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¡¡¡¡Visual acuity after secondary intraocular lens implantation in 102 patients

¡¡¡¡Abolghasem Rastegar, Mohammad Reza Besharati, Mohammad Reza Shoja

¡¡¡¡Department of Ophthalmology, Shahid Sadoughi University, Yazd, Iran

¡¡¡¡Abstract¤rAIM: To evaluate and analyze the visual acuity after secondary anterior and posterior chamber intraocular lens (IOL) implantation in aphakic patients. The most common reasons for performing secondary implantation were dissatisfied with aphakic glasses and intolerance or reluctance to use contact lenses.

¡¡¡¡¤rMETHODS: In this prospective, non randomized comparaª²tive trial study was done at Ophthalmology Department of Sadoughi Hospital, Yazd, Iran from 1995 to 2005. Posterior chamber lens was inserted in 62 eyes (60.78%) and anterior chamber lens in 40 eyes (39.21%) depending upon the type of previous cataract surgery. Demographic and clinical data was analyzed from the patient¬ðs medical records during follow up.

¡¡¡¡¤rRESULTS: 102 patients [42 females (41.18%) and 60 males (58.82%)] underwent secondary lens implantation from 1995 to 2005. Their age range was between 48 and 72 years (mean= 62.6 years), and mean follow up time was 20.2 months (range of 6 ª² 72 months).There were minor intra operative and post operative complications. The state of visual acuity three months after procedure and final suture removal was as follows: visual acuity of 20/20 in 48 cases (47.05%), visual acuity of 20/40 or better in 51 patients (50%), and decrease in visual acuity (3 lines of snellens chart) in 3 cases (2.95%).

¡¡¡¡¤rCONCLUSION: The short term complications were not more than that of primary cataract surgery with lens insertion and the visual acuity outcome was as good as the preoperative best correction, so secondary lens implantation appears to be safe and effective for aphakic correction.

¡¡¡¡¤rKEYWORDS: secondary intraocular lens (IOL); aphakia; optical rehabilitation

¡¡¡¡Rastegar A, Besharati MR, Shoja MR. Visual acuity after secondary intraocular lens implantation in 102 patients. Int J Ophthalmol

¡¡¡¡(Guoji Yanke Zazhi)2008;8(11):2161ª²2163

¡¡¡¡INTRODUCTION

¡¡¡¡As the major problem of cataract extraction is aphakia, the essential reason for secondary intraocular lens implantation is rehabilitation of the visual function as far as possible as in aphakic cases after primary cataract extraction without lens insertion [1].

¡¡¡¡The problems of aphakic correction with plus spectacles include magnification (about 25%), image distortion, visual field limitation as well as ring scotoma formation and image jumping in and out of the visual field. Though contact lens results in 7% magnification and reduces the spectacles difficulties, in certain conditions it is desirable to have secondary lens implantation[2ª² 4]. The type of cataract extraction and anterior chamber (AC) condition determine the style and technique of secondary procedure.

¡¡¡¡Secondary IOL has been reported to account for up to 6% of all IOL¬ðs, but nowadays the frequency of secondary implant has decreased as most implantations are done at the time of primary cataract surgery. In this study, the main aim of the procedure was optical rehabilitation. Desire for improving visual function is one of the important factors and ophthalmologists need to evaluate the visual condition along with the surgical advantages and disadvantages very carefully [5ª²7].

¡¡¡¡MATERIALS AND METHODS

¡¡¡¡This study was done from the 1995ª²2005 at the Training Hospital Affiliated to Yazd Medical Sciences University in Yazd, Iran. All of the patients in this study underwent secondary IOL implantation after primary cataract surgery without lens insertion for any reason.

¡¡¡¡Of the 102 cases, 42 patients (41.18%) were females and 60 (58.82%) were males with ages ranging between 48ª²72 years (mean 62.6 years). All had undergone cataract surgery without primary lens insertion with best corrected visual acuity outcomes between 20/40 to 20/20.

