THE LANCET
Huibregtse K. Biliary endoprostheses in elderly patients with
endoscopically irretrievable common bile duct stones: report on 117
patients. Gastrointest Endosc 1995; 42: 195–201.
19 Staritz M, Poralla T, Klose K, Meyer zum Buschenfelde KH.
Magnification of the endoscope during endoscopic retrograde
cholangiography—a reliable standard for exact measurement of
bileduct and bilestones. Z Gastroenterol 1984; 22: 697–700.
20 Berkman WA, Bishop AF, Palagallo GL, Cashman MD.
Transhepatic balloon dilation of the distal common bile duct and
ampulla of Vater for removal of calculi. Radiology 1988; 167:
453–55.
21 Steidle B, Kurtz B. Transhepatic balloon dilatation of the ductus
choledochus and the removal of choledochal calculi. Rofo Fortschr
Geb Rontgenstr Neuen Bildgeb Verfahr 1991; 155: 128–34.
22 Perissat J, Huibregtse K, Keane FBV, Russell RCG, Neoptolemos
JP. Management of bile duct stones in the era of laparoscopic
cholecystectomy. Br J Surg 1994; 81: 799–810.
23 Carroll BJ, Phillips EH, Chandra M, Fallas M. Laparoscopic
Randomised controlled trial of anterior-chamber intraocular
lenses
A Hennig, J R Evans, D Pradhan, G J Johnson, R P Pokhrel, R M C Gregson, R Hayes, R P L Wormald, A Foster
Summary
Background There are an estimated 16 million people
blind in both eyes with cataracts. Most live in rural areas
of developing c ount ries w here surg ic al resourc es are
scarce. There is no consensus on the most appropriate
type of intraocular lens in situations where high-volume
low-cost surgery is required. This study was undertaken
t o evaluat e t he safet y of mult iflex open-loop ant erior-
chamber lenses (ACIOLs).
Methods 2000 people at t ending Lahan Ey e Hospit al,
southern Nepal, with bilateral cataracts reducing vision to
6/36 or less were randomly allocated to receive standard
surgery—intracapsular ex traction ( ICCE) w ith aphakic
correction—or ICCE with an ACIOL in their first operated
eye. The primary outcome was a visual acuity of less than
6/ 60 in t he operat ed ey e at 1 y ear follow -up. Visual
acuity was measured for 91% of the cohort at 1 year. The
sample size was estimated to detect a doubling in poor
v isual out c ome from an est imat ed rat e of 4% in t he
standard surgery (control) group.
Findings The median (range) time taken to do the surgery
w as 6·0 ( 3·0–17·2) min for t he A CIOL g roup and 4·1
(2·4–10·3) min for the control group. 1 year after surgery,
Lahan Eye Hospital, Nepal (A Hennig MD, D Pradham MD);
Department of Opththalmic Epidemiology, Moorfields Eye
Hospital/Institute of Ophthalmology, London EC1V 2PD, UK
(J R Evans MSc , R P L Wormald FRCOphth); Department of Preventive
Ophthalmology, Institute of Ophthalmology, London
(Prof G J Johnson FRCOphth, A Foster FRCOphth);
Nepal Netra Jyoti Singh, Kathmandu, Nepal (R P Pokhrel FRCS);
Queens Medical Centre, University Hospital, Nottingham
(R M C Gregson FRCOphth); and London School of Hygiene and
Tropical Medicine, London (Prof R Hayes MSc )
Correspondence to: Ms J R Evans
Vol 349 • April 19, 1997
transcystic duct balloon dilatation of the sphincter of Oddi. Surg
Endosc 1993; 7: 514–17.
24 Nelson DB, Freeman ML. Major hemorrhage from endoscopic
sphincterotomy: risk factor analysis. J Clin Gastroenterol 1994; 19:
283–87.
25 Maki T. Pathogenesis of calcium bilirubinate gallstone: role of E coli,
beta-glucuronidase and coagulation by inorganic ions,
polyelectrolytes and agitation. Ann Surg 1966; 164: 90–100.
26 Goldman LD, Steer ML, Silen W. Recurrent cholangitis after biliary
surgery. Am J Surg 1983; 145: 450–54.
27 Bergman JJGHM, Mey S van der, Raues EAJ, et al. Long-term
follow-up after endoscopic sphincterotomy for bile duct stones;
report on 100 patients with a median follow-up of 15 years.
