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PubMed1996

Combined phacoemulsification and trabeculectomy with mitomycin-C.

PURPOSE: To examine the safety and efficacy of primary combined phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and trabeculectomy with mitomycin-C (0.4 mg/ml) in patients with open-angle glaucoma and visually significant cataract. SETTING: University-hospital-based glaucoma referral practice. METHODS: In this study, data of 43 patients of a single surgeon were retrospectively analyzed. These consecutive patients had combined phacoemulsification, posterior chamber IOL implantation, and trabeculectomy with mitomycin-C. RESULTS: Thirty-eight patients (88%) had open-angle glaucoma and 5 (12%) pseudoexfoliative glaucoma. Thirty-eight patients (88%) had 12 months of follow-up; all had at least 6 months follow-up. Mean preoperative intraocular pressure (IOP) was 21.6 mm Hg +/- 6.8 (SD) (range 12.0 to 41.0 mm Hg) with 2.5 +/- 1.0 glaucoma medications. At last follow-up, mean IOP had decreased to 14.2 +/- 6.2 mm Hg (range 3.0 to 40.0 mm Hg) with 0.5 +/- 0.5 glaucoma medications. Twenty-one patients (55%) had an IOP of 15 mm Hg or less at 12 months. Best corrected visual acuity was 20/40 or better in 31 of 43 patients (72%) at last follow-up. A filtration bleb was noted in 33 of 40 patients (83%) at their last visit. Postoperative IOP spikes occurred in 17 patients (40%), transient hyphema in 12 (28%), transient wound leaks in 11 (26%), and superficial punctate keratopathy in 11 (26%). Three cases of persistent hypotony (IOP less than 5 mm Hg) and 1 case of epithelial downgrowth were also noted. CONCLUSION: Phacoemulsification with IOL implantation and combined trabeculectomy with mitomycin-C produced good visual acuity and excellent IOP control but resulted in some complications. The use of mitomycin-C in combined procedures does not appear to confer a significant benefit.

Antibiotics, Antineoplastic↗
PubMed1996

Temperature measurements during phacoemulsification and erbium:YAG laser phacoablation in model systems.

PURPOSE: To compare the potential for thermal injury to ocular structure resulting from phacoemulsification ultrasound energy and erbium:YAG (Er:YAG) laser output. SETTING: Morse Laser Laboratory, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston. METHODS: Ultrasonic phacoemulsification energy and ER:YAG laser output (10 J/cm2, 10 Hz, 0.3 watts) sufficient for lens removal were applied to model systems and human cadaver eyes. Temperatures were measured with ultrafine thermocouples interfaced to a microcomputer data acquisition system. RESULTS: Although greater than 95% of energy from laser output is converted to thermal energy, temperature rise in model systems and cadaver eyes was 10 to 15 times greater after pulsed application of ultrasound energy than after Er:YAG laser application. At 100% power, approximately 4 watts of ultrasound power is converted to heat. Temperature rise following both laser and ultrasound applications decreased with irrigation in cadaver eyes and increasing volume in a model system. With continuous irrigation (20 cc/min), the temperature rise at 2 minutes measured at the corneal endothelial surface, within the corneal stroma, and in the anterior chamber angle of cadaver eyes was approximately 0.5 degrees Celsius (degrees C) after laser application and 7.0 degrees C after ultrasound application. Without irrigation, temperatures rose 2.5 degrees C after laser application and 35.0 degrees C after ultrasound application. CONCLUSION: At operating parameters sufficient for lens removal, the Er:YAG laser imparted less thermal energy to whole eyes and model systems than ultrasonic phacoemulsification.

Anterior Chamber↗
PubMedDate not supplied

Modified stretch technique for small pupil phacoemulsification with topical anesthesia.

