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Presbyopia correction possible with anterior ciliary sclerotomy using expansion plugs
In a study of 12 presbyopic patients treated with ACS-SEP, there was a 1.5-D improvement in accommodative amplitude over 18 months.
January 2001
YOKOHAMA, Japan — With new theories suggesting that presbyopia may be caused by posterior chamber crowding rather than lens sclerosis, as has been the traditional teaching, there has been renewed interest in the possible surgical correction of presbyopia.
Anterior ciliary sclerotomy (ACS) was first proposed by Spencer Thornton, MD, in 1997. Results thus far have shown initial improvement in presbyopia with ACS, but rapid regression in effects with healing.
In a study I conducted at the Fukasaku Eye Center located here, 12 patients between the ages of 46 and 67 underwent ACS with the addition of implantation of silicone expansion plugs (SEP) in the ACS incision (ACS-SEP).
Prior to surgery, patients underwent refraction, keratometry, tonometry and ultrasonic biomicroscopy to measure scleral thickness. Following topical anesthesia and peritomy, the Thornton triple-edge diamond knife (Mastel-KOI) was used to create a 3-mm, 95% thickness radial sclerotomy in each of the oblique quadrants. The sclerotomy was opened to the subscleral space using the Fukasaku ACS forceps (Katena) with the bluish blush of the uveal tract serving as the indicator of proper depth.
Silicone plugs measuring 0.6 by 0.6 by 2.4 mm were then sutured into the sclerotomy using a single criss-cross 10-nylon suture through both sclera and plug.
The peritomy was closed with 8-0 silk, and antibiotics were placed in the eye. Patients were seen at 1 day, 1 week, 1 month and every 3 months thereafter.
Measuring results
The initial mean improvement in accommodative amplitude 1 day postoperatively was 1.8 D (1.7 D preoperative to 3.5 D postoperative). Over the next several months, there was slight regression in effect (0.3 D or 16%) with stabilization at approximately 6 months. All distance refractions remained unchanged after surgery.
Subjectively, all patients were delighted with the results and reported marked improvement in their daily near visual tasks. Several patients reported slight foreign-body sensation that cleared in several days, and no patients experienced uveitis, scleritis or infection.
Intraocular pressure reduction
A mean drop in intraocular pressure (IOP) of 6 mmHg was noted in patients undergoing ACS-SEP. This unexpected and intriguing phenomenon is probably due to increased uveoscleral outflow. I theorize that the full-thickness sclerotomy of ACS-SEP creates a localized ciliochoroidal detachment that remains open with the silicone plug sutured in the depth of the sclerotomy. This ciliochoroidal detachment increases the uveoscleral outflow of aqueous as is well documented in traumatic and surgical ciliochoroidal detachment.
My colleagues and I are currently working to further elucidate the mechanism of lowering of IOP with ACS-SEP with the hope of using differing numbers of silicone plugs to titrate reduction in IOP. The use of ACS-SEP as another weapon in the fight against glaucoma has encouraged their efforts.
Keys to success
Success with ACS-SEP depends on several important steps that must be rigidly adhered to: Careful measurement of scleral thickness overlying the ciliary body must be done to ensure safe scleral incision. Full-thickness incision initially using a diamond blade and then carefully dissecting with forceps to the uveal “bluish blush” ensures maximal effect. And, finally, implantation of the silicone plugs must ensure that the plugs are securely sutured into the depth of the incision to ensure maximal effect and limit regression in improved accommodative amplitude as well as to avoid conjunctival erosion or plug extrusion.
Modifications in ACS-SEP technique, including rhomboidal rather than rectangular silicone plugs with pre-formed holes for easier suturing and the use of 11-0 mersilene sutures to secure plugs, are already under investigation at the Fukasaku Eye Center.
| Preop and postop IOP following ACS-SEP | Preop and postop accommodative amplitude following ACS-SEP |
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For Your Information:
- Hideharu Fukasaku, MD, can be reached at The Fukasaku Eye Center, 1-11-15 Kitasaiwai, Nishu-ku, Yokohama, Japan, 220-004; +(81) 45-325-0055; fax: +(81) 45-325-0054; e-mail: h-f-eye@po.iijnet.or.jp. Dr. Fukasaku has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.