Reevaluación de pacientes débiles visuales tras intervención quirúrgica: presentación de cuatro casos / Reassessment of visually impaired patients after surgery: a four-case report

La pérdida visual causa un enorme sufrimiento tanto para aquellos que la padecen como para sus familiares. Cerca del 80 por ciento de la ceguera es evitable (prevenible o curable). Por tales razones se presentan cuatro casos atendidos durante varios años en la consulta de baja visión del Hospital General Universitario Gustavo Aldereguía Lima de Cienfuegos, por ser pacientes clasificados con una diversidad funcional secundaria a diferentes entidades oftalmológicas: hipermetropía elevada, miopía elevada, glaucoma crónico simple en estadio 4 y afaquia no corregida. Se empleó la técnica quirúrgica de extracción extracapsular con implante de lente intraocular, en uno de ellos Piggy Back primario; en todos los casos hubo resultados satisfactorios en diversos parámetros como agudeza visual, campo visual y disminución del defecto refractivo, por lo que se logró mejorar la calidad de vida de los pacientes, así como su inclusión social y escolar(AU)

Visual loss causes enormous suffering to both the patients and their families. About 80 percent of blindness is avoidable (preventable or curable). Therefore, we present four cases treated for several years in the low vision consultation of the Gustavo Aldereguía Lima University General Hospital of Cienfuegos due to a functional diversity secondary to various ophthalmologic conditions including high hyperopia, high myopia, chronic simple glaucoma at stage 4 and uncorrected aphakia. An extracapsular extraction with intraocular lens implantation was performed, using a primary Piggyback in one of them. All cases showed satisfactory results in various parameters such as visual acuity, visual field and reduced refractive error; thus, it was possible to improve the quality of life of these patients as well as their social and school inclusion(AU)

Contact lens correction for an aphakic patient with megalocornea.

A 55-year old pseudophakic man with megalocornea presented with a progressive monocular diplopia. On examination the patient was found to have subluxation of the posterior chamber intraocular lens (IOL)/capsular-bag-complex. Surgical removal of the complex was performed resulting in aphakic status. The patient was subsequently fitted with a custom contact lens for aphakia, with successful visual rehabilitation.

Long-term visual and ocular health outcomes of 2 sets of bilaterally aphakic siblings utilizing contact lens correction.

We report the long-term clinical courses of 8 aphakic eyes of 2 sets of siblings who used contact lenses for both refractive correction and amblyopia treatment following neonatal cataract extraction. Early cataract removal, aggressive contact lens use, and robust professional supervision seem to have substantially contributed to visual success in our four patients. All eyes did well visually with contact lenses, all developing acuities close to 20/20 despite contact lens and non-contact lens related complications that were managed. Complications of most concern were corneal neovascularization and glaucoma. We believe this to be the first case series documenting consistent long-term visual and ocular health outcomes of sets of bilaterally aphakic siblings optically treated with contact lenses.

Rigid gas-permeable contact lens for visual rehabilitation in aphakia following trauma.

PURPOSE: The aim here was to study the safety and efficacy of fitting a rigid gas-permeable contact lens (RGP CL) for visual rehabilitation in patients with ocular trauma. METHODS: A retrospective study was performed on 17 aphakic eyes of patients (16 men and one woman) after surgery for ocular trauma. RGP CLs (including nine brown-tinted lenses) were fitted unilaterally for visual rehabilitation in these patients. The uncorrected vision, spectacle visual acuity and contact lens (CL) visual acuity were recorded. RESULTS: Seventeen patients were selected on the basis that they had undergone surgery following ocular trauma. All eyes fitted were aphakic (n = 17) and nine eyes were fitted with brown-tinted RGP lenses to compensate for traumatic aniridia. All eyes were fitted with RGP CL. A visual acuity of 6/20 or better was seen in seven eyes (41.2 per cent) with spectacle correction and in 15 eyes (88.2 per cent) with CL correction. A visual acuity of 6/12 or better was seen in four eyes (23.5 per cent) and 10 eyes (58.8 per cent), respectively. CONCLUSIONS: A RGP CL is one of the methods available for treating refractive abnormalities in traumatic unilateral aphakia. The procedure is effective, safe and tolerable. RGP CLs can correct the vision of patients with irregular corneal astigmatism. The brown-tinted RGP CL can improve the symptoms of photophobia and the cosmetic appearance of brown eyes.

