implants in retina work. Doctor Charles, a vitreoretinal surgeon who specializes in vitrectomy, and shares the operating room with me uses implants frequently at the time of vitreoretinal repair. Doctor Troutman pointed out that there is a difference between putting implants in when you are doing vitreoretinal work and at the time of comeal transplantation. It is not easy to suture implants to the sclera at the time ofcorneal
transplantation. I have gone back to what Doctor Troutman said that for an anterior segment surgeon, it is not only quicker, but I think much safer to suture the lenses to the iris. You save yourself a lot of work and maybe an expulsive hemorrhage. Thank you. DR GEORGE WARING. The vast majority of these are done, I think, with penetrating keratoplasty and Doctor Stulting has devised a very simple method of doing it under direct visualization so you can see where the needle goes. This involves, with an open anterior segment, simply grasping the edge of the iris, the edge of the corneal wound and then depressing the limbus with a straight instrument. You can seen the ciliary sulcus directly and know exactly where to put the needle. This distorts the front of the eye a little bit but it is a nice way to know where the needle goes. I also endorse Doctor Drews point about iridoplasty. Particularly in combination with penetrating keratoplasty where you want to put the pupil under the center of the graft and where it is very easy to make iridotomies, sphincterot-
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omies and to put in as many sutures as you need. Even a purse-string suture around the pupil to pull it down, but not too small for the retinal surgeon, approximately 4 mm so it is centered underneath the graft.
DR DAVID K. BERLER. Thank you Doctor Troutman for your very kind comments. Halfof the people in this room seem to be able to think of somebody who we have not mentioned that has been helpful in facilitating the fixation of posterior chamber lenses. I find it very interesting that Strampelli performed a suture fixation of a lens to the sulcus in 1955. You asked about our criteria for selection of cases for this procedure. We did not exclude anyone and quite frankly we took whatever cases we could get. The removal of a lens at the time of vitrectomy is becoming less frequent. The accurate determination of a lens power for the selected IOL has been easier than we expected, and we have not had any significant surprises with too much plus or too much minus. All of the cases that we operated on were performed at an elective time several months after the initial insult, and none of them had significant retinal detachments. This may explain why our A-scan and calculations could be so uneventful. We have no information about specular microscopy since it was not done. Doctor Troutman asked about the problems of secondary retinal surgery and dislocated lens implants that might be associated with this. We have not yet had to go back and do secondary retinal surgery in one of our vitrectomy patients where a lens has been sutured to the pars plana. We would not anticipate any special problems with the lens since we routinely repair dislocated lenses at the time of vitrectomy, and do this by manipulating them with a vitreous forcep after the vitreous has been cleared from the front of the lens, and reattaching it in a variety of ways. Usually we create a loop of suture by partially inserting a needle with Prolene backhand creating a loop of suture. The haptic is placed through the loop, the suture is pulled tight so that the haptic is placed against the sclera and then the suture is tied. This can be done with 1-haptic of a subluxed lens or with both haptics in a completely dislocated lens. Doctor Taylor suggested that a single suture passage may be safer than the double suture passage that we use. We have not had any complications with a double passage. We shared Doctor Lindstrom's concern about hemorrhage but we have not had any hemorrhage from the needle punctures. I believe that the closed system of vitrectomy surgery with an infusion cannula and the ability to raise the intraocular pressure at will, creates a margin of safety that would be very helpful if such hemorrhage occurs. Doctor Lindstrom's question about using a 2-stage procedure instead of implanting a lens at the time of vitrectomy is a critical question. We believe that patients would be better served by having one operation instead of two and the purpose of this paper was to see if lens implantation could be safely and sensibly combined with vitrectomy surgery. Doctor Drews suggested that we pay attention to repair of sector iridectomies when these are necessary for our surgical approach. It might be difficult to convince retinal surgeons to close up large pupils since they like mydriasis.
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The question ofwhich lens to use for scleral fixation has been raised. This is not completely clear at this time but perhaps a 1-piece lens would be best for stability. We are aware that corneal surgeons do have means of visualizing the ciliary sulcus for exact placement when a penetrating keratoplasty is performed. We have not used any techniques to visualize the sulcus directly. Thank you very much.
