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Pandey SK, Werner L, Escobar-Gomez M, Roig-Melo EA, Apple DJ. Dye-enhanced cataract surgery. Part 1: anterior capsule staining for capsulorhexis in advanced/white cataract. J Cataract Refract Surg 2000; 26:1052-9. [PMID: 10946199 DOI: 10.1016/s0886-3350(00)00296-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate anterior capsule staining using 3 dyes to perform continuous curvilinear capsulorhexis (CCC) in postmortem human eyes with advanced/white cataract. SETTING Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS In experimental closed-system surgery, CCC was performed in 12 postmortem human eyes with cataract after the anterior capsule was stained with 3 capsule dyes (fluorescein sodium 2%, indocyanine green [ICG] 0.5%, and trypan blue 0.1%). Two commonly used techniques for capsule staining were also compared: staining within an air bubble and intracameral subcapsular injection of dye. RESULTS In all globes, CCC was uneventful using the 3 dyes and with both techniques. With the intracameral subcapsular injection, the dye remained trapped in the subcapsular space in contact with the posterior surface of the anterior capsule, allowing enough time to perform any maneuver. The staining provided by ICG, at the concentration used, was slightly superior to that of the other dyes. Leakage of fluorescein sodium into the vitreous cavity was seen using the Miyake-Apple posterior video/photographic technique. CONCLUSION Intracameral subcapsular injection of ICG allowed the easiest recognition of the capsular flap by staining the posterior surface of the anterior capsule and without leaking into the vitreous cavity.
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Werner L, Pandey SK, Escobar-Gomez M, Hoddinott DS, Apple DJ. Dye-enhanced cataract surgery. Part 2: learning critical steps of phacoemulsification. J Cataract Refract Surg 2000; 26:1060-5. [PMID: 10946200 DOI: 10.1016/s0886-3350(00)00363-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To use capsule dyes to enhance visualization to learn and perform various critical steps of the phacoemulsification procedure in a laboratory setting using postmortem human eyes. SETTING Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS Indocyanine green 0.5% (ICG) and trypan blue 0.1% were used to enhance visualization for performing critical steps of phacoemulsification in 8 human eyes obtained postmortem. All eyes were prepared according to the Miyake-Apple posterior video technique. After a continuous curvilinear capsulorhexis (CCC) was made, the dyes were used to enhance visualization for hydrodissection, hydrodelineation, and various maneuvers for nuclear emulsification and cortical cleanup. In 8 eyes, all the aforementioned steps were performed without using dye (control group). RESULTS Both dyes helped enhance visualization during the critical steps of phacoemulsification. The use of a dye solution instead of balanced salt solution (BSS) for hydrodissection/delineation helped localize the complete plane of cleavage between the capsule and cortex and the nucleus-epinucleus complex. During various nuclear sculpting maneuvers, the use of dye helped visualization of the position of the phaco tip and its relation to the posterior capsule. It also helped localize remaining cortical fibers, facilitating complete cleaning of the capsular bag. CONCLUSIONS Dye-enhanced cataract surgery was useful in learning various critical steps of phacoemulsification in a wet laboratory setting.
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Apple DJ, Werner L, Escobar-Gomez M, Pandey SK. Deposits on the optical surfaces of Hydroview intraocular lenses. J Cataract Refract Surg 2000; 26:796-7. [PMID: 10991679 DOI: 10.1016/s0886-3350(00)00517-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Apple DJ. Sir Harold Ridley receives England's highest honor. Surv Ophthalmol 2000; 44:542. [PMID: 10914524 DOI: 10.1016/s0039-6257(00)00121-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Pandey SK, Werner L, Vasavada AR, Apple DJ. Induction of cataracts of varying degrees of hardness in human eyes obtained postmortem for cataract surgeon training. Am J Ophthalmol 2000; 129:557-8. [PMID: 10764881 DOI: 10.1016/s0002-9394(99)00437-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To report a method of inducing nuclear cataracts of varying degree of hardness using intralenticular injection of the Karnovsky solution. METHODS Twelve postmortem human eyes were prepared according to the Miyake-Apple posterior video technique. After performing capsulorhexis and hydrodissection/delineation, 0.2 ml of the Karnovsky solution was injected into the lens nucleus of the eyes. Manual extracapular cataract extraction techniques and various two-handed phacoemulsification maneuvers were then practiced at various time intervals after the injection. RESULTS Uniform nuclear cataracts with varying degrees of hardness were successfully induced in all globes. The optimum dose of the Karnovsky solution and time for induction of nuclear hardness of grade 3 (ideal for practicing two-handed phacoemulsification maneuvers) were 0.2 ml and 15 minutes, respectively. CONCLUSION The Karnovsky solution can be successfully used for the induction of hard, uniform nuclear cataracts for learning/practicing extracapular cataract extraction and phacoemulsification.