Long-term results of early contact lens use in pediatric unilateral aphakia.

OBJECTIVES: To evaluate which factor(s) might predict excellent Snellen visual acuity results in unilateral nontraumatic pediatric aphakes. METHODS: Retrospective review of all unilateral pediatric aphakic patients seen in a specialty contact lens clinic between 1982 and 2009. Inclusion criteria as follows: (1) cataract extraction before age 6 weeks, (2) no other health complications, (3) contact lens fitting within 3 weeks postsurgery, and (4) measurable subjective visual performance on a clinical Snellen acuity chart. Fifteen patients were identified: 10 patients with persistent fetal vasculature syndrome (PFV) and 5 patients with the diagnosis of idiopathic congenital cataract (ICC). RESULTS: Final Snellen acuity results showed seven patients (46.67%) developed excellent Snellen visual acuities (defined as 20/50 or better), four patients (26.67%) developed moderate Snellen visual acuities (20/125 to 20/60), and four total patients (26.67%) developed poor Snellen visual acuities (worse than 20/200). Analysis used descriptive statistics. CONCLUSIONS: Approximately 50% of our unilateral nontraumatic pediatric aphakic patients aged older than 5 years achieved excellent Snellen visual acuity in the aphakic eye. The amount of surgical or ocular complications seems to have an inverse relationship with Snellen visual acuity in PFV. Patching compliance, without implying cause-effect direction, also had a direct relationship with final Snellen visual acuity for patients. Early cataract extraction, good to moderate patching compliance, and aggressive early contact lens management can lead to moderate to excellent Snellen visual results in several unilateral pediatric aphakic patients.

[Correction of aphakia with retroiridally fixated IOL]. / Ergebnisse der Aphakiekorrektur durch retroiridal fixierte Kunstlinse.

BACKGROUND: We report the results of the secondary implantation of retroiridally fixated irisclaw-lenses (Artisan(R)) to correct aphakia. PATIENTS AND METHODS: This retrospective study included all eyes that had undergone outpatient implantation of an Artisan IOL by the senior author (MK) between July 2004 and January 2008. We analysed 48 eyes of 46 patients (27 female, 19 male) aged 17 to 87 years. Underlying conditions were: aphakia after congenital cataract or trauma (19 eyes), late luxation of a posterior chamber IOL (16 eyes), intraoperative zonulolysis during cataract surgery that did not allow PC IOL implantation (12 eyes, including 10 eyes with pseudoexfoliation and one eye with Marfan syndrome), anterior chamber IOL with corneal decompensation problems and recurrent hyphema (1 eye). Simultaneous surgical procedures included: anterior vitrectomy (48 eyes), pars plana vitrectomy (14 eyes), removal of PC IOL (16 eyes), removal of AC IOL (1 eye), and penetrating keratoplasty (1 eye). Mean follow-up was 14.3 months (range: 1 - 31 months). IOL power was calculated using the SRKT formula and an A constant of 116.7. RESULTS: Surgery was uneventful in all cases with safe enclavation of both IOL haptics. Mean postoperative refraction was 0 dpt. (range: -0.75 to + 1.0 dpt.), median postoperative visual acuity in Log-Mar was 0.2; compared to preoperative visual acuity (median 0.4 Log-Mar); all patients improved. Pre- and postoperative intraocular pressures were in the normal range in all eyes. Complications were few: one eye without patent iridotomy developed pupillary block glaucoma one day following surgery and was successfully treated by Nd:YAG iridotomy. One patient following blunt ocular trauma developed a retinal detachment with PVR 10 months following implantation of the Artisan IOL that was repaired uneventfully by pars plana vitrectomy with silicone oil instillation. In this case, the Artisan IOL was left in place. In two eyes, secondary trauma resulted in dislocation of one haptic of the Artisan IOL. In both of these cases, refixation of the Artisan IOL was easily performed by enclavation of the iris claw. In two patients cystoid macula oedema was observed. CONCLUSIONS: With correct indications the implantation of a retroiridally fixated IOL (Artisan) is a safe and predictable method to correct aphakia and has become our method of choice instead of anterior chamber IOLs and sclera fixated IOLs.