Mark A. Friedberg, MD INTRODUCTION
INTRAOCULAR LENSES (IOLs) HAVE NOT BEEN WIDELY USED IN CONJUNC-
tion with pars plana vitrectomy-lensectomy, even though IOLs are accepted as the standard of care for the safe and efficacious rehabilitation of aphakia. Selection of a particular IOL remains variable. Anterior chamber lenses have been de-emphasized due to complications of earlier models,1-6 although newer anterior chamber implants may be safer.7-10 The presumed advantages of posterior chamber lens implants are such that they are recommended by many investigators, even when capsular and zonular support are lacking. 11-14 Most reports of suture-fixated posterior chamber IOLs concern their use in penetrating keratoplasty. Implantation of posterior chamber IOLs at the time of pars plana vitrectomy has been reported,15-17 but these cases depended on capsular support. We sutured posterior chamber IOLs to sclera at the time of vitrectomy when the lens and lens capsule were sacrificed. Our suture technique is a direct modification of a technique elaborated by J. Lewis (oral communication) but never published, and it also owes much to descriptions by others. 11,18-21 Our modifications were designed to avoid the complications of lens displacement, suture erosion, and endophthalmitis that have been noted in association with scleral fixation of posterior chamber IOLs. 21-23 SURGICAL TECHNIQUE
Patients were prepared and draped in the routine way for pars plana vitrectomy. A 2700 conjunctival peritomy was made sparing the inferior *From the Retina Service, Department of Ophthalmology, Washington Washington, DC. TR. AM. OPHTH. SOC. VOl. LXXXIX, 1991
Hospital Center,
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FIGURE 1
A: Deep scleral grooves 0.75 mm posterior to surgical limbus in oblique meridians. B: Straight needle with Prolene suture (straight arrow) about to engage 27-gauge needle (curved arrow). C: Needle and Prolene suture withdrawn. D: Suture spans posterior chamber.
area between the 4- and 7-o'clock positions. Three standard sclerotomies, each 3.0 mm posterior to the limbus, were made using an MVR blade, and then lensectomy and vitrectomy were performed in the usual manner. Attempts were made to remove all peripheral cortical and capsular lens remnants to avoid any mechanical interference with subsequent IOL placement. The irrigating cannula was left in place at the conclusion of the vitrectomy, and the sclerotomy sites were plugged for temporary closure. In the middle of the superior-temporal quadrant (approximately at the 1:30-o'clock position, using the left eye as an example), 0.75 mm posterior to the posterior surgical limbus, a deep 3.0-mm limbal parallel groove was created (Fig 1A). An identical incision was made in the middle of the inferior nasal quadrant (at the 7:30-o'clock position, using the left eye as an example). A 27-gauge needle was passed into the vitreous cavity through the upper end of the 1:30-o'clock groove and directed into the
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pupillary space, just posterior to the iris. In the upper end of the 7:30o'clock groove, 1800 away, a straight needle (Ethicon STC-6 Plus) attached to a 10-0 Prolene suture was similarly placed and directed into the lumen of the 27-gauge needle, where it was lodged (Fig 1B). The 27-gauge needle was withdrawn, pulling the straight needle and attached 10-0 Prolene suture with it (Fig 1C). A Prolene suture now spanned the posterior chamber, exiting near the upper end of each groove (Fig 1D). Identical maneuvers were performed through the lower ends of the same grooves (Fig 2A), resulting in two parallel Prolene sutures spanning the posterior chamber (Fig 2B). The needles attached to the 10-0 Prolene were removed. A 2. 0-mm limbal-parallel incision was made at the surgical limbus into the anterior chamber at the 12-o'clock position, and a Sinsky hook was inserted through this incision to withdraw the more superior Prolene suture from the eye (Fig 2C). The externalized suture was cut, and each end was sutured to the appropriate haptic of the selected posterior chamber IOL (Fig 2D).
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FIGURE 2
A: Straight needle lodged in lumen of27-gauge needle using lower aspects of scleral grooves. B: Two parallel sutures span posterior chamber. C: Superior suture extracted through 2.0mm limbal opening. D: Superior suture tied to IOL haptics.
