陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 6熏晕燥援 2熏 Apr.18, 圆园13 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 窑ClinicalResearch窑 Blackdiaphragmintraocularlensimplantationand penetratingkeratoplastyinaphakiceyeswithtraumatic aniridia
1QingdaoUniversityMedicalCollege,Qingdao266071, largerstudypopulationandlongerfollow-upmaybe ShandongProvince,China beneficial. 2 ShandongEyeInstitute,ShandongAcademyofMedical ·KEYWORDS: blackdiaphragmintraocularlens;penetrating Sciences,Qingdao266071,ShandongProvince,China keratoplasty;aniridia;trauma Correspondence to: Xiao-GuangDong.ShandongEye DOI:10.3980/j.issn.2222-3959.2013.02.15 Institute,5YanerdaoRoad,Qingdao266071,Shandong Province,[email protected] LiJ,DongXG.Blackdiaphragmintraocularlensimplantationand Received:2013-03-05Accepted:2013-04-01 penetratingkeratoplastyinaphakiceyeswithtraumaticaniridia. 2013;6(2):183-186 Abstract INTRODUCTION ·AIM:Toevaluatethelong-termoutcomeofimplantation everetraumaticruptureoftheglobeoftenresultsin ofblackdiaphragmintraocular(BDI)lenscombinedwith S corneallaceration,aniridia,lensopacityordislocation, penetratingkeratoplasty (PKP)formanagingaphakic vitreoushemorrhage,andretinaldetachment,whichare eyeswithtraumaticaniridiaandcornealdamage. usuallytreatedbycombinedcornealcrackingsuturing,lens · METHODS:Sixaphakiceyesofsixpatientswith extraction,parsplanavitrectomy,andretinalreattachmentto traumaticaniridiaandcornealdamagehadBDIlens keeptheeyeballcompleteandrestoresomevisualfunctions. implantationatQingdaoEyeHospital,ShandongEye However,duetosphericalaberrationandchromatic InstitutefromJune2008toNovember2011.Medical dispersioncausedbydefectsintheiris,photophobia,glare, recordsofthepatientswerereviewed.Threepatients andvisualdysfunctionoftenoccuraftersurgery.Theblack receivedPKPandafter12-18monthswereimplantedwith diaphragmintraocular(BDI)lensisaspecialtypedesigned BDIlens.TheotherthreepatientscompletedPKPand tomeettheneedsofpatientswithaniridiaorsevereiris BDIlensimplantationatthesametime.Thecorrected defects [1].Butsomeofthepatientshadseverecornealscarat visualacuity,intraocularpressureandnumberofcorneal endothelialcellsweremonitored. the centerofcornea,orcornealedemaandbullous keratopathy.Asingleintraocularlens(IOL)implantation · RESULTS:Thepatientswerefollowedupforan cannotcorrectvisualacuity,andcombinedpenetrating averageof24.3 依12.1months (range14-48months).All keratoplasty(PKP)isneededtoremovescarandcloudiness BDIlenseswerelocatedwell.Thebestcorrectedvisual andimproveeyesight. acuitygotimprovedin5patients(0.1-1.0)anddecreased GoodclinicaleffectsofBDIlensimplantationineyeswith in1patientfrom0.4to0.2.Threepatientshadnormal aniridiaandaphakiahavebeenreported [2-5],including intraocular pressure (IOP) after implantation. Two patientsrequiredantiglaucomamedicationstocontrol eliminationofphotophobia,goodcosmeticeffectofthe IOPwithinthenormalrangeand1patientimplanted appearanceoftheeye,andcorrectionofametropiawiththe