Eye (1988) 2, 370-375
Secondary Lens Implantation: Incidence, Indications and Complications
B. LEATHERBARROW, A. TREVETT and A. B. TULLO
Manchester
Summary A retrospective study of 79 secondary intraocular lens implants performed during 1984-87 in a large teaching hospital is reported. The period of follow-up ranged from 6 months to 3.9 years (mean 16.6 months). The principal indication for surgery was contact lens intolerance. Thirty four per cent of the patients had previously undergone cataract surgery with implantation of the other eye. Eighty-three per cent of the patients achieved a visual acuity within one Snellen line of best-corrected preoperative visual acuity. A further 2.5% lost two lines of Snellen chart acuity, and 14.5% had a substantial reduction in visual acuity. We conclude that in carefully selected patients secondary intraocular lens implantation is an acceptable and often highly successful way of treating monocular aphakia and we discuss the selection and preoperative investigation of such patients.
The practice of secondary intraocular lens within 3 weeks of failed primary implantation implantation in the management of aphakia as this prevented accurate assessment of best has gained widespread acceptance in the corrected visual acuity prior to secondary United States of America. (l·8) It is probable implantation. All data were obtained by that this procedure is also being carried out in retrospective review of patient records. The many centres in this country, perhaps on an intraocular lenses were all implanted via a occasional basis, though no reported series corneal incision which was placed either have been identified in the British literature. superiorly or temporally. We report here experience at the Royal Eye The mean age of the patients was 73 years Hospital, Manchester, which currently (range 15-94 years). The age categories of the accounts for a small but growing proportion patients are given in Table I. Twenty-eight of the total number of lens implants used. patients (39%) were male and 44 (61 %) were female. Fifty-two operations (66%) were Patients performed under general anaesthesia and 27 Seventy-nine secondary intraocular lens operations (34%) under local anaesthesia. implantations performed by 18 surgeons The average interval between the primary were included in this study. This involved 72 and secondary procedures was 5.2 years patients as 7 patients underwent bilateral (range 3 months to 27 years). This interval secondary intraocular lens implantation. The was greater than one year in 71 cases (90%). surgery was performed in the 40 month All patients have been followed-up for a period from February 1984 to July 1987. minimum period of 6 months. The average Excluded from the study were 15 secondary length of follow-up was 16.6 months with a intraocular lens implantations performed range of 6 to 46 months.
Correspondence to: B. Leatherbarrow Royal Eye Hospital, Oxford Road, Manchester, M13 9WL.
Presented at the Annual Congress of the Ophthalmological Society of the United Kingdom, April 1988. SECONDARY LENS IMPLANTATION: INCIDENCE, INDICATIONS AND COMPLICATIONS 371
Table I Ag e categ ories of patients (y ears) No. of cases
0- 20 21- 40 41 - 60 61 - 80 81- 100 60 2 4 12 39 15
The indications for secondary intraocular 50 lens implantation were contact lens intolerance in 50 cases (63% ), contact lens related problems such as a corneal ulceration 40 and corneal vascularisati�n in 12 cases (15%), aphakic intolerance in 11 cases (14%) and failed primary implantation due to 30 operative complications in 6 cases (8%), Twenty-six operations (32%) were performed by a consultant, 43 operations 20 (55%) by a senior registrar, 8 operations (10%) by a registrar and 2 operations (3%) by a senior house officer, 10 The incidence of this procedure is rapidly increasing at this centre, This is illustrated in Figure 1, Fifty-five eyes (70%) had previously undergone an intracapsular cataract 1984 1985 1986 1987 extraction, Of the remaining 24 eyes (30%), Fig. 1. Incidence of secondary implantation at eight had suffered a penetrating eye injury Manch ester Roy al Ey e Hospital 1984-87. Al cases in each year included and subsequently had undergone an extracapsular cataract extraction leaving the Post-op VA posterior capsule intact. Five eyes had Results cataractous, 4% were aphakic and 34% were Best-corrected preoperative and post pseudophakic. operative visual acuities are given in Table I The incidence of complications is shown in and Figure 2. Best-corrected postoperative Table IV. Vitreous loss necessitating anterior acuity was within 1 Snellen line of best vitrectomy was the only immediate surgical corrected preoperative acuity or better in complication occurring in three cases. 