Gastrointest Endosc 1996; 44: 643–49.
28 MacMathuna P, Siegenberg D, Gibbons D, et al. The acute and
long-term effect of balloon sphincteroplasty on papillary structure in
pigs. Gastrointest Endosc 1996; 44: 650–55.
5·0% of t he A C I OL g roup and 5·4% of c ont rols had
functional vision less than 6/60 (OR 0·93 [0·60–1·43],
p=0·71) . The c auses of poor vision in t he A CIOL and
control groups were: correctable refractive error (22 and
2 9 ) , u v e i t i s/ se c o n d a r y g l a u c o m a ( 1 3 a n d t w o ) ,
endopht hal mi t i s ( four and sev en) , pre- ex i st i ng ey e
disease ( four and five) , retinal detac hment ( none and
four) , cystoid macular oedema ( tw o and none) , corneal
ulcer (one and one), and corneal decompensation (none
and one).
Interpretation This study provides evidence that, in rural
areas of developing countries, multiflex open-loop ACIOLs
can be implanted safely by ex perienced ophthalmologists
after routine ICCE, avoiding the disadvantages of aphakic
spectacle correction. Further follow-up is planned.
Lancet 1997; 349: 1129–33
Introduction
There are estimated to be 16 million people bilaterally
blind with cataracts in the world in 1990, most of whom
live in rural areas of developing countries where expert
surgical resources are scarce.1 Cataracts can be taken out
in two ways (see glossary): intracapsular cataract
extraction (ICCE) is simple and quick and involves
removal of the whole lens; extracapsular extraction
(ECCE) removes the lens contents only, leaving the
posterior lens capsule intact. To correct for not having a
lens in the eye, (aphakia), either an intraocular lens can
be implanted during surgery or the patient can use
spectacles or contact lenses after surgery.
Glossary
ICCE=intracapsular cataract ex traction
ECCE=ex tracapsular cataract ex traction
PCIOL=posterior chamber intraocular lens
ACIOL=anterior chamber intraocular lens
1129
THE LANCET

In industrialised countries, the usual surgical Eligible patients (n=2908)

technique is ECCE followed by implantation of a
posterior chamber lens (PCIOL) in the remaining lens Not randomised
capsule. Surgery is done with an operating microscope. Ex cluded (n=379) Refused (n=529)
This technique preserves the structural integrity of the
eye, prevents prolapse of the vitreous body into the
ICCE + ACIOL (n=1002) ICCE + spectacles (n=998)
anterior chamber, and reduces the risk of retinal First operated eye only in trial (standard surgery)
detachment. The disadvantage is that in some patients 98·7% of first eyes operated First operated eye only in trial
blind (visual acuity <3/60) 98·0% of first eyes operated
the posterior capsule will opacify and further Everyone received surgery as blind (visual acuity <3/60)
intervention will be needed. allocated Everyone received surgery as
allocated
Most eye surgeons in rural Africa and Asia have been
trained to do ICCE. In many cases, they do not have
Follow-up at 6 weeks (data not presented)
access to an operating microscope and use a magnifying
loupe to do the operation. Patients receive spectacles Follow-up at 1 year
after the operation. These spectacles are heavy, distort
vision, and are easily broken. Surveys in Africa2 and in
Hospital follow-up 512 (51%) Hospital follow-up 426 (43%)
Asia3 have shown that uncorrected aphakia is one of the Village follow-up 406 (41%) Village follow-up 483 (48%)
most important causes of blindness. Total vision measured 918 (92%) Total vision measured 909 (91%)
Resident not ex amined 51 Resident not ex amined 42
It is accepted that cataract surgeons in developing 45 reported vision OK 36 reported vision OK
countries should use intraocular lenses to overcome the 1 reported vision problems 1 reported vision problems
(but not blind) (but not blind)
difficulties of aphakic spectacles, but there is no Emigrated 3 Emigrated 7
agreement as to whether it is justified to retrain surgeons Died 12 3 reported vision OK
11 reported vision OK Died 27
experienced in ICCE in the ECCE with PCIOL Not traced 18 22 reported vision OK
technique, since this procedure is relatively expensive Total 1002 1 reported vision problems
(but not blind)
and usually requires an operating microscope. Not traced 13
The simplest method of using a lens implant after Total 998
ICCE is to place it in front of the iris in the anterior
chamber of the eye. Older anterior-chamber intraocular Trial profile
lens (ACIOL) implants had a bad reputation because of
faulty design and manufacture.4.5 Studies in
industrialised countries, where ACIOLs are used when cataract extraction was with a cryoextractor. The anterior
chamber was reformed with air. If the pupil was still dilated,
the posterior capsule is ruptured at operation, suggest
acetylcholine was used to constrict it. A drop of
that modern multiflex open-loop ACIOLs are well hydroxypropylmethyl cellulose was put on a standard 19·0 or