The remaining posterior chamber suture was similarly retrieved, cut, and tied to the haptics of the IOL. Care was taken to ensure that the more superior suture on each haptic matched the suture exiting the superior aspect of the corresponding groove and that the more inferior haptic sutures likewise related to those sutures exiting the more inferior aspects of the grooves (Fig 3A). If the selected IOL had Prolene haptics, each haptic end was enlarged to a bulbous tip by heating with a hand-held cautery to prevent the knots from slipping off, as described by Cowden and Hu. 11. 8 Sodium hyaluronate (Healon) was injected into the anterior chamber for corneal protection, and the limbal wound was enlarged to the diameter of the selected IOL. The lens was placed in the eye posterior to the iris and centered (Fig 3B and C). The two sutures exiting the 7:30 o'clock groove were tied to each other, and the knot buried itself in the groove. The sutures at 1:30-o'clock were tied in the same manner (Fig 3D). The eyes were then examined by indirect ophthalmoscopy, and
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scleral depression and sclerotomies, grooves, and peritomies were sutured closed. The grooves themselves may be sutured or left open if not gaping. PATIENTS
The following six patients all underwent pars plana vitrectomy-lensectomy, membrane peeling if indicated, and four-point scleral fixation of a posterior chamber IOL using the techniques just described. Patient 1 was a 39-year-old man who had traumatic hyphema, secondary glaucoma, dislocated lens, and vitreous hemorrhage. The hyphema progressed to 100% with no visualization of ocular contents. Twelve days after injury, surgery was performed. Patient 2 was a 27-year-old man who presented with a dislocated cataract and vitreous opacities resulting from blunt trauma. Surgery was performed 3 months after injury. Patient 3 was a 44-year-old man who had a subluxed lens and vitreous hemorrhage resulting from blunt trauma. Surgery was performed 3 months after injury. Patient 4 was a 55year-old man with proliferative diabetic retinopathy and cataract. Surgery
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A: Two sutures attached to each haptic. B and C: IOL inserted into posterior chamber and centered. D: Knots buried in grooves.
included membrane peeling. Patient 5 was a 28-year-old woman who had long-standing dense cataract and vitreous membrane of unknown cause and a history of strabismus and amblyopia. Patient 6 was a 42-year-old man who had suffered a penetrating injury from a nail after removing his safety glasses while hammering. The cornea was repaired initially, and later lensectomy-vitrectomy was performed for dense cataract, organized vitreous, and hemorrhage (Fig 4). RESULTS
All patients experienced significant visual improvement (Table I). Patient 1 improved from preoperative acuity of hand motions to 20/20 after surgery. Patient 2 improved from hand motions preoperatively to 20/400 postoperatively. A choroidal rupture at the fovea was considered responsible for reduced acuity. Patient 3 improved from counting finger vision preoperatively to 20/40 after surgery. Patient 4 had counting finger acuity preoperatively and 20/40 after surgery. Patient 5 had counting finger
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vision preoperatively and 20/100 postoperatively. Amblyopia exanopsia explained the final acuity. Patient 6 improved from hand motion pre-
operatively to 20/20 after surgery. Patient ages ranged from 27 to 55 years. Follow-up varied from 4 months to 10 months (average, 7 months). No operative or postoperative complications were associated with scleral fixation of posterior chamber IOLs in our patients. Specifically, problems such as suture exposure, lens rotation or displacement, infection, hemorrhage, or chronic iritis and discomfort were not observed. TABLE I: RESULTS PATIENT NO.
AGE
PREOPERATIVE VISION*
POSTOPERATIVE VISION
1 2 3 4 5 6
39 27 44 55 28 42
HM HM CF CF CF HM
20/20 20/400t 20/40 20/40 20/100t 20/40
*HM, hand motion; CF, counting fingers. tTrauma-incuded subfoveal choroidal rupture.
tAmblyopia exanopsia.
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FIGURE 4
Patient 6, with penetrating injury and anterior segment distortion. A: After initial corneal repair. B: After pars plana vitrectomy-lensectomy and scleral fixation of posterior chamber IOL. Suture knots are not visible.
