The main indications for refractive lens exchange

Transcription

1 Strategies to Avoid Complications After RLE Understanding the risk factors for posterior capsular opacification and retinal detachment is key to their prevention and management. BY DANIEL KOOK, MD, PhD, FEBO; NINO HIRNSCHALL, MD, PhD; OLIVER FINDL, MD, MBA, FEBO; AND THOMAS KOHNEN, MD, PhD, FEBO The main indications for refractive lens exchange (RLE) are high myopia or hyperopia with coexisting presbyopia. Other possible indications include presbyopia without ametropia and prepresbyopia with high ametropia in patients not amenable to keratorefractive surgery or phakic IOL implantation. RLE is therefore mainly performed in very short or very long eyes, and patient age is significantly lower in RLE compared with cataract surgery. Strategies have been established to avoid postoperative complications of RLE, particularly posterior capsular opacification (PCO) and retinal detachment (RD). Despite advances in vitreoretinal surgery, severe vision loss is frequent after RLE complicated by subsequent pseudophakic RD. Almost half of patients who experience this complication end up with vision below reading acuity. 1 Preventing complications after an elective refractive surgical procedure such as RLE is paramount for patient satisfaction. This article reviews the incidence of PCO and RD after RLE and presents strategies for avoiding these complications. PCO AFTER RLE PCO, the most common long-term complication of phacoemulsification, has been reported to occur in 2% to 15% of eyes within 1 year and 2% to 63% within 3 years after surgery. 2-5 Although many factors associated with PCO development remain unknown, risk factors appear to include patient age 6 and IOL design. 7 A Cochrane Review published in 2010 showed a significantly lower PCO score in patients implanted with sharpedged IOLs (Figure 1); however, no difference between one- and three-piece IOL designs was observed. 7 Additionally, no significant differences in PCO development were found between IOL materials (PMMA, hydrogel [hydrophilic acrylic], hydrophobic acrylic, or silicone); however, in this review, hydrophilic acrylic IOLs tended Despite advances in vitreoretinal surgery, severe vision loss is frequent after RLE complicated by subsequent pseudophakic RD. to have higher PCO scores and silicone IOLs lower PCO scores. Possible reasons for the higher rate of PCO with hydrophilic acrylic IOLs include the lens material itself and the less-sharp optic edges of these IOLs compared with those of hydrophobic acrylic IOLs. Other risk factors for PCO that should be considered include a history of uveitis 8 and pseudoexfoliation syndrome. 9 In these cases, patients should especially be informed about their higher risk of PCO. Another aspect that should be considered is history of glaucoma, as a trend of higher PCO rates in glaucoma patients has been observed. 10 However, these pathologies should play a minor role in the context of RLE, as they form relative or absolute contraindications for refractive surgery. STRATEGIES TO PREVENT PCO AFTER RLE Independent of the type of IOL implanted, RLE is associated with an increased rate of PCO in comparison with cataract surgery due to the relatively younger patient age. 6 Based on the evidence available, only IOLs with sharp-edged designs are advisable in RLE, and a detailed informed consent is necessary. An additional step that can be taken during surgery to prevent PCO is polishing of the anterior capsule to reduce the number of lens epithelial cells remaining in the capsular bag. The IOL should be centered in the 22 CATARACT & REFRACTIVE SURGERY TODAY EUROPE OCTOBER 2014

2 A B PCO and axial lengths (ALs) of more than 24 mm, one should carefully weigh the risks of laser capsulotomy against the benefit of some gain in visual acuity. In certain cases, it may be advisable to perform surgical polishing of the posterior capsule instead of using the laser in order to avoid opening of the posterior capsule. Figure 1. Biomicroscopic images of PCO 3 years after phacoemulsification and IOL implantation, showing PCO after implantation of an IOL with a round optic edge (A) and with a sharp optic edge (B). capsular bag, and the size of the anterior capsulorrhexis should allow a complete overlap of the anterior capsule and the IOL optic. A recent study showed a higher incidence of PCO among patients operated on by junior surgeons compared with those operated on by senior surgeons. 