tolerated.6–10 There is currently insufficient evidence to 19·5 dioptre single-piece four-point fixation CILCO Kelman
justify their widescale use as a primary procedure in the Multiflex III lens (ALCON, Hemel Hempstead, UK) before
developing world. insertion. Facilities for measuring the power requirement were
After a pilot study,11 we undertook a randomised not available. The corneal section was closed with at least five
controlled trial at Lahan Eye Hospital, southern Nepal, 8/0 virgin silk sutures. In ACIOL operations the air in the
comparing ICCE surgery with a multiflex open loop anterior chamber was replaced by Ringer’s lactate at the end of
ACIOL with ICCE surgery and spectacles. Our the operation. Postoperatively, a sub-conjunctival injection of
hypothesis was that ACIOLs would give better vision gentamycin 20 mg was given in the lower fornix, with
dexamethasone 4 mg in ACIOL operations. Chloramphenicol
after surgery but might be associated with more
or neosporin eye ointment was applied followed by an eye
complications leading to blindness. Lahan is a rural bandage.
eye hospital with three ophthalmologists doing Postoperatively, patients were examined by an
approximately 12 000 eye operations each year. This ophthalmologist daily for 5 days. At discharge on day 6,
paper describes visual outcome 1 year after surgery; patients who had had ICCE only were given +11D spectacles.
analyses of clinical data, quality of life, and cost Follow-up examinations were at 6 weeks and 1 year. Those not
effectiveness will be published elsewehere. returning for follow up were visited by an ophthalmic assistant
who was trained to measure visual acuity and diagnose the
main blinding conditions.
Methods The primary outcome measure was poor vision defined as
Protocol visual acuity less than 6/60 in the operated eye at 1 year follow-
Patients attending Lahan Eye Hospital were eligible if aged up. Visual acuity was measured as the patient presented with or
40–64 years, with bilateral cataract reducing vision to 6/36 or without prescribed spectacles—we measured the functional
less in both eyes, and living within accessible districts. vision the patient was using in everyday life. A modified Snellen
Exclusion criteria were known pre-existing ocular disease, E chart with four optotypes on each line was used. Vision was
hypertension, or diabetes. Patients gave informed consent to taken as the last line on which at least three optotypes were
participate in the trial, which was approved by the Medical read correctly. Best corrected vision after refraction was also
Research Council of Nepal. recorded, with pinhole vision when refraction could not be
ICCE with an ACIOL was compared with ICCE with done on home visits. Early and late surgical complications were
aphakic spectacles. Surgery was done under local anaesthetic by recorded.
two experienced ophthalmologists (AH, DP) with 4·5
loupe A sample size of 2000 was estimated to be capable of
magnification. The horizontal corneal diameter was measured detecting a doubling in poor visual outcome at 1 year in the
and 1 mm added to calculate the diameter of the ACIOL. ACIOL group, at the 5% significance level, with a power of
Three diameters of lens were available: 12 mm, 12·5 mm, and 90%, assuming a 4% prevalence of poor outcome in the control
13·0 mm. A corneoscleral ab-interno incision was made with a group and a follow-up rate of 80%. An interim analysis was
von Graefe knife, with a small conjunctival flap. A peripheral done after 300 patients in each group had been followed up at 6
iridectomy was done at 10 or 2 o’clock positions. Intracapsular weeks and 1 year. The condition for termination was a

1130 Vol 349 • April 19, 1997

 THE LANCET

ACIOL Control Causes of poor visual Causes of blindness

outcome (<6/60) (<3/60)
n % n %
ACIOL Control ACIOL Control
Number randomised 1002 100 998 100 n=918 n=909 n=918 n=909
Male 479 47·8 505 50·6 Pre-existing eye disease 4 (0·4%) 5 (0·6%) 3 (0·3%) 2 (0·2%)
Mean (SD) age (yr) 55 (6·6) 55 (6·6) Correctable refractive error 22 (2·4%) 29 (3·2%) 2 (0·2%) 26 (2·9%)
Preoperative visual Complications (sub-total) 20 (2·2%) 15 (1·7%) 12 (1·3%) 14 (1·5%)
acuity in operated eye Endophthalmitis 4 7 4 7
6/60 1 0·1 1 0·1 Corneal decompensation 0 1 0 1
3/60 12 1·2 19 1·9 Corneal ulcer (late) 1 1 1 1
HM/PL 989 98·7 978 98·0 Uveitis/secondary glaucoma 13 2 7 1
HM=hand movements; PL=perception of light. Cystoid macular oedema 2 0 0 0
Retinal detachment 0 4 0 4
Table 1: Study groups
Total 46 (5·0%) 49 (5·4%) 17 (1·9%) 42 (4·6%)
statistically significant increase (1% significance level) in poor Poor functional visual outcome: visual acuity less than 6/60 in operated eye with
visual outcome (best corrected) in the ACIOL group. spectacles if wearing them. Functional blindness: visual acuity less than 3/60 in
operated eye with spectacles if wearing them.
