Limbal Approach Research Articles

Surgery of the Hereditary Subluxated Lens in Children

To describe the criteria and techniques for the surgery of hereditary subluxated lens in children and analyze the visual and surgical outcome after an extended period of follow-up. From 1982 to 1994, 65 children who had subluxation of their lens were followed in the authors' clinic. Thirty-seven children (59 eyes) underwent surgery (27 eyes had Marfan syndrome; 23 eyes had essential dislocation; and 9 eyes had a diagnosis of homocystinuria, aniridia, microphthalmia, or Weill-Marchesani syndrome). The indications for surgery were best-corrected visual acuity of less than 20/70, forward sub-luxation of the lens to the anterior chamber, monocular diplopia, or rapidly progressing posterior subluxation of the lens. All 54 eyes with subluxation of the crystalline lens behind the iris underwent pars plana lensectomy combined with anterior vitrectomy. In five eyes with total forward dislocation of the lens in the anterior chamber, a limbal approach for removal of the lens and protruding vitreous was used. Postoperative follow-up ranged from 12 to 144 months (average, 55 months). After surgery, 522 eyes (88%) of the entire group achieved an improvement (2 lines or more on the Snellen chart) in best-corrected visual acuity. Seven eyes (12%) did not show improvement and remained with the same visual acuity as before the surgery. Retinal detachment was detected in one eye 2 years after surgery and was the only major postoperative complications observed in these patients. These results and the unique continuous and long-term follow-up on our patients demonstrate that lensectomy of ectopia lentis combined with anterior vitrectomy using a closed-system technique is a beneficial and relatively safe procedure.

May I bend down after my cataract operation, doctor?

We reviewed the records of 21 patients with posttraumatic wound dehiscence following cataract surgery to establish the cause of injury and assess the complications and outcome following injury. Wound dehiscence most commonly resulted from patients knocking their eye accidentally with their own hand, and falls were the second most frequent cause. None of these patients suffered injury as a result of bending down. Eyes that had undergone cataract surgery through corneal sections were more prone to wound dehiscence than those operated on via a limbal approach. The visual outcome following repair was good in the majority of cases, but eyes with expulsion of lens implant and/or vitreous loss tended to have a relatively poor outcome.

Long-term Effect of Cataract Extraction on the Function of an Established Filtering Bleb

For patients with advanced glaucoma, care must be taken in the management of cataract to prevent loss of long-term intraocular pressure (IOP) control. The authors evaluated the effect of extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (PC IOL) implantation via the inferotemporal limbal approach on the function of an established glaucoma filtering bleb. Twenty-three eyes of 21 patients with a minimum of 48 months of follow-up (range 48 to 97 months) were retrospectively evaluated. IOP, bleb status, visual field, and visual acuity were compared before and after operation. Average IOP increased from 8.7 mm Hg preoperatively to 12.2 mm Hg at last follow-up. Six blebs (26.1%) decreased in size, 11 (47.8%) did not change, 4 (17.4%) increased in size, and 2 (8.7%) were lost and required refiltration. At last follow-up, 23 eyes had an IOP of less than 20 mm Hg and did not show progression of glaucoma damage by optic disc or visual field evaluation. Six eyes required resumption of medical therapy and 2 eyes required refiltration for adequate control. ECCE with PC IOL implantation via the inferotemporal limbal approach in the presence of an established filtering bleb is effective in the long-term management of the glaucomatous eye with cataract.

Surgical management of dislocated intraocular lenses

Intraocular lens (IOL) malpositions range from simple IOL decentration to luxation into the posterior segment. Many surgical techniques and approaches have been devised to treat visually significant IOL dislocation. In this series, 78 eyes with IOL dislocation were managed by anterior segment and vitreous surgeons with a variety of surgical techniques using a limbal, pars plana, or combined limbal-pars plana approach. Most of the dislocated lenses were posterior chamber IOLs. In 39 of 78 eyes (50%), final visual acuity was 20/50 or better. Neither surgical approach nor management technique appeared to be related to outcome. The timing of surgery did not appear to affect visual outcome but was not examined in a randomized fashion. Guidelines for determining optimal management are presented.