83% of the cases. Visual acuity deteriorated Postoperative complications have been by more than 2 Snellen lines in 13 cases. The divided into those considered to be major or reasons for visual deterioration are given in minor; postoperative astigmatism is Table III. considered separately. The visual acuities of the contralateral eyes (65 eyes as 7 patients received bilateral Major complications: intraocular lenses) are given in � Table II. One of the cases of vitreous loss had a Seventy-two per cent contralateral eyes had a persistently shallow anterior chamber best-corrected visual acuity of 6/12 or better. Twenty-eight per cent of the contralateral Table IV Incidence of complications" eyes were phakic and normal, 34% were Major: 13 cases (16.5%) Minor: 13 cases Table II Visual acuities with secondary (16.5%) implantation Vitreous loss: 3 Secondary OAG: 3 Best-corrected visual acuity, % Retinal detachment: 1 Hypopyon: 3 Corneal decompensation: 3 Hyphaema: 1 Preoperative Postoperative Contralateral Macular oedema: 1 Iris bombe: 1 Eye Tilted IOL with endothelial Repositioning of touch: 1 IOL: 1 6/6 - 6/9 72 55 57 Displaced IOL: 1 PC opacification: 2 6/12 - 6/18 21 30 30 Incorrect power IOL: 3 Wound leak: 1 6/24 - 6/36 6 7 6 Vitreous to section: 1 6/60- CF 1 7 5 Table III Reasons for two or more Snellen Line decrease in best corrected visual acuity following secondary implantation Visual acuities" Reason for decreased Patient Preoperative Postoperative Visual acuity" 1 6/9 CF Tilted IOL with corneal touch 2 6/6 6/18 Worsening of SMD 3 6/6 6/24 Unknown 4 6/60 CF Corneal decompensation 5 6/9 6/18 Worsening of diabetic maculopathy 6 6/12 CF Senile macular hole 7 6/6 NPL Total retinal detachment 8 6/6 6/24 PC opacification 9 6/6 6/18 PC opacification 10 6/9 CF Corneal decompensation 11 6/9 6/18 Macular oedema 12 6/9 6/24 Displaced IOL 13 6/9 CF Corneal decompensation "CF - Counting fingers; NPL - No perception of light tIOL - Intraocular lens; SMD - Senile macular degeneration; PC - Posterior capsule SECONDARY LENS IMPLANTATION: INCIDENCE, INDICATIONS AND COMPLICATIONS 373 postoperatively necessitating removal of the postoperative sterile hypopyon which implant with a further anterior vitrectomy, resolved on topical steroids alone. One This eye suffered a retinal detachment 6 postoperative hyphaema occurred which weeks postoperatively, which ultimately resolved spontaneously. One case of iris resulted in a blind eye, Three eyes developed bombe occured due to blockage of the corneal decompensation, Persistent peripheral iridectomy by vitreous. This postoperative macular oedema developed resolved after a laser iridotomy was only in one eye. One anterior chamber performed. Two cases of posterior capsular intraocular lens was found to be tilted opacification have occurred. These are postoperatively resulting in endothelial awaiting laser caps ulotomy . One wound leak touch. This could not be repositioned occurred which resolved without sequelae. successfully and was removed. One posterior One case of pupillary distortion with a strand chamber intraocular lens was found to be of vitreous to the wound occurred with no displaced postoperatively resulting in other sequelae, One intraocular lens was ' persistent monocular diplopia. Attempted incorrectly positioned and successfully repositioning proved to be unsuccessful. readjusted. Three eyes received intraocular lenses of an inappropriate power resulting in marked Astigmatism: anisometropia. Two of these cases were due Seventeen eyes (21%) had a postoperative to an error of judgement on the part of the astigmatic error greater than 3.00 D with all surgeon. In the other case the intraocular sutures removed. Table V documents these lens was found to have been incorrectly cases and shows the site of corneal incision. packaged. Unfortunately, in seven of these cases no record of the preoperative astigmatic error Minor complications: was available. There were three cases of secondary open Specular microscopy ws performed on 28 angle glaucoma successfully controlled on eyes preoperatively but only 14 of these eyes topical B-blockers. There were three cases of could be subjected to postoperative specular microscopy. The time interval between Table V Data on eyes with postoperative surgery and postoperative specular astigmatic error> 3.00 dioptres microscopy ranged from 6 to 36 months with an average of 14 months. The endothelial cell Patient Preoperative Postoperative Section: • loss ranged from 2 to 30% with a mean of Cylinder Cylinder 15.6%. Thirty-seven eyes underwent preoperative 1 +3.50x130 +3.25x145 superior biometry. In these the postoperative 2 Plano +5.00xI45 