Confidence intervals for odds ratios were calculated by the
Cornfield method.12 Table 3: Causes of poor functional visual outcome and
blindness at 1 year follow up in the operated eye of 1827
patients
Assignment
The unit of randomisation was the patient. The allocation were not in the village when the examiner called. (51
schedule was computer generated in London. Serially ACIOL, 42 control). Visual acuity was measured in 1827
numbered sealed opaque envelopes were prepared and sent to patients (91%) (918 ACIOL, 909 control). Median
Nepal where they were kept locked. Retrieval of the envelopes follow-up time was 60 weeks (range 43–93) for the
required two different keys, one held by the study administrator ACIOL group and 61 weeks (range 43–73) for controls.
and one by one of the surgeons. The first operated eye was For those patients for whom visual acuity was not
entered into the trial. This was agreed by the patient and
measured (82 ACIOL, 91 control), a verbal report on
surgeon and was usually the eye with poorer vision if one eye
was worse. When the patient was on the operating table having
visual status was obtained where possible (57 ACIOL, 63
had local anaesthetic, the envelope assigning the treatment control). For only three people were there reports of
group was opened in view of all the staff present. No-one doing vision problems (one ACIOL, two control).
the study in Nepal was told how the randomisation list was
prepared and no copy of the schedule was kept in Nepal. Analysis
Patients who had an ACIOL and who requested a second eye 1 year after surgery, 5·0% of the ACIOL group and 5·4%
operation were given an ECCE with PCIOL; the second eyes of
of controls had poor visual outcome (OR 0·93
an ICCE-only patients underwent ECCE with spectacles.
[0·60–1·43], 2=0·13, p=0·71) (table 2). Of 46 eyes in
the ACIOL group with poor visual outcome, four had
Masking pre-existing eye disease, 22 had correctable refractive
Because there were obvious differences between the treatment error, and 20 (2·2%) had complications attributable to
groups the trial was not masked.
the surgical procedure. In control eyes with acuity of less
than 6/60, five were due to pre-existing eye disease, 29
Results correctable refractive errors, and 15 (1·7%)
Participants flow and follow up complications attributable to surgery (table 3). There
Figure 1 shows the trial profile. Of 2908 eligible patients were 13 eyes with poor outcome due to uveitis and/or
presenting between February, 1992, and March, 1995, secondary glaucoma in the ACIOL group compared with
379 were excluded for medical reasons and 529 declined: two controls (OR 6·51 [1·47–59·58], 2=8·02, p=0·005),
2000 were randomised—1002 to ICCE and ACIOL and and a further two due to cystoid macular oedema with no
998 to ICCE only (controls), all of whom received the controls so affected. Four control eyes but no ACIOL
assigned procedure. Table 1 shows the age, sex, and eye had retinal detachment. There were ten cases of early
preoperative visual acuity in the two groups. The median endophthalmitis of which six occurred in the control
(range) time taken to do the surgery (mins between group (nine of the ten cases occurred in a 48-h period
placing the superior rectus muscle suture and closing the due to a faulty autoclave). Uncorrected refractive error in
wound) was 6·0 (3·0–17·2) min for the ACIOL group 26 control eyes caused an acuity of less than 3/60
and 4·1 (2·4–10·3) min for the control group. compared with two eyes in the ACIOL group; 4·6% of
At one year, ten patients had emigrated (three ACIOL, control eyes were functionally blind compared with 1·9%
seven control), 39 had died (12 ACIOL, 27 control) and of ACIOL eyes (OR 0·39 [0·21–0·71], 2=11·2,
31 could not be traced (18 ACIOL, 13 control). A p=0·0008).
