Documenta Ophthalmologica 81: 267-280, 1992. 9 1992 Kluwer Academic Publishers. Printed in the Netherlands.
Cataract surgery and IOL implantation More than 40 years of personal experience My present criteria and considerations JOAQUIN
BARRAQUER
Instituto Barraquer, Calle Laforja 88, E-08021 Barcelona, Spain
Accepted 9 July 1992
Key words: Cataract surgery, combined procedures, IOL implantation, Phaco-Ersatz, posterior chamber lenses, viscosurgery Abstract. The author refers his personal experience with different types of IOL since 1950.
After an initial period of enthusiasm (1950 to 1961) the author abandoned the techniques of Ridley, Strampelli and Dannheim, because of the considerable incidence of severe complications directly related to the IOL. Over many years he emphasized the serious postoperative complications which appeared in the course of the years, even with the different new types of IOL which acquired a certain prestige. With the new posterior chamber lenses placed in the capsular bag, the results became more encouraging and the author resumed IOL implantation with this type of lenses after an adequate period of observation and experimentation. The present criteria, technique and results of the author are discussed together with some consi~derations on future research work to develop new techniques for substitution of the opacified lens and also to attempt to restore accommodation.
Introduction In 1949 H a r o l d Ridley p e r f o r m e d the first intraocular lens implantation in a h u m a n being with a g o o d result, using a p r o t o t y p e of a posterior c h a m b e r lens after extracapsular cataract extraction. T h e Ridley lenses gave some encouraging results but there were also a lot of early and late complications. To obviate some of these complications B e n e d e t t o Strampelli designed a n o t h e r type of intraocular lenses, the a n t e r i o r c h a m b e r lenses, which represented a great advance in the early fifties, b e c a u s e the implantation could be p e r f o r m e d after intracapsular cataract extraction, which was the p r o c e d u r e m o s t c o m m o n l y used at that time. A l s o , H e l m u t D a n n h e i m designed a different type of anterior c h a m b e r lenses with flexible supports, which were considered advantageous. A f t e r implanting s o m e Ridley posterior c h a m b e r lenses, I b e c a m e very enthusiastic a b o u t anterior c h a m b e r lenses. T h e technique was simple and easy, the implantation was p e r f o r m e d three m o n t h s after intracapsular c a t a r a c t extraction. M y results were very satisfactory and in m y first series of 132 cases there were only two serious postoperative complications. H o w -
268 ever, the longterm results were not so good and severe late complications presented, leading to functional loss of the eye in a certain number of cases. Twelve eyes had to be enucleated. For this reason I followed the general trend of the early sixties and abandoned IOL implantation in 1961, as recommended at that time by the eminent masters and teachers of ocular surgery. In 1975, I almost convinced myself that I should start IOL implantation again, because many of my colleagues and friends insisted that I should try the iris clip lenses which, at that time, were supposed to give very good consistent results. However, observing very closely the evolution of these techniques, I started to see quite a lot of complications related to these procedures and I decided to wait a little longer. As time went by, the surgeons who had recommended so warmly the iris clip lenses changed to iridocapsular fixation, which was then said to be the 'non plus ultra'. However, after a certain time the posterior chamber lenses were said to be much better, first placed in the sulcus and then in the capsular bag. While I was still waiting and observing, in 1983 according to the Official Report presented at the 95th Congress of the French Ophthalmological Society, iris fixation of the IOL had been completely abandoned. At that time the opinions of the different schools were largely divided, some favored returning to the anterior chamber lens technique, others considered posterior chamber lenses the only safe IOL implantation technique. All this made me very critical and it was only in September 1989, after seeing the excellent, consistent longterm results of many of my colleagues that I decided to start again IOL implantation in selected cases.
Subjects (case selection) and methods Candidates for IOl implantation are subjected to a severe protocol to prevent problems: Complete general physical examination before deciding the surgical indication. Complementary eye examinations: Specular microscopy is very important to evaluate the corneal endothelium. A and B scan echography. The A scan should determine very precisely the visual axial length which is fundamental for estimation of the dioptric power of the IOL to be implanted. Keratometry is essential to determine the corneal diopters K a and K 2 which, together with the value obtained with the A scan and the " A " factor of the lens to be implanted make precise calculation possible. The visual field is examined with the Goldmann perimeter. Gonioscopy and ocular pressure curve. Funduscopy, if possible.
