JUL 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 54 of 66

52 EW RESIDENTS July 2013 EyeWorld journal club Review of "Management and outcomes of intraocular lens dislocation in patients by Matthew B. Kaufman, MD, Jessica J. Kovarik, MD, Anna G. Gushchin, MD, Carlos A. Medina, MD, Angela R. Elam, MD, Peter M. Brennen, MD, UPMC Eye Center, University of Pittsburgh School of Medicine Evan L. Waxman, MD, PhD, director of residency training, UPMC Eye Center, University of Pittsburgh School of Medicine This month, a very impressive series of bag-IOL dislocation cases associated with pseudoexfoliation is published in JCRS. I asked the UPMC (Pittsburgh) residents to review this important paper. David F. Chang, MD, chief medical editor P seudoexfoliation syndrome (PXF) is a significant risk factor for complications in patients undergoing phacoemulsification surgery. PXF is associated with weakened zonules and decreased stability of the lens-capsule complex. Pupillary dilation is often reduced and the lens-iris diaphragm can move anteriorly, making the surgery more challenging. Postoperative fibrosis and shrinkage of the capsule can further weaken the zonular fibers.1 These patients are at increased risk for in-the-bag subluxation or dislocation of the intraocular lens (IOL) implant. Bradford J. Shingleton, MD, and his colleagues addressed the complex management of this complication in their recent publication in the Journal of Cataract & Refractive Surgery. This retrospective study included 81 eyes of 76 patients with PXF who underwent surgery for IOL Management and outcomes of intraocular lens dislocation in patients with pseudoexfoliation Bradford J. Shingleton, MD, Yang Yang, OD, PhD, Mark W. O'Donoghue, OD J Cataract Refract Surg (July) 2013; 39: 984-993 Purpose: To analyze the outcomes of surgery for dislocated intraocular lenses (IOLs) in patients with pseudoexfoliation (PXF). Setting: Private practice, Boston, Mass. Design: Retrospective case study. Methods: Eyes with PXF and IOL dislocations that had IOL exchange or repositioning were reviewed. An outcomes analysis compared the surgical techniques with regard to corrected distance visual acuity (CDVA), intraocular pressure (IOP), and glaucoma medication requirements. Results: The IOL exchange was performed in 64 eyes (79%) and IOL repositioning in 17 eyes (21%). The CDVA improved in all eyes, from a preoperative mean of 0.78 logMAR ±0.50 (SD) to a mean of 0.35±0.31 logMAR at the final follow-up (mean 2.5±2.6 years) (P<.0001). The mean IOP was reduced by 4.2 mm Hg at final follow-up (P<.0001). The mean glaucoma medication requirement remained stable at the final follow-up compared with preoperative levels (P>.05). There were no significant differences in the mean CDVA, IOP, or glaucoma medication requirement between eyes that had IOL exchange and eyes that had IOL repositioning. There were no significant intraoperative complications. The most common postoperative complication was a transient decrease in IOP to 5 mm Hg or lower or an increase in IOP to 30 mm Hg or higher. Conclusions: Patients with PXF having surgical treatment of IOL dislocation have the potential for excellent visual outcomes with minimal intraoperative and postoperative complications. Financial disclosure: No author has a financial or proprietary interest in any material or method mentioned. dislocation from June 1990 through July 2012. Dr. Shingleton performed all surgeries. Demographic characteristics of the patients, the time from their initial surgery to dislocation, and the type and severity of the dislocation were recorded. Preoperative and postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), and glaucoma medication requirements were analyzed. Patients were divided into two groups, one that underwent IOL exchange and one that underwent IOL repositioning. They compared three surgical approaches for IOL exchange: using an anterior chamber IOL (ACIOL), a scleral-sutured posterior chamber IOL (PCIOL), or an irissutured PCIOL. IOL repositioning was performed using either an iris suture or a lasso suture via the ciliary sulcus. All patients had the same postoperative medications and follow-up schedule. Results were analyzed using a two-sided two-sample t-test for equality of means for logMAR CDVA, IOP, and glaucoma medication requirements. Pairedsample t-tests were used to compare preoperative and postoperative results in each group. The authors provided detailed descriptions of the different surgical techniques compared in the study. We found these descriptions helpful as they allow readers to apply the results to their own practice by incorporating similar techniques. In the description of IOL exchange for totally dislocated lenses, the technique employed pars plana vitrectomy to bring the dislocated IOL into the anterior chamber and out of the eye. Since the paper states that Dr. Shingleton performed all surgeries, we must assume that he also performed the PPV in these patients, which would be atypical for most anterior segment surgeons. We were also unclear as to whether Dr. Shingleton performed the patients' initial cataract surgery or just the surgery to correct the dislocated lens. That a single surgeon performed all surgeries was debated as both a strength and a weakness of the study. Some of us thought this was clearly a strength, since it allows a more objective comparison of the outcomes from the various techniques. Others observed that we see a wide variety of surgical techniques performed by our faculty at UPMC, and what works well for one surgeon may not be ideal for another. Our feeling was that combining data from multiple surgeons may yield more representative results. Of the 81 eyes in the study, 64 (79%) underwent IOL exchange and 17 (21%) underwent IOL repositioning. IOL exchange with an ACIOL or a scleral-sutured PCIOL were the most common techniques, being employed in 42% and 36% of the eyes, respectively. There were no statistically significant differences in postoperative CDVA or IOP between eyes that underwent exchange and those that underwent repositioning. Mean IOP was significantly decreased postoperatively for all techniques, and a breakdown comparing postoperative mean IOP between the five techniques showed no statistically significant differences. We would like to have seen a similar breakdown of the postoperative CDVA between patients who had IOL exchange with an ACIOL compared with those who had a posterior chamber lens placed. We found it encouraging that most patients either maintained or decreased their level of glaucoma medication postoperatively. However, we were unsure of the criteria used for determining medication levels. We felt that a target IOP should have been set preoperatively for each patient. The most common postoperative complication was hypotony. This was observed more frequently in the IOL exchange group, which the authors attributed to the large incision required to remove the lens. We noted that cystoid macular edema occurred in five patients, all of which had exchange with an ACIOL. While other complications were few, we did note that there were more complications in the exchange with an ACIOL group than the exchange with a scleral-sutured PCIOL group, which both had a similar number of patients. With only one patient undergoing IOL exchange with an iris-sutured PCIOL, we felt it was difficult to make any conclusions regarding that technique. Similarly, only four out of the 17 patients who underwent repositioning had an iris-sutured lens. We found it interesting that only one patient in the study had a

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