I present an atraumatic technique for small pupil phacoemulsification using topical anesthesia. Fifty consecutive small pupil phacoemulsification cases were performed with topical anesthesia and mild intravenous sedation. Viscoelastic combined with a modified two instrument stretch was used for pupillary enlargement adequate for phacoemulsification. After preoperative cycloplegia, two or more multidirectional stretches were used for 3.0 to 5.0 mm pupils; three or more multidirectional stretches were used for pupils less than 3.0 mm. Pain and proprioceptive responses were avoided by reducing the stretch length, leaving the angle structures and ciliary body untouched. Sodium hyaluronate (Healon GV) created additional expansive power. Of 50 successfully implanted cases, 45 (90%) had acceptable pupillary form and function postoperatively. The 5 (10%) with enlarged, atonic pupils had past injury or inflammatory disease. This technique minimizes anterior segment trauma, instrumentation, and operating time.

Anesthesia, Local↗
PubMedDate not supplied

Long-term endothelial cell loss following phacoemulsification through a temporal clear corneal incision.

PURPOSE: To evaluate central endothelial cell loss (ECL) following clear corneal cataract surgery using two different incision sizes and the effect of ultrasound time (UST) and power on postoperative ECL and various cell parameters. METHODS: Fifty-eight patients had phacoemulsification through temporal, two-step clear corneal tunnel incisions. In Group A (n = 28), a one-piece, plate-haptic foldable silicone intraocular lens (IOL) was implanted through a 3.5 mm sutureless incision. In Group B (n = 30), a poly(methyl methacrylate) IOL was implanted through a 5.0 mm incision with one radial suture. The central endothelial cell counts were recorded preoperatively and postoperatively at 2 to 5 days, after 6 months, and after 1 year. Color-coded, computer-assisted specular microscopy was used for special cell analysis after 1 year. RESULTS: Collective data showed an ECL of 7.9 +/- 4.1% (mean +/- standard deviation) at 2 to 5 days postoperatively, 6.7 +/- 2.9% after 6 months, and 7.3 +/- 3.3% after 1 year. A direct linear relationship was found between ECL and UST and power: ECL increased as UST and power increased. After 1 year, ECL in Group A was 4.2% with UST < or = 11/2 minutes, 6.7% with UST > 11/2 to 21/2 min, and 9.6% with UST > 21/2 to 31/2 min; in Group B it was 6.0%, 7.5%, and 11.4%, respectively. Specular microscopy showed normal, age-related cell parameters 1 year postoperatively. CONCLUSIONS: Phacoemulsification with 3.5 mm clear corneal incisions produced slightly less ECL (6.7%) than phacoemulsification with 5.0 mm incisions (7.9%). Total ECL of 7.3% at 1 year postoperatively compared favorably with ECL rates of other cataract extraction methods.

Aged↗
PubMed1997

Topical and subconjunctival anesthesia for phacoemulsification: prospective study.

PURPOSE: To evaluate the efficacy and safety of topical and subconjunctival anesthesia for phacoemulsification and to compare the results with those of retrobulbar-peribulbar anesthesia. METHODS: This prospective study evaluated 402 patients having phacoemulsification during 60 surgical sessions. Patients were randomly assigned to receive a topical and subconjunctival injection of lidocaine 4% or a retrobulbar injection of the same anesthetic. RESULTS: Patients who received topical and subconjunctival anesthesia received less anesthetic (0.25 versus 3.25 mL) and had fewer side effects from the intravenous sedation and a lower incidence of capsular rupture associated with positive vitreous pressure during surgery (0 versus 2.9%). The difference in postoperative discomfort was not statistically significant, and there were no complications resulting from needle insertion. CONCLUSION: Topical and subconjunctival anesthesia using lidocaine 4% was as effective as retrobulbar and peribulbar anesthesia for routine phacoemulsification. In addition, fewer anesthetic drugs and less patient sedation were required, and there were fewer intraoperative and postoperative complications.

Administration, Topical↗
PubMedDate not supplied

Exfoliation syndrome and phacoemulsification.

