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Journal Français d'Ophtalmologie
Vol 25, N° 2  - février 2002
pp. 154-160
Doi : JFO-02-2002-25-2-0181-5512-101019-ART6
Vitreous luxated PC-IOLs: complications
 

M. Roldán Pallarés [1], M. D. Martin Sánchez [2]
[1]  Hospital Clinico San Carlos. Universidad Complutense de Madrid. Madrid.
[2]  Hospital Universitario Getafe. Madrid.

Tirés à part : Manuela Roldàn Pallarés [3]

[3]  C/ Rey Francisco 11 28008 Madrid.

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Implants de chambre postérieure luxés dans le vitré : complications

Objectifs : Notre étude consiste à déterminer les complications pré, per et post-opératoires de cas d'implants de chambre postérieure luxés dans le vitré.

Méthodes : Nous présentons une analyse rétrospective, sur une période de 10 ans allant de 1989 à 1999, de patients présentant un implant de chambre postérieure luxé dans le vitré.

La durée du suivi est au minimum de 6 mois. Sur 41 yeux, 4 cas ont été exclus de l'étude à cause d'un suivi insuffisant et au total 37 yeux ont été retenus pour cette étude rétrospective.

Vingt et un yeux ont bénéficié, après réalisation d'une vitrectomie, d'un repositionnement dans le même temps opératoire de l'implant intra-oculaire avec dans 9 cas utilisation de perfluorocarbone pour remonter l'implant luxé dans le vitré. Pour 16 yeux, a été réalisé, après utilisation dans 7 cas de perfluorocarbone, un échange d'implant dans le même temps opératoire, avec implantation transciliaire.

Résultats : L'âge moyen des patients était de 67,5 ans. En pré-opératoire 15 yeux soit 40 % étaient porteurs d'une hypertonie oculaire, 8 soit 24 % présentaient un oedème épithélial cornéen, 6 yeux soit 16 % présentaient une hémorragie intra-vitréenne de moyenne abondance et 4 yeux soit 11 % un décollement de rétine. En per-opératoire 9 yeux (24 %) se sont compliqués d'une hémorragie intra-vitréenne secondaire à la fixation transciliaire de l'implant. En post-opératoire nous avons observé un gain d'acuité visuelle dans 86 % des cas soit 32 yeux. Trois cas ont présenté un décollement de rétine post-opératoire dont l'origine est probablement iatrogène, 1 cas a présenté un glaucome post-opératoire et un autre une membrane épirétinienne.

Conclusion : De nombreuses techniques ont été proposées pour la gestion des implants de chambre postérieure luxés dans le vitré. Il semblerait que quelle que soit la méthode il est préférable de conserver et repositionner l'implant luxé. Le problème principal est la survenue de complications rétiniennes per-opératoires à l'occasion des manipulations intra-vitréennes de l'implant. Le taux de décollements de rétine dans notre série est de 11 %. L'utilisation du PFCL a simplifié la technique chirurgicale à la fois pour la prévention du décollement de rétine, son traitement et la remise en place de l'implant luxé. La fixation transclérale d'implant peut provoquer une dispersion pigmentaire irienne, une uvéite chronique, un oedème maculaire cystoïde et un décentrement de l'implant. Nous n'avons cependant pas trouvé de différence de résultat entre le repositionnement et l'échange de lentille intra-oculaire.

Au total la combinaison de ces différentes techniques permet en général d'obtenir de bons résultats visuels.

Abstract
Vitreous luxated PC-IOLs: complications

Purpose: To determine pre-, intra- and postoperative complications of posterior chamber intraocular lenses (PC-IOL) posteriorly luxated in the vitreous.

Methods: We retrospectively reviewed reports of all patients with luxated PC-IOLs at our institution (1989-1999) with a minimum follow-up of 6 months. We identified 41 eyes; 4 were excluded because of short follow-up. Thirty-seven eyes were finally considered. Twenty-one eyes had “ in situ ” repositioning with vitrectomy, in 9 of them perfluorocarbon liquids (Perfluoro-DK-line) (PFCL) were used to refloat the luxated lenses. Sixteen eyes had IOL exchange, in 7 of them PFCL was used to refloat the IOL.