AhmedglaucomavalvetocontrolIOP.Thecornealgrafts transparentcentralopticalarea.Wefollowedupsome kepttransparentinalleyesandthecornealendothelial patientswhoreceivedPKPandBDIlensimplantation, counting>1000/mm2,althoughtwopatientsexperienced expectingtoevaluatethelong-termeffectsofthissurgical acutegraftrejectionandlossmorethan30%corneal treatment. endothelialcells. SUBJECTSANDMETHODS ·CONCLUSION:ImplantationofBDIlenscombinedwith ThisstudywasapprovedbytheInstitutionalReviewBoard PKPisaneffectiveoptionformanagingaphakiceyes ofShandongEyeInstitute.Sixeyesofsixpatientsreceived withtraumaticaniridiaandcornealdamage.Althoughthe PKPandBDIlensimplantationsurgeryfortraumaticaniridia resultsinourstudyareencouraging,additionalstudies atQingdaoEyeHospital,ShandongEyeInstitutefromJune ofthelong-termsafetyandefficacyarerequired.A 2008toNovember2011.Theywereallmale,withamean
183 BDIlensimplantationandPKPinaniridia
Table 1 Traumatic aniridia patients’ data before black diaphragm intraocular lens implantation. Duration from PKP Original ocular Visual acuity Endothelial cell Lens No. Sex Age (a) IOP Cornea status to implantation problem density (/mm2) status Uncorrected Best corrected (months) 1 M 25 Rupture 0.1 0.4 Normal Graft transparent 1718 14 2 M 10 Penetrating injury 0.05 0.6 Normal Graft transparent 1945 18 Intraocular foreign 3 M 9 0.02 0.3 Normal Graft transparent 2352 12 body injury Aphakic Normal with 4 M 35 Penetrating injury FC/BE FC/BE Cornea edema Uncountable / travoprost 5 M 44 Rupture FC/30cm FC/30cm Normal Cornea edema Uncountable / 6 M 35 Rupture 0.02 0.02 Normal Cornea edema Uncountable / M: Male; FC: Finger counting; BE: Before eye. ageof26.6years(range9-44years)atsurgery.Theiriswas Afteratriangularscleralflapwaspreparedat6o'clockfor defectedduetooculartraumainalleyes,incombination coveringthesutureforIOLfixation,a10-0polypropylene withcornealdamage,traumaticaphakiaorcataract,and double-armsuturewaspassedintotheanteriorchamber vitreoushemorrhage.Rupturesuture,cataractextraction,and underthe12o'clockscleralflapandpulledoutunderthe6 vitrectomyhadbeenperformedinthesepatientspriortoPKP o'clockscleralflap,both2mmposteriortothelimbus.Then andBDIlensimplantation. a3.2-mmkeratomewasused thesuperiorscleraltunnel. Preoperatively,bestcorrectedvisualacuity(BCVA)and Thesuturewasretrievedthroughthesuperiorlimbalincision intraocularpressure(IOP)wereexamined.Aslit-lamp beforecutinthemiddle,andthecutendsweresecuredto anterior segmentevaluation,fundusexamination,and therespectiveeyelet.Thesuperiorscleraltunnelwassutured cornealendothelialcelldensitywerecarriedout.The afterIOLinsertion.TheotherthreepatientscompletedPKP preoperativeophthalmichistoryandfindingsareshownin andBDIlensimplantationatthesametime.Thescleral Table1.Accordingtothepatients'surgery,theycouldbe tunnelwasnotneededintheprocess,andtheBDIlenswas dividedintotwogroups.OnegroupdidPKPfirstandthen insertedthroughthepenetratingholeforkeratoplastyinthe