Early postoperative capsular block syndrome related to saccadic-eye-movement-induced fluid flow into the capsular bag

PURPOSE

To determine the relationship between saccadic eye movements and the development of early postoperative capsular block syndrome.

SETTING

Fundacion Oftalmologica, Los Andes, Santiago, Chile.

METHODS

An artificial experimental setup was designed to reproduce the anatomical, hydrodynamic, and kinetic conditions of an early postoperative pseudophakic eye with a capsulorhexis and intracapsular intraocular lens (IOL) implantation. An electromechanical transducer driven by a digital-to-analog converter was used to mimic saccadic eye movements at physiological speeds and accelerations. Position information and differential pressure measurements between the intracapsular space and the extracapsular space were digitized. Various anterior capsule-IOL configurations were tested including partial adhesion of the anterior capsule to the lens.

RESULTS

Saccadic movements increased intracapsular pressure by displacing fluid into the capsular bag. This finding was inconstant and only observed when the capsular rim adhered to the IOL optic by more than 70%. Development of positive intracapsular pressure was noted above 4 mm Hg.

CONCLUSION

A valve-like mechanism formed by the capsulorhexis rim partially adhered to the IOL optic can occur postoperatively. Under these conditions, saccadic eye movements can increase intracapsular pressure by a unidirectional inertial displacement of fluid into the capsular bag.

Analysis of liquid accumulated in the distended capsular bag in early postoperative capsular block syndrome

PURPOSE

To analyze the transparent liquid between the posterior lens capsule and the posterior chamber intraocular lens (PC IOL) in early postoperative capsular block syndrome and discuss the mechanism of posterior capsule distention.

SETTING

Department of Ophthalmology, Tokyo University School of Medicine, and Tokyo Research Institute, Seikagaku Corporation, Tokyo, Japan.

METHODS

This study evaluated 3 cases of capsular block syndrome presenting with transparent liquid in the distended capsular bag 1 day after cataract surgery. The transparent liquid material between the posterior capsule and PC IOL was aspirated and analyzed using high-performance liquid chromatography (HPLC). Also, sodium hyaluronate was diluted using a dialyzer to determine whether the aqueous humor was drawn into the capsular bag by an osmotic gradient across the capsule.

RESULTS

The elution time of the samples was almost the same as that of sodium hyaluronate 1.0% (Healon) The concentration of the samples ranged from 3.29 to 9. 01 mg/mL by HPLC analysis. The sodium hyaluronate absorbed the physiological salt solutions through the dialyzer and expanded to 1. 9 times its original volume.

CONCLUSIONS

These results indicate that the main ingredient of the transparent liquid in capsular bags is sodium hyaluronate and that the distention is caused by aqueous humor being drawn into the capsular bag by an osmotic gradient across the capsule when the capsulorhexis diameter is smaller than that of the PC IOL and by viscoelastic material retained and trapped in the bag intraoperatively.

Capsular block syndrome: A case series

Capsular block syndrome (CBS) or capsular bag distension syndrome has been described after cataract removal with in-the-bag placement of a posterior chamber intraocular lens in the presence of an anterior continuous curvilinear capsulorhexis. Features of CBS include shallowing of the anterior chamber and an unexpected myopic overrefraction; occasionally, there is a persistent uveitis. The patient may be mistakenly diagnosed with pupil block glaucoma or endophthalmitis. We report 9 cases of CBS and their initial diagnoses and management. In 1 case, the capsular bag distention and anterior chamber shallowing are illustrated by ultrasound biomicroscopy.

Electron microscopic study on the development of precapsular layer in eyes with exfoliation syndrome

PURPOSE

To search for a pathogenic mechanism for the formation of the precapsular layer on the anterior lens surface in pre-exfoliative eyes.

METHODS

We examined anterior lens capsules obtained during surgery from 38 patients (control, 16; exfoliation suspect, 10; exfoliation, 12) by transmission electron microscopy.

RESULTS

A precapsular layer was found in 5 of 16 controls and 7 of 10 exfoliation suspects. It was composed mainly of microfibrils 5-8 nm in diameter. Degenerated zonular fragments were occasionally found interspersed in, and sometimes merged with microfibrils of the precapsular layer.