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Remarkable visual improvement is possible with current vitrectomy techniques, yet vitreous surgeons have been slow to embrace the use of lens implants. Encouraging results have been reported using posterior chamber IOLs at the time of pars plana vitrectomy,15-17 but these surgeons utilized capsular support, not scleral fixation. We sutured posterior chamber IOLs to sclera when pars plana vitrectomy-lensectomy destroyed all capsular support. Lakenpal and Dogra have fixed posterior chamber IOLs to sclera at the time of pars plana vitrectomy, but this technique has not been published. We did not try to place anterior chamber implants, and occasionally anterior segment damage may preclude such placement, as in patient 6 (Fig 4A). Corneal surgeons have led the way in establishing the safety and efficacy of suture fixation of posterior chamber IOLs in complicated cases of aphakia by reporting large series of successes at the time ofpenetrating keratoplasty.5,12"19,20,23 Scleral fixation enjoys a slight preference over iris fixation at this time.24 Scleral fixation of a posterior chamber IOL is not a new procedure, and Girard25 reported fixation of a haptic into the sclera in 1981. Most investigators prefer ciliary sulcus fixation but Apple and associates26 have shown that posterior chamber IOL haptics often miss the sulcus and that the sulcus diameter is only 11.0 to 11.5 mm, less than most surgeons think. Duffey and associates27 used needles perpendicular to the sclera to demonstrate scleral relationships to the ciliary sulcus and found that the sulcus lies only 1.0 mm posterior to the posterior surgical limbus in the vertical meridians and barely 0.5 mm behind the limbus in the horizontal meridians. In view of this, we placed sutures 0.75 mm posterior to the limbus in the oblique meridians. Careful scleral location of needle entries maximized our chances for ciliary sulcus fixation, reducing the risk of bleeding from inadvertent perforation of the major arterial circle of the iris, which is located in the anterior ciliary body. Our technique was further modified to minimize reported complications of suture exposure, lens rotation, and endophthalmitis.22,23,28 A deep groove allowed for easy concealment of knots, and four-point fixation was used for both stability and for simplicity of knot tying. The two sutures that exited from each groove (Fig 3D) were tied to each other, and the resulting knot was buried and unlikely to erode, reducing the risks of discomfort and infection (Fig 4B). These modifications directly derived from the technique of James and Lewis but also owe much to the methods of Cowden and Hu," Girard,13 Hu and associates,18 Shin,20 and Spigelman and associates.21 The only negative features of these maneuvers may be some initial
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confusion by the surgeon when four sutures are seen exiting from the limbal wound at the 12-o'clock position (Fig 3A), but this is easily adjusted to after the first operation. The visual results in our small patient population were very satisfying (Table I), but attention is called to the young age-range involved, 27 to 55 years. Two patients had a final acuity of less than 20/40 owing to maculopathy in one and preexisting amblyopia in the other. Follow-up has been relatively brief (average, 7 months), but the smooth course of all patients and analysis of extensive posterior chamber IOL experienced by others in the literature suggests that no special complications need be anticipated. Posterior chamber IOLs are safe and useful. We encourage the appropriate use of IOLs with vitrectomy surgery, and we offer an implantation technique that my prove helpful. REFERENCES 1. Kraff MC, Sanders DR, Lieberman HL: Monitoring for continuing endothelial cell loss with cataract extraction and intraocular lens implantation. Ophthalmology 1982; 89:3034. 2. Smith PW, Wong SK, Stark WJ, et al: Complications of semiflexible, closed-loop anterior chamber intraocular lenses. Arch Ophthalmol 1987; 105:52-57. 3. Speaker MG, Lugo M, Laibson PR: Penetrating keratoplasty for pseudophakic bullous keratopathy. Ophthalmology 1988; 95:1260-1268. 4. Stark WJ, Cowen CL, Worthen DM, et al: Complications of flexible and semiflexible anterior chamber lenses. Arch Ophthalmol 1987; 105:20-21. 5. Stark WJ, Gottsch JD, Goodman DF, et al: Posterior chamber lens implantation in the absence of capsular support. Arch Ophthalmol 1989; 107:1078-1083. 6. Apple DJ, Olson RJ: Closed loop anterior chamber lenses. Arch Ophthalmol 1987; 105:19-20. 7. Kraff MC, Lieberman HL, Sandlers DR: Secondary intraocular lens implantation: Rigid/semirigid versus flexible lenses. J Cataract Refract Surg 1987; 13:21-26. 8. Lindstrom RL, Harris WS: Secondary anterior chamber lens implantation. CLAO J 1986; 10:133-136. 9. Wong SK, Koch DD, Emery JM: Secondary intraocular lens implantation. J Cataract Refract Surg 1987; 13:17-20. 10. Lim ES, Apple DJ, Tsai JC: An analysis of flexible anterior chamber lenses with special reference to the normalized rate of lens explantation. Ophthalmology 1991; 98:243-246. 11. Cowden JW, Hu BV: A new surgical technique for posterior chamber lens fixation during penetrating keratoplasty in the absence of capsular or zonular support. Cornea 1988; 7:231-235. 12. Gaster RN, Troutman RC, Aspasia D: Combined penetrating keratoplasty and posterior chamber lens implantation in pseudophakic keratopathy. Trans Am Ophthalmol Soc 1990; 88:326-342. 13. Girard L: PC-IOL implantation in the absence ofposterior capsule support. Ophthalmic Surg 1988; 19:680-682. 14. Pannu JS: A new suturing technique for ciliary sulcus fixation in the absence of posterior capsule. Ophthalmic Surg 1988; 19:751-754. 15. Koenig SB, Han DP, Mieler WF, et al: Combined phakoemulsification and pars plana vitrectomy. Arch Ophthalmol 1990; 108:362-364.
