O@PoC
eISSN 2399-3685
Ophthalmol @ Point Care 2017; 1(1): e30-e35 DOI: 10.5301/oapoc.0000008
RESEARCH @ Point of care
Deep anterior lamellar keratoplasty followed by toric lens implantation for the treatment of concomitant anterior stromal diseases and cataract Vincenzo Scorcia1, Andrea Lucisano1, Vincenzo Savoca Corona1, Valentina De Luca1, Adriano Carnevali1, Massimo Busin1-3 Department of Ophthalmology, University of “Magna Graecia”, Catanzaro - Italy Department of Ophthalmology, Ospedale Privato “Villa Igea”, Forlì - Italy 3 IRFO (Istituto internazionale di Ricerca e Formazione in Oftalmologia), Forlì - Italy 1 2
ABSTRACT Purpose: To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) followed by phacoemulsification and toric intraocular lens (IOL) implantation for the treatment of concomitant stromal disease and cataract. Methods: In this retrospective non-comparative interventional case series, ten eyes affected by stromal disease and cataract underwent DALK followed by phacoemulsification with toric IOL implantation after a minimum period of 5 months from complete suture removal. In each case, topographic astigmatism, refraction, visual acuity, and endothelial cell density were recorded before DALK and 1, 6, and 12 months after cataract surgery. In addition, IOL rotation was evaluated using anterior segment optical coherence tomography. Results: Big-bubble DALK was performed in all eyes but one that received manual dissection. Topographic astigmatism averaged 5.6 ± 2.2 diopters (D) after suture removal; refractive astigmatism decreased to 0.55 ± 0.61 D as early as one month after cataract surgery and did not change substantially throughout the follow-up period. In all patients, one month after phacoemulsification uncorrected and best spectacle-corrected visual acuity were, respectively, ≥20/40 and ≥20/25 with a residual spherical equivalent of 0.00 ± 0.84 D. At the latest follow-up visit, in all cases the IOL rotation was ≤5 degrees from the intended position and the endothelial cell loss within 8.5%. No complications were recorded. Conclusions: DALK followed by phacoemulsification with toric IOL implantation optimizes visual and refractive outcomes in patients with concomitant stromal disease and cataract. In comparison with a combined procedure, the sequential approach offers better predictability of the postoperative refraction in the absence of an increased risk of complications. Keywords: Astigmatism, Cataract surgery, Cornea, DALK, Keratoplasty, Toric IOL
Introduction For many years, a combined surgical procedure including penetrating keratoplasty (PK), cataract extraction and intraocular lens (IOL) implantation, the so-called “triple procedure”, has been considered a valid option for the treatment of eyes with simultaneous stromal disease and cataract (1, 2). A combined approach may offer a visual rehabilitation faster than that obtained with sequential surgery, and avoid the damage to the transplanted endothelium caused by subsequent cataract surgery (3). Accepted: April 5, 2017 Published online: May 8, 2017 Corresponding author: Vincenzo Scorcia Via dei Crociati 40 88100 Catanzaro, Italy
[email protected]
More recently, deep anterior lamellar keratoplasty (DALK) has been developed as an alternative to PK for the treatment of stromal diseases with healthy endothelium (4); when cataract is present, DALK in combination with phacoemulsification has been proposed as the surgical treatment of choice to restore vision (5). Although this approach maintains the advantages of a single procedure, including the main one of a faster visual recovery, unsatisfactory refractive outcomes may result from both the difficulty of accurately calculating the IOL power and the possible occurrence of high-degree postoperative astigmatism (5, 6). In the last few years, phacoemulsification combined with toric IOL implantation has been reported to provide predictable and stable correction in eyes with cataract developing after PK or DALK in eyes with high-degree postoperative astigmatism, but no sequential strategy has been described to date for DALK and cataract surgery in eyes with concomitantly diseased cornea and crystalline lens (7-10). To optimize the final refraction in eyes with stromal diseases and cataract, we performed a two-stage procedure
© 2017 The Authors. This article is published by Wichtig International and licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0). Any commercial use is not permitted and is subject to Publisher’s permissions. Full information is available at www.wichtig.com
Scorcia et al
e31
Fig. 1 - (A) Clinical appearance of the anterior segment of a 59-year-old patient showing a clear cornea after deep anterior lamellar keratoplasty in the presence of nuclear cataract. (B) Topographic map obtained with the anterior segment optical coherence tomographer (AS-OCT) showing a regular corneal astigmatism of 4.50 diopters. (C) One day after cataract surgery the cornea is transparent with the toric IOL perfectly aligned along the intended axes (100°). (D) Twelve months after surgery, the AS-OCT infrared image shows that the IOL alignment is unchanged. IOL = intraocular lens.
including DALK followed by phacoemulsification and toric IOL implantation and report herein the outcomes of this approach.
Patients and methods We reviewed the charts of 10 eyes of 10 patients with stromal disease and cataract, who underwent a two-step surgical treatment consisting of DALK (big-bubble technique) followed by phacoemulsification with a toric IOL implantation in the capsular bag. Inclusion criteria for implantation of a toric IOL were senile cataract and post-keratoplasty stable and regular topographic astigmatism higher than 2.00 diopters (D), as measured no earlier than five months after complete DALK suture removal. Institutional review board approval was obtained from the University of Magna Graecia; the study followed the tenets of the 1964 Declaration of Helsinki and all patients had signed a detailed informed consent. © 2017 The Authors. Published by Wichtig International
Before and after DALK, as well as 1, 6, and 12 months after phacoemulsification a complete ophthalmologic examination was performed including assessment of uncorrected (UCVA) and best spectacle-corrected visual acuity (BSCVA), refraction, slit lamp biomicroscopy (Fig. 1A and C), tonometry, and fundus examination in mydriasis; when preoperative corneal opacity did not allow fundus examination, a B-scan echography was performed. The amount and meridian of post-DALK corneal astigmatism were determined by means of anterior segment optical coherence tomography (AS-OCT, SS-1000 CASIA, Tomey, Enlargen, Germany) (Fig. 1B). Optical partial coherence interferometry (IOLMaster, Carl Zeiss Meditec AG, Jena, Germany) was used for biometric purposes; all data were forwarded to the IOL manufacturer, who calculated the dioptric power of the lens aiming at postoperative emmetropia. Postoperatively, an internal AS-OCT software tool, included in the “Corneal map” section, was used to evaluate the toric IOL position and
Toric IOL in DALK
e32
assess postoperative rotation through a dilated pupil (Fig. 1D), by simply aligning a linear cursor passing across the IOL center on the peripheral marks of the lens. The targeted toric correction, residual postoperative astigmatism and spherical equivalent were recorded in each case and the accuracy of cylinder correction was calculated as percentage value of the achieved toric correction from the intended value. Endothelial cell density (ECD) was calculated with the cornea module of the HRT-II device (Heidelberg Technology, Heidelberg, Germany). An analysis of variance (ANOVA) test was used to determine the significance of changes in UCVA, BSCVA, ECD, and IOL rotation. Statistical analysis was performed using GraphPad (GraphPad Software, La Jolla, California, USA); differences were considered statistically significant when the p value was