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Apple DJ, Peng Q. Harold Ridley knighted. Ophthalmology 2000; 107:412-3. [PMID: 10711873 DOI: 10.1016/s0161-6420(00)00018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Werner L, Pandey SK, Escobar-Gomez M, Visessook N, Peng Q, Apple DJ. Anterior capsule opacification: a histopathological study comparing different IOL styles. Ophthalmology 2000; 107:463-71. [PMID: 10711882 DOI: 10.1016/s0161-6420(99)00088-3] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To compare the degree of anterior capsule opacification (ACO) in human eyes obtained post-mortem containing various rigid and foldable posterior chamber intraocular lens (PC-IOL) designs. DESIGN Comparative autopsy tissue study with clinicopathologic correlations. MATERIALS Four hundred sixty human globes containing the following PC-IOL styles were analyzed: (1) one-piece polymethylmethacrylate (PMMA) optic-PMMA haptic (n = 50), (2) one-piece silicone-plate IOL, large hole (n = 40), (3) one-piece silicone-plate IOL, small hole (n = 67), (4) three-piece PMMA optic-PMMA/Prolene haptic (n = 51), (5) three-piece acrylic optic-PMMA haptic (n = 96), (6) three-piece silicone optic-PMMA haptic (n = 24), (7) three-piece silicone optic-polyimide haptic (n = 40), and (8) three-piece silicone optic-prolene haptic (n = 92). TESTING The globes were sectioned in the equatorial plane for gross examination and then processed through paraffin; sectioned, and stained with hematoxylin-eosin, periodic acid-Schiff, and Masson's trichrome stains; and examined by light microscopy. MAIN OUTCOME MEASURES Anterior capsule opacification was scored in each eye by grading the histologic sections from 0 to III, according to the amount (thickness) of proliferative tissue and cells measured in sagittal sections on the inner surface of the anterior capsule at the capsulorhexis margin. RESULTS The difference among the eight groups was significant (P < 0.0001). Mean ACO scores were highest with the large and small hole one-piece silicone-plate lenses (1.77 +/- 0.86 and 1.28 +/- 0.77, respectively). The lowest mean score was observed in the group of three-piece acrylic optic-PMMA haptics lenses (0.51 +/- 0.52). CONCLUSIONS Our results confirm previous clinical observations that the rate of ACO is relatively high with plate-haptic silicone IOLs. The lowest rate was noted with the three-piece acrylic optic-PMMA haptic IOL. The IOL design and IOL material are significant factors in the development of ACO.
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Pandey SK, Werner L, Escobar-Gomez M, Visessook N, Peng Q, Apple DJ. Creating cataracts of varying hardness to practice extracapsular cataract extraction and phacoemulsification(2). J Cataract Refract Surg 2000; 26:322-9. [PMID: 10713223 DOI: 10.1016/s0886-3350(99)00397-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We describe a method to harden the nucleus of crystalline lenses in postmortem human globes by intralenticular injection of a mixture of paraformaldehyde and glutaraldehyde (Karnovsky's solution). Evaluation of the nuclear manipulations, using the Miyake-Apple posterior video/photographic technique, shows that the method provides suitable specimens for practicing extracapsular cataract extraction and phacoemulsification.
