ARTICLE

Sutured posterior chamber intraocular lenses for traumatic cataract in Africa Graeme Rogers, MB ChB, DCH, DO, FCOphth(SA), MMed(UCT), Hamzah Mustak, MB ChB, DO, Mignon Hann, MD, DO, David Steven, MB ChB, FRANZCO, Colin Cook, MB ChB, DO, MPH, FRCOphth, FCS(Ophth)SA

PURPOSE: To determine the outcomes of sutured scleral fixation of posterior chamber intraocular lenses (PC IOLs) after trauma in an African population. SETTING: State hospital and affiliated district hospital, Cape Town, South Africa. DESIGN: Case series. METHODS: A retrospective review was performed of the medical records of patients in whom a sutured PC IOL had been implanted for traumatic aphakia in the preceding 5 years. RESULTS: Eighty-five percent of the 59 patients had a significant improvement in uncorrected distance visual acuity (UDVA) at the final visit. Two-thirds of patients achieved an UDVA of 6/18 or better. Those not improving had severe preexisting macular or corneal pathology. A significant number of patients (28%) with angle recession developed ocular hypertension during the postoperative period. CONCLUSION: After careful preoperative selection, sutured PC IOLs were effective in the visual rehabilitation of eyes with traumatic subluxated cataract in which the capsular bag could not be retained. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; -:-–- Q 2014 ASCRS and ESCRS

The management of unilateral traumatic cataract with inadequate zonular integrity or capsule support poses unique challenges to surgeons. Contact lenses and anterior chamber intraocular lenses (AC IOLs) for aphakic rehabilitation, despite being respectively less invasive and technically easier to implant, are not appropriate in all patients. A sutured posterior chamber IOL (PC

Submitted: June 19, 2013. Final revision submitted: October 26, 2013. Accepted: January 27, 2014. From the Division of Ophthalmology (Rogers, Mustak, Cook), Groote Schuur and Red Cross War Memorial Children’s Hospitals, and Eerste Rivier Hospital Ophthalmology (Hann, Steven), Eerste Rivier, Cape Town, South Africa. Corresponding author: Graeme Rogers, MB ChB, DCH, DO, FCOphth(SA), MMed(UCT), Division of Ophthalmology, Faculty of Health Sciences, Groote Schuur Hospital, H53 Old Main Building Observatory, Cape Town, Western Cape, 7925 South Africa. E-mail: [email protected]. Q 2014 ASCRS and ESCRS Published by Elsevier Inc.

IOL) may be safer because it does not further compromise traumatized angle structures. Suturing PC IOLs is time consuming and intricate. In low-income countries, such as South Africa, indigent patients with unilateral posterior segment ocular trauma and guarded prognoses are often denied intervention. Similarly, one may argue that such unilateral anterior segment interventions are inappropriate. This study was performed to determine whether the visual results of sutured PC IOLs for traumatic cataract justify this intervention in middle-income and lowincome settings. PATIENTS AND METHODS The clinical records of adult patients who had sutured PC IOL implantation for traumatic cataract over a 5-year period (2007 to 2012) were reviewed. Ethical approval for the study was obtained from the Human Ethics Committee, University of Cape Town Faculty of Health Sciences. On examination, all patients had a definite history of ocular trauma, previous ocular surgery for trauma, or evidence of trauma in addition to the lens subluxation. All 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.01.031