11 This difference was also attributed to the fact that the junior surgeons generated a larger mean capsulorrhexis diameter: 5.4 mm, compared with 5.2 mm for the more senior surgeons. Also of note in this study is that female sex was a predisposing factor for PCO development. 11 Another recent study reported that laser-assisted capsulotomy was associated with lower PCO scores than manual capsulorrhexis. 12 Avoiding PCO is important in order to reduce complications associated with Nd:YAG laser capsulotomy. These include damage of the IOL optic, elevation of intraocular pressure, iritis, vitreous prolapse, induction of a posterior vitreous detachment, cystoid macular edema, and possibly RD. Published data suggest that the incidence of RD after lens surgery and subsequent laser capsulotomy varies between 0% and 4%. 13,14 It is worth noting that some authors postulate that the incidence of RD after laser capsulotomy is not due to the application of laser energy but rather to the opening of the posterior capsule. A direct correlation of RD incidence with mode, configuration, point of time after lens surgery, or level of applied energy for laser capsulotomy has not yet been substantiated. However, the risk of RD after laser capsulotomy increases significantly with the degree of myopia. Therefore, after RLE in eyes with early RD AFTER RLE The incidence of rhegmatogenous RD in the general population is 0.02%. 15 The risk for RD development increases with myopia due to higher degrees of retinal and vitreous degenerations, posterior vitreous detachment, and retinal hole formation. Phacoemulsification also increases the risk of RD, and the combination of myopia and phacoemulsification significantly increases this risk. Intraoperative complications such as rupture of the capsular bag or vitreous loss elevate the risk of RD up to 8% even in the general population (Table 1). Published data on the incidence of RD after phacoemulsification in myopes vary greatly, with rates ranging from 0% to 8.1% (Table 2). 16 The majority of studies of this issue have a retrospective design. Comparing the differences of incidences of RD in the studies listed in Table 2, which represents a meta-analysis of studies examining this issue, one must note the wide variation concerning the various and particularly older operative techniques (eg, intracapsular and extracapsular cataract extractions), the patient s degrees of myopia, and the length of follow-up. Additionally, microincisional surgery, laser-assisted cataract surgery, and IOLs with sharp optic edge designs were not available until recently. The incidence of PCO was higher in younger patient groups, and laser capsulotomy had to be performed more often in these groups. There is an overall tendency for studies with an RD rate of 0% to have a follow-up time of less than 4 years and for studies with longer follow-up to indicate higher rates of RD. In order to estimate the real cumulative incidence of RD after RLE, long-term follow-up is mandatory, as it has been shown that the cumulative risk of RD (Kaplan-Meier analysis) after lens surgery increases in a linear fashion over time. For example, one study demonstrated that the risk of RD after small-incision coaxial phacoemulsification in high myopes (of note, both RLE and cataract surgery) was 0.47% after 3 months, 0.71% after 6 months, 1.71% after 15 months, 2.59% after 48 months, and 3.28% after 63 to 147 months. 17 Therefore, one should consider the cumulative risk of RD for young myopes who undergo RLE as somewhat higher with respect to their significantly longer life expectancy. The risk profile for RD after hyperopic RLE is completely different from that after myopic RLE. Hyperopic eyes exhibit a short AL and typically do not display any OCTOBER 2014 CATARACT & REFRACTIVE SURGERY TODAY EUROPE 23

3 TABLE 1. INCIDENCE OF RHEGMATOGENOUS RD General population 0.02% Myopia >10.00 D 0.7% General population after phacoemulsification 1.2% (10 years follow-up) Myopic patient after phacoemulsification 0% 8.1% Young myopic patient (< 50 years) after phacoemulsification 5.2% General population after complicated phacoemulsification 8% Myopic patient after complicated phacoemulsification > 8% intrinsic retinal pathology. Thus, published data from several retrospective studies including 133 eyes have not shown a single case of RD after hyperopic RLE during follow-up of up to 6 years STRATEGIES TO PREVENT RD AFTER RLE Risk factors for RD after RLE include high AL, age greater