CONCLUSION

Zonular fibers might contribute to the formation of the precapsular layer in pre-exfoliation stages.

Intraoperative complications during cataract surgery in the very old

PURPOSE

To determine if there is a difference in intraoperative complications during cataract surgery in very old patients (> or = 88 years) compared with younger patients (< 88 years).

METHODS

The records of 802 consecutive cataract operations were reviewed. Identical techniques of small-incision phacoemulsification were used in all cases. A total of 102 eyes were in patients aged 88 to 98, designated as the "very old." The remaining 700 eyes were in patients under 88, designated as "younger." The incidence of intraoperative complications in the 2 groups was compared.

RESULTS

Posterior capsule tears, vitreous loss, and loss of the nucleus were found as complications. Overall, these events occurred in 10% of the very old and in only 3% of those under age 88. Vitreous loss occurred in 7% of the very old and in only 1.6% of those under 88. There was 1 dropped nucleus in the very old. In the younger patients, 90.5% of eyes with complicated surgery achieved 20/40 visual acuity or better, but only 40% of complicated cases in the very old achieved this. Furthermore, 50% of complicated cases in the very old had visual acuity of 20/200 or worse, all directly attributed to surgical difficulties. Fifteen percent of patients in both groups had trabeculectomies with no influence on complications. We noted that 8% of the very old required pupil stretching compared with 2% of those under 88.

CONCLUSIONS

This study strongly suggests that very old patients (i.e., those 88 years and older) have a higher incidence of intraoperative complications during cataract surgery than younger patients. Furthermore, such complications may result in severe visual loss. These findings may have significance as the population ages.

Posterior capsule striae

PURPOSE

To find the incidence, contributing factors, outcomes, and clinical impact of intraoperative posterior capsule striae.

SETTING

Iladevi Cataract & IOL Research Centre, Ahmedabad, India.

METHODS

In a prospective study, 100 consecutive eyes had phacoemulsification and intraocular lens (IOL) (AcrySof MA30BA) implantation. The presence of striae was noted at the end of the operation, and factors contributing to their development were identified. Follow-up was done at regular intervals, and the clinical impact of striae on patients' vision was evaluated.

RESULTS

Striae were observed in 56 eyes (Group 1) but were absent in 44 (Group 2). Mean age in Group 1 was 65.96 years +/- 9.15 (SD) and in Group 2, 59.20 +/- 10.36 years (P = .0012). Mean axial lengths were 23.47 +/- 1.63 and 24.12 +/- 1.49 mm, respectively (P = .0419). Average lens thickness was greater in Group 1 (4.50 +/- 0.43 mm) than in Group 2 (4.13 +/- 0.41 mm) (P = .0001). The sex of patient, capsulorhexis size and centration, grade of cataract hardness, scleral rigidity, and IOL centration were not found to contribute to striae development. The striae disappeared by 5 months postoperatively and did not show a positive Maddox rod phenomenon.

CONCLUSION

Intraoperative striae observed in many patients were associated with relatively older age, greater lens thickness, and shorter axial length. The striae eventually disappeared and had no effect on vision.

Risk factors for anterior capsule contraction syndrome with polypropylene or poly(methyl methacrylate) haptics

PURPOSE

To determine the effect of haptic composition on the development of anterior capsule contraction syndrome (CCS) requiring neodymium: YAG anterior capsulotomy.

SETTING

Ophthalmology practice in Lancaster, Pennsylvania, USA.

METHODS

This retrospective study covered a 30 month period during which 1 surgeon discontinued implanting AMO SI-30NB intraocular lenses (IOLs) with polypropylene haptics (n = 216) in favor of SI-40NB IOLs with poly(methyl methacrylate) (PMMA) haptics (n = 127). The transition was motivated by the suspicion that the PMMA haptics would maintain the capsulorhexis opening better and reduce the need for an anterior capsulotomy.

RESULTS

Three eyes with SI-30NB IOLs (1.4%) required anterior capsulotomies; 2 eyes had preoperative pseudoexfoliation syndrome and required the capsulotomy within 3 months of surgery. Three eyes with SI-40NB IOLs (2.4%) required anterior capsulotomies within 4 months; 2 eyes had preoperative pseudoexfoliation syndrome and 1 had traumatic zonular weakness. The incidence of anterior capsulotomy did not differ significantly between the 2 IOL populations (P > .5), although preoperative pseudoexfoliation syndrome was a significant risk factor in both groups (P < .005).