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patients were selected for surgery on the assumption that there would be a visual benefit. The surgeon and the patient in consultation determined the need for surgery. No patients were selected for surgery if they had a preoperative afferent pupillary defect, an abnormal B-mode ultrasonography, or unimproved potential acuity meter (PAM) measurements. Benefit of the doubt was given to patients whose poor fundus view precluded accurate assessment of the fundus or whose vision was too poor for PAM measurements unless other factors excluded them on the basis of a poor prognosis. The IOL dioptric power was based on preoperative biometry; the target was emmetropia in all cases. Patients were aphakic after primary intracapsular cataract extraction, had capsular dehiscence too severe for the use of capsular tension rings and salvage of the capsular bag, or had a dislocated crystalline lens. Surgery was not performed for cosmesis or improved peripheral visual field in any patient with known significant posterior segment trauma. Patients with a short follow-up were not excluded because poor follow-up is typical of trauma patients at the unit where the surgery was performed.1 A standard surgical technique with some minor variation between surgeons was performed using sub-Tenon, peribulbar, or general anesthesia. In all cases, an anterior vitrectomy (with or without lensectomy) was performed via 7.0 mm scleral tunnels at 180 or 90 degrees. In ab externo cases, the sutures were threaded through 26-gauge needles 1.0 mm under scleral flaps. This suture was hooked and withdrawn from the eye and sutured to the eyelets of the haptic of a CZ70BD IOL (Alcon Laboratories, Inc.). In ab interno cases, an STC-6 needle (Ethicon, Inc.) was passed via the tunnels 1.0 mm posterior to the limbus. A double-armed 10-0 polypropylene (Prolene) suture with a CIF-4 curved or straight STC-6 needle (Ethicon, Inc.) was used in all cases. The IOL was placed under the iris via the scleral tunnel, and the sutures were tightened and tied after a second partialthickness scleral pass; the knot was buried under sutured flaps. The scleral tunnel was then closed with 10-0 nylon interrupted sutures. Many recent improvements have been developed, and cases with significant alterations in technique were excluded from the series. Data on postoperative visual acuity, autorefraction, biomicroscopy of the anterior segment, intraocular pressure (IOP) measurement, gonioscopy, and fundoscopy were recorded. Lenticular astigmatism was determined by deducting autorefractor keratometry values from the total astigmatism.2 Snellen and decimal visual acuities were converted into logMAR notation for statistical analysis.3 Hand movements and counting fingers visual acuities were recorded as 0.010 and 0.001, respectively.3 The data were entered into an Excel spreadsheet (Microsoft Corp.). For uniformity, the visual acuities were then reverted to decimal acuities. Statistical analysis was performed using Stata software (version 11.1, Statacorp, LC), and the Wilcoxon rank-sum test was used to determine associations between age, surgeon, primary or secondary surgery, presence of angle recession, preoperative and postoperative corrected and uncorrected visual acuities, intraocular IOL tilt, associated injuries, and other factors.

RESULTS Over the 5-year period, 59 patients (44 men [78.57%]) had sutured PC IOL implantation for traumatic cataract. The case notes were unavailable for 3 patients,

and 1 patient was lost to follow-up in the early postoperative period. The mean follow-up for ophthalmologic examination and refraction was 7.39 months (range 0 to 54 months). The mean age of the patients at surgery was 51.76 years (range 22 to 84 years). Of the 56 patients for whom the case notes were available, none had ocular comorbidities unrelated to the trauma they sustained. Seven patients had previous penetrating corneal laceration repairs, and none had previous scleral injuries. The other patients had sustained blunt closed-globe injuries. Senior residents performed 14 cases (25%) and qualified specialists experienced in sutured IOL techniques performed 42 cases (75%). There was no difference in the visual outcomes (PZ.684) or IOL tilt (PZ.679) between these 2 groups. No patient had decentered or tilted IOLs on clinical examination. The mean postoperative spherical equivalent was 1.797 diopters (D) (range C2.5 to 11.0 D). The mean lenticular astigmatism was 1.00 D (range 0.0 to 6.0 D). The mean preoperative decimal corrected distance visual acuity (CDVA) was 0.02 G 0.146 (SD) (range 0.001 to 0.63). Table 1 shows the preoperative and postoperative visual outcomes. The median postoperative CDVA at the last visit was 0.50 (range 0.80 to 0.001). Patients with a longer follow-up had worse CDVA (0.21 versus 0.48) (PZ.0443). Forty-seven eyes (85.5%) had improved uncorrected distance visual acuity, and an equal number had improved CDVA. The median improvement was 0.39. Thirty-seven eyes (66%) achieved a good result, with a CDVA of 0.32 (6/18) or better at the final visit. Six eyes were unchanged, and 2 were worse postoperatively. There was no significant difference in outcomes between older patients (mean CDVA 0.484) and those younger than 50 years (mean CDVA 0.438) (PZ.425). The 7 patients with corneal scars and a history of penetrating trauma had better vision than those

Table 1. Preoperative and postoperative corrected distance visual acuities (N Z 56). Patients, n (%) CDVA

WHO Category

Preoperative

Postoperative

A B C D d

4 (7.1) 15 (26.8) 2 (3.5) 35 (62.5) 0

40 (71.4) 10 (17.9) 1 (1.8) 4 (7.0) 1 (1.8)

1.00–0.32 !0.32–0.10 !0.10–0.05 !0.05–NLP Unrecorded

CDVA Z corrected distance visual acuity; NLP Z no light perception; WHO Z World Health Organization

