Michel Sickenberg

Comparison of deep sclerectomy with collagen implant and trabeculectomy in open-angle glaucoma

PURPOSE To assess the efficacy and postoperative complications of deep sclerectomy with collagen implant (DSCI), a nonpenetrating filtration procedure. SETTING Glaucoma Unit, Department of Ophthalmology, University of Lausanne, Switzerland. METHODS Forty-four eyes of 44 patients with medically uncontrolled open-angle glaucoma had DSCI and a matched control group of 44 patients, trabeculectomy. A superficial scleral flap was raised and a deep sclerectomy performed in the scleral bed. Schlemms canal was opened, and the cornea was dissected to Descemets membrane. At that stage, aqueous filtered through the remaining trabeculo-Descemets membrane. A collagen implant was sutured radially in the scleral bed; the scleral flap and conjunctiva were then closed. Examinations were performed before surgery and postoperatively at 1 and 7 days and 1, 2, 3, 6, 9, 12, 15, 18, and 24 months. RESULTS The mean follow-up was 14.4 months +/- 6.3 (SD) (range 3 to 24 months). The mean preoperative intraoperative pressure (IOP) was 26.7 +/- 7.3 mm Hg. The mean postoperative IOP was 6.1 +/- 4.5 mm Hg at 1 day and 11.0 +/- 4.4 mm Hg at 1 week; it remained stable for the next 24 months. The success rate, defined as an IOP lower than 21.0 mm Hg without medication, was 69% in the DSCI group and 57% in the trabeculectomy group at 24 months postoperatively (P = .047). The number of postoperative complications was significantly lower in the DSCI group than in the trabeculectomy group. CONCLUSIONS The success rate of DSCI may be comparable to that of trabeculectomy, with fewer complications.

Deep sclerectomy with collagen implant: medium term results

AIMS To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI), a new non-penetrating filtration procedure. METHODS Non-randomised prospective trial involving consecutive patients. 100 eyes of 100 patients with medically uncontrolled primary and secondary open angle glaucoma. A superficial scleral flap was raised and a deep sclerectomy was performed in the scleral bed. Schlemm’s canal was opened and dissection of the cornea was performed up to Descemet’s membrane, at which point aqueous percolated through the remaining trabeculo-Descemet’s membrane. A collagen implant was sutured radially in the scleral bed. Visual acuity, intraocular pressure (IOP) measurements, and slit lamp examinations were performed before surgery and after surgery at 1 and 7 days, and 1, 3, 6, 9, 12, 18, 24, 30, and 36 months. RESULTS The mean follow up period was 17.8 (SD 8.7) months. The mean preoperative IOP was 27.8 (8.6) mm Hg; the mean postoperative IOP was 5.7 (4.0) at day 1, 11.2 (4.6) at month 1, 14.0 (3.5) at month 12, and 13.0 (3.8) at month 36. Complete success rate, defined as an IOP lower than 21 mm Hg without medication, was 44.6% at 36 months. Qualified success rate, defined as an IOP lower than 21 mm Hg with medication, was 97.7% at 36 months. Early postoperative complications included hyphaema in seven patients, wound leak in 10 patients, and subtle choroidal detachment in 11 patients. Goniopuncture was performed in 41 of the patients, and 5-fluorouracil injections were made in 23 patients; cataract progression occurred in seven patients. When comparing the different types of open angle glaucoma, no difference was found in terms of reduction in IOP, number of patients requiring antiglaucoma medications, or success rate. CONCLUSIONS Deep sclerectomy with collagen implant appears to provide reasonable control of IOP at medium term follow up, with few immediate postoperative complications.