PURPOSE: To evaluate intraoperative and postoperative complications of phacoemulsification and intraocular lens (IOL) implantation in eyes with exfoliation syndrome. SETTING: Eye Clinic, University Hospital of Geneva, Switzerland. METHODS: This prospective study evaluated 20 consecutive patients with exfoliation syndrome and 20 consecutive patients without the syndrome (control group) who had phacoemulsification and posterior chamber IOL implantation. One year later, the incidence of zonular tears, operating time, and fibrinoid reaction were studied in another group of 23 consecutive patients who had the same type of surgery by the same surgeon. RESULTS: Maximal pupil dilation was significantly smaller (P < .0001) in the exfoliation than in the control group. Intraoperatively, the incidence of zonular tears was the same in both groups (10%). In the 23 patients who had surgery 1 year later, no zonular tears occurred. The incidence of postoperative complications was similar in both groups. The exfoliation group had a significant decrease in intraocular pressure over preoperative levels at 1 week and 3 months postoperatively. CONCLUSION: Phacoemulsification with posterior chamber IOL implantation appears to be safe in eyes with exfoliation syndrome.

Aged↗
PubMedDate not supplied

Inflammatory response in the rabbit after phacoemulsification and intraocular lens implantation using a 5.2 or 11.0 mm incision.

PURPOSE: To study the effect of two incision sizes, 5.2 and 11.0 mm, on the inflammatory response in rabbit eyes after lens extraction with phacoemulsification. SETTING: S:t Erik's Eye Hospital, Stockholm, and Pharmacia, Uppsala, Sweden. METHODS: Bilateral endocapsular phacoemulsification was performed on 32 rabbits. The wound was enlarged to 5.2 mm, and a poly(methyl methacrylate) intraocular lens (IOL) was implanted in the capsular bag. In each rabbit, one eye was selected at random and the wound in that eye enlarged to 11.0 mm. In both eyes the wound was sutured with a 9-0 polypropylene continuous suture. The number of white blood cells (WBCs) and prostaglandin E2 (PGE2) in the aqueous humor were measured at days 1, 3, 7, and 28 postoperatively. Corneal thickness was also measured by pachymetry. RESULTS: The number of WBCs at day 3 and the PGE2 levels at days 1, 3, and 7 were significantly higher in eyes with 11.0 mm incisions than in eyes with 5.2 mm incisions. One week after surgery, the corneas in the eyes with 11.0 mm incisions were significantly thicker than in those with 5.2 mm incisions. CONCLUSION: The results indicate that incision size is an important factor in the inflammatory response following phacoemulsification and IOL implantation in the rabbit eye.

Animals↗
PubMed1997

Supracapsular phacoemulsification: a capsule-free posterior chamber approach.

We describe a technique that relocates the phacoemulsification process outside the capsular bag by transposing the nucleus through an intact 5.0 to 6.0 mm capsulorhexis. The upside-down nucleus is then returned to the posterior chamber, positioned above the anterior capsule in the "supracapsular space" where it remains throughout the phacoemulsification procedure of choice: cracking, chopping, manual prechoping, or traditional sculpting. The chief advantage of supracapsular phacoemulsification is greater efficiency, which is manifested in reduced emulsification time and energy. Disadvantages include the possibility of mild postoperative corneal edema during the earliest part of the learning curve, as well as inadvertent damage to the iris in cases with suboptimal pupil dilation.

Humans↗
PubMed1997

Mitomycin-C supplemented trabeculectomy, phacoemulsification, and foldable lens implantation.

PURPOSE: To evaluate the outcome of combined mitomycin-C filtering surgery, phacoemulsification, and foldable intraocular lens (IOL) implantation. SETTING: Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA. METHODS: This retrospective study evaluated 182 eyes of 174 patients who had combined mitomycin-C trabeculectomy, phacoemulsification, and insertion of a foldable IOL through a 3.5 mm incision. Success of the combined procedure was defined as intraocular pressure (IOP) below 21 mm Hg, with or without medications, and no serious complication. Success rates were calculated using the Kaplan-Meier actuarial method. RESULTS: Mean follow-up was 16.7 months +/- 5.4 (SD). The probability of success at 6, 12, 18, and 24 months was 98.3, 95.6, 90.6, and 88.0%, respectively. When compared with preoperatively, visual acuity improved one or more lines in 148 eyes (81.3%) and worsened one or more lines in 15 (8.2%); 111 eyes (61.0%) achieved visual acuity of 20/40 or better. The most frequent complication was posterior capsule opacification requiring capsulotomy, which occurred in 22 cases (12.0%). CONCLUSION: The 1 year and 2 year IOP control rate of combined mitomycin-C filtering procedures and phacoemulsification in glaucoma patients was high.