Secondary intraocular lenses in eyes with aphakia or dislocated IOL: impact of suture fixation on early and late complications.

BACKGROUND: Secondary intraocular lens (IOL) implantation is exposed to an increased risk of complications, including endophthalmitis and retinal detachment. The present analysis compares the outcomes and complications experienced in our own series of patients. PATIENTS AND METHODS: We retrospectively reviewed a consecutive series of secondary posterior chamber IOL implantations performed in a single centre, two surgeon setting over a period of 8 years and with a follow up-time of at least 4 months. RESULTS: Between 1997 and 2005, 75 patients received a sulcus-supported secondary IOL without suture fixation, whereas suture fixation was required in 137 instances. Visual acuity improved in both groups (group 1: from 0.36 +/- 0.39 (0.01-1.2) to 0.73 +/- 0.33 (0.02-1.0; p = 0.18); group 2: from 0.33 +/- 0.34 (0.02-1.0) to 0.46 +/- 0.33 (0.01-1.0; p = 0.006), but more pronounced in eyes not requiring suture fixation (p = 0.012). IOL placement was more likely to be combined with endophacoemulsification in the not suture-fixed IOLs (12.7 vs. 5.3 %). In contrast, retinal tears (10.6 vs. 8.6 %, respectively) and retinal detachment (5.3 vs. 2.2 %, respectively) were equally distributed. In the early postoperative phase, IOP was lower in suture-fixed eyes, which showed a higher incidence of minor intraocular haemorrhages and cystoid macular edema (5.3 vs. 8.0 %); late complications up to 5 years postoperatively were equally distributed. CONCLUSION: A preoperatively less complicated anterior segment situation and a lower incidence of postoperative macular edema may account for a better visual outcome after placement of a sulcus supported IOLs without suturing. If required, suture fixation may be performed without exposing the eye to an increased risk of late postoperative complications.

[Aniridia intraocular lenses in eyes with traumatic iris defects]. / Aniridie-Intraokularlinsen bei Augen mit traumatischen Irisdefekten.

BACKGROUND: Globe injuries frequently are the cause of permanent loss of visual function. Especially ruptures of the globe have a 50 times lower chance of achieving a final visual acuity better than 20/200 as compared to contusions of the globe. Besides injury to the retina and choroids, injury of the iris-lens diaphragm plays an important role for visual rehabilitation (10% iris defects and 1% aniridia after blunt trauma). Against this background the surgical results after implantation of aniridia intraocular lenses were investigated. PATIENTS AND METHODS: Eleven patients (41.9+/-19.6 years of age) after globe injury (three ruptures of the globe, eight penetrating injuries with trauma of the iris) were implanted with an aniridia IOL. RESULTS: The implantation of an aniridia IOL was performed on average 1.0+/-0.6 years (range: 0.4-2.3 years) after the primary injury. In ten eyes an aniridia IOL model HMK ANI 2 (Ophtec/Polytech) was implanted and in one eye an aniridia IOL model 67 (Morcher). Most patients were very satisfied with the results achieved (average corrected visual acuity 0.48; 0.05-1.0). Of the operated eyes, 63% reached a visual acuity > or = 0.4. All patients noticed a significant reduction in glare disability as compared to the preoperative condition. The incidence of secondary glaucoma remained unchanged after the secondary implantation. One patient demonstrated retinal detachment 3 months after receiving the secondary implant, which was successfully treated with vitrectomy and gas tamponade. CONCLUSIONS: The implantation of aniridia IOLs seems to be a beneficial therapeutic option in post-traumatic eyes with partial or complete aniridia and aphakia with good visual recovery. During the postoperative follow-up special attention must be paid to sufficient regulation of intraocular pressure and to the retinal situation.

[A new posterior chamber intraocular lens for sutureless iris-fixated ciliary sulcus implantation in aphakic eyes without capsular support]. / Neue Hinterkammerlinse zur sulkusgestützten und nahtlos irisfixierten Implantation in aphake Augen ohne Kapselstrukturen.