centerofthecornea. implantedtheBDIlens,anothergroupcompletedtwoparts RESULTS atthesametime.Theinclusioncriteriaforthepatientswere Allsurgerieswerecompleteduneventfully.Photophobia asfollows:BCVA 0.3andCECdensity 1500/mm2 (for 逸 逸 disappearedinalleyes.Mildanteriorchamberinflammatory thepatientswhohadgotPKP).Thevisualevokedpotential reactionsubsidedwithin1monthafterIOLimplantation. examination(VEP)revealedthattheopticnervefunction Goodvisualacuitywasachieved,andthebestcorrected wasgood(forthepatientswhohadn'tgotPKP).IOPwas visualacuity (BCVA)gotimprovedinalleyes.Because examinedtobewithinthenormalrangewithorwithout theseeyeshadirregularastigmatismduetocorneal intervention.Notractionalretinaldetachmentoranterior transplants,postoperativevisualimprovementwasaffected. proliferativevitreoretinopathywasfoundbyfunduscopes, Patient4wastreatedwithRGPat3monthsaftersurgery, B-ultrasonographyandultrasoundbiomic-roscopic(UBM). andthecorrectedvisualacuityreached0.8,whichwasbetter Informedconsentwasobtainedfromallpatientsbeforethe than0.3withglasses. implantationofablackdiaphragmpoly(methyl Patients2and6requiredantiglaucomamedicationsto methacrylate) (PMMA)IOL(67Band67G,Morcher, controlIOPwithinthenormalrangefor6monthsafter GmBH,Stuttgart,Germany)withanoveralllengthof surgery.TheIOPofpatient5wasuncontrolledwith 12.5mm.EachendoftheC-shapedhapticshadaneyeletfor eyedropsof timolol,brinzolamide,brimonidineand suturefixation.The10.0-mmopticpresenteda3.0-mm travoprostinabout1month,afterwhichanAhmed (67B)or5.0-mm(67G)clearcentralzonesurroundedbya glaucomavalvewasimplantedtodecreasetheelevated peripheraldiaphragmofblackPMMA. pressure.Duringthefollow-upperiodof14-48months,no Onesurgeon(X.D.)performedallsurgery.Threepatients severecomplicationswereobserved.Thecornealgraftskept (patients1-3)weretreatedbyPKP [6] firstlyandimplanted transparentinalleyes,althoughtwopatientsexperienced withBDIlensafter12-18months.AninfusionportforIOP acutegraftrejectionandlossmanycornealendothelialcells regulationwasinsertedandfixedinferotemporallythrough (Table2).The ultrasoundbiomicroscopic examination theparsplana4.0mmposteriortothelimbus.Ascleral showedtheBDIlenswaslocatedwellintheciliarysulcus. tunnel,11.0mmlongand4.0mmwide,wasmadewithout Therewasnoshiftofthelens,andthehapticsdidnot penetratingtheeyejustposteriortothesuperiorlimbus. contactwiththecornea(Figure1).
184 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 6熏晕燥援 2熏 Apr.18, 圆园13 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 Table 2 Patients’ results after BDI lens implantation Follow-up period Visual acuity Endothelial cell No. Type of BDI IOP 2 (months) Uncorrected Best corrected density (/mm ) 1 48 67G 0.1 0.2 Normal 1074 2 30 67B 0.3 1.0 Normal with brinzolamide 11964; 21239 3 24 67B 0.3 0.6 Normal 1862 4 15 67G 0.2 0.3 Normal 2676 5 14 67B 0.1 0.5 Normal with Ahmed valve 11777; 21191 6 15 67B 0.05 0.1 Normal with timolol 1600 1Before corneal graft rejection; 2After corneal graft rejection.