269 Contraindications: Monocular patients. High myopia. Cornea guttata or important endothelial alterations. History of iridocyclitis. Capsular exfoliation. Retinal detachment or history of retinal detachment Children and young patients. Caution is recommended in cases of previous trauma, accidental or surgical. Implantation of IOL should be avoided in diabetics and high surgical risk cases. The surgical technique I started to use in 1989 and which is still the same at present (1992) is as follows: 1. Four hours before the operation: instillation of phenylephrine 10%, half an hour later Voltaren eye drops (sodium diclofenac 0.1%). Three hours before the operation: Tropicamide 1%, half an hour later Voltaren eye drops again. Two hours before the operation: Cyclopentolate clothydrate 0.5%, half an hour later Voltaren eye drops again. One hour before the operation: Tropicamide 1% again and half an hour before the operation Voltaren eye drops again. Voltaren eye drops are used profusely to reduce the tendency for pupil constriction induced by the surgical manipulations. 2. Deep general anesthesia is essential to have a soft eye during the whole operation (and also in order not to depend on patient cooperation during the surgery). 3. Dissection of a fornix-based conjunctival flap. 4. Superior rectus suture. 5. Bipolar preventive coagulation at the surgical limbus, applied with moderation to avoid tissue retraction. 6. Deep non-penetrating vertical incision of 9-10mm. at the surgical limbus. 7. Paracentesis in the groove and injection of a viscoelastic substance (Healon) to deepen the anterior chamber. 8. The deep layers of the groove are sectioned with Jos6 Barraquer's scissors. 9. The anterior capsule is opened with scissors with very fine branches to perform the envelope technique. 10. Separation of the anterior capsule and the lens nucleus by hydrodissection with BSS-plus and epinephrine (0.3 cc. of epinephrine 2% in 500 cc. of BSS-plus). 11. Removal of the nucleus b y expression, eventually 'catching' it and 'guiding' it out of the eye with a fine needle on a syringe. The presence of Healon in the anterior chamber is essential to avoid trauma to the corneal endothelium, the iris and the posterior capsule. 12. The cortical lens remnants are carefully removed by manual aspiration
270
13.
14.
15.
16. 17.
18. 19.
with a syringe. Simultaneous irrigation with BSS-plus and epinephrine from a perfusion bottle, placed at a distance of 30 cm above the eye, is performed with a two-way cannula. Injection of Healon into the capsular bag separating the anterior and posterior capsules for inspection with the slit-lamp surgical microscope and coaxial illumination (red fundus reflex). (Frequently, surgical microscopes are not provided with a slitlamp. This is not easily understandable because if the slitlamp is essential for biomicroscopic examination in the consultation room, it is also just as necessary for intraoperative examination). Implantation of the IOL in the bag. The lens is carefully inspected and irrigated with BSS to prevent any foreign body, lint, etc. from adhering to its surfaces. Also, the forceps are carefully inspected from this point of view. The posterior edge of the wound is covered with Healon to avoid direct contact with the lens. Healon is also applied on the anterior surface of the lens. The lens is then introduced into the anterior chamber, the inferior aptic is pushed into the bag, being easily followed by the optic part of the lens. The superior part is left on the iris in the anterior chamber. Subsequently it is grasped with a special v. Mandach-Barraquer forceps and introduced behind the pupil and the superior anterior capsule which is well separated from the poster!or capsule due to the presence of Healon. Usually the lens is easily brought into position and well centered. Application of 1% acetylcholine in the anterior chamber which remains filled with Healon. Once the pupil has constricted to 7 or 6 mm, the superfluous anterior capsule is removed. This can be done grasping the capsule and exerting adequate traction to obtain a capsulorexis of 6 mm. If the capsule tends to tear towards the periphery it should be cut close to the pupil, using Sutherland scissors, taking care not to touch the iris, the endothelium or the posterior capsule. Viscosurgery makes this much easier. Additional acetylcholine 1% is injected into the anterior chamber until the pupil is constricted to about 4 ram. Peripheral iridectomy. Although many ocular surgeons consider that peripheral iridectomy is not necessary, I prefer to perform it in all cases to avoid problems related to pupillary block (in the literature there are case reports of postoperative pupillary block glaucoma and ciliary block glaucoma requiring YAG-Laser iridotomy). Alternatively a peripheral YAG-Laser iridotomy may be performed two days before the operation. The limbal corneoscleral incision is closed with 6-7 radial 10-0 Nylon sutures and the knot is buried in the sclera. The fornix-based conjunctival flap is sutured at the limbus with two 10-0 Nylon sutures, so that it covers the whole incision. Prior to this, 75% of the Healon remaining in the anterior chamber is aspirated and BSS is injected to restore normal anterior chamber depth.