PURPOSE: To avoid anterior chamber lens implantation in aphakic eyes without capsular or zonular support, the laborious scleral fixation of a standard posterior chamber intraocular lens (IOL) is widely used, despite a large range of possible complications (macular edema, IOL tilt/decentration, suture erosion, vitreous hemorrhage). A sutureless iris-fixed ciliary sulcus implantation of a posterior chamber IOL (Binder-IOL, Fa. Iolution, Itzehoe) designed especially for such cases represents an alternative. METHOD: At the end of both haptics of this IOL, with a 6 mm optic zone, a T-shaped anchor is mounted at an angle of 45 degrees from the optical plane. These anchors are inserted from behind the iris into peripheral iridotomies performed preoperatively with a YAG-laser or intraoperatively with a vitrectomy cutter. The long, C-shaped haptics are thus secured in the ciliary sulcus. RESULTS: After slight modification of the technique, the implantation can be performed securely and reproducibly. In the 22 implantations performed to date, the IOL was well centered and stable, even in cases with only residual iris stroma. If the iridotomies are been performed too centrally, an ovalisation of the pupil may occur. No further side effects have been observed. CONCLUSION: The technique of sutureless sulcus fixation presented here leads to less complications than scleral suture fixation. A prerequisite for safe implantation of the anchors is good visibility of the peripheral iris. The implantation of the Binder-IOL is especially suitable for aphakic eyes with a loosened iris diaphragm.

Evaluation of the ZEBRA 2000 (Z-10) Breger Vision bifocal contact lens.

PURPOSE: Evaluate the ZEBRA 2000 (Z-10) bifocal contact lens on presbyopic and aphakic patients. METHODS: Thirty-eight patients, 37 presbyopes and one aphake, were fit in the Z-10 and evaluated for 6 months. RESULTS: Twenty patients (53%) completed 6 months of contact lens wear. Ten (26%) discontinued due to lens related problems, three (8%) discontinued due to other health problems, and five (13%) were lost to follow-up. Average refits per eye were 1.75. Average distance visual acuity was 20/25; average near visual acuity was J1.6; average wear time, 11 hours. Patient satisfaction was rated good in comfort and vision and fair in nighttime glare by patients' subjective evaluation. CONCLUSIONS: The ZEBRA 2000 (Z-10) can be a useful addition in fitting the general presbyopic patient population.

[Results of implantation of transsclerally sutured posterior chamber lenses in combination with penetrating keratoplasty]. / Implantation skleranahtfixierter Hinterkammerlinsen in Kombination mit perforierender Keratoplastik.

UNLABELLED: Implantation of transsclerally sutured posterior chamber lenses is one possibility of surgical visual rehabilitation of eyes with pseudophacic or aphacic bullous keratopathy without zonular-capsular support. We analyzed the results and complications of the surgical procedures performed in our institution. PATIENTS AND METHODS: Out of 1567 penetrating keratoplasties and 220 transsclerally sutured posterior chamber lenses that were performed at our institution between 1991 and 1996, patients that underwent penetrating keratoplasty and sutured posterior chamber lens implantation in whom sufficient clinical information was available were selected and analyzed in a retrospective, nonselective study. Surgery was performed by a total of four surgeons and included anterior vitrectomy, inside-out suturing and synechiolysis if necessary. Detailed pre- and intraoperative data, postoperative course and complications were recorded and analyzed. RESULTS: A total of 96 eyes were analyzed (patient age 17-92 years, 49 male, 46 female). Penetrating keratoplasty was performed for pseudophacic (63) oder aphacic (15) bullous keratopathy or for corneal scars following penetrating injury (18). Mean follow-up was 22 months. In 82 of 96 eyes, visual acuity improved following surgery. Complications included rhegmatogenous retinal detachment in 4 eyes, graft rejection in 5 eyes, secondary angle-closure glaucoma caused by preexisting anterior synechiae in 7 eyes, and persisting cystoid macular edema in 19 eyes. Luxation or subluxation of the IOL and endophthalmitis were not observed in any of the patients. CONCLUSION: Implantation of transsclerally sutured posterior chamber lenses appears to be a safe procedure and is considered by us to be the procedure of choice to correct aphacia during penetrating keratoplasty in eyes with absent zonular-capsular support. The majority of postoperative complications is apparently caused by preexisting problems related to previous surgery and/or trauma, such as peripheral anterior synechiae, vitreous incarceration or cystoid macular edema.