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Gayton JL, Apple DJ, Peng Q, Visessook N, Sanders V, Werner L, Pandey SK, Escobar-Gomez M, Hoddinott DS, Van Der Karr M. Interlenticular opacification: clinicopathological correlation of a complication of posterior chamber piggyback intraocular lenses. J Cataract Refract Surg 2000; 26:330-6. [PMID: 10713224 DOI: 10.1016/s0886-3350(99)00433-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To present a clinicopathological correlation of 2 pairs of piggyback posterior chamber intraocular lenses (PC IOLs) explanted because of opacification between the lens optics. SETTING Gayton Health Center, Eyesight Associates of Middle Georgia, Warner Robins, Georgia, and Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS Two pairs of piggyback AcrySof lenses were explanted from 2 patients with significant visual loss related to opacification between the optics. They were submitted for pathological analysis. Gross and histopathological examinations were performed, and photomicroscopy was used to document the results. RESULTS Gross examination showed accumulation of a membrane-like white material between the lenses. Histopathological examination revealed that the tissue consisted of retained/proliferative lens epithelial cells (bladder cells or pearls) mixed with lens cortical material. CONCLUSION Piggyback PC IOLs were explanted in 2 cases because of a newly described complication, interlenticular opacification. Three surgical means may help prevent this complication: meticulous cortical cleanup, especially in the equatorial region; creation of a relatively large continuous curvilinear capsulorhexis to sequester retained cells peripheral to the IOL optic within the equatorial fornix; insertion of the posterior IOL in the capsular bag and the anterior IOL in the ciliary sulcus to isolate retained cells from the interlenticular space.
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Peng Q, Apple DJ, Visessook N, Werner L, Pandey SK, Escobar-Gomez M, Schoderbek R, Guindi A. Surgical prevention of posterior capsule opacification. Part 2: Enhancement of cortical cleanup by focusing on hydrodissection. J Cataract Refract Surg 2000; 26:188-97. [PMID: 10683786 DOI: 10.1016/s0886-3350(99)00354-5] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To experimentally analyze the role and efficacy of hydrodissection in achieving maximal cortical cleanup. SETTING Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS Phacoemulsification and irrigation/aspiration were performed in 10 pairs of human eyes (20 eyes) obtained postmortem. Ten eyes had previous hydrodissection and 10 eyes, no hydrodissection. The time (seconds) required for complete lens substance removal in each procedure was measured. In addition, a qualitative evaluation of difficulty of surgery was noted. RESULTS Phacoemulsification required 28.6% less time in eyes with previous hydrodissection than in those without. Irrigation/aspiration time was reduced by 50.9% when hydrodissection was performed. The total time of each procedure required for complete evacuation of the capsular bag was reduced by an average of 37.7% in eyes with hydrodissection. Furthermore, qualitatively the procedure was far easier, less stressful, and caused less posterior capsule stress or rupture when copious hydrodissection was performed. CONCLUSIONS Hydrodissection enhances the general safety and efficiency of cortical cleanup, especially at 12 o'clock. Hydrodissection is the best available, practical, immediately implementable, and inexpensive means to help remove equatorial E-cells and thus alleviate the incidence of posterior capsule opacification.
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Snellingen T, Shrestha JK, Huq F, Husain R, Koirala S, Rao GN, Pokhrel RP, Kolstad A, Upadhyay MP, Apple DJ, Arnesen E, Cheng H, Olsen EG, Vogel M. The South Asian cataract management study: complications, vision outcomes, and corneal endothelial cell loss in a randomized multicenter clinical trial comparing intracapsular cataract extraction with and without anterior chamber intraocular lens implantation. Ophthalmology 2000; 107:231-40. [PMID: 10690817 DOI: 10.1016/s0161-6420(99)00008-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To determine clinical outcomes of primary intracapsular cataract surgery with and without implantation of anterior chamber lenses. DESIGN A multicenter randomized clinical trial. PARTICIPANTS One thousand two hundred twenty-nine male and female patients 40-75 years of age with senile cataract. METHODS Study patients were recruited from screening eye camps and outpatient clinics. Randomization to the two treatment groups was performed after screening for predetermined inclusion and exclusion criteria. Demographics, visual acuity, intraocular pressures, and corneal endothelial cell data were recorded before surgery and at 6 weeks, 12 months, and 24 months after surgery. Monitoring of the study was secured by a standardized image documentation procedure on all patients using the IMAGEnet digital imaging system. Analysis of corneal endothelial cell images was performed with the Cell Soft software (Topcon Corporation, Japan). MAIN OUTCOME MEASURES Visual acuity and central corneal endothelial cell loss. RESULTS The patients were randomized to intraocular lens (IOL; n = 616) and no IOL (n = 613) implantation. Surgical complications were reported in 177 (14.4%) patients (IOL = 14.8%; no IOL = 14.0%). The most frequent complication observed was vitreous loss which occurred in 10.3% of eyes (IOL = 11.2%; no IOL = 9.5%). At the final examination (2 years after surgery), 88% of the operated eyes had a best corrected vision of 6/18 or better (IOL = 88.8%; no IOL = 86.6%). Analysis of corneal endothelial cell data showed a small but significantly greater cell loss 6 weeks after surgery in eyes with IOL compared with those without IOL, but no overall difference was found between the treatment groups in the long term follow-up. CONCLUSIONS The findings indicate that there is a rationale for the use of anterior chamber intraocular lenses in primary intracapsular cataract surgery.