patientsmustbeconfirmedthattherewasnoretinal detachmentoranteriorproliferativevitreoretinopathybefore implantationandre-examinedundertheartificialcorneain surgery.Iftherewastractionordetachment,BDIlenscan't beimplanted.Ourpatientshadtakenvitrectomybefore,so prolapseofvitreousandtractiontoretinawouldn'thappen whentheIOLwasimplanted.Fortheeyeswithvitreous body,the vitreousmustbecutcompletely before implantationandthesurgeonneedtoavoidmakeany artificialholetoretina.Ozbek [7] alsosuggestthatproper managementoftheaccompanyingvitreoretinalproblemsin aphakicandaniridiaeyesshouldbedonebeforeblack diaphragmIOLimplantation.Theyevenprefertoplacea bucklebeforePPVevenifaretinaldetachmentisnot detected. Inpreviousclinicalobservations [8],wefoundthatthe long-termcomplicationswererelatedtothepreoperative degreeofdamagetotheanteriorchamberangleandiris defects,aswellastheimplantedBDIlens.TheBDIlensis Figure1TheconditionoftheeyesbeforeandafterPKPand largerandheavierthantheregularlens,whichmakesit BDIlensimplantation (Patient4:A,BandC.Patient6:D,Eand F)AandD:Therearecornealopacityandedemabeforesurgery;B difficulttofixtheIOLstablyjustwiththesupportfromthe andE:Thecornealgraftskeeptransparentaftersurgery;CandF: twosuspensionsutures.Thecontactofitsedgewiththe UBMshowedtheBDIlenswaslocatedwellintheciliarysulcus. anteriorchamberangleandcorneamaycausechronic irritationtothetrabecularmeshworkandperipheralcornea, DISCUSSION resultinginchronicdamagetotheblood-aqueousbarrierand Traumaticaniridiaisoneofthecommoncomplicationsafter thecornealendothelialcellloss,particularlyineyeswith eyeballrupture.Somepatientsmayhavetheirpartialvisual aniridiawhichlosetheblockingeffectofiristothelens. functionpreserved,butsufferfromphotophobiaandglare. Inthepreviousimplantsurgery [5],thesuspensionneedlewas TheBDIlenshasbeenwidelyusedaroundtheworldfor20 insertedat1.5mmafterthelimbus,butinthesepatients,the yearsforcorrectionofvisualacuityandeliminationof distancewasincreasedto2mm.Webelievedthatthe photophobia.Becauseofseverecornealscarandcorneal backwardshiftoftheIOLpositioncanreducethefriction edema,thevisioncannotbeimprovedbysimplyimplanting opportunitiesbetweentheIOLandchamberangletissue. BDIlenstocorrecttherefractivestate.Therefore,PKP Patients1and3hadabout1mmwideiristissueremained. becomesanecessarysteptorestorethetransparencyof Patients4and5hadcompletelenscapsuleswhichwere refractivemediumandthevisualfunction. resectedinthecenterduringsurgery,whiletheIOLwas BecausePKPandBDIlensimplantationareboth implantedafterthecapsularringwasretained.Theremnant sophisticatedsurgery,it'sveryimportanttochooseasuitable irisandcapsuleplayedtheblockingroleforBDIlens.For patient.Inadditiontoagoodcorrectedvision,thecondition patients2and6,theirisandcapsulewerecompletely ofretinaisakeypoint,anditwouldbeverydifficultto missing,soweaddedtwosuturesbeforeBDIlensduring recoverretinaldetachmentwithaBDIlensintheeye.The surgerytoproduceabarrier. 185 BDIlensimplantationandPKPinaniridia Thefunctionofsodiumpumpincornealendothelialcellsis diaphragmintraocularlensfortraumaticaniridia. . importanttomaintainthetransparencyofcornea.Owingto 1999;25(6):808-813 the lackofreproductiveactivityinendothelialcells, 3BeltrameG,SalvetatML,ChizzoliniM,DriussiGB,BusattoP,DiGiorgio functionaldecompensationwouldoccurwhenexcessiveloss G,BaroscoF,ScuderiB.Implantationofablackdiaphragmintraocular lensintencasesofpost-traumaticaniridia. 