Results: The average age of the patients was 67.5 years. Preoperatively, 15 eyes (40%) had ocular hypertension, 9 eyes (24%) showed epithelial corneal edema (CE), 6 eyes (16%) had light vitreous hemorrhage (VH) and 4 eyes (11%) retinal detachment (RD). Intraoperatively, 9 eyes (24%) had VH related to sulcus fixation. Postoperatively, visual acuity improved in 32 (86%) eyes. In 3 cases (8%) we found a postsurgical RD that could be iatrogenic; one eye developed glaucoma and 1 developed, epiretinal membrane. Two patients were PFCL drops.

Conclusion: Vitrectomy normalizes IOP and CE, PFCL simplifies the surgical technique for RD, and sulcus fixated IOL allows visual restoration. The combined technique generally offers good results.


Mots clés : IOL luxés , vitrectomie , repositionnement in situ , perfluorocarbone liquide , complications

Keywords: Luxated PC-IOL , vitrectomy, in situ repositioning , perfluorocarbon liquid , complications


INTRODUCTION

Posterior dislocation of intraocular lenses (IOLs) is an uncommon complication of cararact surgery, but when it occurs it can lead to severe complications and visual loss [1], [2], [3]. Numerous techniques for management of posteriorly dislocated posterior chamber implants have been described [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]including removal, exchange, or repositioning using residual lens capsule with or without scleral suture fixation techniques [8], [14], [15], [16], [17]. Although we prefer repositioning IOLs, the option of removal or exchange for an AC IOL is an alternative for cases complicated by coexisting retinal detachment [18].

Perfluorocarbon liquids (PFCL) have been advocated as a device for retrieval and repositioning of dislocated PC IOLS [19], [20]. PFCL are not essential but they are well suited for cases with coexisting retinal detachment [18], [21].

Recognizing limitations in the management of posteriorly dislocated PC-IOLs we developed a bimanual surgical technique that allows permanent, controllable relocation of the IOL [22]. We compare, herein, our experience with “ in situ ” repositioning [23]versus “exchange” of PC-IOL. PFCL were used in several cases with both techniques to float the IOL off the retina.

METHODS

We retrospectively reviewed reports of all patients with vitreous luxated PC-IOL operated on at our institution between February 1, 1989 and May 1, 1999. Surgery was always done by the same surgeon (M R-P). Minimum follow-up of 6 months after surgery was considered.

Fourty-one eyes were identified; four eyes were excluded because of short follow-up. Thirty-seven eyes were finally considered. Patient's data are shown in tableau Itableau IV. In all patients best-corrected preoperative and postoperative VA was obtained and also associated conditions were considered as high intraocular pressure (>25mmHg), vitreous hemorrhage, retinal detachment, corneal edema, cystoid macular edema, vitreous incarceration to the wound or age related macular degeneration.

A total of 21 eyes underwent in situ repositioning with vitrectomy, in 9 of them PFCL were used to refloat the luxated PC-IOL. Sixteen eyes underwent IOL exchange, in 7 of them PFCL were used to refloat the PC-IOL.

Surgical selection was usually made considering the characteristics of the luxated IOL and biomicroscopic characteristics of the anterior and posterior segment of the eye.

In situ repositioning was preferred when the anterior segment of the eye showed light corneal edema and/or inflammation that allows good fundus visibility, when integrity and characteristics of the luxated PC-IOL allows safely repositioning (PC-PMMA) and when coexistence of retinal detachment and/or vitreous hemorrhage makes safely working under pressure control.

IOL exchange was preferred when replacement of the luxated PC-IOL may be dangerous because of flexibility of the IOL; broken, prolene or abnormal haptics or IOL not suitable (silicone-plate IOL=no haptics) for replacement. Also exchange was preferred when inflammation and/or corneal edema makes difficult to maneouver inside the eye.

PFCL were used with both surgical techniques when posterior pole pathology and/or IOL risk on the retina were found.

The in situ repositioning technique consisted of a four-portal closed vitrectomy, with a preset light inserted in the inferonasal quadrant of the eye that leaves both surgeon hands free to grasp the completed dislocated IOL into the vitreous cavity by using Sutherland forceps and a 10-0 polypropylene loop created on a teflon catheter. Two additional scleral grooves with flaps (surgeon's view) at the 2:30 and 8:30 o'clock positions (right eye) or at the 3:30 and 9:30 o'clock position (left eye) allow the haptics to be guided to the desired positions in the ciliary sulcus. The IOL finally rests near the horizontal meridian, away from the corneoscleral wound [23].

