Class Summary

For temporary pupillary constriction to relieve symptoms of optical aberrations.

Pilocarpine HCL (Akarpine, Ocusert Pilo-40, Pilostat, Piloptic, Salagen)

Pilocarpine, with a chemical name of (3S-cis)-2(3H)-Furanone, 3-ethyldihydro-4-[(1-methyl-1H -imidazol-5-yl)methyl], monohydrochloride, has a molecular weight of 244. 72. Pilocarpine HCl ophthalmic solution is a sterile solution for ophthalmic administration having the following composition: a direct-acting cholinergic parasympathomimetic agent, which acts through direct stimulation of muscarinic neuroreceptors and smooth muscle such as the iris and secretory glands.

Pilocarpine produces miosis through contraction of the iris sphincter, causing increased tension on the scleral spur and opening of the trabecular meshwork spaces to facilitate outflow of aqueous humor. Outflow resistance is thereby reduced, lowering intraocular pressure.

Follow-up

Further Outpatient Care

Patients should receive follow-up care as needed.

Deterrence/Prevention

A study by Tappin et al examined some of the intraoperative and postoperative factors leading to IOL decentration in patients requiring IOL exchange in an attempt to identify avoidable causes of IOL decentration. [8] They concluded that significant postoperative subluxation of injected silicone IOLs may be minimized by implanting only into a lens capsule bag with an intact capsulorrhexis. The risk of decentration of a small optic (5. 5 mm) PMMA IOL may be minimized by positioning the haptics at 90° to any capsulorrhexis tear. After cataract surgery complicated by posterior capsular rupture or zonular dehiscence, it is important to assess the remaining capsular support and, if sufficient, implant a large optic diameter (7 mm) PCL in the ciliary sulcus.

The anterior segment surgeon should be advised to avoid implantation of a flexible silicone plate IOL if there is a break in the posterior capsule, radial notch, or tear in the anterior capsular rim or zonular dialysis.

Small capsulorrhexis openings should be avoided.

Current models of ACIOLs often do not result in the same types of complications as older models. These lenses should be considered if adequate capsular support is lacking rather than risking a posterior dislocation of an IOL.

Complications

Complications from a decentered IOL

Complications associated with ACIOL, iris-fixated IOLs, and older PCIOLs are much more severe than those encountered with modern PCIOL decentration. Corneal edema and inflammatory consequences such as uveitis-glaucoma-hyphema syndrome and chronic CME were common reasons for explanation in the above cases.

Complications from a dislocated IOL

Complications associated with dislocated IOL include the following: Vitreous hemorrhage

Retinal detachment has been estimated to occur in at least 2% of cases. It frequently is caused by attempts at relocation by the cataract surgeon or as a complication of vitreoretinal surgery.

Cystoid macular edema

Uncorrected aphakia, glare, or distortion

Complications from transscleral suture fixation

Late endophthalmitis through the suture track has been reported.

IOL torque may occur. In addition, to place the IOL truly in the sulcus, the suture must be placed 0. 8 mm posterior to the limbus in the vertical meridian and 0. 46 mm in the horizontal meridian. The effective lens power is probably less than the desired one.

Vitreous hemorrhage may occur if the major arterial circle of the iris is pierced inadvertently during the maneuvers required to suture the IOL. In addition, these maneuvers also may raise the risk of a postoperative retinal detachment.

Erosion of the suture through the conjunctiva also has been reported in cases where scleral flaps were used. An attempt to melt the eroded sutures with the argon laser has been recommended. The sutures cannot be removed because the IOL haptics do not scar into place if placed in the ciliary sulcus. Once the sutures are removed, the IOL will redislocate.

Prognosis

With proper vitreoretinal techniques, excellent visual results and a low complication rate is possible. Long-term prognosis is highly dependent on the prevention of retinal detachment and choroidal hemorrhage secondary to surgical manipulation.