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without. The mean CDVA was 0.49 G 0.19 and 0.27 G 0.23, respectively (PZ.1734). Eyes with postoperative evidence of previous posterior segment injury had statistically significantly worse CDVA than eyes without posterior segment injury (mean 0.21 versus 0.33) (PZ.0017). In 1 eye with optic atrophy detected postoperatively, CDVA did not improve beyond 0.25. The remainder had significant macular scars, choroidal ruptures, or epiretinal membranes involving the fovea. Those with transient vitreous hemorrhages were excluded from this group. Eighteen patients (32.7%) were treated and controlled medically for ocular hypertension postoperatively. All except 2 of these patients had 1 or more clock hours of angle recession. One patient without angle recession developed raised IOP that resolved after withdrawal of topical steroids. One patient developed glaucoma without angle recession but had peripheral anterior synechiae. During the follow-up, 1 patient required surgery (a glaucoma drainage implant) due to refractory high IOP in the only sighted eye. The presence of angle-recession glaucoma in 16 patients (28%) did not significantly influence the visual outcome (PZ.849). Figure 1 shows the association between angle recession and the presence of postoperative ocular hypertension. All patients had mild to moderate corneal edema within the first postoperative fortnight. Two patients developed longstanding mild corneal decompensation. Two eyes developed significant hypotony within the first postoperative month, 1 of which had evidence of hypotony maculopathy. Eighteen eyes had mild postoperative vitreous hemorrhage that cleared within the first postoperative month. One eye required an Nd:YAG vitreous strandectomy for a residual vitreous wick. No eye developed endophthalmitis, spontaneous suprachoroidal hemorrhage, or suture-related complications during the follow-up.

Figure 1. Angle recession and IOP (mm Hg) (y-axis) after sutured PC IOL implantation for traumatic cataract (PZ.02).

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One patient sustained postoperative trauma to the operated eye (the only sighted eye) within 2 months of sutured PC IOL implantation for traumatic cataract. The eye required pars plana vitrectomy for rhegmatogenous retinal detachment, suprachoroidal hemorrhage, and IOL extrusion. DISCUSSION Approximately one half of all severe eye injuries involve the lens.4 The management of these traumatic cataracts may be far more difficult than that for age-related cataract. There is, however, a paucity of evidence that any sort of IOL implantation is the best treatment for traumatic cataract in eyes without adequate capsule support. Indeed, this uncertainty may apply to management of subluxated IOLs of all causes.5,6 Comparison with other series is therefore difficult. A review article by Shah and Turalba7 on IOL implantation in penetrating ocular trauma did not specifically deal with cases without capsule support. Our analysis of a cohort in which sutured PC IOL implantation was performed for traumatic cataract sought to determine whether the outcomes justify the intervention. To our knowledge, this is the largest single-center series of sutured IOLs for traumatic cataract. Deductions about sutured PC IOLs for traumatic cataract based on the literature may be difficult because the reported series are small2,8,9; they do not specify whether the cataracts were traumatic in origin and/or they do not analyze the results for each cause separately.2,5,8,10,11 Also, some studies of sutured PC IOL implantation for traumatic cataract are restricted to pediatric cases.12,13 Some of the studies most relevant to traumatic cataract management involve the retention of the capsular bag. A large series from Singapore14 evaluated the results of management using fixated capsular tension devices and phacoemulsification; this method achieved a good visual outcome in 92.7% of cases. In contrast, our series excluded all cases in which the capsular bag was deemed salvageable. This may mean that these eyes with more subluxation suffered more severe trauma or that the surgical management or results are inferior. It seems intuitive that using retained capsular rim as the literature recommends would yield better results.15 The consequences of additional manipulation, intracapsular extraction, and anterior vitrectomy may explain our significantly worse outcomes. Intraocular lens tilt and decentration due to the absence of capsule support with unreliable positioning of haptics in the ciliary sulcus may also be important contributors to poor vision postoperatively.16 Chee and Jap14 found that retention of the capsular bag resulted in better vision. It has been