2003;13(1): ofendothelialcellswascausedbyanyinjury,andcouldlead 62-68 tocornealedemaandopacity.Thisalsomighthappentothe 4ChenYJ,WuPC.Favorableoutcomeusingablackdiaphragmintraocular [9,10] endotheliumofcornealgraftafterPKP .Althoughthe lensfortraumaticaniridiawithtotaliridectomy. influencecausedbyBDIlenstothecorneareduced,acute 2003;29(12):2455-2457 graftrejectionoccurredinpatients2and5atabouthalfa 5DongX,YuB,XieL.Blackdiaphragmintraocularlensimplantationin yearaftersurgery.Aftertreatmentintime,cornealedema aphakiceyeswithtraumaticaniridiaandpreviousparsplanavitrectomy. regressedandcorrectedvisualacuityrecovered,butthe 2003;29(11):2168-2173 numberofcornealendothelialcellssignificantlyreduced. 6XieL. .2000.Beijing.People'sMedical PublishingHouse.296-300 Thereweremanyriskfactorsthatcandirectlyandindirectly 7OzbekZ,KaynakS,ZenginO.Transscleralfixationofablackdiaphragm injuretheendotheliumofgrafts.Rejectionwasthehighest intraocularlensinseverelytraumatizedeyesrequiringvitreoretinalsurgery. amongallfactorsandmostendothelialdecompensation 2007;33(8):1494-1498 occurredwithin2years,whichmayberelatedtoearly 8DongX,XuH,YuB,YingL,XieL.Long-termoutcomeofblack rejection [11].Therefore,ourpatientsneedlong-term diaphragmintraocularlensimplantationintraumaticaniridia. observationandanti-rejectiontreatment. 2010;94(4):456-459 Traumaticaniridiaisoftenaccompaniedbysubstantial 9BourneWM,O'FallonWM.Endothelialcelllossduringpenetrating damageintheanteriorsegment.ElevatedIOPbecomesthe keratoplasty. 1978;85(6):760-766 mostcommonpostoperativecomplicationafterimplantation 10PriceMO,ThompsonRW,PriceFW.Riskfactorsforvariouscausesof failureininitialcornealgrafts. 2003;121(8):1087-1092 ofBDIlens [3,5,8,12-14].Reinhard [15] foundabout65%of 11XiaoX,XieL.Theinfluencingfactorsandcharacteristicsofcorneal theidentifiablehapticswerenotfoundintheciliarysulcus graftendothelialdecompensationafterpenetratingkeratoplasty. butintheangleoftheanteriorchamber.Itmaybe 2010;20(1):21-28 attributabletothedirectcompressionfromthehapticstothe 12OmuleckiW,SynderA.Parsplanavitrectomyandtransscleralfixation trabecularmeshwork [15,16].Halfofourpatients(3/6)suffered ofblackdiaphragmintraocularlensforthemanagementoftraumatic IOPincrease,andtheycouldbecontrolledbymedicineor aniridia. 2002;33(5):357-361 Ahmedglaucomavalve.Theproportionofsecondary 13Lanzagorta-ArestiA,Menezo-RozalenJL,Martinez-CostaR, glaucomainthisseriesdidnotexceedthepreviousreports. Cisneros-LanuzaA.Ahmedvalveforelevatedintraocularpressure associatedwithblackdiaphragmlensesforaniridia. Insummary,implantationofBDIlenscombinedwithPKPis 2007;17(3):437-440 aneffectiveoptionformanagingaphakiceyeswithtraumatic 14MoghimiS,RiaziEM,MaghsoudipourM.Visualfunctionafter aniridiaandcornealdamage.Althoughtheresultsinour implantationofaniridiaintraocularlensfortraumaticaniridiain studyareencouraging,additionalstudiesofthelong-term vitrectomizedeye. 2007;17(4):660-665 safetyandefficacyarerequired.Alargerstudypopulation 15ReinhardT,EngelhardtS,SundmacherR.Blackdiaphragmaniridia andlongerfollow-upmaybebeneficial. intraocularlensforcongenitalaniridia:long-termfollow-up. REFERENCES 2000;26(3):375-381 1SundmacherR,ReinhardT,AlthausC.Black-diaphragmintraocular 16AslamSA,WongSC,FickerLA,MacLarenRE.Implantationofthe lensforcorrectionofaniridia. 1994;25(3):180-185 blackdiaphragmintraocularlensincongenitalandtraumaticaniridia. 2ThompsonCG,FawzyK,BryceIG,NobleBA.Implantationofablack 2008;115(10):1705-1712
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