271 20. Subconjunctival injection of a solution of Gentamycin (20rag) and Betamethason (1.5 mg). Application of pilocarpine 1% and timolol 0.5% eye drops. A sterile dressing of cotton and gauze is prepared and adapted to each individual case. (Pre-fabricated dressings are not recommended because they may exert too much pressure on the eye). The dressing is covered with a plastic shield which is fixed with adhesive tape to the orbital rim to avoid trauma if the patient accidentally touches his eye. 24 h after the operation the patient is examined in his room with a hand slitlamp and from then on biomicroscopic control is performed daily for 10 days and every second day for another 20 days. Systemic and local corticosteroids are used for 10 to 20 days and Voltaren eye drops are instilled 4 times a day for six weeks or longer. Atropin eye drops should be avoided because longlasting mydriasis may induce the formation of posterior synechiae between the iris and capsule and, possibly, favor capture of the IOL in the pupil. If dilatation of the pupil is considered convenient short-acting mydriatics, like Tropicamide or cyclopentholate are preferred. After using for some time this technique in cataract cases without any other known eye pathology, we started doing also combined procedures for cataract and glaucoma: trabeculectomy, ECCE and posterior chamber IOL. In these cases the anterior chamber must be very carefully restored with Healon to avoid postoperative flattening of the chamber due to the trabeculectomy. Also, since September 1989, in some selected cases of severe trauma in one eye, the fellow eye being normal, we combined penetrating keratoplasty, synechiotomy, ECCE, implantation of a posterior chamber IOL, reconstruction of the iris diaphragm and trabeculectomy with very encouraging results.
Results
Between September 1989 and March 1992 I operated 125 cases with very satisfactory results. The number of cases is not sufficient to reach conclusions of statistical value. However, we can review a number of typical results and demonstrate how we gradually extend the indications to more complicated cases after observing the excellent evolution of the first series of cases. Case I. Standard ECCE + posterior chamber IOL (Figs. 1, 2, 3, 4 and 5). Case II. Combined penetrating keratoplasty, extraction of foreign body, ECCE and posterior chamber IOL (Figs. 6, 7 and 8). Case III. Standard ECCE and inclusion of posterior chamber IOL designed by Joaquin Barraquer (Figs. 9, 10 and 11). Case IV. ECCE and posterior chamber IOL in an eye operated previously for glaucoma (Figs. 12, 13, 14 and 15).
272
Fig. 1-5. Case I. (1) Corticonuclear and posterior subcapsular cataract; (2) Corneal endothelium before operation; (3) Result two days after ECCE and posterior chamber IOL implantation; (4) Result two months after the operation; (5) Corneal endothelium without changes.
Case V.
Combined E C C E , posterior chamber IOL and trabeculectomy (Figs. 16 and 17). Case VI: Combined penetrating keratoplasty, synechiotomy, E C C E , posterior chamber IOL, vitrectomy, reconstruction of the pupil and trabeculectomy (Figs. 18 and 19).
273
Fig. 6-8. Case II. (6) Traumatic central leucoma. Intraocular foreign body. Intumescent cataract; (7) Result two days after a 7.6mm. penetrating keratoplasty, extraction of the foreign body, ECCE and posterior chamber IOL implantation; (8) Result 15 months after the operation. Vision 20/20 with +1.75 cyl.-2.25 x 30~ vision without correction 20/30 Jaeger 1 (with +3.50).
Fig. 9-11. Case III. (9) Corticonuclear cataract; (10) Posterior chamber lens designed by Joaqu/n Barraquer (1990), optic 6.5 mm., aptic 10.5 ram., aptic very flexible (modification PCM-11 after Jacques Charleux); (11) Result one week after inclusion of the lens shown in fig. 10. In this case surgery was performed by Dr. Rafael Barraquer.
274
Fig. 12-15. Case IV. (12) This eye was operated for glaucoma (trabeculectomy) in 1984. In March 1991 corticonuclear cataract had developed. Good filtration bleb; (13) Corneal endothelium; (14) Result 8 months after ECCE and posterior chamber IOL. Corneal incision in front of the bleb; (15) Postoperative aspect of the corneal endothelium. No significant alterations. The intraocular pressure is normal.
Fig. 16-17. Case V. (16) Open-angle glaucoma not controlled with medical treatment. Corticonuclear cataract; (/7) Result 20 months after ECCE, posterior chamber IOL implantation and trabeculectomy. Tension normalized without medication.
275
Fig. 18-19. Case VI. (18) Vascularized leucoma. Anterior and posterior synechiae. Cataract
and secondary glaucoma; (19) Result three months after a 7.5 ram. penetrating keratoplasty, anterior and posterior synechiotomy, resection of inflammatory pupillary membrane, ECCE (two radial total iridotomies were necessary to 'dilate' the rigid pupil), posterior chamber IOL implantation. (At the end of the insertion of the lens the capsule ruptured at 5 o'clock with vitrious prolapse. Anterior vitrectomy was necessary). Suture of the radial iridotomies with prolene for reconstruction of the pupil. Trabeculectomy. At the end of the operation the anterior chamber is left completely filled with Healon.