Long-term Results after Removal of Dislocated Intraocular Lenses from the Retinal Surface through a Limbal Approach

The authors describe the use of a limbal approach for removing dislocated intraocular lenses (IOLs) from the retinal surface to minimize surgical trauma and optimize visual outcome. Thirteen consecutive patients underwent removal of a dislocated posterior chamber IOL (PC IOL) from the retinal surface through a limbal approach. The surgical technique used in all patients included a limbal incision from the 3- to 9-o'clock positions; open-sky vitrectomy, grasping the IOL at the angle between loops and optics with an iris hook; and IOL removal through the corneoscleral opening. In all except one patient, who had high-degree myopia, an IOL was re-implanted during the same surgical procedure (free sulcus fixation of a PC IOL over remnants of the capsular bag, 7 patients; sulcus fixation of a PC IOL over remnants of the capsular bag combined with 1 transscleral suture, 3 patients; and implantation of an anterior chamber IOL, 2 patients). No retinal or corneal complications secondary to IOL removal and re-implantation through a limbal approach could be detected over an average follow-up period of 22.3 months (range, 17-27 months). Best-corrected visual acuity was 20/40 or better in seven patients, between 20/50 and 20/400 in three, and less than 20/400 in three. Visual outcome worse than 20/40 was related to pre-existing macular degeneration in five patients and retinitis pigmentosa in an additional one. The use of a limbal approach allows removal of an IOL from the retinal surface and secondary IOL implantation in the preferred site during the same surgical procedure. Because no special instrumentation is needed, this technique also is suitable for primary removal if dislocation occurs intraoperatively. The visual outcome and the long-term absence of complications recorded in our series indicate that a limbal approach may offer a reasonable alternative in managing IOLs luxated onto the retinal surface.

Suturing a Posterior Chamber Intraocular Lens to the Iris Through Limbal Incisions: Results in 30 Eyes

I have previously reported a new technique of suture fixation of a posterior chamber intraocular lens (IOL) to the iris through a limbal incision in the absence of a posterior lens capsule. This study evaluated the results of that technique as an alternative to anterior chamber lens implantation or suturing of a posterior chamber lens through the ciliary sulcus and sclera. The clinical records of 30 consecutive eyes that underwent this procedure between September 1987 and February 1991 were studied retrospectively. Four sutures were attached to four holes in the optic of a posterior chamber IOL. Two sutures on straight needles were passed through a superior limbal wound, to the pupil, reaching the inferior iris to be tied onto this iris. The two upper sutures on curved needles were passed through the pupil and going to the superior iris and then tied. An anterior vitrectomy was done in the pupil in 18 (60%) eyes. The mean postoperative follow-up time was 40 months (range, 24 to 66 months). Nineteen eyes (63%) had visual acuities of 20/40 or better; and 10 eyes (33%) had visual acuities between 20/50 and 20/80. The remaining eye had persistent cystoid macular edema, proven by fluorescein angiography, with 20/100 visual acuity. No serious anterior segment complications occurred. There was mild pigment dispersion on the IOL in four eyes. Four eyes needed timolol drops to lower the intraocular pressure. This technique offers a viable alternative to transscleral fixation of a posterior chamber IOL via a limbal approach.

Ocutome lensectomy: results and complications.

We describe the results and the complications encountered in 69 lensectomies performed via a limbal approach with the Ocutome vitrectomy instrument, in which it was the intention at surgery to maintain the integrity of the posterior capsule. After operation 87% improved in visual acuity, and 68% achieved 6/12 or better. The main early complications encountered were perioperative rupture of the posterior capsule and iris damage. The main late complications were postoperative thickening of the posterior capsule, retinal detachment, and bullous keratopathy. Of the eyes in which the posterior capsule remained intact after operation 17% developed thickening of the posterior capsule to a degree that required capsulotomy over a mean follow-up period of 50 months.

Simplified Limbal Incision for Extraocular Rectus Muscle Surgery

We describe a limbal incision for extraocular muscle surgery which involves only one incision to the conjunctival-Tenon's layer instead of the three separate incisions required in the standard limbal approach. Based on the 316 extraocular muscle operations in which we have used this one-snip procedure, we conclude that it is simpler and faster than the standard limbal incision, and that it provides good surgical exposure and probably less tissue damage.

