LETTERS

Syringe or pump for air-assisted DSAEKIndescribing their technique for air-assisteddesceme-

torhexis for Descemet-stripping automated endothelialkeratoplasty,Mehta et al.1 note that air tends to leave theeye during the Descemet stripping and they managethis with constant injection of air by an assistant. Thistechnique results in repeated shallowing and reformingof the anterior chamber and risks iris damage, miosis,and lens damage in phakic eye procedures.

I reported a similar technique that uses a vitrectomyair exchange pump and anterior chamber maintainer.2

I find it to be more effective than the syringe and tapmethod as it prevents the fluctuation in air fill de-scribed. Use of the pump also eliminates the require-ment for a surgical assistant.

Martin Leyland, BSc, MD, FRCOphthReading, United Kingdom

REFERENCES1. Mehta JS, Hantera MM, Tan DT. Modified air-assisted desceme-

torhexis for Descemet-stripping automated endothelial kerato-

plasty. J Cataract Refract Surg 2008; 34:889–891

2. Leyland M. Anterior chamber maintenance during Descemet

stripping [letter]. Cornea 2007; 26:1292–1293; reply by AA Mear-

za, CK Rostron, 1293

REPLY: The issues that Leyland describes, ie,repeated shallowing and the risk for iris damage, areapplicable only if multiple syringes of air are required.If the stripping is performed with a reverse Price-Sinskey hook, as we described, the entire strippingcan be performedwith a single full air syringe througha small paracentesis incision. In the technique de-scribed by Leyland,1 which is similar to the originaltechnique of Melles et al.,2 the stripping is performedwith a scraper and/or forceps, hence requiring a largerparacentesis than is needed by a reverse Price-Sinskeyhook to enter the anterior chamber. This will inevita-bly lead to greater air escape than a smaller incision,causing greater anterior chamber variation. We wouldnot advocate using our technique with large incisionsusing a Descemet scraper or forceps.

With reference to phakic eyes, most DSAEK sur-geons advocate the removal of even aminimal catarac-tous lens at the time of DSAEK surgery3 because of thelikelihood of post-DSAEK cataract progression. Subse-quent cataract removal may have a deleterious effecton the donor graft. Hence, we have minimal experi-ence with this technique in phakic eyes. The elimina-tion of an assistant with the vitrectomy air exchangesystem is also debatable since the provision of air bythe syringe is easily achieved by the scrub nurse.dJodhbir S. Mehta, BSc, MBBS, FRCOphth, FRCS(Ed),Donald T. Tan, MD, FRCS(Ed)

Q 2009 ASCRS and ESCRS

Published by Elsevier Inc.

2

REFERENCES1. Leyland M. Anterior chamber maintenance during Descemet

stripping [letter]. Cornea 2007; 26:1292–1293

2. Melles GRJ, Wijdh RH, Nieuwendaal CP. A technique to excise

the Descemet membrane from a recipient cornea (descemeto-

rhexis). Cornea 2004; 23:286–288

3. Price MO, Price FW Jr. Cataract progression and treatment

following posterior lamellar keratoplasty. J Cataract Refract

Surg 2004; 30:1310–1315

Complications of CTR implantation in pediatriceyes

In the article by Vasavada et al.1 on the use of thesutured Cionni endocapsular tension ring (CTR) forintraocular lens (IOL) implantation in children withlens subluxation, the procedure was thought to be‘‘safe and effective.with few significant complica-tions.’’ Unfortunately, the article did not provide theIOL powers, which are necessary to determinewhether the procedures were indicated.

The authors assert that ‘‘[t]his alternative [CTR/IOL]is certainly more attractive than leaving the childaphakic.’’ However, 13 patients (22 eyes) had Marfansyndrome. Eyes with dislocated lenses owing to Mar-fan syndrome tend to have longer axial lengths2 andflatter corneas2,3 than normal eyes. In combination,this can result in an aphakic refractive error of lessthan C5 diopters and in some cases a negative-powerIOL is required to achieve aplano result. Intraocular ac-robatics are not justified in these patients as they seequite well with ordinary spectacles that incorporatea progressive bifocal. Aphakia means there is nothingto dislodge during soccer practice, no polypropylenesutures to erode or break over the course of decades,no need for secondary procedures to open the posteriorcapsule, and an optimumview of the peripheral retina.The authors should justify their decision to performa complex and technically challenging procedure byproviding aphakic refraction and IOL power data.This criticism has been leveled against other authors.4,5

A total of 35 eyes of 22 children were treated. Ofthese, 11 (31%) had a neodymium:YAG (Nd:YAG)posterior capsulotomy, 12 (34%) required a second in-traocular surgery to open the posterior capsule or forexplantation or resuturing, and the fate of 12 is unde-termined. Of the 12 eyes, 6 were in children youngerthan 8 years. If we assume that none of these patientscan have a timely Nd:YAG capsulotomy, then 18 of 35eyes (51%) will require 2 intraocular procedures. Thefinal result after Nd:YAG or surgical capsulotomywill be a CTR encasedwith the IOL haptics in the equa-torial capsular bag, with mechanical support providedby the polypropylene sutures securing the CTR tosclera. The authors fail to explain the anatomicaladvantage of this situation compared with that of a

0886-3350/09/$dsee front matter

doi:10.1016/j.jcrs.2008.09.022

3LETTERS

lensectomy/vitrectomy combined with an IOL sewndirectly to sclera, in which posterior capsule opacifica-tion is a nonissue as long as the vitrectomy is adequate.