The “exchange” technique consisted of a three-port pars plana vitrectomy. The IOL was grasped with Sutherland end-gripping intraocular forceps and removed by reopening the previous incision cataract. Then a new IOL was placed, either an anterior chamber (AC) IOL, a PC-IOL over residual posterior lens capsule and without suturing (NS) or a PC-IOL sutured to the sulcus (S) under the scleral flaps made 1 to 1.5 mm posterior to the limbus in the horizontal meridian 180º apart.

When PFCL were used during the surgery, the vitreous was before completely removed and the IOL was mobile, then PFCL was injected in between the retina and the IOL to float the dislocated IOL off the retina just posterior to the iris plane. When concurrent retinal detachment the PFCL displaced the subretinal fluid through the preexisting retinal breaks reattaching the retina. In these cases PFCL was mantained after IOL replacement, then endophotocoagulation to the retinal breaks was performed through PFCL and finally PFCL-air exchange was made. An encircling scleral buckling was used and the eye was insuflated with 20% sulfur hexafluoride. Similar technique for retinal detachment repair was used under air when no PFCL was associated to the surgery.

RESULTS

Results are given in tableau Itableau IV. Forty-one patients with PC-IOL posteriorly luxated in the vitreous were identified; Four eyes were excluded because of short follow-up. Thirty-seven patients were finally considered. Average age of the patients was 67.5 years. Luxation occurred spontaneously in 31 eyes (12 high myops) between 1 week and 3 months after cataract surgery. Six cases reported a history of ocular trauma before luxation (1 week-two years).

Preoperative visual acuities ranged from 20/60 to HM. Preoperatively, 15 eyes (40%) had ocular hypertension (OH), 9 eyes (24%) showed epithelial corneal edema (CE), 6 eyes (16%) had light vitreous hemorrhage (VH) and 4 eyes (11%) had retinal detachment. Ten eyes (27%) showed cystoid macular edema (CME) and 2 eyes (5%), age related macular degeneration (AMD). One eye (3%) had a macular hole tableau Itableau IV.

Intraoperatively 9 eyes (24%) had light VH related with sulcus fixation that resolved between 1 and 3 months. Two eyes had small bubbles of residual intravitreal PFCL that did not result in any apparent complication. No other complication did occur intraoperatively.

Postoperatively VA improved in 32 eyes (86%) tableau Itableau IVand figure 1. tableau Vtableau VIshow the VA distribution pre and postoperatively. In 3 eyes (8%) a postsurgical RD was found that could be iatrogenic, but resolved successfully with a new surgery. Ten eyes (27%) showed postsurgical OH that resolved with medical treatment one to three months after surgery. Postsurgical CE was permanent in 2 eyes (5%), one of them with AC-IOL after IOL-exchange. CME was chronic in 4 eyes (11%), also was it AMD (2 eyes, 5%) and also persisted the macular hole (one eye). Only one eye (3%) developed glaucoma after surgery and also, one eye (3%) developed epiretinal membrane (EM).

Only 3 eyes, which underwent exchange tableau IIItableau IVwith a new PC-IOL over the capsule remnants and without suturing (NS), had a new PC-IOL vitreous luxation that required a second vitrectomy procedure with a PC sulcus fixated IOL.

When we consider keratometric change with both surgical techniques tableau VII, only significant changes were found the first week after surgery. Exchange induced more change than in situ repositioning shortly after surgery, but no difference was found after three months.

The eyes with RD remained with an attached retina at the last follow-up examination. Until the last follow-up examination, postoperative complications had not developed in any of the eyes, and the IOLs have remained well centered, without tilting.

DISCUSSION

Numerous techniques for management of posteriorly dislocated posterior chamber implants have been described, including removal, exchange, or repositioning using residual lens capsule with or without scleral suture fixation techniques [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21].

The factors to be considered before recommending surgery to a patient with a posteriorly dislocated IOL include the visual needs of the patient, the presence of intraocular complications, and the risk of each particular surgical technique to be associated with intraoperative and/or postoperative complications.

