Retinopathy progression and visual outcomes after phacoemulsification in patients with diabetes mellitus.

OBJECTIVES: To determine the rate of progression of diabetic retinopathy after phacoemulsification surgery, and whether surgeon experience and/or surgical duration adversely affect visual outcome. METHODS: A retrospective review of 150 eyes of 119 diabetic patients who underwent phacoemulsification surgery during a 5-year period was performed. Data collected included patient age, sex, type and duration of diabetes, diabetic control, associated systemic health factors, preoperative visual acuity and retinopathy grade, duration of surgery, intraoperative complications, and postoperative course. The effect of these factors on visual outcome and rate of retinopathy progression was studied by means of univariate and stepwise multivariate logistic regression analyses. Resident and private cases were compared. RESULTS: Visual acuity improved by 2 or more lines in 117 eyes (78%); 93 eyes (62%) had a final visual acuity of at least 20/40. Retinopathy progression was seen in 37 eyes (25%) with 6 to 10 months of follow-up. Preoperative nonproliferative diabetic retinopathy, proliferative diabetic retinopathy, and limited surgical experience were statistically associated with retinopathy progression and poor visual outcome. CONCLUSIONS: The visual results and rate of retinopathy progression after phacoemulsification surgery in our series did not differ significantly from those reported that used other techniques. Nonproliferative and proliferative diabetic retinopathy and surgical inexperience resulted in an increased rate of retinopathy progression. Arch Ophthalmol. 2000;118:912-917

Combined pars plana lensectomy-vitrectomy with open-loop flexible anterior chamber intraocular lens (AC IOL) implantation for subluxated lenses.

OBJECTIVES: To review our experience with combined pars plana lensectomy-vitrectomy and open-loop flexible anterior chamber intraocular lens (AC IOL) implantation for managing subluxated crystalline lenses. METHODS: Retrospective review of 36 consecutive eyes (28 patients), all of which had subluxated crystalline lenses, managed by pars plana lensectomy-vitrectomy with insertion of an open-loop flexible AC IOL. The study was performed at the Medical College of Wisconsin, Milwaukee, over an 8-year period. RESULTS: An average preoperative visual acuity of 20/163 (range, 20/25 to hand motions) improved to 20/36 (range, 20/20 to 4/200) with surgery after a mean follow-up of 14 months (range, 1 to 59 months) (P < .001, Student's paired t test). Final visual acuity of 20/40 or better was achieved in 75% of eyes (27/36). Complications included cystoid macular edema (8% [3/36]), pupillary block (6% [2/36]), retinal detachment (3% [1/36]), hyphema (3% [1/36]), wound leak (3% [1/36]), and transient vitreous hemorrhage (3% [1/36]). No persistent ocular hypertension was seen, nor did angle abnormalities or corneal decompensation develop. CONCLUSIONS: Pars plana lensectomy-vitrectomy with AC IOL implantation appears to be an excellent technique for managing subluxated crystalline lenses. It is associated with a significant improvement in visual acuity (P < .001) and avoids many of the complications seen with extraction of a subluxated lens through a limbal wound. Additionally, use of an AC IOL offers a simplified alternative to placement of a ciliary sulcus sutured posterior chamber intraocular lens (PC IOL).

Retinopathy progression and visual outcomes after phacoemulsification in patients with diabetes mellitus.

PURPOSE: To determine the rate of progression of diabetic retinopathy following phacoemulsification surgery and to determine if surgeon experience and/or surgical duration adversely affect visual outcome. METHODS: A retrospective review of 150 eyes of 119 diabetic patients who underwent phacoemulsification surgery over a 5-year period was performed. Data collected included patient age, sex, type and duration of diabetes, diabetic control, associated systemic health factors, preoperative visual acuity and retinopathy grade, duration of surgery, intraoperative complications, and postoperative course. The effect of these factors on visual outcome and rate of retinopathy progression was studied. Resident and private cases were compared. RESULTS: The visual acuity improved by two or more lines in 117 eyes (78%). Ninety-three eyes (62%) had a final visual acuity greater than or equal to 20/40. Retinopathy progression was seen in 37 eyes (25%) followed up for 6 to 10 months. Preoperative nonproliferative diabetic retinopathy, prolonged surgical duration, and limited surgical experience were statistically associated with retinopathy progression. CONCLUSIONS: The visual results and rate of retinopathy progression after phacoemulsification surgery in our series do not appear to differ significantly from those reported using other techniques. Nonproliferative diabetic retinopathy, longer surgical duration, and surgical inexperience resulted in an increased rate of retinopathy progression.