than 50 years, male sex, white race, existence of peripheral retinal degenerations, intraoperative complications, and postoperative application of laser capsulotomy for the treatment of PCO. 16 Approaches to avoid RD target the last three items in this list. The debate over the role of prophylactic peripheral retinal photocoagulation in myopes to prevent RD after lens surgery is lengthy. It is noteworthy that retinal hole formation may also emerge in clinically unsuspicious areas. The main arguments against prophylactic retinal photocoagulation are that an unnecessary and nonevidence-based therapy is inefficient and expensive and may cause later complications, including a higher incidence of macular pucker, macular edema, and posterior vitreous detachment. Finally, the question TAKE-HOME MESSAGE The risk for RD development increases with myopia due to higher rates of retinal and vitreous degenerations, posterior vitreous detachment, and retinal hole formation; a combination of myopia and phacoemulsification significantly increases the risk. Despite advances in vitreoretinal surgery, risk of severe vision loss after myopic RLE and subsequent pseudophakic RD has to be considered and is mandatory to include in the informed consent. One risk factor for PCO after RLE is IOL design. Compared with cataract surgery, RLE causes an increased rate of PCO regardless of the type of IOL used due to the relatively younger patient age. of whether prophylactic peripheral retinal photocoagulation is beneficial in high myopes cannot yet be answered based on the heterogeneity of the current, mostly retrospective published data. Indication is therefore still based on individual consideration of the patient s age, degree of myopia, existing retinal degenerations, state of the vitreous body, and complication profile of the lens surgery. Because the incidence of RD after myopic RLE increases with intraoperative complications, as displayed in Table 1, avoiding capsular rupture and vitreous loss is mandatory and the most important element of performing RLE in myopes. Although the development of retinal holes and subsequent RD after laser capsulotomy has been described in the literature, novel data from recent studies show controversial results. In one study, no correlation between RD and laser capsulotomy was found. 23 However, there was a tendency for problems to occur if laser capsulotomy was performed very early after lens surgery. 23 SUMMARY Strategies to prevent complications after RLE resemble those to prevent complications after cataract surgery. However, particular differences in patient age and underlying degree of ametropia translate to specific caveats. n Daniel Kook, MD, PhD, FEBO, is a Consultant in the Department of Ophthalmology, Ludwig- Maximilians-University Munich, Germany. Dr. Kook states that he has no financial interest in the products or companies mentioned. He may be reached at daniel.kook@med.uni-muenchen.de. Nino Hirnschall, MD, PhD, is a Resident at the Vienna Institute of Research in Ocular Surgery (VIROS), Hanusch Hospital, Department of Ophthalmology, Vienna, Austria. 24 CATARACT & REFRACTIVE SURGERY TODAY EUROPE OCTOBER 2014

4 TABLE 2. META-ANALYSIS OF PUBLICATIONS PRESENTING THE INCIDENCE OF RHEGMATOGENOUS RD AFTER RLE OR CATARACT SURGERY IN MYOPES First Study Author Year Prospective or Retrospective Number of Eyes Mean or Range of Follow-Up (months) Alió 2007 Retrospective Alldredge 1998 Retrospective Arraes 2006 Retrospective Barraquer 1994 Retrospective Ceschi 1998 Retrospective Chastang 1998 Retrospective Colin 1994 Prospective Colin 1997 Prospective Colin 1999 Prospective Fan 1999 Retrospective Fernandez-Vega 2003 Retrospective Fritch 1998 Retrospective 581 NA 0.3 Gabric 2002 Prospective Gris 1996 Retrospective 46 NA 2.2 Guell 2003 Retrospective Horgan 2005 Retrospective Jacobi 1997 Retrospective Jahn 2003 Prospective Jimenez-Alfaro 1998 Retrospective Kohnen 1996 Retrospective Ku 2002 Retrospective 125 NA 1.7 Lee 1996 Retrospective Liang 1997 Retrospective Liesenhoff 1994 Prospective Lyle 1996 Retrospective Martinez-Castillo 2005 Retrospective Nissen 1998 Retrospective Pokroy 2002 Retrospective 151 > 6 3 Powell 1995 Retrospective 430 NA 0.8 Pucci 2001 Retrospective Ravalico 2003 Retrospective Ripandelli 2003 Retrospective Sheu 2006 Retrospective Tosi 2003 Retrospective Tsai 2008 Retrospective Uhlmann 2006 Retrospective Vicary 1999 Retrospective Wang 1998 Retrospective Wang 2001 Retrospective NA = information not available Incidence of Retinal Detachment (%) 26 CATARACT & REFRACTIVE SURGERY TODAY EUROPE OCTOBER 2014