Contributor Information and Disclosures

Author

Lihteh Wu, MD Ophthalmologist, Costa Rica Vitreo and Retina Macular Associates

Lihteh Wu, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Club Jules Gonin, Macula Society, Pan-American Association of Ophthalmology, Retina Society

Disclosure: Received income in an amount equal to or greater than $250 from: Bayer Health; Quantel Medical; Heidelberg Engineering; Novartis.

Coauthor(s)

Rafael Alberto Garcí a, MD Disclosure: Nothing to disclose.

Robert H Graham, MD Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, Arizona Ophthalmological Society, American Medical Association

Disclosure: Partner received salary from Medscape/WebMD for employment. Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Steve Charles, MD Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Disclosure: Received royalty and consulting fees for: Alcon Laboratories. Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose. Additional Contributors

Brian A Phillpotts, MD, MD

Brian A Phillpotts, MD, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, National Medical Association

Disclosure: Nothing to disclose. Acknowledgements

Teodoro Evans, MD Consulting Surgeon, Vitreo-Retinal Section, Clinica de Ojos, Costa Rica Disclosure: Nothing to disclose.

References

1. Davis D, Brubaker J, Espandar L, Stringham J, Crandall A, Werner L. Late in-the-bag spontaneous intraocular lens dislocation: evaluation of 86 consecutive cases. Ophthalmology. 2009 Apr. 116(4): 664-70. [Medline].

2. Gross JG, Kokame GT, Weinberg DV. In-the-bag intraocular lens dislocation. Am J Ophthalmol. 2004 Apr. 137(4): 630-5. [Medline].

3. Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens dislocation: incidence, prevention, and management. J Cataract Refract Surg. 2005 Nov. 31(11): 2193-204. [Medline].

4. Krepste L, Kuzmiene L, Miliauskas A, Januleviciene I. Possible predisposing factors for late intraocular lens dislocation after routine cataract surgery. Medicina (Kaunas). 2013. 49(5): 229-34. [Medline].

5. Fernandez-Buenaga R, Alio JL, Perez-Ardoy AL, et al. Late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes. Eye (Lond). 2013 Jul. 27(7): 795-801; quiz 802. [Medline]. [Full Text].

6. Shingleton BJ, Yang Y, O'Donoghue MW. Management and outcomes of intraocular lens dislocation in patients with pseudoexfoliation. J Cataract Refract Surg. 2013 Jul. 39(7): 984-93. [Medline].

7. Pueringer SL, Hodge DO, Erie JC. Risk of late intraocular lens dislocation after cataract surgery, 1980-2009: a population-based study. Am J Ophthalmol. 2011 Oct. 152(4): 618-23. [Medline].

8. Tappin MJ, Larkin DF. Factors leading to lens implant decentration and exchange. Eye (Lond). 2000 Oct. 14 Pt 5: 773-6. [Medline].

9. Mamalis N, Brubaker J, Davis D, Espandar L, Werner L. Complications of foldable intraocular lenses requiring explantation or secondary intervention--2007 survey update. J Cataract Refract Surg. 2008 Sep. 34(9): 1584-91. [Medline].

10. Al-Halafi AM, Al-Harthi E, Al-Amro S, El-Asrar AA. Visual outcome and complications of pars plana vitrectomy for dislocated intraocular lenses. Saudi J Ophthalmol. 2011 Apr. 25 (2): 187-92. [Medline].

11. Rusu I, Chen Z, Zizva J, Myung JS, Wald KJ. Incidence of cystoid macular edema with iris-fixated posterior chamber intraocular lenses in patients presenting with lens dislocation. Int Ophthalmol. 2014 Oct. 34 (5): 1153-8. [Medline].

12. Jakobsson G, Zetterberg M, Sundelin K, Stenevi U. Surgical repositioning of intraocular lenses after late dislocation: Complications, effect on intraocular pressure, and visual outcomes. J Cataract Refract Surg. 2013 Dec. 39(12): 1879-85. [Medline].