further 93 were resident but not examined because they Control eyes achieved better visual rehabilitation with

Visual acuity Snellen As functioning at 1 year Best corrected at 1 year

WHO categories acuity
ACIOL Control ACIOL Control
n % n % n % n %
Normal vision 6/6–6/18 416 45·3 540 59·4 824 89·9 847 93·2
Visual impairment 6/24–6/60 456 49·7 320 35·2 69 7·5 42 4·6
Severe visual impairment 5/60–3/60 29 3·2 7 0·8 9 1·0 4 0·4
Blindness 2/60–NPL 17 1·9 42 4·6 15 1·6 16 1·8
Total 918* 100·0 909 100·0 917* 100·0 909 100·0
*One patient did not have best acuity recorded.
Table 2: Visual status at 1 year follow-up in the first operated eye of 1827 patients

Vol 349 • April 19, 1997 1131

THE LANCET
45·3% of ACIOL group achieving an acuity of 6/18 or
better compared with 59·4% of control eyes (2 36·4,
p<0·0001). After correction, 89·9% of ACIOL eyes
compared with 93·2% of control eyes had a vision of
6/18 or better (2 6·48, p=0·01).
901 (98%) ACIOL eyes and 867 (95%) control eyes
achieved a better functional visual acuity at 1 year
compared with their pre-operative acuity. Four (0·4%)
ACIOL eyes and nine (1%) control eyes had a best
corrected acuity that was worse than their pre-operative
acuity.
Discussion
This study shows that multiflex open-loop ACIOLs can
be implanted safely by experienced ophthalmologists
after routine ICCE. Approximately 5% of patients had
an acuity of less than 6/60 in the trial eye 1 year after
surgery. In both groups the main cause of poor visual
outcome was uncorrected refractive error. In only 2% of
people was the reduced vision due to surgical
complications. By contrast with most surgical trials, this
study had a relatively large sample size providing
reasonably precise estimates of risk of a poor outcome
associated with ACIOL s compared with aphakic
correction: OR 0·93 (0·6–1·43).
We were able to trace 98·5% of the people entering the
trial, measuring vision on 91% and obtaining verbal
reports on vision from a further 6%. An unexpected
finding for which we have no explanation was that the
number of people dying in the ACIOL group was
significantly lower than in the control group (12 vs 27, 2
5·95, p=0·01). Verbal report was available for 11 of the
ACIOL deaths and 23 of the controls indicating no
major problems with vision. This difference in death rate
is unlikely to bias the study findings.
As a cause of poor visual outcome in this trial, uveitis
and secondary glaucoma occurred more often in the
ACIOL group than controls. For those participants who
had received an ACIOL and who wanted surgery on their
other eye, the same surgeons performed ECCE with a
PCIOL (437 people). Four eyes receiving a PCIOL had
poor visual outcome at 1 year attributable to uveitis or
secondary glaucoma (0·9%).
No instance of corneal decompensation resulting from
contact between the ACIOL and the corneal
endothelium was observed at 1 year. This complication
may occur several years after the operation so our follow-
up will continue. There were four cases of retinal
detachment in control eyes but none in the ACIOL
group.
People in the ACIOL group had a 60% reduced risk of
having a functionally blind eye (visual acuity <3/60) 1
year after surgery. In the control group there was an
increased risk of functional blindness due to uncorrected
refractive error (26 people); 24 (2·4%) of whom were
people known to be blind because they were not wearing
aphakic spectacles due to loss or breakage and failure to
come forward for a replacement pair. Some studies have
suggested that as many as 46% of patients stop using
aphakic correction.13 The lower rate observed in our
study probably reflects the relatively short follow-up and
the benefits of participating in a trial. The quality of life
and cost effectiveness of ACIOLs depend to a large
extent on the difficulties of using aphakic spectacles and
their replacement in rural areas of developing countries.