Aged↗
PubMed1997

Reduced intraocular pressure after phacoemulsification and posterior chamber intraocular lens implantation.

PURPOSE: To ascertain whether phacoemulsification with posterior chamber intraocular lens (IOL) implantation causes long-term reduction in intraocular pressure (IOP). SETTING: Private practice, Kempten, Germany. METHODS: Intraocular pressure was measured in both eyes of 120 consecutive patients who were unilaterally phakic after phacoemulsification a mean of 17 months +/- 17 (SD) previously. Mean age of the 36 men and 84 women was 76 +/- 10 years. Data were analyzed using binomial distribution and the Wilcoxon signed-rank test. RESULTS: The median ratio of IOP in the pseudophakic eye to IOP in the phakic eye was 0.83. The IOP was lower in the pseudophakic eye in 96 patients (80%). The median IOP was 12 mm Hg in the pseudophakic eyes and 14 mm Hg in the phakic eyes (P < .001). As measured by the interquartile range, IOP distribution was more centered in the pseudophakic than in the phakic eyes (3 versus 4). The IOP in the pseudophakic eyes remained lower to the last measurement, 5 years postoperatively, and appeared to be independent of patient age. Lower IOP in the pseudophakic eye was consistently present in patients with higher IOP in the phakic eye (16 to 22 mm Hg). CONCLUSION: Phacoemulsification with posterior chamber IOL implantation reduced IOP in most but not all patients with a preoperative IOP of 22 mm Hg or less. This reduction was maintained over several years, with the cause yet to be established. Lower IOP may decrease the risk of subsequent glaucomatous nerve damage in these patients.

Aged↗
PubMed1998

Phacoemulsification, primary posterior capsulorhexis, and capsular intraocular lens implantation for uveitic cataract.

PURPOSE: To evaluate the safety and efficacy of phacoemulsification, primary posterior capsulorhexis (PCCC), and primary intraocular lens (IOL) implantation for uveitic cataracts. SETTING: Institutional practice. METHODS: Fifteen consecutive eyes of 13 patients with various causes of uveitis received anterior capsulorhexis, phacoemulsification, PCCC, and in-the-bag implantation of a heparin-surface-modified IOL for visually disabling cataract. The safety and efficacy of the combined operation were studied prospectively. RESULTS: At a mean follow-up of 16.9 months (range 8 to 30 months), all eyes had a clear central visual area. Fourteen of 15 eyes (93.3%) had good visual improvement after surgery. Eight eyes (53%) achieved a best corrected visual acuity (BCVA) of 20/30 or better and 6 (40%), 20/20 or better. Seventy-three percent of eyes attained a BCVA of 20/80 or better. The mean improvement in visual acuity was 5.2 Snellen lines (range 0 to 11 lines). No cases of uveitis flare-up or other major complications related to the cataract surgery occurred. CONCLUSIONS: The study's preliminary results are encouraging and indicate that phacoemulsification, PCCC, and IOL implantation can be considered in patients with visually disabling uveitic cataract.

Adolescent↗
PubMed1998

Vitreous loss during conversion from conventional extracapsular cataract extraction to phacoemulsification.