¡¡¡¡All of the patients were evaluated completely for diabetes mellitus, high blood pressure, systemic disease and medications that could alter the outcomes of surgery. None of the cases had noticeable systemic problems, and the complete eye examination including anterior and posterior segment examination, was also done.

¡¡¡¡Patients were divided into two groups: a) those who had undergone intra capsular cataract extraction (ICCE) mainly without vitreous loss (40 cases) were candidates for AC IOL implantation, and b) cases who underwent extra capsular cataract extraction (ECCE) with posterior capsular intact (62 cases) were listed for PC IOL insertion, respectively. Most of the patients were intolerant or reluctant to use glasses or contact lens.

¡¡¡¡IOL with power ranging between +17.50 to +22.50 diopters selected with calculation error within ¡À0.50 diopters. Demographic and clinical data were collected from the medical records. All of the aphakic patients for any reason with bscva between 20/40 to 20/20 were included and exclusion criteria were all complicated primary cataract surgeries with BSCVA <20/40.

¡¡¡¡The technique of secondary and primary anterior chamber IOL insertion is the same. IOL choices considerations include: 1ª²1.5mm larger than white to white limbus diameter in AC IOL, optical zone 6mm, diameter 12.5mm, angulations step vaulted, AC depth 2.9mm in AC IOL and 4.8mm in PC IOL, constant 115 in AC and 118 in PC IOL,four pointed IOL(kelman z style, mainly alcon, domi and bausch &lomb), viscoellastic materials and so forth. Limbal incision done as routine cataract surgery. After surgery, injection of subconjunctival antibiotic and steroid was given for prophylaxis of infection and inflammation.

¡¡¡¡The day after surgery a complete examination was done and followed 3 days, 1 week, 2 weeks, monthly for 3 months and 6 months after surgery.

¡¡¡¡RESULTS

¡¡¡¡Visual acuity outcomes of about 20/20 was achieved in 48 cases (47.05%) and 20/40 or more in 51 cases (50%) between 3 to 6 months after surgery. 3 cases (2.95%) had decreased visual acuity of 3 lines because of cystoid macular edema (CME) in 2 cases and corneal graft in 1 case. The difference in pre and post operative visual acuity was insignificant (P=0.779).

¡¡¡¡Intra operative complications were mainly minor including 3 cases of descemet¬ðs membrane separation (1 relatively extensive and 2 local), but none of them resulted in keratopathy. There was 1 case of iridodialysis, 4 surgical miosis, 4 iris damage (small sphincter rupture during lens insertion 2 cases, iris fraying during vitrectomy 1 case, damage to iris for posterior synechia dehiscence 1 case, posterior capsular ruptures 2 cases, iris tucks and iris misshapen 4 cases, complications attributed to each group AC and PC IOL).

¡¡¡¡Postoperative complications were not major and included macroscopic anterior chamber bleeding (hyphema) in 2 cases, pupillary membrane formation 1 case, high intra ocular pressure up to 36mmHg, in 8 cases that was controlled by medications. Hypotony (approximately 6mmHg till 3 days post surgery) in 3 cases, choroidal detachment 1 case, corneal edema and descemet¬ðs fold 6 cases, bullous keratopathy 1 case which finally required a corneal graft, pupillary lens capture 3 cases, atonic pupil 2 cases and CME in 2 cases that was confirmed by fluorscein angiography.

¡¡¡¡Overall, optical rehabilitation of aphakia with intraocular lens implantation was safe and no major complications and difficulties was seen intra or post operatively follow up.

¡¡¡¡DISCUSSION

¡¡¡¡The main goal of rehabilitation after cataract surgery is to return visual function including clear central and peripheral vision, binocular single vision, stereopsis when possible and comfort. In the last few decades, advances in the optical rehabilitation of aphakic patients have been made and IOL implantation is the most frequently used form of secondary aphakic optical correction. Lens implants include anterior chamber, posterior chamber, iris supported and cilliary sulcus fixation. Due to the frequent complications of iris supported and scleral fixation lenses such as retinal detachment, choroidal hemorrhage, lens dislocation, suture exposure, risk of endophthalmitis, glaucoma and cystoid macular edema, modern flexible anterior chamber lenses were used instead of them in the study [1ª²7].