1132
We anticipated that more people in the ACIOL group
would achieve a functional visual acuity of 6/18 or better
but the reverse happened. It was observed that people in
the control group improved their visual acuity by tilting
their head back and looking through the lower portion of
their +11·0 spectacles lenses. This induces a prismatic
effect and corrects the most common surgically induced
astigmatism (minus cylinder at 90°). The visual results
for the ACIOL group could be improved if either the
required ACIOL power was estimated preoperatively and
a range of lens power was available for implantation
(which was not the case at Lahan during the study) or
the residual refractive error in ACIOL eyes was corrected
with spectacles after surgery.
We cannot explain why more people in the control
group achieved a very good corrected acuity. A simple
explanation is that aphakic spectacles produce image
magnification. Other possibilities include an increased
rate of mild uveitis or mild cystoid macular oedema not
reducing vision to less than 6/60 in the ACIOL group.
Immediately after the operation, uveitis was common
(99% ACIOL, 89% control) but in most cases was mild
(a few cells only). However, at 1 year, only eight of 929
people followed up at the hospital had mild uveitis which
did not reduce vision to less than 6/60 (seven ACIOL,
one control). We have no evidence that mild cystoid
macular oedema was more common in the ACIOL
group, although it is possible that we were unable to
detect this with the facilities available.
To our knowledge, there are no completed
randomised controlled trials evaluating ACIOLs. The
South Asian Cataract Study Group reported an interim
analysis of 6 week follow-up on 343 patients in Nepal;
there were more surgical complications overall and more
complications at 6 weeks in their ACIOL group than in
controls.14 Our results correspond well with previous case
series on multiflex open-loop ACIOLs which suggest
that 70–80% of patients achieve vision of 6/12 or better.
Previous studies have been too small to give good
estimates of the incidence of sight-threatening
complications but do suggest that these occur relatively
infrequently. Rattigan et al7 did a retrospective analysis
of 50 cases where an ACIOL had been implanted after
complications with an ECCE procedure with follow-up
of 3–81 months. There was one case of prolonged uveitis
and three cases of cystoid macular oedema, all of whom
achieved good vision; and two retinal detachments, one
of which was due to postoperative trauma. In a
prospective study of 90 cases of ACIOL after either
ECCE or ICCE, Anmarkrud et al8 found one case of
secondary glaucoma, two of corneal oedema, two
macular oedema, and one retinal detachment at 1 year.
Nikica et al9 found that two of 22 people had cystoid
macular oedema (detected with fluorescein angiography)
6 months after ICCE with ACIOL. Eriksen and Ring10
found that two of 60 eyes followed up to 2 years after
surgery had vision less than 6/12 attributable to the
surgery—one case of macular oedema and one retinal
detachment.
This study provides evidence that well manufactured
multiflex open loop ACIOLs can be implanted safely by
experienced ophthalmologists after routine ICCE,
avoiding the disadvantages of aphakic spectacle
correction. Inserting an ACIOL extended the average
time of operation by 2 mins. Uveitis and glaucoma as a
cause of visual loss occurred more frequently in the
Vol 349 • April 19, 1997

ACIOL group. Blindness due to uncorrected refractive
error occurred more commonly in controls. Longer
follow-up is needed, but the results so far offer hope that
ACIOLs may be a safe alternative to aphakic spectacles
in many parts of the world where there is a need for low-
cost high-volume cataract surgery.
We thank patients who took part in the trial and Bindeshwar Mahato
who co-ordinated the study in Lahan; Kedar Timilsina, Janardan
Khatiwada, Ganesh Prasad Updahaya, Mahendra Mahato, and
Ramchandra Pasman for recruitment of patients, execution of the trial,
and data collection; and Kristina Hennig for managing data entry and
databases in Kathmandu. At various times over the course of the study,
members of the Steering Committee included Noel Rice, Dominic
Negrel, Bjorn Thylefors, and Christian Garms. ALCON (UK) donated
the lenses. The study was funded by Christoffel
Blindenmission/Christian Blind Mission International.
References
1 Thylefors B, Negrel D, Pararajasegaram R, Dadzie KY. Global Data
on Blindness an Update. World Health Organization. Geneva.
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2 Bucher PJM, Ijsselmuiden CB. Prevalence and causes of blindness in
the Northern Transvaal. Br J Ophthalmol 1988; 72: 721–26.
3 Directorate General of Health Services (ophthalmology section).
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4 Apple DJ, Brems RN, Park RB, et al. Anterior chamber lenses.