CONCLUSIONS

The polypropylene haptics of the SI-30NB IOL and the PMMA haptics of the SI-40NB IOL did not differ significantly in their ability to prevent CCS requiring anterior capsulotomy. Regardless of IOL haptic composition, eyes with preoperative zonular weakness associated with pseudoexfoliation syndrome or ocular trauma can develop CCS within 3 months of surgery and should, therefore, be followed closely in the early postoperative weeks to minimize the sequelae of anterior capsule fibrosis.

Capsule contraction after continuous curvilinear capsulorhexis: poly(methyl methacrylate) versus silicone intraocular lenses

PURPOSE

To evaluate the progressive contraction of the anterior capsule opening after in-the-bag implantation of 2 types of intraocular lenses (IOLs).

SETTING

Department of Ophthalmology, University of Brest, Brest, France.

METHODS

In this prospective study, 32 single-piece poly(methyl methacrylate) (PMMA) (Pharmacia 812 C) and 30 3-piece silicone IOLs with PMMA haptics (Allergan SI-40NB) were implanted in the bag after standardized phacoemulsification performed by the same surgeon. All patients were older than 70 years, and none had zonular weakness. The surface of continuous curvilinear capsulorhexis (CCC) was measured 1, 30, and 150 days postoperatively using a 3 charge-coupled device camera and a digitized computer analysis system.

RESULTS

A significant progressive constriction was observed at 150 days in 70% in the silicone group and 32% in the PMMA group. In addition, CCC contraction was greater in silicone group (P < .05). The mean surface decrease was 4.20 mm2 in the silicone group and 1.53 mm2 in the PMMA group. There was no correlation between sex, age, initial capsulorhexis area, final capsule shrinkage. In some eyes, especially in those with a single-piece PMMA IOL (41%), there was no constriction, but fine changes in the capsule opening were seen.

CONCLUSION

Evolutive anterior capsulorhexis modifications were observed in all patients; however, the contraction rate was statistically higher in the silicone group. These results suggest that silicone IOL implantation should be avoided in eyes at risk for CCC constriction.

Combined secondary capsulorhexis and vitreous surgery in a case of anterior capsule contraction and vitreous hemorrhage

A 59-year-old woman with diabetic vitreous hemorrhage and contracted anterior capsule opening received secondary capsulorhexis and trans pars plana vitrectomy in a single operation. The combined surgery was successful. In addition, the anterior capsule opening was enlarged by the procedure and no further vitreous hemorrhage occurred during the 6 month follow-up period in both eyes. When anterior capsule opening reduction is encountered in patients requiring vitreoretinal surgery, combining secondary capsulorhexis and vitreoretinal surgery together in a single operation maybe provide a good treatment alternative.

Loss of iridolenticular contact in eyes with exfoliation syndrome may protect against glaucoma

PURPOSE

To provide evidence for the hypothesis that dynamic iridolenticular contact predisposes to the development of glaucoma in exfoliation syndrome (XFS).

METHODS

We present four patients with bilateral XFS and unilateral exfoliation glaucoma (XFG) whose normotensive eyes had suffered traumatic loss of dynamic iridolenticular contact.

RESULTS

All 4 patients had bilateral XFS and developed XFG only in the untraumatized eyes. One patient had loss of iridolenticular contact in the traumatized eye, two had a nonreactive pupil, and one had had intracapsular cataract extraction at age 28.

CONCLUSIONS

Loss of dynamic iridolenticular contact may help to protect against development of glaucoma in eyes with XFS.

Interpseudophakos Elschnig pearls associated with late hyperopic shift: a complication of piggyback posterior chamber intraocular lens implantation

We report 3 cases of bilateral piggyback lens implantation in which late hyperopic shift occurred associated with Elschnig pearl formation in the peripheral interface between the 2 lenses.

Capsular block syndrome with external blockage of the capsular opening by a ciliary sulcus fixated posterior chamber lens

PURPOSE

To report capsular block syndrome with external blockage of the capsular opening by a posterior chamber lens fixated in the ciliary sulcus.