Phacoemulsification Combined With Pars Plana Vitrectomy

Phacoemulsification combined with pars plana vitrectomy was performed on seven patients with both cataracts and vitreoretinal disease. Six of the seven had a posterior chamber intraocular lens (PC-IOL) placed in the capsular bag following cataract extraction. Visual acuities ranging from light perception to hand movement preoperatively, postoperatively ranged from hand movement to 20/25. There were no perioperative complications. During an average follow-up of more than 6 months, neovascular glaucoma developed in one patient, and a conjunctival cyst in another. The PC-IOLs were well tolerated. The small limbal incision used in phacoemulsification allows better control during the vitrectomy procedure and ensures a water-tight wound. In addition, with the limbal approach, the posterior lens capsule is maintained, with all the attendant advantages.

Pediatric cataract surgery and intraocular lens implantation: A new technique for preventing or excising postoperative secondary membranes

This report describes a series of six children who had a retropseudophakic vitrectomy performed via a limbal approach (limbal approach retropseudophakic vitrectomy, LARV). This technique ensures a permanently clear visual axis when performed at the time of cataract/implant surgery and can also be used to excise secondary membranes in patients who have had prior cataract extraction and intraocular lens implantation. A modification of this method permits the retrolenticular opacity in children with persistent hyperplastic primary vitreous (PHPV) to he relocated or excised at the time of cataract or cataract/implant surgery.

The Surgical Approaches to Paediatric Cataract

The pars plana and limbal approaches to cataract extraction in the paediatric age group are discussed. The advantages and possible disadvantages of each method are briefly described and the indications outlined. A combined limbal-pars plana approach in cases with large plaques of the posterior capsule and vitreous abnormalities (PHPV) is also described. The choice of approach should be made according to the surgeon's familiarity with the techniques and the planned type of post-aphakic correction. It is my opinion that a limbal approach should be performed in all cases where an implantation of intraocular lens (IOL) is planned. A guarded posterior capsulectomy lowers the incidence of secondary cataract and is advisable. A combined anterior vitrectomy appears to lower the postoperative inflammatory reaction and is recommended for all cases younger than 5 years at the time of surgery. Anterior vitrectomy is mandatory if implantation of IOL is carried out in these young patients.

Extracapsular cataract extraction using a temporal limbal approach after filtering operations.

We reviewed the charts of 29 patients who underwent extracapsular cataract extraction after filtering surgery. Seven of these patients also had simultaneous implantation of a posterior chamber intraocular lens. All eyes were operated on using a temporal limbal approach. The median postoperative follow-up was 13 months. There was no statistically significant difference between the preoperative and postoperative intraocular pressures, but there tended to be an increase in the number of antiglaucoma medications administered postoperatively. None of these patients, however, required further surgery for intraocular pressure control.

An Anterior Limbal Approach to Vitrectomy for the Surgical Management of Infectious Endophthalmitis

We present two cases illustrating a surgical approach to the diagnosis and treatment of infectious endophthalmitis following extracapsular cataract extraction with insertion of a posterior chamber lens. In both cases, a vitrectomy was initiated through a limbal approach after clearing the anterior chamber, thus allowing improved visualization of the vitreous cavity. The vitrectomy probe was then passed through a peripheral iridotomy, the peripheral posterior capsule and/or zonules, and into the anterior vitreous. The peripheral iridotomy allowed access to the vitreous cavity for an anterior vitrectomy. The entire anterior chamber and vitreous aspirate was then analyzed for culture and sensitivity. This technique minimizes the risks of pars plana vitrectomy for endophthalmitis by improving visualization and possibly decreasing the risk of retinal detachment.