Corneal refractive and endothelial changes following THC:YAG (holmium) laser sclerostomy.

BACKGROUND AND OBJECTIVE: To determine the effect of THC:YAG (holmium) laser sclerostomy on corneal curvature and endothelial cell counts. PATIENTS AND METHODS: One hundred twenty-five cases were reviewed for high postoperative corneal astigmatism (> 5 D) or preoperative and postoperative endothelial cell count measurements in eyes without preoperative evidence of corneal endothelial compromise. RESULTS: Nine patients had keratometry reading at 2 to 3 months with documented corneal astigmatic changes of 5.62 to 12 D (mean 7.27 +/- 2.16 D). Sixteen eyes of 14 patients studied with specular microscopy had central mean endothelial cell count reductions of 6.5% following THC:YAG laser sclerostomy. The total energy applied correlated with the percentage reduction in endothelial cell counts (r = .507, P = .045, n = 16, Spearman correlation). CONCLUSION: Higher laser energy levels can result in high corneal astigmatism, which in some cases may be persistent, and a reduction in endothelial cell count.

Removal of dislocated intraocular lenses using pars plana vitrectomy with placement of an open-loop, flexible anterior chamber lens.

OBJECTIVE: There are many alternatives available to the vitreoretinal surgeon in the management of posteriorly dislocated intraocular lenses (IOL). The lens may be repositioned in the ciliary sulcus if there is adequate capsular support, but if this support is absent, it must either be sutured in place (to the sclera or iris) or exchanged for an anterior chamber (AC) IOL. Scleral-sutured IOLs can be associated with hemorrhage, cystoid macular edema, retinal detachment, and endophthalmitis (through the suture tract), and use sutures that must last for the lifetime of the patient. Anterior chamber IOLs (ACIOLs) are easier to implant but require a limbal incision for insertion. The authors sought to determine the safety and efficacy of combining removal of posteriorly dislocated IOLs with ACIOL placement. DESIGN: A retrospective chart review, in which all cases of dislocated IOLs managed at the authors' institution over the last 5 years were reviewed. Patient characteristics, pre-existing ocular conditions, preoperative visual acuity (VA), intraocular pressure (IOP), type of lens dislocated, operation performed, postoperative VA and IOP, and length of follow-up were recorded. RESULTS: A total of nine cases were identified. Seven of these underwent primary posterior chamber (PC) IOL removal with ACIOL implantation. One had an ACIOL placed after a sulcus-sutured PCIOL dislocated, and one had enough capsular support for placement of a PCIOL after removal of a plate haptic silicone lens. Of the seven primary ACIOL cases, the best-corrected VA improved in five cases, was unchanged in one (remained 20/20), and declined in another. The final postoperative VA (mean follow-up, 12 months) was 20/30 or better in five patients, and was limited by age-related macular degeneration and epiretinal membrane in the other two. A hyphema occurred in two patients and cleared in both without visual compromise. There was no evidence of corneal compromise or exacerbation of glaucoma in any of the patients. CONCLUSIONS: Given that the results and complication rates in this small series appear to be similar to those reported for sulcus-suture techniques, implantation of an ACIOL after removal of a posteriorly dislocated IOL appears to be a viable alternative to suture fixation in the absence of capsular support.

Management of ectopia lentis in a family with Marfan syndrome.

OBJECTIVE: To determine the effectiveness of combined pars plana vitrectomy-lensectomy and open-loop anterior chamber lens implantation for the management of ectopia lentis associated with Marfan syndrome. METHODS: Retrospective review of the medical records of 4 consecutive patients with Marfan syndrome who underwent combined pars plana lensectomy-vitrectomy and anterior chamber lens implantation at our institution between August 1994 and July 1995. RESULTS: All patients demonstrated postoperative visual acuity of 20/25 or better during an average follow-up period of 6 months (range, 4-9 months). Two patients developed pseudophakic pupillary block and required YAG laser iridotomy postoperatively. CONCLUSIONS: Pars plana lensectomy-vitrectomy and anterior chamber intraocular lens implantation appears to be an excellent technique for the management of ectopia lentis associated with Marfan syndrome. A bimanual, closed-system endosurgical technique avoids many of the complications previously associated with surgery for ectopia lentis.