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16. Pang MP, Peyman GA, Minatoya HK: Posterior chamber lens implantation following pars plana lensectomy and vitrectomy in severe proliferative diabetic retinopathy. CanJ Ophthalmol 1989; 24:175-178. 17. Ruiz RS, Saatci OA: Posterior chamber intraocular lens implantation in eyes with inactive and active proliferative diabetic retinopathy. Am J Ophthalmol 1991; 111:158162. 18. Hu BV, Shin DH, Gibbs KA, et al: Implantation of a posterior chamber lens in the absence of capsular and zonular support. Arch Ophthalmol 1988; 106:416-420. 19. Price FW, Whitson WE: Visual results of suture-fixated posterior chamber lenses during penetrating keratoplasty. Ophthalmology 1989; 96:1234-1240. 20. Shin DH: Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens. Ophthalmic Surg 1988; 19:755-756. 21. Spigelman AV, Lindstrom RL, Nichols BD, et al: Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant. Ophthalmic Surg 1988; 19:396-398. 22. Heilskov T, Joondeph BC, Olsen KR, et al: Late endophthalmitis after transcleral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1989; 107:1427. 23. Johnson SM: Results of exchanging anterior chamber lenses with sulcus-fixated posterior chamber IOLs without capsular support in penetrating keratoplasty. Ophthalmic Surg 1989; 20:465-468. 24. Sen HA, Smith PW: Current trends in suture fixation of posterior chamber intraocular lenses. Ophthalmic Surg 1990; 212:689-695. 25. Girard LJ: Pars plana phakoprosthesis (aphakic intraocular implant): A preliminary report. Ophthalmic Surg 1981; 12:19-22. 26. Apple DJ, Price FW, Gwin T, et al: Sutured retropupillary posterior chamber intraocular lenses for exchange or secondary implantation. Ophthalmology 1989; 96:1241-1247. 27. Duffey RJ, Holland EJ, Agapitos PJ, et al: Anatomic study of transsclerally sutured intraocular lens implantation. Am J Ophthalmol 1989; 108:300-309. 28. Lindquist TD, Agapitos PJ, Lindstrom RL, et al: Transcleral fixation of posterior chamber intraocular lenses in the absence of capsular support. Ophthalmic Surg 1989; 20:769-775.
DISCUSSION
DR RICHARD C. TROUTMAN. I am particularly pleased to discuss this paper, not only because it has been presented by Doctor Berler, a new member and longtime friend, but also because Doctor Berler and I shared the same mentor, Doctor McLean, who I am sure would have been most proud to welcome Doctor Berler to join our number. The authors have presented a new approach to the visual rehabilitation of patients undergoing vitreoretinal surgery combined with pars plana total extraction of the lens. They have recognized that successful management of the primary disease is but halfway to a cure. After carefully surveying the literature, they have chosen to use posterior chamber lenses, fixated to the sclera through the scleral sulcus, to avoid the late complications inherent to anterior chamber angle-fixated lenses (eg, Kelman-style lenses), pseudophakic bullous keratopathy, uveitis and glaucoma, and cystoid maculopathy. They have cited in particular the experience of corneal surgeons, such as myself and Gaster, who routinely use posterior chamber lenses in the management of pseudophakic bullous keratopathy. Our pathology differs, however, in that the already-present anterior chamber intraocu-
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lar lens and keratopathy necessitate an anterior approach. This facilitates not only vitrectomy but, in the presence of an intact iris, the alternative use of an irisfixated posterior chamber lens. This approach is preferred in particular over the use of "blind" sulcus fixation as opposed to the technique described by Berler and Friedberg. Their technique, derived from a technique described by Lewis, is particularly effective in the intact globe. As he has illustrated, all needles are inserted from externally, the needle arming the fixating suture as well as the 27gauge needle guiding its exit from the opposite sulcus. This reduces the possibility of hemorrhage and assures accurate sulcus positioning of the lens haptics, and it is my preferred technique in corneal surgery when the iris sphincter is compromised and in an intact globe. One objection to the authors' technique is the necessity to tie the thread to the free end of the haptic, which might become untied or slip off during or following the procedure. Also, there is the unknown toxicity that may be elicited from heating the haptic to prevent slipping. I have found both the iris and sulcus fixation techniques are facilitated by the use of an intraocular lens, the haptics of which have been fitted with fixation holes proximal to the optic (for iris fixation) and at the peripheral curve of the haptic (for sulcus fixation), the "lens for all reasons" (ORC). These allow the suture thread to be fixated in the loop without knotting. For iris fixation, suturing is further facilitated by the use of a doublearmed (BVIOO-4 Ethicon) 2-inch polypropylene thread. Lewis has recently modified his technique for use with a similar lens (Cilco, Alcon, CC70BD). This lens has