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Suturing microscopically leaking Crystalens wounds avoids myopic shifts
Frequently, surgeons contact me about myopic shifts that can occur about a month after Crystalens (Bausch & Lomb) surgery. These shifts are usually less than 1 D but cause enough degradation of distance vision to require enhancement procedures in the majority of patients. Laser enhancements or piggyback lens implants can treat these shifts, but how do we avoid them? Here are some possibilities:
Capsulorrhexis size: Some have suggested that capsulorrhexis size and shape matter. Jack Singer and others have suggested that a 5 mm x 8 mm oval capsulorrhexis may avoid refractive shifts, yet many surgeons use a variety of capsulorrhexis sizes, ranging from 5 mm to nearly 8 mm, and still experience occasional myopic shifts. A group of Crystalens users is currently looking into the relationship between capsulorrhexis size and outcome. We'll keep you updated on the group's findings.
Cycloplegia: Others have suggested that the use of cycloplegic drops during and after surgery. For 3 years, my group practice (Harvard Eye Associates, www.harvardeye.com) in southern Orange County, Calif., used atropine during and after surgery. After discontinuing this part of our regimen, we saw no increase in myopic shifts.
Pupil size: Some surgeons think the small elevation in the central 2 mm of the Crystalens HD optic is responsible for this shift, especially among patients with small pupils. Again, a study is under way to examine this correlation.
Wound leaks/suturing: One factor does make a difference: small wound leaks at the end of surgery. This idea had been suggested by a number of surgeons, but no formal studies had been performed. To test the association between wound leaks and myopic shifts with Crystalens, I performed a controlled, retrospective study, which I presented as a poster at AAO 2008 (click here for poster). For several months, I had been routinely performing a Seidel test at the end of cataract surgery. Initially I was surprised to find small (not detectable without a Seidel test) wound leaks in about one-third of patients. As a side note, this process helped me learn a great deal more about my clear corneal wound construction and how to keep wounds leak-free at the end of surgery. Retrospectively, I reviewed 100 charts of Crystalens patients — 50 who had Seidel negative wounds and 50 with small leaks. Neither group had received sutures. One month later, I learned that leaking wounds had an average refraction 0.54 D more myopic than those that were Seidel negative at the time of surgery.
It is now my standard of practice to suture any Seidel positive Crystalens wounds. It is my hope that newer, better methods of sealing incisions may allow us to use a technology even better than suture. In an upcoming blog entry, I will be writing about one such technology that is currently under FDA phase 3 investigation.