Annular keratotomy for the treatment of painful bullous keratopathy.

PURPOSE: To determine whether annular keratotomy can relieve pain associated with bullous keratopathy. METHODS: Three patients with painful bullous keratopathy and poor visual potential underwent partial-thickness (0.30 to 0.42 mm) trephination of the cornea under local anesthesia. RESULTS: All patients reported an absence of pain and foreign body sensation during an average follow-up interval of six months. The surgical procedure was uncomplicated; however, two eyes developed increased central corneal stromal edema. CONCLUSIONS: Annular keratotomy appears to be a relatively safe and simple surgical procedure that may be useful in managing pain in eyes with painful cornea edema and poor visual potential.

Combined pars plana vitrectomy-lensectomy and open-loop anterior chamber lens implantation.

PURPOSE: To investigate the effectiveness of open-loop, one-piece, flexible, Kelman-style, all-polymethylmethacrylate (PMMA) anterior chamber intraocular lenses (AC IOLs) in patients undergoing pars plana vitrectomy surgery for a variety of vitreoretinal disorders. METHODS: Fifteen patients (6 women and 9 men) underwent combined pars plana vitrectomy with insertion of an open-loop AC IOL. Postoperative results were evaluated. RESULTS: The average preoperative visual acuity of 20/360 (logMAR scale, 1.25 +/- 0.80) improved to 20/52 (logMAR scale, 0.42 +/- 0.35) after an average follow-up of 10.2 months (range, 1-41 months). Of 15 eyes, 7 (47%) achieved a visual acuity of better than 20/40. There was no evidence of glaucoma exacerbation or corneal decompensation. Visual acuity was limited primarily by chronic cystoid macular edema in 4 (27%) of 15 eyes. CONCLUSION: In this preliminary series of patients, open-loop, flexible, all-PMMA, Kelman-style AC IOLs appear to be well tolerated and represent a viable, simple alternative to transscleral fixation of a posterior chamber IOL or surgical aphakia in patients undergoing vitrectomy surgery.

Penetrating keratoplasty and intraocular lens exchange: open-loop anterior chamber lenses versus sutured posterior chamber lenses.

Penetrating keratoplasty with intraocular lens (IOL) exchange is generally recommended for eyes with pseudophakic bullous keratopathy, especially when the keratopathy is associated with uveitis, chronic cystoid macular edema, or a uveitis-glaucoma-hyphema syndrome. Review of the literature has shown basically equivalent long-term results of penetrating keratoplasty and IOL exchange using both Kelman-style, flexible, open-loop anterior chamber lenses and acapsular fixation of sutured posterior chamber lenses. The use of suture-fixated posterior chamber IOLs appears warranted in centers where the surgeon has extensive experience with this specific technique and in cases with special indications, for example, in eyes with extensive angle abnormalities. However, because this technique is more difficult to perform, and in the absence of such preexisting contraindications, for most practices we do not hesitate to recommend the use of a Kelman-style anterior chamber lens during routine cases of penetrating keratoplasty and IOL exchange.

Pseudophakia for traumatic cataracts in children.

PURPOSE: The purpose of this prospective study is to evaluate the postoperative visual acuity, refractive error, intraocular pressure, and status of the posterior capsule in children with traumatic cataracts who undergo extracapsular cataract extraction and insertion of a posterior chamber lens. METHODS: Extracapsular cataract extraction and primary endocapsular fixation of a posterior chamber lens implant were performed in eight children (age range, 4-17 years) with unilateral traumatic cataracts. RESULTS: There were no intraoperative complications, and seven of eight eyes achieved 20/40 or greater spectacle visual acuity during an average follow-up interval of 10 months (range, 5-20 months). The average postoperative spherical equivalent refractive error was +0.33 diopter (D) (range, -2.25 to +2.12 D); the average postoperative anisometropia was approximately 1 D (range, 0-2.25 D). In one patient, a coagulase-negative staphylococcal endophthalmitis developed 10 days after surgery. In three eyes that had opacified posterior capsules, YAG laser capsulotomy was performed. CONCLUSIONS: These preliminary results suggest that intraocular lens (IOL) implantation may be a safe and effective method of optical correction for children with traumatic cataracts.