METHOD

Case report.

RESULTS

In an 89-year-old man who had undergone cataract surgery, a posterior chamber lens was accidentally fixated in the ciliary sulcus after continuous curvilinear capsulohhexis and phacoemulsification/aspiration. The next day, capsular block syndrome was noted along the posterior chamber lens optic, which was blocking the capsular opening from the outside.

CONCLUSION

In all previously reported eyes with capsular block syndrome, the posterior chamber lens had been placed inside the lens capsule to block the continuous curvilinear capsulorhexis opening from the inside.

Capsular bag distension after optic capture of a sulcus-fixated intraocular lens

Capsular bag distension from occlusion of the circular anterior capsule opening by the intraocular lens (IOL) optic is a rare complication of capsulorhexis. The nature and source of fluid remain unclear. We report a case of capsular bag distension in an eye with an optic-captured, all-poly(methyl methacrylate), sulcus-fixated IOL. The fluid behind the IOL optic was visible on the first postoperative day and resolved spontaneously by the sixth postoperative week. We believe that retained viscoelastic material in the capsular bag was a major contributor to the fluid.

Prevention of lens damage associated with cigarette smoke exposure in rats by alpha-tocopherol (vitamin E) treatment

PURPOSE

To evaluate the possible protective effect and mechanism of alpha-tocopherol (vitamin E) treatment on lens degeneration associated with in vivo exposure to cigarette smoke and to further clarify the role of iron in cigarette smoke-generated lens damage.

METHODS

Twenty-eight male Wistar rats were randomly divided into four equal groups. Rats in groups 3 and 4 were exposed to cigarette smoke for 1 hour each day over 90 consecutive days, and rats in groups 1 and 2 were treated in similar fashion but only exposed to room air. Additionally, vitamin E was given to the rats in groups 2 and 4 via intramuscular route. At the end of the study, both eyes of all the animals were enucleated; one eye was prepared for histopathologic examination, and the fellow eye was used for the measurement of iron and calcium levels.

RESULTS

Significantly higher iron and calcium levels were observed in the lenses of group 3 rats than in other groups. Similar comparisons performed between groups 1 and 2, groups 1 and 4, and groups 2 and 4 did not show any significant difference. Distinct histopathologic changes in the anterior lens epithelium, such as hyperplasia, hypertrophy, epithelial multilayering, and the presence of epithelial cells over posterior lens capsule, observed in group 3 rats were not present in other groups.

CONCLUSIONS

Cataractogenesis after cigarette smoke exposure was associated with an accumulation of iron and calcium in the rat lens, and vitamin E supplementation protected such accumulations and cataractogenesis.

The effect of continuous light on refractive error and the ocular components of the rat

Phototoxic induced degeneration of the rat retina is a well-documented phenomenon resulting in losses of photoreceptors and their cell bodies, and an overall retinal thinning. This process may serve as a test of the hypothesis that the retinoscopic reflex originates from the inner limiting membrane of the retina. Retinal thinning should produce myopia in the absence of any other ocular component changes in a stable, mature eye if the inner limiting membrane model is correct. Phototoxic retinal degeneration was induced in 10 albino rats by exposure to 19 days of continuous light (1,800 cd m-2). Another 10 albino rats exposed to 12-hr on/12-hr off cycled light served as controls. Before and after the exposure to constant light, measures were made of refractive state by cycloplegic retinoscopy, corneal curvature and lens curvature by Purkinje image photography, and axial length of the globe by A-scan ultrasonography. Comparing pre- to post-exposure values, phototoxic degeneration resulted in a mean (+/- S.D.) myopic shift of -5.10 +/- 2.12 D (P < 0.002). The corneal curvature also steepened significantly (0.17 +/- 0.11 mm, equivalent to -6.0 D; P < 0.004), while the posterior curvature of the crystalline lens flattened by 0.21 +/- 0.22 equivalent mm (P < 0.027), and the axial length shortened by 0.11 +/- 0.11 equivalent mm (all tests Wilcoxon signed-rank; P < 0.025). Phototoxic rats underwent a mean retinal thinning of 49.6 mu compared to controls (Kruskal-Wallis test; P < 0.0008). No refractive or ocular parameters changed significantly in the controls. Phototoxic degeneration in the rat has optical consequences beyond simple retinal thinning. The size of the eye and the curvature of refractive surfaces can be altered in a mature eye well after the completion of development. The multiple changes which occur prevent phototoxic retinal thinning from serving as a test of the inner limiting membrane model for retinoscopic reflections.