superior spherical equivalent range was +2.50 D to 3 Unknown +4.00X180 temporal -4.00 D with a mean of 1.23 D. Forty-two 4 Unknown +3.25x115 temporal 5 Unknown +3.50xI80 temporal eyes were implanted without preoperative 6 Unknown +4.00X105 temporal biometry. In these the postoperative 7 Unknown +4.50x5 temporal spherical equivalent range was +7.25 D to 8 +3.25x5 +3.25xI5 temporal ':"'5.25 D with a mean of 1.90 D. 9 Unknown +4.00xlO temporal 10 +1.25xI80 +5.00x20 superior Discussion 11 +4.00xI40 +6.00xI75 superior We have been impressed by the overall 12 +O.50x90 +3.50x90 temporal improvement in visual function which 13 +3.50xI65 +4.50xlO superior secondary intraocular lens implantation 14 +2.00xlO +4.50xI65 superior affords. In a retrospective study, however, 15 + 1.50x45 +3.50x60 temporal 16 +2.25xI60 +4.5xI80 temporal the only available measure of success is post 17 Unknown +3.25x110 temporal operative visual acuity and indeed this is the only criterion which is included in most 'Site of corneal incision publications on this topic. In this respect our 374 B. LEATHERBARROW ET AL. results are not as good as those which have further compromise of the corneal previously been published. The latter, endothelium. Specular microscopy should however, tend to be single or double surgeon therefore be considered in all patients. This series whereas our study concerns a large investigation was not performed in the 3 number of surgeons in training. It is, patients whose corneas decompensated as a therefore, important to attempt to meet strict result of surgery and this event might criteria in selecting patients for this therefore have been avoided. procedure which can only be achieved by Our results also show that accurate performing a number of investigations. preoperative refraction, keratometry and Much useful information can be gained by biometry are essential. The overall a full clinical examination. Aphakic impression gained is that corneal glaucoma is a contraindication particularly if astigmatism, present as a result of the the drainage angle has been compromised by primary procedure, is liable to be made previous cataract surgery and where worse by a secondary procedure without any implantation of an angle-supported lens is significant change in the axis of the cylinder. contemplated. Gonioscopy, therefore, is This was true even in those cases where a mandatory. A single site of peripheral temporal corneal inclSlon was used. anterior synechiae, particularly to the Nevertheless, a secondary procedure does primary wound, may not exclude surgery but provide an opportunity to correct any may necessitate the use of a temporal incision marked astigmatism already present. The in the secondary procedure. temporal incision described by Masket{1O) as a Of major importance is the presence of means of reducing against-the-rule vitreous in the anterior chamber. (8) In our astigmatism was through a scleral pocket series this was considered a strict incision whereas all surgeons in our series contraindication and probably accounts for used a corneal incision. In either case it our relatively low incidence of retinal would seem likely that an incision made complications, especially of cystoid macular through undisturbed tissue would yield a oedema (CMO). Kraff et aU3) found that more predictable result. A careful choice of 16% of eyes with a ruptured anterior hyaloid the power of intraocular lens to be implanted face lost vitreous at the secondary procedure. cannot be over-emphasised, taking into Even when such a complication is account the corrected visual acuity of the anticipated and an elective anterior other eye and its status i.e. phakic, aphakic vitrectomy performed, Wong et aU8) found a or pseudophakic. It has been shown by 28% incidence of retinal complications. It Summers and Lindstrom(5) that preoperative has also been shown that fluorescein biometry is much more accurate than relying angiography, by establishing the presence or on the refraction method. Nevertheless, in absence of subclinical CMO, may help to our series a large postoperative error was identify the patient at risk, particularly those found' in 3 cases. In one case the error in whom there is only a small area of vitreous occurred because the intraocular lens had herniation. It also seems that a primary to been incorrectly packaged by the secondary procedure interval of greater than manufacturer, and in the other two cases one year reduces the risk of CMO(9), which because of an error of judgement on the part applied to most of our patients. of the surgeon. Although we were obliged to Although most authors advocate the use of exclude from this series some patients where specular microscopy, only