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Effect of renal-artery stenting on progression of renovascular
renal failure
P N Harden, M J MacLeod, R S C Rodger, G M Bax ter, J M C Connell, A F Dominiczak, B J R Junor,
J D Briggs, J G Moss
Summary
Background Placement of renal-artery stents has a high
technical success rate in atherosclerotic renovascular
disease, but little is known about the clinical benefits of
the procedure. We monitored renal function serially before
and after stent insertion in patients w ith renovascular
renal failure.
Methods Renal function w as assessed before and after
st ent plac ement by means of serial serum c reat inine
values in 32 patients w ith atherosclerotic renal-artery
stenosis. The effect on the progression of renal failure
w as anal y sed i n 23 pat i ent s by c ompar i son of t he
reciprocal slopes of serum creatinine versus time plots
before and after stent placement.
Findings 33 t ransluminal st ent s w ere plac ed in 32
pat ient s w it h at herosc lerot ic renov asc ular disease.
I mmedi at e pat enc y w as ac hi ev ed i n al l c ases; t he
Renal Unit and Department of Medicine and Radiology,
Western Infirmary, Glasgow, UK (P N Harden MRCP ,
M J MacLeod MRCP , R S C Rodger FRCP , G M Baxter FRCR,
J M C Connell MD, A F Dominiczak MD, B J R Junor MD,
J D Briggs FRCP , J G Moss FRCR)
Correspondence to: Dr P N Harden, Department of Nephrology,
North Staffordshire Royal Infirmary, Hartshill, Stoke-on-Trent
ST4 7LN, UK
Vol 349 • April 19, 1997
THE LANCET
5 Apple DJ, Hansen SO, Richards SC, et al. Anterior chamber lenses.
Part II: a laboratory study. J Cataract Refract Surg 1987; 13: 175–89.
6 Auffarth GU, Wesendahl TA, Brown SJ, Apple DJ. Are there
acceptable anterior chamber intraocular lenses for clinical use in the
1990s? An analysis of 4104 explanted anterior chamber intraocular
lenses.Ophthalmology 1994; 101: 1913–22.
7 Rattigan SM, Ellerton CR, Chitkara DK, Smerdon DL. Flexible
open-loop anterior chamber intraocular lens implantation after
posterior capsule complications in extracapsular cataract extraction.
J Cataract Refract Surg 1996; 22: 243–46.
8 Anmarkrud N, Bergaust B, Bulie T, Sand AB. Evaluation of a
flexible one-piece open-loop anterior chamber lens “Symflex 350B”
3–4 years after implantation. Acta Ophthalmol 1993; 71: 796–800.
9 Nikica G, Ljerka HP, Jelena P, Metez-Soldo K, Mladen B. Cystoid
macular edema in anterior chamber lens implantation following
posterior capsule rupture. Documenta Ophthalmol 1992; 81:
309–15.
10 Eriksen JS, Ring K. Intracapsular cataract extraction with and
without implantation of an anterior chamber lens. A comparative
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Intra-ocular lens implantation during cataract surgery in Nepal
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13 Hogeweg M, Sapkota YD, Foster A. Acceptability of aphakic
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ang iog raphic rest enosis rat e at 6 mont hs w as 12%
( n=24) . One pat ient died aft er a proc edure-relat ed
haemorrhag e. M edian diast olic blood pressure w as
significantly low er after stenting than before ( 95 [ IQR
86–103] v s 87 [ 81–90] mm Hg ; p>0·01) but t he
requirement for antihypertensive drugs w as unchanged.
Renal function improved or stabilised in 22 (69%) of the
32 patients. Progression of renal failure was significantly
slowed after the procedure; the mean (SE) of the slopes
of reciprocal serum creatinine values was 4·34 (0·85) L
mol 1 day 1 before stent placement, and 0·55 (1·0) L
mol 1 day 1 after stent placement (p<0·01, two-sample t
test).
Interpretation Renal-stent placement in selected patients
slow s the progression of renovascular renal failure and
may delay the need for renal replacement therapy.
Lancet 1997; 349: 1133–36
See Commentary page 1115
Introduction
Atherosclerotic renal-artery stenosis (ARAS) is an
important cause of progressive renal failure, and is
usually associated with widespread atherosclerosis of the
cerebral, carotid, and peripheral vasculature. 1 The
disorder is restricted to the proximal renal artery in many
cases; aortic atheroma frequently surrounds the ostium
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