PURPOSE: To study the outcome of vitreous loss among senior surgeons converting from conventional extracapsular cataract extraction (ECCE) to phacoemulsification. SETTING: A university teaching hospital in the United Kingdom. METHODS: A retrospective analysis of 87 planned cataract extractions performed from January 1992 to December 1996 and complicated by vitreous loss was done. Outcome measures included postoperative complication rates and visual acuity. RESULTS: During the study, vitreous loss occurred in 39 patients having ECCE and in 48 having phacoemulsification; the latter group included 8 patients with dropped nucleus. Postoperative complications included cystoid macular edema (18.7% of phaco patients, 30.8% of ECCE patients), retinal detachment (2.1% of phaco patients, 5.1% of ECCE patients), and expulsive hemorrhage (5.1% of ECCE patients). Phaco patients had higher rates of postoperative corneal edema (27.1%) than ECCE patients (12.8%) and transient intraocular pressure elevation (33.3%) versus 20.5%) but were more likely to receive posterior chamber intraocular lenses (70.8% versus 35.9%; P = .0024, chi-square test). After excluding pre-existing diseases, 83.3% of phaco patients and 67.6% of ECCE patients achieved a visual acuity of 6/12 or better. CONCLUSIONS: With careful patient selection, experienced extracapsular surgeons converting to phacoemulsification can achieve favorable results even in the presence of complications such as vitreous loss or dropped nucleus.

Aged↗
PubMed1998

Phacoemulsification cataract surgery in vitrectomized eyes.

PURPOSE: To determine the problems, safety, and results of phacoemulsification cataract surgery in previously vitrectomized eyes. SETTING: Department of Ophthalmology of Galdácano Hospital, Galdacano, Spain. METHODS: In this prospective study, phacoemulsification was performed in 23 eyes that had had vitrectomy between February 1992 and May 1994. Surgical and postsurgical difficulties and complications and visual acuity results were analyzed. Follow-up ranged from 12 to 24 months. RESULTS: The incidence of surgical problems and complications was higher than usual: 7 eyes presented small pupil size (< 3.0 mm); sudden changes in anterior chamber depth and pupil size during surgery occurred in 6 eyes; unusual mobility and flaccidity of the posterior capsule was observed in 6 cases, which was associated with posterior subcapsular cataract and young age (< 50 years); posterior capsule tear occurred in 2 eyes, 1 of which required anterior vitrectomy. Postoperatively, best visual acuity improved two Snellen lines or more in 17 eyes (73.91%), did not change in 3 (13.04%), and worsened in 3. CONCLUSION: Phacoemulsification in vitrectomized eyes presented more problems and complications than usual. However, it seems to be safer than manual extracapsular surgery because it minimized the risk of intraoperative eye hypotony or collapse.

Adult↗
PubMed1998

Intraoperative complications of 1000 phacoemulsification procedures: a prospective study.

PURPOSE: To determine the frequency and nature of intraoperative complications of endocapsular phacoemulsification cataract surgery. SETTING: Dalcross Private Hospital and the Departments of Ophthalmology, Concord Hospital and Prince of Wales Hospital, Sydney, Australia. METHODS: This prospective study included the first 1000 cases of planned endocapsular phacoemulsification cataract surgery performed by an experienced surgeon. A standardized proforma was completed at the time of surgery. Data recorded included pre-existing ocular abnormalities, duration of surgery, nuclear sclerosis grade, and intraoperative complications. RESULTS: Major complications comprised posterior capsule tears with vitreous loss (1.4%), isolated posterior capsule tears (0.7%), and zonulysis (0.1%). Minor complications included anterior capsule tears (3.8%), iris prolapse (0.6%), and ciliary body incision (0.2%). There was a significant trend toward complications as the nuclear sclerosis grade increased. The incidence of major complications was 9.3% in the first 150 cases and 0.9% in the last 850. This represents a relative risk of 9.9 (95% confidence interval 4.2 to 23.0) of a major complication occurring in the first 150 compared with the later 850 cases. CONCLUSION: The frequency of major and minor complications fell sharply after the first 150 operations and was maintained. This study may provide a guide for beginning phacoemulsification surgeons and a basis for experienced surgeons to compare their performance outcomes.

Adult↗
PubMed1998

Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification.