A polypropylene 10-0 suture was used during thefirst half of the study period. This suture is no longerrecommended for children because of the high risk forspontaneous breakage, which occurs, on average,about 5 years after surgery (E.G. Buckley, MD, ‘‘Su-tured Posterior Chamber Intraocular Lenses in Child-rendHanging by a Thread;’’ the Costenbader Lecture,presented at the annual meeting of the American Asso-ciation for Pediatric Ophthalmology and Strabismus,Washington, DC, USA, April 2008. Abstract availableat: http://www.medscape.com/viewarticle/574580.Accessed October 15, 2008). All children operated onwith 10-0 polypropylene will probably experience dis-location of the entire CTR/IOL complex within 10years. This illustrates one hazard of the over-rapid ap-plication of adult surgical techniques to children.

When considering a novel surgical technique, theprincipal question is not whether it can be accom-plished, but whether it is in the patient’s best interest.In a pediatric patient with a low hyperopic aphakicrefraction, any form of sutured IOL implantation isdifficult to justify. If an IOL is optically indicated, a len-sectomy/vitrectomy with a sutured IOL (withoutCTR) provides the same result without the almost cer-tain requirement for a second capsule-opening proce-dure and its attendant risks.

Sandra Brown, MDConcord, North Carolina, USA

REFERENCES1. Vasavada V, Vasavada VA, Hoffman RO, Spencer TS,

Kumar RV, Crandall AS. Intraoperative performance and postop-

erative outcomes of endocapsular ring implantation in pediatric

eyes. J Cataract Refract Surg 2008; 34:1499–1508

2. MaumeneeIH.Theeye in theMarfansyndrome.TransAmOphthal-

mol Soc 1981; 79:684–733. Available at: http://www.pubmedcentral.

nih.gov/picrender.fcgi?artidZ1312201&blobtypeZpdf. Accessed

October 15, 2008

3. Heur M, Costin B, Crowe S, Grimm RA, Moran R, Svensson LG,

Traboulsi EI. The value of keratometry and central corneal thick-

ness measurements in the clinical diagnosis of Marfan syndrome.

Am J Ophthalmol 2008; 145:997–1001

4. Morrison D, Sternberg P Jr, Donahue S. Anterior chamber

intraocular lens (ACIOL) placement after pars plana lensectomy

in pediatric Marfan syndrome. J AAPOS 2005; 9:240–242

5. Singh DV, Sharma YR, Sharma R. Primary versus secondary

intraocular lens placement after pars plana lensectomy in pediat-

ric Marfan syndrome. J AAPOS 2007; 11:317–318; reply by

Morrison D, Sternberg P Jr, Donahue S, 318

REPLY: Surgical options for lens removal in pediatriceyes with ectopia lentis include lensectomy/vitrec-tomy performed through the pars plicata route andbimanual irrigation/aspiration of lens material via

J CATARACT REFRACT SUR

a limbal approach. However, lensectomy/vitrectomyis not without complications in the posterior segmentand leads to disruption of the capsular bag–zonularcomplex. With the limbal approach, it is possible topreserve the capsular bag–zonular complex andmain-tain the normal anatomical barriers. Although there isno evidence that clearly supports this approach, itseems logical to us to maintain the anatomical integ-rity of the eye as much as possible.

Following lens removal, several options are avail-able. The child can be left aphakic or IOL implantationcan be performed. The IOL can be implanted in theanterior chamber, suture-fixated to the iris, scleral-fix-ated, or implanted in the bag following Cionni CTRimplantation. To date, there is no evidence in the liter-ature as to which of these is the best approach for pe-diatric ectopia lentis. With the expertise andexperience of the surgeon (A.S.C.), our choice was tomaintain the intact capsular bag and place an IOL afterCionni CTR implantation.

We realize this approach is technically challengingand has not been proven superior to the othermethodsof IOL fixation.We by nomeans intend to suggest thatit is the best approach for managing a subluxated lensin a child’s eye, merely that it is a viable alternativefor management of such cases. In our hands, thisapproach works better than the others.

We agree with Brown that 10-0 polypropylene is nolonger the material of choice for suturing the IOL orCionni CTR to the sclera. We used a 10-0 suture in theearly half of our study,when the use of 9-0 polypropyl-ene was not common practice for us. Thereafter, 9-0polypropylene was used in all cases.dVaishaliA. Vasavada, MS, Viraj A. Vasavada, MS, RobertO. Hoffman, MD, Terrence S. Spencer, MD, RishiV. Kumar, MD, Alan S. Crandall, MD

Diagnosis of post-LASIK occult Chandlersyndrome

Mocan et al.1 have described a patient who wasdiagnosedwith Chandler syndrome, one of the entitiescomprising the iridocorneal endothelial (ICE) syn-drome, after unilateral iris distortion andglaucoma fol-lowing bilateral laser in situ keratomileusis (LASIK).Wehave treated a similar patient, a 36-year-oldwomanwith a refractive error of�2.00C1.50� 180 in the righteye and �2.50 C 1.75 � 165 in the left eye who haduneventful bilateral LASIK procedures. Preoperativetesting revealed no significant abnormalities; the intra-ocular pressure (IOP) by applanation was 17 mm Hgbilaterally and the central pachymetry by ultrasoundwas 509 mm in the right eye and 514 mm in the lefteye. One day postoperatively, the uncorrected visualacuity (UCVA)was 20/20 in both eyes, but on the third

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