Fani Segev

Primary cataract extraction and intraocular lens implantation in penetrating ocular trauma

PURPOSE To analyze the postoperative outcome and complication rate after cataract extraction or lensectomy with primary intraocular lens (IOL) implantation for penetrating traumatic cataract. DESIGN Retrospective, nonconsecutive, noncomparative case series. METHODS We retrospectively reviewed the files of 21 patients who were admitted to our departments because of traumatic cataract with corneal or scleral laceration caused by penetrating trauma with or without intraocular foreign body (IOFB) from 1992 through 1997. Lens aspiration or manual extracapsular cataract extraction with primary IOL implantation was performed in all patients. Removal of an IOFB was performed in eight patients. MAIN OUTCOME MEASURES Final visual acuity and deviation of actual refraction from emmetropia and from expected postoperative refraction. RESULTS The mean follow-up was 20.4 months. Fourteen eyes (67%) achieved final visual acuity of 20/40 or better, 95% obtained 20/60 or better final visual acuity, and all eyes achieved 20/100 or better final visual acuity. Major causes of limited visual acuity were central corneal scar and central retinal injury. Eleven eyes (57%) experienced secondary cataract and underwent neodymium:yytrium-aluminum-garnet capsulotomy. CONCLUSIONS Primary implantation of posterior chamber lenses after penetrating ocular trauma is associated with favorable visual outcome and a low rate of postoperative complications.

Downregulation of gene expression in the ageing lens: a possible contributory factor in senile cataract

AbstractPurposeTo study the molecular characteristics of lens epithelial cells from patients with senile cataract by cDNA microarray technique.MethodsLens epithelial cells adhering to anterior capsules taken during cataract surgery collected from 108 patients, aged 56−92 years (senile cataract group), were pooled. Pooled epithelial cells of normal, noncataractous lenses from one patient with ocular trauma, one patient with lens subluxation, and 25 cadaveric eyes, all under the age of 55 years, served as a control. Total RNA was extracted by conventional methods from the two groups of cells, and a fluorescent probe was prepared for each group. The probes were hybridized on 9700 known human cDNA clones. Hybridized clones were analysed using a scanning laser and the results were processed by GEMTools (Incyte Genomics) software.ResultsA total of 1827 clones hybridized with the two probes. Of these, 400 showed differences of more than two-fold in gene expression between the two probes. Relative to controls, gene expression in the senile cataract lenses was upregulated in 318 clones and downregulated in 82. Three genes-filensin, inwardly rectifying potassium channel (IRPC), and pigment epithelium-derived factor (PEDF) were strongly downregulated (by 41.3-, 6.8-, and 5.9-fold, respectively) in senile cataract.ConclusionsCataractogenesis is associated with numerous changes in the genetic profile of the lens epithelial cells. Since filensin, IRPC, and PEDF genes are known to have important roles in the physiology and morphology of the transparent lens, substantial downregulation of their expression might contribute to the formation of senile cataract.

Deep anterior lamellar keratoplasty for post-LASIK ectasia.

Purpose: To describe 2 cases of post-laser in situ keratomileusis (LASIK) ectasia managed with deep anterior lamellar keratoplasty (DALK). Methods: Clinical findings, surgical interventions, and outcomes are reported. The surgical technique of DALK is described. Results: Two patients developed progressive loss of vision after LASIK surgery with enhancement procedure(s). Corneal ectasia was diagnosed on the basis of clinical findings, progressive central corneal thinning on pachymetry, and topographical changes with irregular astigmatism and inferior corneal steepening. Both patients underwent uneventful DALK surgery, in which the anterior 80% of the central corneal stroma was replaced by a donor button and sutured in place. The postoperative recovery was uneventful, except for mild interface haze in 1 case, which resolved within 2 weeks of surgery. However, 1 patient underwent additional surgery, including clear lens extraction with intraocular lens placement, astigmatic keratotomies, and photorefractive keratectomy (PRK) to achieve good unaided visual acuity. At last follow-up, at least 2 years after DALK, both patients were satisfied with their vision. Their uncorrected visual acuity (UCVA) was 20/60+ and 20/40− in their operated eyes, improving to 20/40+ and 20/30− with minimal refractive corrections. The grafts and lamellar interfaces were clear. Conclusions: We believe that DALK should be considered as an alternative to penetrating keratoplasty for the surgical management of post-LASIK ectasia.

Corneal laceration by sharp objects in children seven years of age and younger.

Purpose: Young children are prone to develop amblyopia after penetrating injury. We sought to evaluate the management of penetrating corneal injury without intraocular foreign body (IOFB) in children ≤7 years old and to assess the long-term visual acuity results. Methods: A retrospective chart review was performed in 2 ophthalmology departments to identify children ≤7 years old with penetrating corneal injury from sharp objects that had follow-up of >18 months. Data retrieved included all details from the initial examination, surgical procedures, amblyopia prevention measures, and final visual acuity. Results: Twenty children eligible for the study were identified. The mean age was 4.3 years, and mean follow-up time was 58 months. The corneal wound size range was 1-10 mm, with 8 eyes having wounds ≥6 mm. All patients required primary surgical management. Traumatic cataract extraction was performed at the primary operation in 6 eyes, with intraocular lens (IOL) implantation in 4 eyes. Additional surgical procedures were performed in 12 eyes. Yttrium-Aluminum-Garnet (YAG) capsulotomy was performed in 3 eyes with secondary cataract. Twelve patients required spectacle or contact lens correction, and 11 patients had patching for amblyopia prevention. At the end of follow-up, visual acuity was 20/40 or better in 14 eyes, 20/50 to 20/100 in 4 eyes, no light perception (NLP) in 1 eye, and unknown in 1 eye. Conclusions: Proper management of penetrating corneal injury in young children can result in excellent visual rehabilitation. Major measures include prompt traumatic cataract extraction with either primary or secondary IOL implantation, opening of posterior capsular opacification with YAG laser, correction of refractive errors, and patching for amblyopia prevention.