Vitrectomy and Fluid Infusion in the Treatment of Delayed Suprachoroidal Hemorrhage After Combined Cataract and Glaucoma Filtration Surgery

I report the successful treatment of one case of massive, delayed suprachoroidal hemorrhage that occurred after combined intracapsular cataract extraction and trabeculectomy. Significant vitreous incarceration in the filtration site and consequent vitreoretinal traction were present so that a limbal approach anterior vitrectomy was necessary before choroidal drainage could be accomplished safely. An infusion of balanced salt solution through a limbal infusion cannula was employed during vitrectomy and also during drainage of suprachoroidal blood. The simultaneous intravitreal infusion helped to create an efficient, controlled choroidal drainage procedure. In addition to relieving vitreoretinal traction, this technique helps prevent the periods of extreme hypotony experienced when choroidal drainage and anterior chamber reformation are accomplished serially in step-wise fashion. This use of this method also obviates the compromised view of the peripheral retina which occurs when air is introduced into the vitreous cavity.

Managing dense retropseudosphakos membranes with a pars plana vitrectomy.

Formation of thick and occasionally dense retropseudophakos membranes and rapid fibrosis of the posterior capsule is a complication that adversely affects the outcome of intraocular lens implantation. We have observed this condition in 17 patients, most of whom presented with traumatic and congenital cataracts. It appears to occur more frequently in young individuals and children. Simple capsulotomy, by the limbal approach or with the YAG laser, does not reliably eliminate the membranes. We have used vitrectomy and scissors dissection through the pars plana to achieve good anatomical results. Postoperative visual acuity has been satisfactory, except in amblyopic eyes related to congenital cataracts.

Management of persistent hyperplastic primary vitreous.

Instruments designed for pars plana vitrectomy can be used to manage selected complicated congenital cataracts such as those with persistent hyperplastic primary vitreous (PHPV). We have applied closed-eye vitrectomy techniques through a limbal approach in seven eyes with PHPV. A clear pupillary space was achieved in all cases and two of the seven eyes achieved useful vision. The management of children with complicated congenital cataracts such as those with PHPV is discussed.

Persistent Hyperplastic Primary Vitreous: Surgical Treatment

Instruments designed for pars plana vitrectomy can be used to manage selected complicated congenital cataracts such as those with persistent hyperplastic primary vitreous (PHPV). We have applied closed-eye vitrectomy techniques through a limbal approach in seven eyes with PHPV. A clear pupillary space was achieved in all cases and two eyes achieved useful postoperative vision. The management of children with complicated congenital cataracts, such as with PHPV, is discussed.

Vitrectomy in Infants and Children with Retinal Detachments Caused by Cicatricial Retrolental Fibroplasia

Four infants and one child with retinal detachments from cicatricial retrolental fibroplasia involving traction judged too severe to be relieved by scleral buckling alone underwent lensectomy and vitrectomy. Three retinas were successfully reattached. Because of the incomplete development of the pars plana in infants and the manner in which peripheral retina is pulled anteriorly to a position near or in contact with the posterior lens capsule, entry through the pars plana can create iatrogenic tears in the peripheral retina or introduction of irrigation fluid under the retina. Our experience has shown that a small contact lens makes it possible to work in the posterior vitreous cavity through the limbal approach in these infants. The circumferential traction produced by the ring of fibrovascular proliferation behind the lens can be relieved and tractional bands running forward from the posterior pole can be cut. Fibrovascular proliferative tissue lying on the posterior pole, however, proved resistant to membrane peeling or dissection, and its severity seemed to determine the success or failure of the surgery.

Pars Plana Lensectomy for Subluxated and Dislocated Lenses

Pars plana lensectomy by ultrasonic fragmentation appears to be the treatment of choice for extraction of subluxated and dislocated lenses. The closed system technique allowed extraction of 11/11 subluxated lenses without operative or postoperative complications with an average observation period of 4.5 years. The technique was employed in four traumatically dislocated lenses in eyes with accompanying traumatic pathology requiring additional surgical procedures, i.e., cryoretinopexy and scleral buckling. There were no complications in 4/4 eyes with an average observation period of 1.5 years. Pars plana lensectomy avoids many of the complications of the open-sky limbal approach i.e. anterior synechiae, vitreous incarceration, wound dehiscence, aphakic or pupillary block glaucoma, bullous keratopathy, epithelial ingrowth, stromal ingrowth or outgrowth and surgically induced astigmatism.

Pars Plana vs. the Limbal Approach to Intraocular Surgery

Pars Plana vs. the Limbal Approach to Intraocular Surgery