fixation holes only at the peripheral curve of the haptic. His recent technique is designed to use a single suture loop passing freely through the hole in the haptic. This also permits the knot to be rotated into the needle tract, obviating the necessity to create a groove or flap to bury the knot. The double suture is passed as illustrated by Doctor Berler, but after being cut, instead of being tied to the haptic, one cut end is passed through the fixation hole and tied to the cut end exiting from the same side. The knot can then be readily pulled through and externalized and cut off. The thread loop remaining is knotted over the sclera and the free end can be easily rotated and buried in a needle tract. The same maneuver is repeated to the opposite side as the lens is positioned behind the iris. In spite of the small series of six patients and the varied pathology, the authors obtained consistently good functional vision results, limited only by preexisting disease, significantly better than our experience in pseudophakic keratopathy. This may be because of the younger patient group (average age, 37 years) and the relatively short follow-up (7 months). Further, one can anticipate the necessity for secondary retinal surgery because of the severe primary disease. Nevertheless, their experience has shown both the feasibility and efficacy of primary visual rehabilitation, which has until now been largely ignored in the management of such severely damaged eyes. I should like to pose the following questions to the authors: 1. What are your exclusion criteria? 2. How were implant powers and accuracy determined in the absence of a cataract in the fellow eye with a significant refractive error?
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3. Did any patient have compromised binocular vision or diplopia? If so, was it related to posterior disease or to the intraocular lens? 4. What were the preoperative and postoperative specular microscopy findings? 5. In the event of secondary vitreoretinal surgery, how would you handle a dislocated intraocular lens? Remove it? Replace it? DR DANIEL M. TAYLOR. I would like to congratulate Doctor Berler on his presentation. I am very pleased to see that the retinal surgeons are moving into the intraocular lens field. Most corneal surgeons probably began to place posterior chamber sutured-in-lenses some 5 years ago after their disenchantment with anterior chamber lenses in eyes requiring penetrating keratoplasty for corneal decompensation secondary to an iris supported or malpositioned anterior chamber lens in eyes that had received intracapsular cataract extraction. Having been badly burned with iris supported lenses and intracapsular extraction, I elected, from the onset, to avoid fixating the posterior chamber IOL to the iris. We began, as Doctor Berler outlined, by making a double pass through the ciliary sulcus and out through the sclera to provide stable fixation. We did not experience a ciliary body hemorrhage with this technique, but other surgeons have and, on occasion, the bleeding has been significant. For this reason, we felt that a single pass through the ciliary body might be preferable to reduce the chance of inadvertent bleeding by at least 50% and that the fixation would still be reasonably stable. With this change in technique, we continued to avoid intraocular bleeding. On only one occasion did we experience a significant rotation of the lens, but this was easily correctable with a spatula. I have not placed an anterior chamber lens in any eye requiring penetrating keratoplasty for over 4 years, and have used them only on very rare occasions during routine cataract surgery. In the latter instance, we elected to use an anterior chamber lens only when there has been extensive capsular rupture and/or vitreous loss with inadequate capsule remaining in to support the posterior chamber lens. The insertion of a sutured-in posterior chamber lens during cataract surgery is a more formidable procedure than during keratoplasty, and in an eye that has already been surgically traumatized, it seems reasonable to avoid excessive manipulation. From 1975 through 1979, I inserted a fairly large number of iris supported lenses, combined with intracapsular cataract extraction. We subsequently experienced a very high instance of cystoid macular edema that frequently progressed to corneal decompensation. When we performed a penetrating keratoplasty and left the iris supported lens in place, we experienced an extremely high incidence of subsequent graft failure within 1 to 3 years after keratoplasty. The cystoid macular edema, corneal decompensation and subsequent graft failure were all due to the presence of chronic low-grade inflammation secondary to chronic iris irritation. Similar results were reported by others with the utilization of anterior chamber lenses, but my own experience in this area was limited since I converted directly to extracapsular cataract extraction with the utilization of posterior chamber lenses in 1979. This is a problem that has been largely eliminated with the