Capsular bag distension associated with sulcus implantation of intraocular lenses

Capsular bag distension syndrome after endophacoemulsification and in-the-bag intraocular lens (IOL) implantation has been reported. We describe 2 cases in which sulcus implantation of a posterior chamber IOL caused marked capsular bag distension. Both cases resolved with conservative treatment or a neodymium:YAG posterior capsulotomy.

Histology of anterior capsule fibrosis following phacoemulsification

PURPOSE

To determine the histology and immunohistochemistry of anterior capsule fibrosis.

SETTING

Department of Ophthalmology and Neurosurgery and Institute of Pathology, University of Siena, Siena, Italy.

METHODS

Tissue sections from 3 patients with anterior capsule fibrosis after phacoemulsification and intraocular lens implantation were examined histologically.

RESULTS

The proliferating tissue was devoid of vessels and composed of dense fibrous tissue and numerous activated fibroblasts with contractile capacity (myofibroblasts). No TGF-beta, which is the most important cytokine in modulating myofibroblasts, was present in the fibrotic tissue.

CONCLUSION

The absence of the cytokine TGF-beta and inflammatory cells in the proliferating tissue confirms the unique character of the reparative activity within the eye.

Pseudoexfoliation syndrome for the comprehensive ophthalmologist. Intraocular and systemic manifestations

BACKGROUND

Renewed interest in pseudoexfoliation syndrome (PEX) may be attributed to an increased awareness of many clinical risks not only for open-angle glaucoma and its recent recognition as a generalized disorder. This review summarizes the range of intraocular and extraocular manifestations. Involvement of all tissues of the anterior segment of the eye results in a spectrum of intraocular complications that have management implication for all practicing ophthalmologists.

DESIGN

The study design was a review.

METHODS

Clinical diagnosis depends on biomicroscopy, biocytology, and laser-tyndallometry. Laboratory research methods range from light and electron microscopy, to immunohistochemical and molecular biologic approaches.

OBSERVATIONS

Clinical-histopathologic correlations focus on the involvement of lens (PEX-phacopathy), zonular apparatus (zonulopathy), ciliary body (cyclopathy), iris (iridopathy), trabecular meshwork (trabeculopathy), and cornea (corneal endotheliopathy) leading to the following complications: (1) open-angle glaucoma as well as angle-closure glaucoma due to pupillary and ciliary block; (2) phacodonesis, lens dislocation, and increased incidence of vitreous loss in extracapsular cataract surgery caused by alterations of the zonular apparatus and its insertion into the ciliary body and lens; (3) blood-aqueous barrier breakdown (pseudouveitis), anterior chamber hypoxia, iris stromal hemorrhage, pigment epithelial melanin dispersion, poor or asymmetric pupillary dilatation, and formation of posterior synechiae due to involvement of all cell populations of the iris; and (4) early diffuse corneal endothelial decompensation explained by a damaged and numerically reduced endothelium.

CONCLUSIONS

In view of the multitude of clinical complications, PEX is of relevance to comprehensive ophthalmologists, including specialists in glaucoma, cataract, cornea, neuro-ophthalmology, and retina. Special attention to the risks associated with PEX is advised before, during, and after surgery.

Capsulorhexis phymosis following uncomplicated phacoemulsification surgery

PURPOSE

The aim of the study was to assess and compare the degree of capsulorhexis phymosis following uncomplicated phacoemulsification cataract surgery in polymethylmethacrylate (PMMA) and silicone lens implants.

METHOD

Sixty-four patients were evaluated 1 day, 6 weeks and 6 months following phacoemulsification cataract extraction. The anterior capsular diameters were measured with the illuminated beam of the slit lamp at 45 degrees and 135 degrees and the surface area of the opening calculated. We have measured and compared the change in the capsulorhexis size for both lens types and assessed its statistical significance with a paired Student's t-test.