If surgery becomes necessary, it is generally believed that repositioning of the dislocated IOL provides the most advantages; however its difficulty and potential complications have led some authors to recommend either removal or exchange of posteriorly dislocated IOL [2], [4], [5], [6] [14], [17], [18].

One of the problems associated with removal, exchange, or repositioning of a posteriorly dislocated IOL is the potential for causing retinal complications during the intraocular manipulation required to retrieve the IOL from the vitreous cavity or during its removal or repositioning. These complications include, among others, intraocular hemorrhage, contusion of the retina, retinal breaks, and retinal detachment.

The intraocular manipulations also can be associated with postoperative complications such us uveitis, cystoid macular edema, secondary glaucoma, and retinal detachment [6], [7]. The rates of coexisting retinal detachment in our series of 37 eyes before vitrectomy was 11% (4 eyes) which is higher than the rate reported by other authors [18], [22]. Combining data from reported series of vitrectomy for dislocated posterior chamber implants [10], [11], [16], [22], [24]shows a 1.3% (2/154) incidence of coexisting retinal detachment before vitrectomy [18]. Also retinal detachment in our study appeared relatively early after cataract surgery (1 week – 3 months) what can be related to more surgical manipulation during cataract surgery. Our prevalence of RD after vitrectomy is also higher in our series (3 eyes, 8%) than the reported rate in the literature [18], [22]. Smiddy and Flynn [11]reported 3% (1/32 eyes) of RD after vitrectomy and a combined rate (before and after vitrectomy) of 6%.

Combining data from reported series of vitrectomy for dislocated posterior chamber implants [10], [11], [16], [22], [24]shows a 0.6% (1/154) rate of retinal detachment following vitrectomy [18]. Retinal reattachment surgery has been anatomically successful in our cases, but long-term visual results depend mostly on preoperative macular status.

We successfully used PFCL in 16 eyes to effectively and safely retrieve the dislocated IOL from the retina. The advantages of PFCL in this surgery include 1) the heavy liquid lifts the dislocated IOL from the retina into the posterior chamber; 2) their high specific gravity exerts a flattening force that reattaches the retina (when concurrent retinal detachment; and 3) their viscosity provides a cushion that supports the IOL while it is being repositioned or removed.

Thus, the potential for intraocular damage during surgery is greatly reduced [20]. In our PFCL cases, two coexisting RD were resolved tableau IIwhile in situ repositioning; and one RD (1/3) appeared postoperatively after “exchange” combined with PFCL. No differences were found between both surgical techniques used considering using or not PFCL. These liquids are not essential but they are well suited for cases with coexisting retinal detachment. Only two of our 16 PFCL eyes reported “drops” during follow-up.

The potential for postoperative complications results from the specific surgical technique used to reposition the posteriorly dislocated IOL. The iris fixation technique may produce erosion of the iris, chronic uveitis, cystoid macular edema, and unpredictable centration of the IOL [4], [22]. The sutureless sulcus fixation technique frequently leads to postoperative subluxation or dislocation [5], [6]. We used this method in 3 eyes (“exchange”: tableau IItableau IV) and all of them suffered new PC posterior vitreous luxation between 3 and 6 months after first vitrectomy. Scleral or transcleral fixation sutures have more risk of endophthalmitis and postoperative rotation of the IOL [5], [6], [7] [10], [14], [17].

The surgical technique we used leaves the scleral knots perfectly covered by the scleral flaps with no postoperative complications as endophthalmitis or rotation of the IOL. With our repositioning technique positioning IOL holes are not necessary as previously reported [20].

No significant differences have been found in our cases between both surgical techniques used ( in situ /”exchange”) considering intra – or postoperative complications, astigmatism or visual acuity, neither between using or not PFCL. For surgical election, careful biomicroscopic evaluation of the anterior and posterior segments of the eye and evaluation of morphology and characteristics of vitreous luxated IOL will be helpful.

We can say that in our cases vitrectomy normalized IOP and corneal edema; PFCL simplified surgical technique when coexisting retinal detachment and sulcus fixated IOL allowed visual restoration. Combined technique offers, in general, good results.

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