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Apple DJ, Peng Q, Visessook N, Werner L, Pandey SK, Escobar-Gomez M, Ram J, Whiteside SB, Schoderbeck R, Ready EL, Guindi A. Surgical prevention of posterior capsule opacification. Part 1: Progress in eliminating this complication of cataract surgery. J Cataract Refract Surg 2000; 26:180-7. [PMID: 10683785 DOI: 10.1016/s0886-3350(99)00353-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate over almost 2 decades the success of a component of cataract surgery that represents a critical step in reducing the incidence of posterior capsule opacification (PCO); namely, the efficacy of cortical cleanup. SETTING Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS Accessioned from the early 1980s to 1997, 3320 eyes obtained postmortem with posterior chamber intraocular lenses were analyzed with respect to formation of a postoperative Soemmering's ring. This anatomic lesion, the precursor of clinical PCO, represents an important and measurable indication of the quality of cortical cleanup. Its formation was documented using Miyake-Apple posterior photographic analysis. RESULTS The quality and thoroughness of cortical cleanup and overall effectiveness in eliminating retained and/or regenerating cortical cells, as measured by scoring of Soemmering's rings, showed virtually no net change since the early 1980s. The intensity of Soemmering's ring was higher in the most recent specimens than in those in the early 1980s. CONCLUSION The results indicate that renewed attention to cortical cleanup in cataract surgery is warranted for significant reduction in incidence or the elimination of PCO. More attention to the hydrodissection (cortical cleaving hydrodissection) step of the procedure is likely a practical, immediately implementable, and inexpensive remedy.
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Peng Q, Visessook N, Apple DJ, Pandey SK, Werner L, Escobar-Gomez M, Schoderbek R, Solomon KD, Guindi A. Surgical prevention of posterior capsule opacification. Part 3: Intraocular lens optic barrier effect as a second line of defense. J Cataract Refract Surg 2000; 26:198-213. [PMID: 10683787 DOI: 10.1016/s0886-3350(99)00352-1] [Citation(s) in RCA: 161] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To emphasize an important aspect of preventing posterior capsule opacification (PCO), the barrier effect established by the optic of a posterior chamber intraocular lens (PC IOL), and present a new classification regarding capsular bag status after extra-capsular cataract extraction, including phacoemulsification. SETTING Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS This analysis included 150 consecutive eyes obtained postmortem with United States-manufactured PC IOLs including (1) poly(methyl methacrylate), (2) silicone, and (3) hydrophobic acrylic designs that were accessioned in the Center from September 1995 to January 1, 1998. Gross photographs from behind (Miyake-Apple views) were taken and serial histologic sections prepared. RESULTS Microscopic analysis of the 150 eyes showed that the morphologic appearance of the capsular bag could be grouped into 2 categories: (1) those with little or no evidence of retained cortical material and cells, and (2) those with retained cortical material and cells in which a Soemmering's ring formed. With the latter, when a distinct barricade to cellular migration created by the IOL optic was noted, 2 discrete configurations occurred, depending on the different geometries of the optic components. With a classic biconvex optic with a curved and tapered edge, in many instances some ingrowth of cells proceeded posteriorly around the edge of the IOL optic in the direction of the central axis. With a lens optic that had a squared, truncated, and relatively thick edge, there was often abrupt termination of cells at the peripheral edge of the optic. The posterior capsule subtending the entire optic zone was therefore relatively or totally cell free. CONCLUSIONS The barrier effect of the IOL optic appears to be of critical importance in retarding ingrowth of cells, functioning as a second line of defense when cortical cleanup is incomplete. Analysis of PC IOLs obtained postmortem showed that a square, truncated optic edge seemed to provide the maximum impediment to cell growth behind the IOL optic.