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found that IOL tilt of more than 15 degrees causes coma aberration that cannot be corrected by spectacles.17 There was no significant difference in IOL tilt in primary and secondary implantation surgeries, which was also reported in a prospective series using Purkinje images.17 We may have expected more IOL tilt and decentration from the secondary implantation group given the increased likelihood of iridolenticular fibrosis. We also found lenticular astigmatism to be less contributory than corneal astigmatism in our series; however, comparing the surgically induced astigmatism with the preoperative astigmatism was beyond the scope of this study. The only relevant African study was performed in Kenya and yielded good results in 71% of patients with primary IOL implantation for traumatic cataract.18 However, in none of these cases was a sutured PC IOL implanted for traumatic cataract. Nevertheless, the presence or degree of lens subluxation has not been found to be predictive of the final visual outcome, although all series on this topic have been small. Studies of the management of traumatic cataract with predominantly intact capsules in middle- to lowincome countries report that between 43.5%19 and 71%18 of patients achieved a CDVA of 20/60 or better. Several papers controversially quote youth7 and the presence of angle or iris anomalies as contraindications to AC IOL implantation.3,20 In our study, patient age was not significantly associated with visual outcomes and our unit has traditionally avoided these IOLs in traumatized eyes. The cumulative lifetime prevalence of angle recession in parts of our hospital's patient population is as high as 14.6%, and 5.5% of these patients develop glaucoma.21 In eyes with previous closed globe injury, angle recession of more than 180 degrees and lens subluxation have a separately increased relative risk for causing glaucoma. Those with subluxated cataract had a relative risk of 3.5 of developing glaucoma.22 In our series with known ocular trauma, 16 of the 31 eyes with 1 or more quadrants of recession developed postoperative elevated IOP. The proportion of patients with angle recession who developed ocular hypertension in our series is higher than the 35.8% reported elsewhere.23 Although it is known that increasing degrees of recession may be associated with an increased likelihood of glaucoma, we postulate that angle recession and coexisting lens subluxation may be associated with a cumulatively increased risk for glaucoma. This secondary finding may require further study to determine whether sutured PC IOL implantation for traumatic cataract precipitates glaucoma in eyes with more severe or more widespread recession. Only 2 (10.5%) of our patients without recession developed a transient rise in IOP.

Other studies report markedly variable proportions of patients without preoperative glaucoma who develop persistent postoperative glaucoma8; the reported range is from as low as 2.2%4 to 9.0%.15 However, gonioscopy findings were not mentioned in these studies and the length of follow-up also varied significantly between studies.2 In a study by Krause et al.,8 ophthalmic viscosurgical device use was the predominant cause of glaucoma; however, again no mention was made of the presence or absence of angle recession. Better results in patients with corneal scars is in keeping with the findings by others that patients with traumatic cataract from penetrating trauma do significantly better than those with traumatic cataract from blunt injury.7,19 Those with posterior segment injury have worse results in all studies involving management of concomitant cataract.24 Posterior segment injury in our series was 30.3%, more than the 11.0% to 23.0% in other studies.24,25 Again, our sample may have comprised more severely traumatized eyes. There was 1 retinal detachment during the follow-up period. This incidence is similar to that in other series.2,8 Our study has weaknesses. It is a retrospective case series with all the weaknesses implicit in that study design. Data were not available for 3 patients. There were minor variations in the surgical technique used. The follow-up was relatively short and possibly more comparable to series with an intermediate follow-up.9 Long-term complications, such IOL instability, glaucoma, corneal decompensation, and suture erosion, would probably have been underestimated in this series. However, a 10-year follow-up of scleralfixated IOLs10 reports that complications tended to occur in the first 2 postoperative years. In another large series,26 the mean time to the first complication was 1.1 months. Patients in our series with complications were followed longer and often had poorer outcomes. There may be merit in performing a prospective randomized trial comparing sutured PC IOLs, iris-fixated IOLs, and AC IOLs for traumatic cataract in eyes in which there is inadequate capsule support for bag or sulcus-fixated IOLs. This may be particularly relevant because other nontraumatic studies report no difference in6 or better results with AC IOLs.5 Notwithstanding the weaknesses of our study, it is a large series and provides important evidence that there is benefit in our resource-poor setting of offering this surgery, where indicated, for traumatic cataract. Visual rehabilitation after severe lenticular trauma is effectively achieved by scleral fixation of PC IOLs, even in a low-income setting where phacoemulsification may not be available or possible. Careful preoperative patient selection, regular postoperative follow-up, and early recognition and management of complications are mandatory.

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WHAT WAS KNOWN  Trauma is a common cause of subluxated cataract, and an accepted procedure to rehabilitate such eyes is to implant scleral-fixated IOLs. WHAT THIS PAPER ADDS  A large series of scleral-fixated IOLs for traumatic cataract determined the unique characteristics of this group of eyes and that good results can be achieved despite severe ocular trauma. This is the largest paper of its kind specifically evaluating traumatic subluxated lens rehabilitation in a low-income context.

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First author: Graeme Rogers, MB ChB, DCH, DO, FCOphth(SA), MMed(UCT) Division of Ophthalmology, Groote Schuur and Red Cross War Memorial Children's Hospitals, Cape Town, South Africa

Sutured posterior chamber intraocular lenses for traumatic cataract in Africa.

To determine the outcomes of sutured scleral fixation of posterior chamber intraocular lenses (PC IOLs) after trauma in an African population...
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