DEEP SCLERECTOMY : RESULTS WITH AND WITHOUT COLLAGEN IMPLANT

Purpose: To study the need, the safety and the success rate of collagen implant in eyes that underwent deep sclerectomy, a new non penetrating filtration procedure, we compared the results of deep sclerectomy with (DSCI) and without (DS) collagen implant. Methods: Of 168 patients (168 eyes) with various types of medically uncontrolled open angle glaucoma, 86 (86 eyes) underwent DSCI, and 82 (82 eyes) underwent DS. Visual acuity, slit lamp examination, intraocular pressure (IOP) measurements were performed before surgery and prospectively at days 1 and 7 and months, 1, 2, 3, 6, 9, 12, 15, 18, and 24 after surgery. Deep sclerectomy was performed according to Kozlovs original technique. The collagen implant drainage device was radially secured in the center of the deep sclerectomy dissection. Results: The mean follow-up period was 9.7 ± 6.5 months for DSCI, and 9.0 ± 4.8 months for DS. The mean preoperative IOP was 26.9 ± 8.8 mmHg for DSCI and 25.8 ± 8.5 mmHg for DS. The mean postoperative IOP and visual acuity were similar between the two groups. Complete and qualified success rates were better when the collagen implant was used (Log-Rank test: p = 0.0002 and 0.033 for complete and qualified success respectively). The need for postoperative glaucoma medications was significantly lower when the collagen implant was used (0.2 ± 0.5 versus 0.5 ± 0.7 medication per patient in the DSCI and DS respectively, Students t test: p = 0.0038). There was significantly less bleb fibrosis when the collagen implant was used (2% and 11% in DSCI and DS respectively, p = 0.029). Conclusion: The collagen implant device is safe, increases the success rate of deep sclerectomy, and lowers the need for postoperative glaucoma medications.

Implantable contact lens for moderate to high myopia: Short-term follow-up of 2 models

Purpose: To confirm the safety, efficacy, and predictability of the surgical correction of moderate to high myopia by the ICM V3 and ICM V4 implantable contact lenses (ICLs), with emphasis on vaulting, intraocular pressure (IOP), and pigment dispersion. Setting: University Eye Hospital, Lausanne, Switzerland. Methods: Thirty‐two eyes had implantation of an ICL. In 22 eyes with a mean spherical equivalent (SE) of −11.5 diopters (D), the target was emmetropia; in 10 eyes with a mean SE of −22.3 D, the goal was a reduction in the myopia. Nineteen eyes received the ICM V3 ICL and 13, the ICM V4 ICL. The mean follow‐up was 7.4 months. Results: The mean postoperative SE in the 32 eyes was –2.16 D. Best spectacle‐corrected visual acuity was maintained or improved in all eyes. In the 22 eyes targeted to achieve emmetropia, 10 (45%) were within ±1.00 D; 15 (68%) had an uncorrected visual acuity of 20/40 or better and 4 (18%), of 20/20 or better. Vaulting of the ICL over the crystalline lens was more pronounced with the V4 than with the V3, and the difference was statistically significant. Subtle, localized anterior subcapsular opacification was encountered in 4 eyes. In 3 of them, the ICL (model V3) vaulting was minimal and 1 ICL (model V4) did not show any vaulting. Eighteen eyes had an IOP higher than the preoperative level, and the difference was statistically significant. No correlation was seen between final IOP and vaulting. Pigment dispersion on the ICL did not appear to be related to vaulting or ICL thickness. Conclusion: Implantation of an ICL was effective in correcting moderate to high myopia of up to –17.50 D. Although the procedure appears to be safe, the predictability of the refractive outcome must be improved. The new generation of ICLs for myopia (ICM V4) offers a better vault over the crystalline lens than the older models (ICM V3), which should decrease the risk of cataract. No explanation was found for the IOP increase in several eyes 3 months or more after surgery.

