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ARTICLES |
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Year : 1989 | Volume
: 37
| Issue : 2 | Page : 75-77 |
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Endocapsular insertion of intra ocular implant
S Tony Fernandez, Sebastian Pious, Noel Moniz
Chief Ophthalmic Consultant & Head of the Dept; CB M Ophthalmic Institute, Little Flower Hospital, Angamally - 683 572, Kerala, India
Correspondence Address: S Tony Fernandez Chief Ophthalmic Consultant & Head of the Dept; CB M Ophthalmic Institute, Little Flower Hospital, Angamally - 683 572, Kerala India
Source of Support: None, Conflict of Interest: None | Check |
PMID: 2583785
The first 500 posterior chamber lenses inserted in the capsular bag, have been analysed in detail. The cases included in this study were developmental, traumatic and complicated cataracts in addition to senile cataract. The follow-up ranged from 6 months to 2 years. Although posterior capsule rupture occured in 23 cases, the lens was inserted in 12 cases with a small tear. In general the complications were found to be minimal and visual recovery was good in more than 80 % of the cases. The only problems we have been facing were thickening of the posterior capsule (11.6 %), high astigmatism (12.2 %), pupillary capture (5.6 %) and decentering of the lens (2.8 %).
How to cite this article: Fernandez S T, Pious S, Moniz N. Endocapsular insertion of intra ocular implant. Indian J Ophthalmol 1989;37:75-7 |
Introduction | | |
Capsular bag insertion of the Infra Ocular Lens implant is established as a much safer technique than `in the sulcus insertion'. It is the anatomical position of the lens. The loops being within the capsular bag, pressure to the ciliary body or trauma to the iris is minimal. Only in this procedure one is sure that both the haptics and optic are within the capsule. In most of the other procedures done, one is sure of only the lower loop. The upper loop may or may not get into the bag.
Our procedure is a modification of Galand et al, and we have used a modified J loop lens.
Material and Methods | | |
In this study an analysis of the first 500 cases who underwent endocapsular IOL implantation is attempted. The follow up period ranged from a minimum of 6 months to 2 years.
CASE SELECTION:
Maximum number of patients were in the age group of 51 to 60 (37.6 %). 5 cases of unilateral congenital cataract, 13 cases of complicated cataract and 31 cases of traumatic cataract were included in this study. 15.2 % of cases were diabetic and in all these cases the diabetic age was less than 7 to 8 years and fundus examination showed minimal or no changes of diabetic retinopathy. 31 patients had both eyes operated (62 eyes) upon.
OPERATIVE PROCEDURE:
- Fornix based conjunctival flap
- Limbal groove made with a blade
- Horizontal anterior capsulotomy about 3 to 4 mm below the upper equator made through a small puncture at the IT O clock limbus.
- Section extended to 160° to facilitate delivery of the nucleus.
- Cortical matter washed out (adrenaline used in the irrigating solution to maintain pupillary dilation).
- Polishing of the posterior capsule done, if necessary.
- Methylcellulose introduced, to expand the capsular bag, to maintain the pupillary dilation and protect the comea.
- Insertion of the lower loop of the posterior chamber lens vertically towards 6 O'clock position.
- Insertion of the upper loop and dialling it making the loops lie horizontally.
- A triangular part of the anterior capsule is cut with microscissors after deepening the anterior chamber with methyl cellulose.
- One PBI at 12 O'clock position.
- Cornea sutured with 10' o monofilament.
COMPLICATIONS DURING THE OPERATION:
Posterior capsule rutpure occured in 23 cases. This happened especially in larger nuclear cataracts with a weak capsular bag. In 12 cases, as the tear was small we could still insert the lens after a limited anterior vitrectomy. In 10 cases of hyper mature cataract, the anterior capsule was torn in the vertical direction while attempting a horizontal capsulotomy. In all these cases the lens could be inserted but with difficulty.
IMMEDIATE POST OPERATIVE COMPLICATIONS:
This is shown in [Table - 1]. All the eyes which had striate keratitis cleared within 2 or 3 days. In 2 cases hyphaema had to be washed out. Other case of hyphaema cleared well with conservative management. Frequent instilation of steroid and Cyclopentolate drops once a day and ibuprofen orally took care of iritis in all the cases. Raised tension was controlled with medical treatment.
LATE COMPLICATIONS:
During follow up we found complications like high astigmatism, vitritis, cystoid macular oedema, thickening of posterior capsule, posterior uveitis, secondary glaucoma and decentering of the lens in a few cases, as shown in [Table - 2].
VISUAL RESULTS AFTER SURGERY:
According to the visual acuity recorded at the last follow up, 152 cases got 6/6 or better with correction [Table - 3]. The causes for poor vision in 21 cases included macular degeneration, myopic degeneraion, vitreous haemorrhage, diabetic maculopathy, herpes zoster ophthalmicus with posterior uveitis and retinal detachment in 1 case. 2 cases had corneal opacifiction probably due to endothelial damage.
Discussion | | |
A posterior chamber lens inserted in the sulcus give rise to uveal touch complications like atrophy, pigment dispersion, haemorrhage, inflammation, soreness and occasional retinal oedema. Other complications described are sunset syndrome, windshield wiper syndrome and pupillary entrapment of the lens.
Pathological postmortem study done on 3 human eyes by Crawford revealed some potential anatomical hazards of cilliary sulcus placement. Shearing lenses were found to be embeded in the ciliary body near a major artery. The ideal position of the lens is the capsular bag. From the experiments in Rhesus monkey, Irvin concluded that a lens implanted within the capsular bag became well fixed and had no discernible effect on the adjacent ciliary body.
The present series showed that a lens inserted in the capsular bag is well tolerated by the eye and the complications were minimal. It causes least trauma to the endothelium as the washing is done with the anterior capsule intact. The few problems we have been facing were,
- Thickening of the posterior capsule
- High astigmatism
- Pupilliary capture
- Decentering of the lens.
Posterior capsular opacification was observed in 11.6 % of cases. This is an universally accepted complication of planned extra capsular extraction. The incidence of after cataract was quite high in children and young patients and repeated needling had to be done in 3 children. Yag laser capsulotomy being a non-invasive procedure, should tackle the problem of after catract.
High astigmatism was a distressing problem in 12.2 % of cases. The highest recorded was -6.00 D cylinder 180°. This is actually an inherent problem of monofilament suture. All of these became minimal or nearly normal with removal of sutures.
Pupillary capture was more common in children and in young patients. Incidence of pupillary capture is relatively high (5.6 %) probably because we have included more children and young patients in our study. Another reason may be the use of Cyclopentolate drops routinely for 1 month. Mild to moderate decentring of the lens occured in 2.8 % of cases. Most of these cases were associated with thickened capsule either due to retained lens matter or mild uveitis or haemorrhage occuring after a few months. For pupillary capture and decentering large diameter optics or even disc lenses of 8mm are now advised. Minimal decentering normally does not give rise to much of a problem except a change in the refraction.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]
[Table - 1], [Table - 2], [Table - 3]
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