13. Gonnermann J, Klamann MK, Maier AK, Rjasanow J, Joussen AM, Bertelmann E, et al. Visual outcome and complications after posterior iris-claw aphakic intraocular lens implantation. J Cataract Refract Surg. 2012 Dec. 38 (12): 2139-43. [Medline].

14. Yamane S, Inoue M, Arakawa A, Kadonosono K. Sutureless 27-gauge needle-guided intrascleral intraocular lens implantation with lamellar scleral dissection. Ophthalmology. 2014 Jan. 121 (1): 61-6. [Medline].

15. Khan MA, Gupta OP, Smith RG, Ayres BD, Raber IM, Bailey RS, et al. Scleral fixation of intraocular lenses using Gore-Tex suture: clinical outcomes and safety profile. Br J Ophthalmol. 2016 May. 100 (5): 638-43. [Medline].

16. Bourke RD, Gray PJ, Rosen PH, Cooling RJ. Retinal detachment complicating scleral-sutured posterior chamber intraocular lens surgery. Eye. 1996. 10 (Pt 4): 501-8. [Medline].

17. Campo RV, Chung KD, Oyakawa RT. Pars plana vitrectomy in the management of dislocated posterior chamber lenses. Am J Ophthalmol. 1989 Nov 15. 108(5): 529-34. [Medline].

18. Chan CK. An improved technique for management of dislocated posterior chamber implants. Ophthalmology. 1992 Jan. 99(1): 51-7. [Medline].

19. Chan CK, Agarwal A, Agarwal S, Agarwal A. Management of dislocated intraocular implants. Ophthalmol Clin North Am. 2001 Dec. 14(4): 681-93. [Medline].

20. Duffey RJ, Holland EJ, Agapitos PJ, Lindstrom RL. Anatomic study of transsclerally sutured intraocular lens implantation. Am J Ophthalmol. 1989 Sep 15. 108(3): 300-9. [Medline].

21. Flynn HW Jr. Pars plana vitrectomy in the management of subluxed and posteriorly dislocated intraocular lenses. Graefes Arch Clin Exp Ophthalmol. 1987. 225(3): 169-72. [Medline].

22. Framme C, Hoerauf H, Roider J, Laqua H. Delayed intraocular lens dislocation after neodymium: YAG capsulotomy. J Cataract Refract Surg. 1998 Nov. 24(11): 1541-3. [Medline].

23. Gonzalez GA, Irvine AR. Posterior dislocation of plate haptic silicone lenses. Arch Ophthalmol. 1996 Jun. 114(6): 775-6. [Medline].

24. Hayashi K, Hirata A, Hayashi H. Possible predisposing factors for in-the-bag and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens exchange surgery. Ophthalmology. 2007 May. 114(5): 969-75. [Medline].

25. Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transscleral fixation of a posterior chamber intraocular lens. Arch Ophthalmol. 1989 Oct. 107(10): 1427. [Medline].

26. Joo CK, Shin JA, Kim JH. Capsular opening contraction after continuous curvilinear capsulorhexis and intraocular lens implantation. J Cataract Refract Surg. 1996 Jun. 22(5): 585-90. [Medline].

27. Kokame GT, Yamamoto I, Mandel H. Scleral fixation of dislocated posterior chamber intraocular lenses: Temporary haptic externalization through a clear corneal incision. J Cataract Refract Surg. 2004 May. 30(5): 1049-56. [Medline].

28. Lanzetta P, Menchini U, Virgili G, Crovato S, Rapizzi E. Scleral fixated intraocular lenses: an angiographic study. Retina. 1998. 18(6): 515-20. [Medline].

29. Lewis H, Sanchez G. The use of perfluorocarbon liquids in the repositioning of posteriorly dislocated intraocular lenses. Ophthalmology. 1993 Jul. 100(7): 1055-9. [Medline].