Change in capsulorhexis size after implantation of three types of intraocular lenses

Purpose: To compare the change in size of continuous curvilinear capsulorhexis (CCC) used for implantation of three types of intraocular lenses (IOLs) and to determine the role of postoperative inflammation, initial CCC dimension, haptic design, and optic material. Setting: Hôpital Ophtalmique Universitaire Jules Gonin, Lausanne, Switzerland. Method: Twenty‐nine three‐piece, silicone/poly(methyl methacrylate) (PMMA) IOLs (lovision 127), 26 one‐piece PMMA IOLs (Pharmacia 812A), and 27 plate‐haptic silicone IOLs (Staar AA4203) were implanted in the capsular bag after phacoemulsification. Photographs of the CCCs taken 1 day and 6 months after surgery were scanned and digitized on a computer. Using different software, the surface of the CCC was measured and the 6 month change evaluated. Flare, measured the day before surgery and postoperatively at days 1, 7, 30, and 180, was integrated to obtain a global estimate of inflammation during the 180 day follow‐up. Results: The CCCs used with three‐piece, silicone/PMMA IOLs showed little changes in surface, with a mean enlargement of +0.57 mm2 ± 1.15 (SD) (+3.5%). The CCCs used with the one‐piece PMMA IOLs had a slight tendency to constrict, with a mean surface decrease of −0.59 ± 2.16 mm2 (−4.3%). The CCCs used with plate‐haptic silicone IOLs showed a marked and statistically significant constriction, with a mean decrease of −2.55 ± 3.51 mm2 (−14.4%). The change in CCC size was not associated with the integrated flare, and no correlation was found between the initial CCC size and the magnitude of change. There was no statistically significant difference in CCC change between the PMMA optic IOL (Pharmacia) and silicone optic IOL (lovision and Staar) groups. The CCC in the plate‐haptic IOL (Staar) group showed a significant (P < .0002) constriction when compared with that in the loop‐haptic IOL (Pharmacia and lovision) group. Conclusion: The IOLs’ haptic design seemed to play a major role in the evolution of the CCC. The CCC constriction seen with the Staar IOLs was related to their plate haptics.

Change in capsulorhexis size with four foldable loop-haptic lenses over 6 months

Purpose: To compare the change in continuous curvilinear capsulorhexis (CCC) size after implantation of four types of three‐piece foldable intraocular lenses (IOLs) and determine whether initial CCC size and IOL characteristics play a role in the change. Methods: This study comprised 133 eyes that had phacoemulsification and in‐thebag implantation of one of four types of foldable IOLs: Alcon AcrySof™ MA30BA (n = 36); lovision™ 127 (n = 29); Mentor ORC MemoryLens™ (n = 39); Allergan PhacoFlex II™ (n = 29). Photographs of the CCCs were taken with a digital retinograph 1 day and 6 months after surgery. Using image‐analysis software, the CCC surface was measured and changes between 1 week and 6 months were evaluated. Characteristics of the IOLs including overall diameter, optic thickness, and haptic centrifugal force were measured with micrometric tools. Results: The median change in CCC surface size at 6 months was +5.5% in the lovision group, indicating a slight enlargement. This finding was significantly different from that in the other three IOL groups (P < .0001), which had a tendency toward CCC contraction. Median change in CCC size was −2.3% in the MemoryLens group, −2.8% in the AcrySof group, and −6% in the PhacoFlex group. The MemoryLens was the most predictive IOL, with the smallest standard deviation; it was the only group in which no patient developed CCC contraction of more than 10%. Although the lovision and PhacoFex IOLs have common physical characteristics except for optic thickness (lovision 30% thicker), the CCCs in the lovision group were significantly more stable (P < .0001). Results indicate that the high centrifugal haptic force associated with acrylate/methacrylate polymer optics of the AcrySof and MemoryLens IOLs may prevent CCC contraction of greater than 10% in 97.4% of cases. Conclusion: Although there were statistically significant differences, patients in all four three‐piece foldable IOL groups had good CCC stability. However, the more stable and predictable CCCs were in the IOL groups that had the strongest centrifugal haptic force and an acrylate/methacrylate polymer optic (AcrySof and MemoryLens).