[Visual rehabilitation in aphakia with air lenses]. / Reabilitatea vizuala a afacului cu lentile aeriene.

The article shows a comparative study between two groups of 50 patients operated for cataract in 1990 and 1995. In both of these groups aphakia was corrected with aerian lenses. The study was made to demonstrate the visual problems due to strong convergent lenses, to shows the difficult adaptation to this kind of spectacles and to determine the degree of dissatisfaction of the spectacles wear aphak.

Unilateral pseudophakia in children under 4 years.

PURPOSE: We examined the efficacy of intraocular lens implantation (IOL) in children younger than 4 years of age for unilateral aphakic visual rehabilitation. METHODS: Twenty-one patients underwent unilateral cataract extraction, IOL placement, posterior capsulotomy, and anterior vitrectomy between 1990 and 1994. Postoperative vision, refractive change, and complications were monitored prospectively. Two cataract subgroups were analyzed: 12 patients with infantile (congenital and developmental) cataracts, and nine patients with posttraumatic cataracts. RESULTS: Overall age at surgery averaged 26 months (range 9 to 44 months), with follow up of 5 to 55 months. Fifty-two percent achieved 20/40 or better vision: 42% in the infantile group and 67% in the traumatic group. IOL power averaged 22.6 diopters (D). The difference between predicted and actual postoperative refraction was less than 1 D in 70%. After 6 months, the average change in refraction was 0.50 D (21 patients). An increasing myopic shift of 1.10 D at 12 months (14 patients), 1.80 D at 18 months (nine patients), and 2.90 D after 24 months (eight patients) was noted. This trend was greater in the infantile group. Amblyopia treatment was implemented in 18 patients. Half have completed occlusion successfully, one third continue therapy, 17% are treatment failures, and 11% (two patients) were lost to follow up. Six patients required strabismus surgery; five had infantile cataracts. Postoperative complications occurred in four eyes, two infantile and two traumatic; they consisted of posttraumatic temporal IOL dislocation, corectopia, partial pupillary capture of an IOL, and partial pupillary membrane. CONCLUSION: Primary IOL implantation is an effective way to rapidly achieve aphakic visual rehabilitation in preschool children. We continue to evaluate the long-term safety and effects of pediatric pseudophakia.

Multifocal intraocular lens: a new development in aphakic visual rehabilitation.

Multifocal intraocular lenses have been in the market for three to four years. They were designed to achieve bifocal effect, minimising the need for additional spectacle correction for near vision. This is a retrospective analysis of visual results in one hundred and four eyes implanted with multifocal intraocular lenses. They were followed up for two months to one year. The results showed that 95 eyes (93%) achieved best corrected distant visual acuity of 6/6-6/12; 99 eyes (97%) achieved near visual acuity of N5-N6; 92 eyes (90%) achieved their best near vision with their distant correction, not requiring further refractive correction for near. The selection of patients was done at random. Two patients were excluded from the analysis due to macular degeneration. The quality of vision was not assessed in this study.

[Improving the function of the visual system in children with aphakia]. / Usprawnianie funkcji ukladu wzrokowego u dzieci z bezsoczewkowoscia.

Systematic reeducation by pleoptic-orthoptic exercises was performed in children with posttraumatic and congenital aphakia for the improvement of the visual acuity, normal retinal fixation and binocular vision. The treatment comprised 244 children aged 1-16 years who were formerly given a correcting contact lens on the aphakic eye. In the result of rehabilitation a visual acuity of over 5/16 was attained in 79.5 per cent of cases, a normal retinal fixation in 73.77 per cent and the binocular vision in 46.31 p.c. Better results were obtained after treatment of a posttraumatic cataract, poorer results after extraction of a congenital cataract.