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Apple DJ. Influence of intraocular lens material and design on postoperative intracapsular cellular reactivity. TRANSACTIONS OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY 2000; 98:257-83. [PMID: 11190028 PMCID: PMC1298231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
PURPOSE To evaluate the influence of intraocular lens (IOL) material and design on the outcome of postoperative lens epithelial cell proliferation within the capsular bag after cataract surgery. METHODS A total of 5,079 human globes containing rigid and foldable posterior chamber IOL styles commonly implanted in the United States (n = 8) were analyzed in this study. Each globe, fixated in 10% formalin, was sectioned at the equator and analyzed using the Miyake-Apple posterior technique. The study consisted of 3 parts: First, to evaluate posterior capsule opacification (PCO); the Nd:YAG laser posterior capsulotomy rate (%) was documented and plotted on a monthly basis, creating a computerized trend line for each IOL style. Second, to evaluate anterior capsule opacification (ACO); 460 globes were processed for histologic examination. Anterior capsule fibrosis was scored from 0 to III, according to the thickness of proliferative tissue/cells on the inner surface of the anterior capsule at the capsulorhexis margin. Third, interlenticular opacification (ILO) was studied by analysis of 3 pairs of acrylic piggyback lenses that had been explanted because of opacification between their optics. Each IOL pair was processed for histologic examination, and scanning electron microscopy was performed on 1 of the lenses. RESULTS In the first study, relatively higher Nd:YAG laser posterior capsulotomy rates (19.1% to 32.8%) were noted with the 4 oldest IOL designs in this study (2 foldable lenses, 1 3-piece polymethyl methacrylate [PMMA] design, and 1 single-piece all-PMMA design). Four modern lenses, 1 acrylic lens, and 3 silicone foldable IOL designs had Nd:YAG rates ranging from 1.3% to 14.6% (P < .0001). In the second study, mean ACO scores were highest with silicone-plate lenses (1.77 +/- 0.86 and 1.28 +/- 0.77). The lowest mean score was observed with the acrylic lens (0.51 +/- 0.52; P < .0001). In study 3, the analyses of the 3 pairs of explanted acrylic piggyback lenses showed that the opacification between them (ILO) may have different forms. CONCLUSIONS Control of postoperative intracapsular cellular proliferation is important in avoiding 3 significant clinical complications. Postoperative lens epithelial cell proliferation is involved in the pathogenesis of PCO, ACO, and ILO, the latter being a newly described form of opacification within the capsular bag related to piggyback IOL implantation. IOL material and design are important factors influencing the outcome of these complications.
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Pandey SK, Ram J, Werner L, Brar GS, Jain AK, Gupta A, Apple DJ. Visual results and postoperative complications of capsular bag and ciliary sulcus fixation of posterior chamber intraocular lenses in children with traumatic cataracts. J Cataract Refract Surg 1999; 25:1576-84. [PMID: 10609199 DOI: 10.1016/s0886-3350(99)00297-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the visual results and postoperative complications of capsular bag and ciliary sulcus fixation of posterior chamber intraocular lenses (IOLs) for traumatic cataracts in children. SETTING Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. METHODS Twenty children (20 eyes) with traumatic cataracts had extracapsular cataract extraction (ECCE) and posterior chamber IOL implantation. They were randomly divided into 2 groups. Capsular bag fixation was performed in 10 children (Group A) and ciliary sulcus fixation in the other 10 (Group B). Traumatic cataracts associated with large corneal lacerations (10.0 mm or more), hyphema, angle recession, or posterior segment involvement were excluded. The best corrected visual acuity (BCVA) as well as early and delayed postoperative complications were prospectively evaluated in both groups. RESULTS The BCVA was 6/12 or better in 9 eyes (90%) in Group A and 8 eyes (80%) in Group B at the end of the mean follow-up (24.6 months +/- 10.6 [SD]). Amblyopia (1 eye in Group A) and corneal scar and commotio retinae (1 eye each in Group B) accounted for a visual acuity of worse than 6/12. The residual refractive error did not exceed 3.50 diopters in either group. The incidences of fibrinous anterior uveitis and pupillary capture were significantly higher in Group B (P < .05, Fisher exact test). CONCLUSION Capsular bag fixation of posterior chamber IOLs provided visual results similar to those with ciliary sulcus fixation but was associated with fewer postoperative complications, particularly uveitis and pupillary capture. This represents another important reason to attempt in-the-bag fixation in cases of traumatic cataract.