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adoption of extracapsular surgery and posterior chamber lens insertion by almost all surgeons. In the past, a number of our patients who had experienced the above sequence of events developed permanent visual loss secondary to macular degenerative changes caused by the persistent cystoid macular edema. In some of our patients who have received a penetrating keratoplasty, anterior vitrectomy and sutured-in posterior chamber lens, for what we perceived to be permanent loss of macular function and corneal decompensation due to the presence of an iris fixated or anterior chamber lens, we have actually noticed a resolution of the cystoid macular edema and an improvement in visual acuity to the 20/60 to 20/40 range. This is a bit anecdotal and will require carefully controlled studies, but it seems to be a vast improvement over the hopelessly burned out maculas that we have dealt with in the past where the vision was permanently reduced to the 20/200 to 20/400 range. I would like to suggest again to Doctor Berler that he consider converting to the single suture scleral fixation technique since the fixation appears to be adequate and reduces the change of intraocular hemorrhage by at least 50% over the double fixation technique. We really have not had any problems with knots or loss of lenses into the vitreous or late intraocular infection. In essence, we have had no complications from this procedure and believe it has a distinct advantage over the anterior chamber lens technique. Again, my congratulations to Doctor Berler for his excellent presentation. DR RICHARD LINDSTROM. Thank you for an excellent paper. I now have a retinal surgeon in my association who is also doing this. The retinal surgeons are moving into intraocular lenses. It is quite interesting. I think after traveling around the world and being interested in this now for several years, there are several people that deserve some credit. They include Strampelli, Epstein from South Africa who is not commonly mentioned but did this in the middle of the 1970s, Louis Girard and Enrique Malbran. In many of the publications they have not all been credited. Two-point fixation or four-point fixation, both work. In addition, I would like to mention that I think it works equally well if you pass the needle inside out as it does from outside in. It is crucial, however, to bury the sutures. The question I have, is have you had any hemorrhage? In the several hundred cases that we have done we have seen hemorrhages. We have found that we can always control it, sometimes, with irrigation of thrombin, 100 U/ml. I think in particular one should watch for the anticoagulated patient who consumes a lot of aspirin or Coumadin. This may carry some extra risk. Did you have any hemorrhage at all and since you deal with a lot of hemorrhage, as a retinal surgeon, what would you recommend to manage it? In addition, I would like to ask again if you think it is better in a complicated situation, such as you deal with, to do it in one stage or two stages? I would think intraocular lens power calculation in these complex cases might be quite difficult. Some of the retinal surgeons that I work with prefer the two stage procedure. They will simply reconstruct the eye as a
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retinal surgeon and have the implant placed later. Have you done any as a second stage and what would be your recommendation? DR ROBERT C. DREWS. It is interesting to see the variation in techniques for fixating these lenses. We even had one retinal surgeon in St Louis who did a series of about 20 cases where he placed the loops in the ciliary sulcus under direct visualization without sutures. He just left them there. That was a little scary, but these patients did well. A few thoughts. When you heat Prolene you have to be a little careful. If you heat it lightly it is easy to form a mushroom cap on the end of the Prolene. The edges of that cap are quite sharp and may lead to late tissue erosion and irritation. In trauma cases especially, I think it is important to do a pupil-plasty to repair iris defects to improve the patient's visual function. Because of the few cases of endophthalmitis that are reported, I think it is important in all of these cases to instruct the patient on the early signs of irritation of a suture end sticking up and of endophthalmitis, so hopefully they will come before infection occurs. The question is not whether complications occur, the question is how often? DR THOMAS 0. WOOD. Historically, I would like to mention that Doctor Muenzler in Oklahoma City, is the guy that got us all suturing in posterior chamber intraocular lenses in corneal transplant patients about 1979 or 1980. Doctor Gettelfinger, in Memphis, was right on his heels. Doctor Troutman, this was an elegant presentation on the use of implants in retina work. Doctor Charles, a vitreoretinal surgeon who specializes in vitrectomy, and shares the operating room with me uses implants frequently at the time of vitreoretinal repair. Doctor Troutman pointed out that there is a difference between putting implants in when you are doing vitreoretinal work and at the time of comeal transplantation. It is not easy to suture implants to the sclera at the time ofcorneal
