Suture-wick endophthalmitis with sutured posterior chamber intraocular lenses Robert

J.

Schechter, M.D.

ABSTRACT A patient had a corneal transplant with removal of an anterior chamber lens. As part of the procedure , an exchange posterior chamber lens was inserted and sutured transsc1eral1y into the ciliary sulcus with two subconjunctival 10-0 polypropylene (Prolene®) sutures. One month later the patient experienced a sudden decrease in vision and severe eye pain. Streptococcus viridans was cultured from the vitreous tap and the eye eventually was lost from this endophthalmitis. The infecting organism appeared to gain access to the eye through one of the Prolene sutures that had eroded through the conjunctiva and become extedorized. This report presents a case in which an eroding 10-0 Prolene suture used for transsc1eral posterior chamber lens Sxation was the probable mechanism causing endophthalmitis. This complication represents an avoidable risk unique to this type of intraocular lens Sxation. Key Words: Ciliary sulcus fi xation , corneal transplant , e ndophthalmitis , penetratin g keratoplasty, posterior chamber intraocul a r I n s, scl e ral fix ation , Stre ptococcus Giridall s, suture wi ck

lens is necessary. Although some techniques involve suturing the lens haptics to the iris, 1,2,3 more recent investigators have sutured the haptic transsclerally through the ciliary sulcus. 4 - 7 Studies in cadaver eyes have suggested that for true ciliary sulcus fixation, sutures should exit the sclera less than 1 mm posterior to the corneosclerallimbus. 8 Transscleral IOL fixation presents a risk factor not found in any other type ofIOL Sxation -the risk of intraocular passage of pathogens through the externalized suture tract. A case of endophthalmitis has been reported with a 9-0 polypropylene (Prolene®)sutured sclerally Sxated lens in an eye following trauma with subsequent retinal detachment and vitrectomy. 9 This report presents a case with a 10-0 Prolene transsclerally sutured posterior chamber lens following penetrating keratoplasty. CASE REPORT An 80-year-old patient was seen with corneal decompensation secondary to uveitis associated with a closed-loop anterior chamber lens. On May 14, 1989, a corneal transplant was performed with IOL removal and anterior vitrectomy. A posterior chamber lens was inserted, supported by two 10-0 Prolene sulcus sutures. The sutures emerged on the sclera externally, and the ends were tied on themselves to flatten them so that all residual ends initially lay flat beneath the conjunctiva. The patient did well for approximately one month, then returned with sudden incapacitating eye pain and decreased vision. One of the two sutures had eroded through the conjunctiva and was exposed and externalized (Figure 1). The diagnosis of endophthalmitis was made, and Streptococcus viridans later grew from the vitreous tap. In spite of a complete vitrectomy and appropriate intravitreal, topical, and

It is now technically possible to insert a posterior chamber intraocular lens (IOL) in an eye without adequate posterior capsular support. The technique may be useful in eyes that are unsuitable for capsular-supported posterior chamber lenses and would otherwise require an anterior chamber IOL. In the absence of adequate posterior capsular support, however, another method of securing the From the Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, California. Reprint requests to Robert]. Schechter, M.D., 1515 North Vermont Avenue, Los Angeles, California 90027.

J CATARACT REFRACT

Fig. 1.

(Schechter) One of the two 10-0 Prolene sutures (arrow) has become exposed and externalized, providing a potential pathway into the eye for ocular pathogens.

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systemic antibiotics, the eye ultimately went into phthisis. DISCUSSION Several investigators prefer a posterior chamber lens to an anterior chamber lens after a corneal transplant. 2 ,10 Graft survival may be enhanced by the lack of "hardware" in the anterior chamber and possibly by some stabilizing effect of a posterior chamber lens. 2 Intraocular lenses supported by scleral sutures have a risk not found in any other currently used implantation technique. The scleral suture, covered only by conjunctiva, presents a potential wick for bacterial entry into the posterior chamber and vitreous space. Conjunctivitis and ocular irritation must be viewed more seriously in these patients. If the suture becomes exposed or externalized in any way, consideration should be given to covering the suture with conjunctiva or a scleral patch. Surgical techniques may be used to minimize this risk. The externalized suture may be passed more posteriorly, taking another bite of sclera to allow the knot to be covered by the thicker posterior Tenon's capsule. Sutures may be buried in sclera or cauterized flat. Finally, sutures may be externalized beneath a partial-thickness scleral flap, which serves to protect the suture from exposure. Even in cases like these, however, the knot may erode through the overlying scleral flap, resulting in suture exposure and subsequent endophthalmitis. l l The risks of using a sclerally fixated posterior chamber lens must be compared with those associated with using a flexible anterior chamber implant, which appears to be a viable alternative even in cases in which a corneal transplant is performed. 12

8. 9.

10. 11. 12.

tion of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant. Ophthalmic Surg 1988; 19:396-398 Duffey RJ, Holland EJ, Agapitos pJ, Lindstrom RL. Anatomic study of transsclerally sutured intraocular lens implantation. Am J Ophthalmol 1989; 108:300-309 Heilskov T, Joondeph BC, Olsen KR, Blankenship Gw. Late endophthalmitis after trans scleral fixation of a posterior chamber intraocular lens [letter]. Arch Ophthalmol 1989; 107:1427 Price FW Jr, Whitson WE. Visual results of suture-fixated posterior chamber lenses during penetrating keratoplasty. Ophthalmology 1989; 96:1234-1240 Epstein E. Suture problems [letter]. J Cataract Refract Surg 1989; 15:116 Koenig SB, McDermott ML, Hyndiuk RA. Penetrating keratoplasty and intraocular lens exchange for pseudophakic bullous keratopathy associated with a closed-loop anterior chamber intraocular lens. Am J Ophthalmol1989; 108:43-48

REFERENCES 1. Alpar JJ. Use of the Ethicon 1713 suture for McCannel suturing. Am Intra-Ocular Implant Soc J 1985; 11:296-298 2. Drews RC. Posterior chamber lens implantation during keratoplasty without posterior lens capsule support. Cor. nea 1987; 6:38-40 3. Apple DJ, Price FW, Gwin T, et al. Sutured retropupillary posterior chamber intraocular lenses for exchange or secondary implantation; the 12th annual Binkhorst lecture, 1988. Ophthalmology 1989; 96:1241-1247 4. Grehn F, Sundmacher R. Fixation of posterior chamber lenses by transscleral sutures: technique and preliminary results. Arch Ophthalmol 1989; 107:954-955 5. Insler MS, Mani H, Peyman GA. A new surgical technique for dislocated posterior chamber intraocular lenses. Ophthalmic Surg 1988; 19:480-481 6. Lindquist TD, Agapitos pJ, Lindstrom RL, et al. Transscleral fixation of posterior chamber intraocular lenses in the absence of capsular support. Ophthalmic Surg 1989; 20:769-775 7. Spigelman AV, Lindstrom RL, Nichols BD, et al. Implanta756

J CATARACT REFRACT SURG- VOL

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Suture-wick endophthalmitis with sutured posterior chamber intraocular lenses.

A patient had a corneal transplant with removal of an anterior chamber lens. As part of the procedure, an exchange posterior chamber lens was inserted...
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