Discussion If the indication is correct and the surgery adequately performed, posterior c h a m b e r I O L are the best optical correction for cataract rehabilitation at present. M a n y of my colleagues consider that I waited too long before resuming I O L implantation and that this was due to my discouraging experience with the primitive anterior chamber lenses. In the beginning this was quite true, I did not implant a single I O L since 1961, because we had to remove a lot of lenses and in 12 or m o r e cases the eye had to be enucleated. H o w e v e r , I followed very closely the evolution in this field. In 1975, during a Congress, m a n y of my colleagues and friends urged me, saying " y o u should start again I O L implantation using iris clip lenses. This technique is quite different from the anterior chamber lenses you used years ago. We now have a long experience with very consistent good results". This sounded really very convincing and I thought I might consider a new start. However, soon I began to see complications directly related to the iris clip lenses and I noticed that the surgeons who had sustained that the iris clip lenses were so good, changed to iridocapsular fixation. So I decided to wait a little longer to see what was going to happen. After some time the same surgeons started to change f r o m iris or iridocapsular fixation to the insertion of the lens in the posterior chamber, first placing it in the sulcus and later in the capsular bag. Seeing this evolution, I concluded that probably the iris clip lens and the iridocapsular fixation were not so good as they had been said to b e . So I continued to wait and observe. In 1983, at the 95th Congress of the French Ophthalmological Society, it became evident that I O L surgeons had corn-
276 pletely abandoned iris fixation. Some favored again the use of anterior chamber lenses, others were in favor of posterior chamber lenses, but there was no uniform criterion. We continued to observe until September 1989. Then, after seeing the consistent good results obtained by our colleagues with the posterior chamber IOL, we did our first implantation of such a lens in our Clinic in Barcelona on September 13, in a case of subcapsular posterior cataract. The surgeon was my daughter, Dra. Elena Barraquer, who had gained considerable experience with posterior chamber IO1 during here residency in USA, I was the assistant. Today the technique is part of the routine procedures in our Clinic, but we continue to be very strict with regard to the indications, the meticulous execution of the surgery and the very rigorous postoperative control to prevent and treat complications. Now, let us have a look into the future. In 1981, when I was investigating the use of viscosurgery in congenital cataract surgery, I established a new technique, as follows: 1. 2. 3. 4.
Injection of Healon into the anterior chamber. A small opening in the periphery of the anterior capsule. Endocapsular aspiration of the cataract (Fig. 20). Endocapsular irrigation with BSS to clean the anterior and posterior capsule. 5. Injection of Healon into the bag forming a 'new lens' in the capsule (Fig. 21). This was, of course, only an idea, because Healon is not adequate to reform the lens; I did this to separate the anterior and the posterior capsules to facilitate anterior capsulectomy; but we could see a project for the future: Reformation of a clear lens in the capsular bag after extracapsular cataract extraction. I had been thinking about this for 8 years but I did not publish my idea. Independently, in 1981, Pard, JM, Director of the Biophysics Department of the Bascom Palmer Eye Institute, et al., presented and published a project: 'Phaco-Ersatz 2001', to restore an endocapsular lens. We are giving full credit to him and the Bascom Palmer Eye Institute for this new technique, which we are now developing together. The Bascom Palmer group was using a silicon gel with an index of refraction of 1.4 to obtain an appropriate power of the lens. Accommodation of this lens is possible, as demonstrated in Miami; after application of 1% pilocarpine in the anterior chamber of a monkey's eye, the lens accommodated about 4 diopters (Fig. 22). However, there are still many problems to be resolved: 1. The formation of secondary cataract must be avoided. The use of photodynamic therapy with hematoporphyrin or Rose Bengal or monoclonal antibodies plus erythrosin B, activated with endosaeular Argon dye green laser application (Fig. 23) are under investgiation.
277
Fig. 20-23. (20) Endocapsular aspiration of cataract; (21) Reformation of a 'new' lens in the capsular bag (Joaqufn Barraquer); (22) Accommodation of the artificial crystalline lens (pilocarpine) after endocapsular substitution (Courtesy of Parel JM et al.); (23) Photodynamic therapy. Activation of drugs (specific monoclonal antibodies and erythrosin B) by Argon dye green laser through a special probe with fiber optic and quartz spherical diffuser (Courtesy of Mei Mei Mui and Parel JM).
2. T h e most adequate substance and the amount to be injected in the bag to obtain e m m e t r o p i a and allow accommodation must be determined. 3. Mechanical problems to aspirate the lens without breaking the capsule a n d / o r the zonule must be resolved. This is a great challenge and different investigators are working hard in order to obtain some practical results for clinical use before the year 2000. With this in mind the ' A c c o m m o d a t i o n Club' was founded in 1989 'to foster Research on Cataract Surgery designed to preserve and restore A c c o m m o d a t i o n ' , with the collaboration of ophthalmic surgeons, specialists in biopolymers, in photodynamic therapy and photoablation, physiologists, photobiologists, laser physicists and opticists, photochemists, radiologists, etc.
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