PURPOSE: To investigate patient and surgeon acceptance of topical anesthesia as an alternative to peribulbar anesthesia for clear corneal phacoemulsification. SETTING: Department of Ophthalmology, Whipps Cross Hospital, London, England. METHODS: All cataract surgery was performed using a temporal clear corneal approach, bimanual phacoemulsification, and in-the-bag intraocular lens implantation. The results of 51 patients having surgery under topical anesthesia (amethocaine) were compared with those of 30 patients having peribulbar anesthesia (50:50 mixture of lignocaine 2% and bupivacaine 0.5% with hyaluronidase). No sedation was used in either group. Pain perception on administration of the anesthetic, perioperatively (period immediately surrounding and during surgery), and postoperatively was assessed using a visual analog scale from 0 to 10 (0 = no pain: 10 = worst pain imaginable). A questionnaire was used to assess the degree of patient and surgeon satisfaction. RESULTS: Administration of topical amethocaine was significantly less painful than peribulbar bupivacaine (P = .03). Perioperative pain showed a trend toward being worse in the topical anesthesia group but did not reach statistical significance. There was no difference in the postoperative pain scores of the two groups. The surgical experience was rated very satisfactory by 67% in the topical group and 73% in the peribulbar group. The surgeons reported no difficulties or complications. CONCLUSION: Topical anesthesia was safe and effective for clear corneal phacoemulsification and was well tolerated by patients. The slightly greater awareness of ocular discomfort in the topical group perioperatively did not alter patient satisfaction with the surgical experience when compared with the peribulbar group.

Aged↗
PubMed1998

Position of poly(methyl methacrylate) and silicone intraocular lenses after phacoemulsification.

PURPOSE: To compare the positional change of poly(methyl methacrylate) (PMMA) and silicone intraocular lenses (IOLs) in vivo after phacoemulsification. SETTING: Taipei Municipal Yang-Ming Hospital, Taipei, Taiwan. METHODS: A prospective study of 70 cataractous eyes treated by phacoemulsification with IOL implantation was carried out. The eyes were randomized into 2 groups based on IOL type: 1-piece PMMA IOL; 3-piece silicone IOL. The amount of IOL tilt and decentration was measured and anterior chamber depth (ACD) determined by Scheimpflug photography using an anterior eye segment analysis system (EAS-1000, Nidek). All eyes were examined 1 week and 1 to 6 months after surgery. RESULTS: No statistically significantly differences were found in the amount of tilt and decentration between 2 IOL types throughout the study. The ACDs were relatively constant in both groups through the early postoperative periods. CONCLUSION: The stability of PMMA and silicone IOLs were the same after phacoemulsification.

Aged↗
PubMed1999

Induced endothelial cell loss in phacoemulsification using topical anesthesia plus intracameral lidocaine.

PURPOSE: To determine whether lidocaine 1% injected into the anterior chamber during phacoemulsification damaged the corneal endothelium. SETTING: Ophthalmology Service, University Hospital, San Juan de Alicante, Spain. METHODS: In 19 eyes of 19 patients, small incision phacoemulsification and foldable lens (AcrySof MA60BM) implantation was performed using topical anesthesia supplemented by lidocaine 1% (0.3 mL) in the anterior chamber. All cases were operated by the same surgeon. Specular microscopy was performed before surgery and 1 and 3 months postoperatively. RESULTS: Mean endothelial cell loss was 5.41% +/- 8.50 (SD) at 1 month and 5.93 +/- 8.50% at 3 months. CONCLUSIONS: The endothelial damage was similar to that described by other authors, suggesting that phacoemulsification surgery can be performed successfully using topical anesthesia supplemented by lidocaine 1% in the anterior chamber.

Aged↗
PubMed1999

Clinical course of phacoemulsification wound burns.

PURPOSE: To present 3 cases illustrating the outcomes of phacoemulsification corneal wound burns. SETTING: A university referral center. METHODS: This was a retrospective case series. RESULTS: Three patients developed corneal wound burns during phacoemulsification of cataract. All eyes developed from +7.00 to +15.00 diopters of astigmatism in the axis of the incision. In 2 eyes, the astigmatism decreased over several months. The third had permanent high astigmatism and corneal edema requiring corneal transplantation. CONCLUSIONS: Corneal wound burns occurring during phacoemulsification can have serious effects on the cornea, including corneal edema and severe astigmatism. In the milder cases, the astigmatism decreases spontaneously over several months.

Aged↗