Primary intraocular lens an advantage

Cincinnati-The time at which an IOL is implanted following ocular trauma can be controversial. However, primary implantation of an IOL at the time of repair of severe ocular trauma can be advantageous, according to Michael L. Nordlund, MD, PhD, in favor of earlier intervention in these cases.

"While there are different ways to approach treating the results of ocular trauma, the goals of trauma management are the same, that is, to re-establish the integrity of the globe, to remove intraocular foreign bodies and debris, to control IOP and infection, to rehabilitate the eye visually, and to obtain the best cosmesis," Dr. Nordlund said.

With these goals in mind, Dr. Nordlund said the advantages of implanting an IOL at the time that the trauma are being addressed.

As with any procedure, there are disadvantages, he said.

"Because we are often called to repair trauma cases in the middle of the night, the ultimate technology may not always be on hand to treat these eyes," Dr. Nordlund said. "There also can be poor visibility within the eye in some of these patients. The medical arguments against implanting an IOL during repair of the ocular surface include suboptimal determination of the IOL power, a possible increased risk of infection, especially on the contaminated surface of these eyes, and entrance into the eye of bacteria and debris when inserting the IOL."

Three studies

A review of the medical literature produced three studies of IOL implantation at the time of ocular repair during the previous 15 years.

A Turkish study published in 2002 included 10 eyes that sustained corneoscleral lacerations and were repaired with primary implantation of an IOL. Six of the cataracts were removed by manual aspiration and the other four by extracapsular cataract extraction. No measurements of the eyes were done to determine the refractive error, and 21-D polymethylmethacrylate lenses were implanted in all eyes. No complications related to IOL implantation developed and all eyes had 20/100 vision or better, with a few having 20/40 or better vision.

A 2001 study included 19 eyes, 17 of which had only corneal lacerations, and two had lacerations of the cornea and sclera. The lacerations ranged in size from less than 3 to longer than 6 mm. Eight eyes had intraocular foreign bodies and required pars plana vitrectomy, scleral buckling, and laser photocoagulation. Lens aspiration or extracapsular procedures were performed to remove the cataracts. All eyes received a posterior chamber IOL in the capsule or the sulcus. The axial length and keratometry were measured preoperatively in six of the injured eyes and 13 fellow eyes.

Results in this series were good, with two-thirds of patients achieving best-corrected visual acuity (BCVA) of 20/400 or better; 95% had better than 20/60, and all had better than 20/100.

A 1994 series included 14 eyes with corneal lacerations ranging from 1 to 6 millimeters and ruptured lens capsules. Seven eyes had intraocular foreign bodies removed. Lens aspiration, pars plana lensectomy, phacoemulsification, or extracapsular procedures were performed to remove the cataracts. Eight eyes required pars plana vitrectomy. Posterior chamber IOLs were implanted in all eyes, six in the capsule and eight in the sulcus. Axial length and keratometry measurements could be performed on 10 eyes.

Nine patients had a BCVA exceeding 20/40; all patients had better than 20/100 vision. No IOL complications, persistent inflammation, or endophthalmitis developed.

"In all 43 eyes of the three series of patients, primary IOL implantation was safe, expedited visual rehabilitation, and eliminated the need for a second surgery to implant an IOL," Dr. Nordlund concluded. "In cases in which there was good visibility, surgeons should consider this treatment approach as part of the management of ocular trauma. When it is not possible, sparing as much of the capsule as possible during cataract extraction facilitates secondary implantation of the IOL."

FYIMichael L. Nordlund, MD, PhD
E-mail: mnordlund@cincinnatieye.com

Dr. Nordlund has no financial interest in the subject matter.