5 Dr. Hirnschall states that he has no financial interest in the products or companies mentioned. Oliver Findl, MD, MBA, FEBO, is Director and Professor of Ophthalmology at the Hanusch Hospital, Vienna, Austria, and a Consultant Ophthalmic Surgeon at Moorfields Eye Hospital, London. He is the Founder and Head of VIROS, Hanusch Hospital, Department of Ophthalmology, Vienna, Austria. Dr. Findl states that he has no financial interest in the products or companies mentioned. He may be reached at oliver@findl.at. Thomas Kohnen, MD, PhD, FEBO, is Professor and Chairman of the Department of Ophthalmology at Goethe-University, Frankfurt, Germany and is a member of the CRST Europe Editorial Board. Dr. Kohnen states that he has no financial interest in the products or companies mentioned. He may be reached at tel: ; kohnen@em.uni-frankfurt.de. 1. Heimann H, Bartz-Schmidt KU, Bornfeld N, Weiss C, Hilgers RD, Foerster MH. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology. 2007;114(12): Ando H, Ando N, Oshika T. Cumulative probability of neodymium:yag laser posterior capsulotomy after phacoemulsification. J Cataract Refract Surg. 2003;29(11): Stordahl PB, Drolsum L. A comparison of Nd:YAG capsulotomy rate in two different intraocular lenses: AcrySof and Stabibag. Acta Ophthalmol Scand. 2003;81(4): Kobayashi H, Ikeda H, Imamura S, et al. Clinical assessment of long-term safety and efficacy of a widely implanted polyacrylic intraocular lens material. Am J Ophthalmol. 2000;130(3): Zemaitiene R, Jasinskas V. Prevention of posterior capsule opacification with 3 intraocular lens models: a prospective, randomized, long-term clinical trial. Medicina (Kaunas). 2011;47(11): Apple DJ, Solomon KD, Tetz MR, et al. Posterior capsule opacification. Surv Ophthalmol. 1992;37(2): Findl O, Buehl W, Bauer P, Sycha T. Interventions for preventing posterior capsule opacification. The Cochrane Database of Systematic Reviews. 2010;(2):CD Rauz S, Stavrou P, Murray PI. Evaluation of foldable intraocular lenses in patients with uveitis. Ophthalmology. 2000;107(5): Kuchle M, Amberg A, Martus P, Nguyen NX, Naumann GO. Pseudoexfoliation syndrome and secondary cataract. Br J Ophthalmol. 1997;81(10): Tetz MR, Nimsgern C. Posterior capsule opacification. Part 2: Clinical findings. J Cataract Refract Surg. 1999;25(12): Fong CS, Mitchell P, Rochtchina E, Cugati S, Hong T, Wang JJ. Three-year incidence and factors associated with posterior capsule opacification after cataract surgery: The Australian Prospective Cataract Surgery and Age-related Macular Degeneration Study. Am J Ophthalmol. 2014;157(1): e Kovacs I, Kranitz K, Sandor GL, et al. The effect of femtosecond laser capsulotomy on the development of posterior capsule opacification. J Refract Surg. 2014; 30(3): Dardenne MU, Gerten GJ, Kokkas K, Kermani O. Retrospective study of retinal detachment following neodymium:yag laser posterior capsulotomy. J Cataract Refract Surg. 1989;15(6): Neuhann IM, Neuhann TF, Heimann H, Schmickler S, Gerl RH, Foerster MH. Retinal detachment after phacoemulsification in high myopia: analysis of 2356 cases. J Cataract Refract Surg. 2008;34(10): Polkinghorne PJ, Craig JP. Northern New Zealand Rhegmatogenous Retinal Detachment Study: epidemiology and risk factors. Clin Experiment Ophthalmol. 2004;32(2): Kook D, Kampik A, Kohnen T. Complications after refractive lens exchange [article in German]. Ophthalmologe. 2008;105(11): Alio JL, Ruiz-Moreno JM, Shabayek MH, Lugo FL, Abd El Rahman AM. The risk of retinal detachment in high myopia after small incision coaxial phacoemulsification. Am J Ophthalmol. 2007;144(1): Kolahdouz-Isfahani AH, Rostamian K, Wallace D, Salz JJ. Clear lens extraction with intraocular lens implantation for hyperopia. J Refract Surg. 1999;15(3): Siganos DS, Siganos CS, Pallikaris IG. Clear lens extraction and intraocular lens implantation in normally sighted hyperopic eyes. J Refract Corneal Surg. 1994;10(2): ; discussion Lyle WA, Jin GJ. Clear lens extraction to correct hyperopia. J Cataract Refract Surg. 1997;23(7): Fink AM, Gore C, Rosen ES. Refractive lensectomy for hyperopia. Ophthalmology. 2000;107(8): Siganos DS, Pallikaris IG. Clear lensectomy and intraocular lens implantation for hyperopia from +7 to +14 diopters. J Refract Surg. 1998;14(2): Sheu SJ, Ger LP, Ho WL. Late increased risk of retinal detachment after cataract extraction. Am J Ophthalmol. 2010; 149(1):