¡¡¡¡In this study a post surgical visual acuity of 20/20 was gained in 48 cases and<20/20ª² >20/40 in 51 cases. Only 3 cases had decreased visual acuity of 3 snellen, s chart lines, but they still were satisfied rather than wearing spectacles or contact lens.

¡¡¡¡In comparison with similar studies such as Jaals F [8] who reviewed 33 patients (37 eyes) between 1983 to 1993 in Malaysia and performed secondary IOL implantation during this period, a visual acuity of 6/9 or better was seen in 25 of 37 eyes (67%), eyes seeing as good or better than before procedure were noted in 34 of 37 eyes(92%), complications were bullous keratopathy, uveitis and glaucoma with ac implants of the rigid type IOL. Stankiewicz[9] and his colleagues survey 35 secondary IOL implantations between 1984ª²1994 in Poland with final visual acuity of 5/10ª²5/5. Sauders A[10] studied in Poland from 1994 to 1996 on 65 cases of secondary lens implantation reported final visual acuity of 20/40 or more in 77% of patients. Bayramlar HS [11] in Turkey compared the results of primary and secondary implantation of AC lens and reported that mean post operative best corrected visual acuity was significantly lower in primary procedure. Jaworowskaª²Ciesli¨½ska I [12] in Poland (1999) evaluated 29 cases of secondary posterior chamber IOL with visual acuity outcome of 20/40 or better in 82.7%. Bellamy J P[13] and his colleagues in France, in the year 2000 assessed results and complications of secondary implantation and showed that rate of increased visual acuity ranged from 77% to 92% for AC IOL. Epley KD [14] in the year 2002 in USA described IOL implantation in the absence or insufficient capsular support and reported adequate outcome, we too implanted PC IOL in 2 inadequate posterior capsular supported cases without complications and good visual acuity outcomes. Lee VY [15] in the year 2003 studied 55 secondary IOL in Hong Kong who gained visual acuity of 6/12 or more in 76% of the cases and showed lower early complication rate as compared to primary implantation. Ravalico G [16] study in 2003 in Italy showed that anterior chamber IOL implantation did not appear to alter corneal endothelial function and this study indicated endothelial cell loss related to corneal trauma during procedure rather than an IOL in the AC, but in this study, we reported 1 case of bullous keratopathy post AC lens insertion due to endothelial cell loss. Dong X [17] in 2003 in China reported no cases of retinal detachment or CME in 15 cases of secondary implant, but in this study, we have had 2 cases of cystoid macular edema but no retinal detachment. Sauder G [18] in 2004 in Germany reported two rare cases of phototoxic maculopathy after secondary IOL implantation, but there was no case reported in our study.

¡¡¡¡Considering the results optical rehabilitation of aphakic patients with secondary IOL implantation appear to be safe, effective and predictable for correction of aphakia. The short and long time risks and complications of the procedure are no greater than those of primary cataract surgery and IOL implantation so can be done on selective cases with advanced methods. Primary cataract extraction and IOL insertion if it is easy, but we can not claim that we don¬ðt need secondary implantation procedure because we have so many cases of congenital, traumatic, wrong IOL power, malpositioned or displaced IOL as well as unpredicted primary cataract extraction problems which require lens implantation for the second time.

¡¡¡¡CONCLUSION

¡¡¡¡This study revealed the success rate of secondary lens implantation with minor complications.The pre and post operative best corrected visual acuity was relatively the same, but patient satisfaction was much more than glasses, and contact lens wearing. We can therefore claim that this procedure is safe, effective and predictable in properly selected cases.

¡¡¡¡¡¾²Î¿¼ÎÄÏס¿

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¡¡¡¡18 Sauder G, Degenring RF, Jaeger M, Heyer C, Jonas JB. Phototoxic maculopathy after secondary intraocular lens implantation. J Cataract±¾ÎÄתÔØÓÚÂÛÎĺÃÍøwww.lunwenhao.comÂÛÎĺÃÍøרҵ´úд´ú·¢ÑÛ¿ÆÂÛÎÄ