RESULTS

A statistically significant contraction of the capsulorhexis was noted in all patients within the first 6 weeks (p < 0.001). Capsular contraction continued between 6 weeks and 6 months post-operatively but to a lesser extent (p < 0.05). The difference in the degree of phymosis between the first period (1 day to 6 weeks) and the second (6 weeks to 6 months) was statistically highly significant for all patients (p < 0.001). The capsular areas for the silicone lens implants were significantly smaller than for the PMMA implants at 6 weeks and 6 months. None of our patients had a clinically significant capsular contracture requiring Nd:YAG laser capsulotomy.

CONCLUSION

Anterior capsular contraction is commonly observed following capsulorhexis in phacoemulsification surgery. This study demonstrates that the maximum rate of contraction occurs in the first 6 weeks following surgery and is more pronounced with silicone lens implants.

Alport syndrome. A review of the ocular manifestations

Alport syndrome has a prevalence of 1/5000, and 85% of patients have the X-linked form, where affected males develop renal failure and usually have a high-tone sensorineural deafness by the age of 20. The typical ocular associations are a dot-and-fleck retinopathy which occurs in about 85% of affected adult males, anterior lenticonus which occurs in about 25%, and the rare posterior polymorphous corneal dystrophy. The retinopathy and anterior lenticonus are not usually demonstrated in childhood but worsen with time so that the retinal lesion is often present at the onset of renal failure, and the anterior lenticonus, later. The demonstration of a dot-and-fleck retinopathy in any individual with a family history of Alport syndrome or with end-stage renal disease is diagnostic of Alport syndrome. The presence of anterior lenticonus or posterior polymorphous corneal dystrophy in any individual is highly suggestive of the diagnosis of Alport syndrome. Additional ocular features described in X-linked Alport syndrome include other corneal dystrophies, microcornea, arcus, iris atrophy, cataracts, spontaneous lens rupture, spherophakia, posterior lenticonus, a poor macular reflex, fluorescein angiogram hyperfluorescence, electrooculogram and electroretinogram abnormalities, and retinal pigmentation. All mutations demonstrated to date in X-linked Alport syndrome have affected the COL4A5 gene which encodes the alpha 5 chain of type IV collagen. This protein is probably common to the basement membranes of the glomerulus, cochlea, retina, lens capsule, and cornea. However, the alpha 3(IV) and 4(IV) as well as the alpha 5(IV) collagen chains are usually absent from the affected basement membranes, because the abnormal alpha 5(IV) molecule interferes with the stability of all three. The loss of these collagen molecules from the affected basement membranes results in an abnormal ultrastructural appearance. The ocular and other clinical features of autosomal recessive Alport syndrome are identical to those seen in X-linked disease, while retinopathy and cataracts are the only ocular abnormalities described in the rare autosomal dominant form of Alport syndrome. There are no ocular associations of thin basement membrane disease which is a common disease that probably represents the heterozygous expression of X-linked or autosomal recessive Alport syndrome.

Incidence, causes, and neodymium:YAG laser treatment of pupillary capture

OBJECTIVE

To report the incidence of and factors associated with pupillary capture after cataract surgery and evaluate the outcomes of treatment with the neodymium:YAG (Nd:YAG) laser.

SETTING

Unit of Ophthalmology, University of Edinburgh, and Royal Infirmary of Edinburgh Trust Hospital, Edinburgh, United Kingdom.

METHODS

This prospective study comprised 792 consecutive patients having cataract extraction by one surgeon from 1989 to 1993. Outcome measures were incidence of pupillary capture associated with eye disease and treatment, surgical technique, and intraocular lens (IOL) placement and style; postoperative progress; and results of Nd:YAG treatment.

RESULTS

Pupillary capture developed in 30 of the 764 patients (3.9%) having implantation of a posterior chamber IOL a mean of 14 weeks postoperatively (range 2 to 44 weeks). The incidence was significantly higher in eyes with angle-closure glaucoma, combined glaucoma and cataract surgery, can-opener capsulotomy, manual extraction, sulcus IOL implantation, large-optic IOLs, and one-piece IOLs. Neodymium:YAG laser treatment was successful in 8 of 12 eyes.

CONCLUSION

Pupiliary capture may be anticipated and when recognized at an early stage, treated successfully with an Nd:YAG laser in most cases.