transplantation. I have gone back to what Doctor Troutman said that for an anterior segment surgeon, it is not only quicker, but I think much safer to suture the lenses to the iris. You save yourself a lot of work and maybe an expulsive hemorrhage. Thank you. DR GEORGE WARING. The vast majority of these are done, I think, with penetrating keratoplasty and Doctor Stulting has devised a very simple method of doing it under direct visualization so you can see where the needle goes. This involves, with an open anterior segment, simply grasping the edge of the iris, the edge of the corneal wound and then depressing the limbus with a straight instrument. You can seen the ciliary sulcus directly and know exactly where to put the needle. This distorts the front of the eye a little bit but it is a nice way to know where the needle goes. I also endorse Doctor Drews point about iridoplasty. Particularly in combination with penetrating keratoplasty where you want to put the pupil under the center of the graft and where it is very easy to make iridotomies, sphincterot-
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omies and to put in as many sutures as you need. Even a purse-string suture around the pupil to pull it down, but not too small for the retinal surgeon, approximately 4 mm so it is centered underneath the graft.
DR DAVID K. BERLER. Thank you Doctor Troutman for your very kind comments. Halfof the people in this room seem to be able to think of somebody who we have not mentioned that has been helpful in facilitating the fixation of posterior chamber lenses. I find it very interesting that Strampelli performed a suture fixation of a lens to the sulcus in 1955. You asked about our criteria for selection of cases for this procedure. We did not exclude anyone and quite frankly we took whatever cases we could get. The removal of a lens at the time of vitrectomy is becoming less frequent. The accurate determination of a lens power for the selected IOL has been easier than we expected, and we have not had any significant surprises with too much plus or too much minus. All of the cases that we operated on were performed at an elective time several months after the initial insult, and none of them had significant retinal detachments. This may explain why our A-scan and calculations could be so uneventful. We have no information about specular microscopy since it was not done. Doctor Troutman asked about the problems of secondary retinal surgery and dislocated lens implants that might be associated with this. We have not yet had to go back and do secondary retinal surgery in one of our vitrectomy patients where a lens has been sutured to the pars plana. We would not anticipate any special problems with the lens since we routinely repair dislocated lenses at the time of vitrectomy, and do this by manipulating them with a vitreous forcep after the vitreous has been cleared from the front of the lens, and reattaching it in a variety of ways. Usually we create a loop of suture by partially inserting a needle with Prolene backhand creating a loop of suture. The haptic is placed through the loop, the suture is pulled tight so that the haptic is placed against the sclera and then the suture is tied. This can be done with 1-haptic of a subluxed lens or with both haptics in a completely dislocated lens. Doctor Taylor suggested that a single suture passage may be safer than the double suture passage that we use. We have not had any complications with a double passage. We shared Doctor Lindstrom's concern about hemorrhage but we have not had any hemorrhage from the needle punctures. I believe that the closed system of vitrectomy surgery with an infusion cannula and the ability to raise the intraocular pressure at will, creates a margin of safety that would be very helpful if such hemorrhage occurs. Doctor Lindstrom's question about using a 2-stage procedure instead of implanting a lens at the time of vitrectomy is a critical question. We believe that patients would be better served by having one operation instead of two and the purpose of this paper was to see if lens implantation could be safely and sensibly combined with vitrectomy surgery. Doctor Drews suggested that we pay attention to repair of sector iridectomies when these are necessary for our surgical approach. It might be difficult to convince retinal surgeons to close up large pupils since they like mydriasis.
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The question ofwhich lens to use for scleral fixation has been raised. This is not completely clear at this time but perhaps a 1-piece lens would be best for stability. We are aware that corneal surgeons do have means of visualizing the ciliary sulcus for exact placement when a penetrating keratoplasty is performed. We have not used any techniques to visualize the sulcus directly. Thank you very much.
