|Year : 1984 | Volume
| Issue : 5 | Page : 399-401
Evaluation of combined procedure: Penetrating keratoplasty and anterior vitrectomy by vitrophage
AP Shroff, OP Billore, RJ Mirza, PH Masani
Rotary Eye Institute, Navsari, Dudhia Talao, Navsari, Gujarat, India
A P Shroff
Rotary Eye Institute, Navsari, Dudhia Talao, Navsari 396445, Gujarat
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shroff A P, Billore O P, Mirza R J, Masani P H. Evaluation of combined procedure: Penetrating keratoplasty and anterior vitrectomy by vitrophage. Indian J Ophthalmol 1984;32:399-401
|How to cite this URL:|
Shroff A P, Billore O P, Mirza R J, Masani P H. Evaluation of combined procedure: Penetrating keratoplasty and anterior vitrectomy by vitrophage. Indian J Ophthalmol [serial online] 1984 [cited 2021 Sep 25];32:399-401. Available from: https://www.ijo.in/text.asp?1984/32/5/399/27521
Long term follow up of aphakic cases, in whom vitreous had escaped into the anterior chamber during cataract surgery, mainly present with the problem of bullous keratopathy because of thick vitreo endothelial adhesions.
Before a decade or so, keratoplasty being a complicated and unpredictable surgery, was not frequently recommended in old aphakic patients, but now the matter is different Improvised suture material, excellent magnification devices, vitrectomy, healon etc. have totally changed the outlook in such patients.
| Material and methods|| |
In present series of 15 cases, 11 were male and 4 were female between the age of 25 to 69 years. 9 were left eyes and 6 were right eyes. Cataract surgery was performed 1 year to 3 years prior to this surgery in 11 cases. As majority of cases were operated elsewhere exact details were not available. All cases were given a fair trial of medical therapy over a period of 2 to 3 months. Majority of cases (10) were agreed upon to undergo second surgery as a symptom relieving measure only e.g. pain, off and on watering, photophobia etc, 4 cases had perforated corneal, ulcer following infection.
Initially they were treated by medical line of treatment but ultimately cornea melted or perforated.
Clinical evaluation on slit lamp biomicroscopy, applanation tonometry, indirect ophthalmoscopy to reveal any posterior fundus pathology, retinal visual acuity to assess visual improvement preoperatively on Rodenstock Retinometer were done, alongwith other routine and general investigations in aphakic bullous keratopathy cases.
In aphakic cases 3 mm sclerotomy wound was prepared for anterior vitrectomy in lower outer quadrant. Edges were diathermised and 6° nylon suture was preplaced. 7.5 to 8.5 mm full thickness corneal graft from fresh donor corneas were sutured using 10° nylon or Dermalon suture (13 cases) and 8°,ethilon suture (in 2 cases) in continuous fashion.
During the procedure escaped vitreous was cut away with scissors and fluid vitreous was aspirated from vitreous cavity by 18 gauge straight needle. Corneal wound was adequately secured by tightening the suture at least 2 to 3 times and only one knot was given to keep it secured.
The surgical technique differed in cases of perforated corneal ulcers., where corneal graft . was transplanted first and then the sclerotomy wound was made. Moreover opaque lens was removed on table only.
Anterior vitrectomy by Peyman's vitrophage through pars plana was done as thoroughly as possible to make the anterior chamber free of any residual vitreous. The previous knot was secured further and the procedure was concluded. The procedure was performed under marcaine anaesthesia in 13 and general anaesthesia in 2 cases. Routine post operative dressing done and notes were prepared.
Cases have been followed up for 10 to 16 months.
| Observations|| |
In group of Bullous keratopathy [Table - 2] larger area of cornea gets involved as the time after cataract surgery passes by. Moreover, there is a marked deterioration of vision where more than 8 mm of cornea was involved. Visual improvement was grouped in 3 grades (as shown in [Table - 2]) and accordingly pre-operative vision was grouped so as to compare post operative improvement. 2 cases of less than 6 mm corneal involvement who had visual acuity between 3/60 to 6/60 improved to 6/36 to 6/24 with glasses. Graft remained clear even after 12 to 16 months. Out of 5, 3 cases of B group where corneal involvement was 6 to 8 mm, had vision between 3/60 to 6/60, and out of 3 cases graft had remained clear and vision had improved to 6/36 to 6/24 with glasses. In one case, though graft had remained clear, vision neither improved nor deteriorated. 2 cases in whom vision was
Post operative complications were encountered as shown in [Table - 4]. In aphakic patient only one case had raised intraocularpressure even after 3-4 weeks which was medically controlled, but ultimately graft had become opaque. Otherwise there were no major post operative complications. Most of the complications were observed in septic cases where intraocular pressure remained at a higher level in 3 cases which was controlled by medical means. The main reason for raised intraocular pressure was anterior synechiae in those 2 cases where anterior synechiotomy was done. In one eye hyphema was seen from 2nd post operative day only, which lasted for nearly 3 weeks but ultimately the graft had become opaque. In one eye sepsis recurred and ultimately the graft became opaque.
| Discussion|| |
Penetrating keratoplasty alone does not have very good results in conditions where vitreous has presented in the anterior chamber or has escaped outside. But management of vitreous by anterior vitrectomy through pars plana by vitrophage alongwith keratoplasty has changed the outlook considerably as it is the best available method to make the anterior chamber free of vitreous. Moreover formation of anterior chamber by Ringer's lactate solution maintain clarity of media to view the anterior segment and posterior fundus as well. There was no anterior synechiae in aphakic cases. The eyes were very quiet from the very next day. Before closure the intraocular pressure could be manipulated by controlling the flow of Ringers lactate.
In cases of perforated corneal ulcers or abscess the cases were mainly tackled as an emergency and lens was either expelled of its own or was removed deliberately as it was considerably opaque. In such cases usually vitreous gets disturbed and presents in the chamber or outside the wound. Iris and other tissues were quite inflammed and hence rate of post-operative complications was much higher. Even though the graft had remained clear for initial 3 to 4 weeks but then 50% cases in this series deteriorated because of complications. Moreover, this procedure helps in clearing the infection if at all it has invaded the interior part of the eye.
| Summary|| |
In this series of 15 cases where 11 cases were of aphakic bullous keratopathy and 4 cases of large perforated corneal ulcers or abscess, penetrating keratoplasty with anterior vitrectomy by vitrophage has certainly given encouraging results.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]