Kraff reported the primary implantation failed, we feel that this degree of endothelial cell loss following is an important group worthy of further secondary implantation showing a 9.4% loss study. This problem is particularly likely to at 3 months. Our demonstration of a mean occur in a training centre where the relatively cell loss of 15.6% indicates that for many inexperienced surgeon may. encounter patients in whom secondary intraocular lens operative problems such as miosis or a poorly implantation is contemplated, especially in maintained anterior chamber preventing safe the elderly, there is a significant risk of implantation. SECONDARY LENS IMPLANTATION: INCIDENCE, INDICATIONS AND COMPLICATIONS 375 Not infrequently, we have found that it is hands of an experienced surgeon, secondary the patient who is the first to raise the lens implantation has an important part to possibility of secondary implantation. This is play in the rehabilitation of aphakic patients. particularly likely where the other eye has already undergone successsful cataract surgery with lens implantation. It is this kind of pressure generated by the patient which References emphasises the need to consider carefully the 1 Mazzocco TR, Kratz RP, Davidson B, Colvard suitability of the eye rather than the patient DM. Secondary posterior chamber for secondary implantation. Ideally, this intraocular lens implants. Am Intraocul J assessment should include careful slit-lamp Implants Soc 1981, 7: 341-3. A. biomicroscopy paying particular attention to 2 Lindstrom RL, Harris WS, Lyle W Secondary and exchange posterior chamber the presence of peripheral anterior synechiae lens implantation. AmIntraoculImplant Soc J and the condition of the anterior hyaloid 1982,8: 353-6. face. The retinal periphery and the macula 3 Kraff MC, Sanders DR, Lieberman HL, Kraff should be examined carefully particularly H. Secondary intraocular lens implantation. where there is a small degree of vitreous Ophthalmology 1983, 90: 324-6. herniation into the anterior chamber. The 4 Shammas HJF and Milkie CF. Secondary corneal endothelium should be examined by implantation of anterior chamber lenses. Am specular microscopy. Refraction, IntraoculImplant Soc J 1983, 9: 313-6. keratome try and biometry should be 5 Summers CG and Lindstrom RL. Secondary A performed. A visco-elastic substance should IOL power calculations: comparison of regression formula and refraction method in be used during surgery which can be accurate prediction of emmetropia. Am performed under either local or general IntraoculImplant Soc J 1984,10: 448-51. anaesthesia. One further consideration is the 6 Binder PS: Secondary intraocular lens age of the patient. The demonstration by implantation during of after corneal l Graham et al.< I)of a low success rate for the transplantation. Am J Ophthalmol 1985, 99: use of daily wear and extended wear contact 515-20. lenses for aphakia in the over 70s suggests 7 Kraff MC, Lieberman HL, Sanders DR: this group should be given full consideration Secondary intraocular lens implantation: J for a secondary procedure. rigid/semi-rigid versus flexible lenses. The development of epikeratophakia Cataract Refract Surg 1987,13: 21-6. 8 Wong SK, Koch DD, Emery JM: Secondary promises a further alternative method of intraocular lens implantation. J Cataract managing aphakia particularly where the Refract Surg 1987,13: 17-20. patient is unsuitable for secondary 9 Shammas HJF and Milkie CF: Cystoid macular (l2.l3) implantation. In the meantime oedema following secondary lens secondary implantation accounted for 3% of implantation. Am Intraocul Implant Soc J all implants used in the Manchester Royal 1981,7: 40-2. Eye Hospital in 1987. We anticipate that the 10 Masket S: Temporal incision for astigmatic incidence of secondary implantation will control in secondary implantation. J Cataract peak within the next few years and then fall Refract Surg 1986,12: 179-81. in line with the numbers of aphakic patients. 11 Graham CM, Dart JKG, Wilson-Holt NW, RJ: Despite the fact that 14% of our patients Buckley Prospects for contact lens wear in aphakia. Eye 1988, 2: 48-55. suffered a significant and irreversible loss of 12Rostron CK: Epikeratophakia: clinical results visual acuity and despite the significant risk and experimental development. Eye 1988, 2: of complications, we have been impressed by 56-62. the dramatic improvement in the visual status 13 Durrie DS, Habrich DL, Dietze TR: Secondary of a large majority of the patients studied. intraocular lens implantation vs With improved selection and preoperative epikeratophakia for the treatment of aphakia. assessment, we feel confident that in the Am J Ophthalmol1987, 103: 384-91.