Lens implantation in traumatized eyes: When is the best time?

Aphakia Source: Jay Futterman, M.D.

Ocular trauma frequently results in damage to the crystalline lens, necessitating its removal at the time of primary repair. Various options are available for achieving optical correction of the resulting aphakia. Among these, most trauma surgeons agree that implantation of an IOL is the most desirable solution. Less clear, however, is the optimal timing of IOL implantation in traumatized eyes. Is it better to implant the IOL at the time of primary repair or to delay implantation until the acute traumatic period has passed? At the 2009 meeting of the American Academy of Ophthalmology in San Francisco, two experts debated the pros and cons of primary versus delayed IOL implantation in traumatically aphakic eyes.

The case for primary implantation

“There are several different ways to approach ocular trauma,” said Michael Nordlund, M.D., Ph.D., assistant professor, Department of Ophthalmology, University of Cincinnati, Cincinnati. He described the four-step approach that he prefers.
“First, we have to re-establish the integrity of the globe,” he said. “Second, we must find and remove—or rule out the presence of—any intraocular foreign bodies. Third, we will need to control infection, inflammation, and intraocular pressure in the peritraumatic period. And finally, we must rehabilitate the vision to its fullest post-trauma potential.”
With regard to visual rehabilitation, Dr. Nordlund prefers to implant an IOL during primary repair of the traumatized eye. “Putting the lens in at the time of trauma provides the quickest rehabilitation,” he said.
He acknowledged that there are some reasons to consider delaying IOL implantation to a second procedure. “Trauma repair often happens at night. There is limited time to plan accordingly for the specific needs of each individual eye. IOL calculations may be harder to get after hours. A skeleton crew in the operating room may not have the full complement of expertise needed to perform a primary lens implantation.”
Other reasons to delay IOL implantation might include limited visibility through the cornea and the potentially increased risk of infection associated with implanting a lens in a freshly injured eye.
On the other hand, Dr. Nordlund reviewed the results of three published case series supporting the beneficial outcomes associated with primary IOL implantation. “These were all small studies, and they were generally retrospective, but their results were remarkably consistent with one another,” he said. “In all three studies, the majority of eyes achieved best uncorrected visual acuity of 20/40 or better, and all subjects in all three studies achieved 20/100 or better best corrected visual acuity. In addition, there were no lens-related complications observed in any of these eyes.”
Based on these data and his own personal experience, Dr. Nordlund concluded, “Primary IOL implantation is safe, it expedites visual rehabilitation, and it eliminates the need for a second procedure for IOL placement. In cases where the corneal clarity can be maintained both during and after surgery, primary IOL implantation should be considered in these eyes.”

The case for secondary implantation

“There is no doubt that an IOL is the best way to correct aphakia in a healthy eye,” said José Dalma, M.D., Mexico City. “But the traumatized eye is not healthy.”
There are potential downsides to primary IOL implantation in traumatized eyes, he said. These include the challenges of obtaining reliable biometric measurements for determining IOL power, as well as limitations of capsular support for in-the-bag or even sulcus placement. “Also, the primary IOL is an additional source of post-operative inflammation,” he said.
Traumatized eyes often require secondary vitreoretinal surgery, he said, and primary placement of an IOL may limit visualization of the peripheral retina during such procedures. “Silicone IOLs should be avoided in these eyes, as there is always the possibility that silicone oil will be required later.”
Surgical planning is often improved by delaying IOL implantation, he said. “Rather than trying to make important decisions late at night when trauma so often occurs, there are advantages to deferring the decisions relating to IOL implantation.
“We have more options if we wait until we have a relatively quiet eye,” he explained. “We can often get more reliable biometric measurements for calculation of IOL power if we let the eye quiet down a bit. Also, we can better assess and address issues pertaining to the posterior segment.” This may broaden the subsequent options for IOL models and materials, he said.
“In addition, the procedure is technically less complicated and has a better chance for good outcomes if we wait until the eye is quiet before proceeding, as the acute inflammation produced by the traumatic injury will have been reduced or eliminated,” Dr. Dalma said. While Dr. Dalma acknowledged that there are alternatives to IOLs for post-traumatic visual rehabilitation—including aphakic spectacles and contact lenses—he believes that placement of an IOL is the optimal way to correct aphakia in traumatized eyes. “But we should maintain a level of caution in these eyes,” he advised, “even if this necessitates a second procedure or an alternative method for correcting aphakia.”

Editors’ note: Drs. Nordlund and Dalma did not indicate any financial interests related to their comments.

Contact information

Dalma: jdalma@data.net.mx
Nordlund: mnordlund@cincinnatieye.com