Cataract surgery in megalocornea Comparison of 2 surgical approaches in a single patient

We describe the outcome of cataract surgery in both eyes of a patient with megalocornea. Phacoemulsification through a scleral tunnel resulted in wound leak; the clear corneal incision was more stable. Using conventional IOL power calculation may result in significant hyperopia.

The Effect of Labor on the Intraocular Pressure in Healthy Women.

Purpose: To investigate the effect of modern vaginal labor using epidural anesthesia on the intraocular pressure (IOP) and on the mean ocular perfusion pressure (MOPP) in healthy women. Patients and Methods: In this prospective observational study, eligible candidates were healthy pregnant women for vaginal delivery with epidural anesthesia, with a singleton pregnancy, who were admitted to the delivery room in the first phase of the first stage of labor. Demographic data as well as medical and obstetric history were obtained at baseline, followed by performance of a biomicroscopic examination. IOP, maternal heart rate, systolic blood pressure, and diastolic blood pressure were measured in the first, second and third stages of labor, 24±2 and 48±2 hours postpartum. IOP was not measured during the contraction phase of stage 2. MOPP was expressed as the difference between the arterial blood pressure and the IOP. Measurements were performed throughout the different stages of labor and were compared with baseline values. Results: Thirty healthy white women were enrolled. Four women dropped out due to unexpected cesarean sections. The average age was 31.8±4.7 years. Nineteen participants received oxytocin during delivery. Twenty-three women were placed in a supine position, whereas 3 in a left decubitus position. No statistically significant changes were recorded in IOP (P=0.50) or MOPP (P=0.17) throughout the different stages of vaginal labor in this study. Conclusions: Vaginal delivery under epidural anesthesia is unlikely to cause significant damage to the optic nerve in healthy women.

Party foam-induced eye injuries and the power of media intervention

Purpose: To describe the clinical features and treatment outcome of eye injuries sustained as a result of contact with artificial snow spray (“party foam”/“silly string”) during 2 consecutive Israeli Independence Day celebrations. Design: Retrospective, multicenter, consecutive case series. Setting: Institutional. Intervention/Study Population: All patients who presented to 2 ophthalmology emergency services in 2007 and in 2008 with eye injury caused by contact with the foam. The medical records of the foam-induced eye injury cases were retrieved and analyzed. Data on injury type, comprehensive ophthalmic examination, and time to resolution were collected and analyzed. Main Outcome Measures: The assessed variables included the number of cases per year, injury type, visual acuity, treatment, and outcome. Results: A total of 96 patients (135 eyes) had suffered from foam-induced ocular chemical injuries during the 2 celebrations. Sex and laterality were evenly distributed in the study population. The mean ± SD age was 12.8 ± 2.14 years (range, 7–17 years). All patients suffered from chemical conjunctivitis (100%) and superficial punctate keratopathy (79%), corneal erosion (27%), and conjunctival erosion (5%). More patients were seen during 2007 compared with 2008 [85 (117 eyes) and 11 (18 eyes), respectively]. This reduction was directly attributable to increased public awareness because of media coverage (newspapers, radio, and national TV). Conclusions: Sprayed foam used in parties and public celebrations can cause mild-to-severe ocular surface injuries. Increased public awareness will inevitably reduce the use of this dangerous agent, but warnings need to be repeated yearly in the national media.

Iris Fixation of Unstable Anterior Chamber Intraocular Lenses.

Purpose: To present a surgical approach for the treatment of unstable anterior chamber intraocular lenses (ACIOLs). Methods: We present a series of 8 patients who underwent iris fixation of an unstable open-looped ACIOL associated with progressive corneal damage. The loops of the intraocular lens were firmly fixated to the iris using 9-0 or 10-0 polypropylene sutures. In 2 cases, iris fixation was associated with penetrating keratoplasty. The other cases were performed using a relatively closed-system technique. Results: All procedures were uneventful, with no intraoperative or postoperative complications. Suture fixation effectively prevented anterior–posterior or propelling movement. The ACIOLs in all cases were stable and well centered at the end of follow-up. Conclusions: Fixation of an existing unstable angle-supported ACIOL to the iris is an effective and simple alternative to intraocular lens exchange and posterior chamber fixation.

Postoperative trendelenburg position for graft adherence after descemet stripping automated endothelial keratoplasty.

Purpose: To present a case of repeated graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK) in a post-trabeculectomy eye and to suggest a simple postoperative maneuver to minimize this occurrence. Methods: A 61-year-old woman presented to our cornea clinic with pseudophakic bullous keratopathy in her left eye 13 years after a trabeculectomy had been performed. After the DSAEK was performed, repeated graft dislocations were observed. When air was seen in the filtering bleb in the immediate postoperative period, it was assumed that it had escaped from the air bubble remaining in the anterior chamber at the end of the surgery. The patient was thus placed in the Trendelenburg position immediately after performing a rebubbling procedure to retain the air bubble in the anterior chamber and away from the filtering bleb. Results: The corneal graft remained centered and clear at postoperative day 1 and remained so at the last follow-up visit 8 months after the surgery had taken place. The patients intraocular pressure was well controlled with a functional filtering bleb. Conclusions: Postoperative Trendelenburg positioning is an easily applied maneuver that may promote graft adherence after performing a DSAEK in eyes that have undergone glaucoma surgery.