30. Lubniewski AJ, Holland EJ, Van Meter WS, Gussler D, Parelman J, Smith ME. Histologic study of eyes with transsclerally sutured posterior chamber intraocular lenses. Am J Ophthalmol. 1990 Sep 15. 110(3): 237-43. [Medline].

31. Maguire AM, Blumenkranz MS, Ward TG, Winkelman JZ. Scleral loop fixation for posteriorly dislocated intraocular lenses. Operative technique and long-term results. Arch Ophthalmol. 1991 Dec. 109(12): 1754-8. [Medline].

32. Malbran ES, Malbran E Jr, Negri I. Lens guide suture for transport and fixation in secondary IOL implantation after intracapsular extraction. Int Ophthalmol. 1986 May. 9(2-3): 151-60. [Medline].

33. Marques FF, Marques DM, Osher RH, Freitas LL. Longitudinal study of intraocular lens exchange. J Cataract Refract Surg. 2007 Feb. 33(2): 254-7. [Medline].

34. Mittra RA, Connor TB, Han DP, Koenig SB, Mieler WF, Pulido JS. Removal of dislocated intraocular lenses using pars plana vitrectomy with placement of an open-loop, flexible anterior chamber lens. Ophthalmology. 1998 Jun. 105(6): 1011-4. [Medline].

35. Por YM, Chee SP. Posterior-assisted levitation: outcomes in the retrieval of nuclear fragments and subluxated intraocular lenses. J Cataract Refract Surg. 2006 Dec. 32(12): 2060-3. [Medline].

36. Ruiz-Moreno JM. Repositioning dislocated posterior chamber intraocular lenses. Retina. 1998. 18(4): 330-4. [Medline].

37. Schecter RJ. Suture-wick endophthalmitis with sutured posterior chamber intraocular lens. J Cataract Refract Surg. 1990. 16: 1755-56.

38. Schneiderman TE, Johnson MW, Smiddy WE, Flynn HW Jr, Bennett SR, Cantrill HL. Surgical management of posteriorly dislocated silicone plate haptic intraocular lenses. Am J Ophthalmol. 1997 May. 123(5): 629-35. [Medline].

39. Smiddy WE. Management of dislocated foldable intraocular lenses. Retina. 2005 Jul-Aug. 25(5): 576-80. [Medline].

40. Smiddy WE. Modification of scleral suture fixation technique for dislocated posterior chamber intraocular lens implants. Arch Ophthalmol. 1998 Jul. 116(7): 967. [Medline].

41. Smiddy WE, Flynn HW Jr. Management of dislocated posterior chamber intraocular lenses. Ophthalmology. 1991 Jun. 98(6): 889-94. [Medline].

42. Smiddy WE, Flynn HW Jr. Needle-assisted scleral fixation suture technique for relocating posteriorly dislocated IOLs. Arch Ophthalmol. 1993 Feb. 111(2): 161-2. [Medline].

43. Smiddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated intraocular lenses. J Cataract Refract Surg. 1995 Jan. 21(1): 64-9. [Medline].

44. Solomon K, Gussler JR, Gussler C, Van Meter WS. Incidence and management of complications of transsclerally sutured posterior chamber lenses. J Cataract Refract Surg. 1993 Jul. 19(4): 488-93. [Medline].

45. Steinmetz RL, Brooks HL, Newell CK. Management of posteriorly dislocated posterior chamber intraocular lenses by vitrectomy and pars plana removal. Retina. 2004 Aug. 24(4): 556-9. [Medline].

46. Tuft SJ, Talks SJ. Delayed dislocation of foldable plate-haptic silicone lenses after Nd: YAG laser anterior capsulotomy. Am J Ophthalmol. 1998 Oct. 126(4): 586-8. [Medline].

47. Williams DF, Del Piero EJ, Ferrone PJ, Jaffe GJ, McDonald HR, Peters MA. Management of complications in eyes containing two intraocular lenses. Ophthalmology. 1998 Nov. 105(11): 2017-22. [Medline].

⇐ Предыдущая 16 17 18 19 20 21 22 23 2425