Combined phacoemulsification, pars plana vitrectomy, and posterior chamber intraocular lens insertion.

Eighteen eyes with coexisting cataract and vitreoretinal disease underwent combined phacoemulsification, pars plana vitrectomy, and posterior chamber lens implantation. Preoperative vitreoretinal disease included nonclearing vitreous hemorrhage (eight eyes), vitreous hemorrhage and tractional retinal detachment (three eyes), tractional retinal detachment (one eye), epiretinal membranes (three eyes), peripheral uveitis (two eyes), and a retained intraocular metallic foreign body (one eye). Postoperative visual acuity improved in each case; 14 eyes achieved visual acuity between 20/20 and 20/80 during an average postoperative period of 11 months (range, 3 to 39 months). Perioperative complications included an iatrogenic retinal break (one eye) and pupillary block glaucoma (one eye). Four eyes required YAG laser capsulotomy postoperatively. Phacoemulsification did not interfere with corneal clarity, allowed water-tight wound closure during vitrectomy, and preserved the capsular bag, allowing endocapsular fixation of the posterior chamber lens. Combining phacoemulsification, posterior chamber lens implantation, and pars plana vitrectomy allows rapid visual rehabilitation and functional unaided vision in these eyes.

Temporary suture tarsorrhaphy after penetrating keratoplasty.

Persistent donor corneal epithelial defects following penetrating keratoplasty may lead to graft failure. We herein describe a method for providing corneal protection using a temporary suture tarsorrhaphy. This technique is simple and completely reversible, and it allows continued observation and instillation of topical medication during the postoperative period.

Long-term follow-up study of scleroplasty using autogenous periosteum.

Autogenous periosteum was used to reinforce scleral thinning, perforation, or corneoscleral wound dehiscence in four eyes of three patients with necrotizing scleritis or peripheral ulcerative keratitis associated with advanced rheumatoid arthritis. All grafts have remained intact during an average follow-up interval of 36 months (range, 19-52 months). The postoperative visual acuity ranged between 20/30-20/60. Two eyes exhibited age-related macular degeneration, and one eye had an epiretinal membrane postoperatively. No systemic complications occurred following surgery.

Combined phacoemulsification and pars plana vitrectomy.

Combined phacoemulsification and pars plana vitrectomy were performed in eight eyes with cataract and vitreoretinal disease. Six eyes had tractional retinal detachment and/or nonclearing vitreous hemorrhage, one eye had a retained metallic intraocular foreign body, and one eye had a traumatic retinal detachment. In six eyes, a posterior chamber lens implant was placed in the capsular bag. Postoperative visual acuity improved in each case and ranged between 20/15 and 6/200. There were no perioperative complications, and the posterior chamber lens implant appeared well tolerated during an average follow-up interval of 8 months (range, 3 to 30 months). This technique allows endocapsular fixation of a posterior chamber lens and provides rapid visual rehabilitation with a single operation.

Localized retinal detachment with combined central retinal artery and vein occlusion after retrobulbar anesthesia.

The authors report a patient who was observed to have a localized retinal detachment with combined central retinal artery and vein occlusion after cataract surgery performed with retrobulbar anesthesia. The authors propose that this condition resulted from injection of the anesthetic mixture into the optic nerve. No acute neurologic symptoms occurred, but visual loss was severe and permanent. This case adds to the previously reported spectrum of complications from retrobulbar anesthesia.

Filter-culture technique using amoeba saline transport medium for the noninvasive diagnosis of Acanthamoeba keratitis.

Acanthamoeba, a common free-living amoeba, is increasingly incriminated as a cause of keratitis and corneal ulceration. Between March 1986 and July 1988, specimens from seven patients submitted by ophthalmologists to the City of Milwaukee Health Department's Bureau of Laboratories were culture positive for Acanthamoeba. All patients were contact lens wearers. The specimens were transported at ambient temperature in amoebasaline (5.0 mL) and filtered through 13 mm 0.22 microns cellulose filters. The filters were then plated in cocultivation with Escherichia coli on nonnutrient agar and had positive results for Acanthamoeba in two to five days. Contact lens cases were culture positive for Acanthamoeba in three instances. These results indicate that corneal scraping in amoeba saline transport medium can provide an effective way to diagnose Acanthamoeba keratitis when direct culture of such specimens is not possible.