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Apple DJ. Discussion by David J. Apple, MD. Ophthalmology 1999. [DOI: 10.1016/s0161-6420(99)90515-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Apple DJ, Peng Q, Ram J. The 50th anniversary of the intraocular lens and a quiet revolution. Ophthalmology 1999; 106:1861-2. [PMID: 10519577 DOI: 10.1016/s0161-6420(99)90393-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Pandey SK, Ram J, Jain A, Singh U, Gupta A, Apple DJ. Surgical management of complete hyperplastic persistent pupillary membrane. J Pediatr Ophthalmol Strabismus 1999; 36:221-3. [PMID: 10442732 DOI: 10.3928/0191-3913-19990701-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Apple DJ. Harold Ridley, MA, MD, FRCS: a golden anniversary celebration and a golden age. ARCHIVES OF OPHTHALMOLOGY (CHICAGO, ILL. : 1960) 1999; 117:827-8. [PMID: 10369599 DOI: 10.1001/archopht.117.6.827] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Ram J, Apple DJ, Peng Q, Visessook N, Auffarth GU, Schoderbek RJ, Ready EL. Update on fixation of rigid and foldable posterior chamber intraocular lenses. Part II: Choosing the correct haptic fixation and intraocular lens design to help eradicate posterior capsule opacification. Ophthalmology 1999; 106:891-900. [PMID: 10328386 DOI: 10.1016/s0161-6420(99)00506-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Posterior capsule opacification (PCO) is one of the most common complications of cataract surgery, and there is an urgent need to reduce its incidence. Its main treatment, neodymium:YAG (Nd:YAG) laser posterior capsulotomy, may be associated with significant morbidity and is expensive. In this study, the authors ascertain the effect of posterior chamber intraocular lens (PC-IOL) fixation and various IOL designs (rigid polymethyl methacrylate [PMMA] optic and small-incision foldable designs) on the pathogenesis of PCO. DESIGN Prospective analysis of pseudophakic eyes obtained postmortem. PARTICIPANTS A total of 3493 eyes with PC-IOLs obtained postmortem and received between 1984 and 1998. METHODS Miyake-Apple posterior photographic technique. MAIN OUTCOME MEASURES Peripheral Soemmering's ring, central PCO in the visual axis, and eyes that have had Nd:YAG laser posterior capsulotomy were analyzed and scored, and these findings were correlated with the type of fixation and IOL design. RESULTS The degree of formation of peripheral Soemmering's ring was not influenced by IOL fixation. The acrylic design revealed relatively low Soemmering's ring scores. In contrast, central PCO and Nd:YAG laser capsulotomy scores were consistently influenced by fixation. The scores were significantly lower in eyes with in-the-bag fixation. The bag-bag fixated acrylic-PMMA design and the three modern silicone IOL designs analyzed in this study had less central PCO and lower posterior capsulotomy scores than did the PMMA IOLs. CONCLUSIONS The formation of peripheral PCO (the Soemmering's ring), the precursor of clinically significant, vision-threatening PCO, is not significantly influenced by the haptic fixation pattern. It is much more dependent on the quality and thoroughness of surgical cortical cleanup. Reduction of Soemmering's ring is an important goal because the retained regenerative cortical cells within this lesion are the cells of origin of PCO. The acrylic IOL design was associated with a lessor amount of peripheral Soemmering's ring as compared with all other designs. In sharp contrast to peripheral PCO, fixation of the IOL was a highly significant factor affecting the formation and quantity of central PCO-the clinically significant opacity behind the IOL optic, measured in this series either by scoring an intact retro-optical membrane or by documenting the presence of a Nd:YAG laser posterior capsulotomy orifice. The quantity of central PCO was consistently much lower in eyes with in-the-bag fixated IOLs compared with lenses with one or both haptics out of the bag. This is best explained by the fact that secure in-the-bag fixation positions the IOL optic in the best possible position to create a barrier effect. The lowest PCO rates were generally noted with the acrylic and modern silicone IOL designs.
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Ram J, Apple DJ, Peng Q, Visessook N, Auffarth GU, Schoderbek RJ, Ready EL. Update on fixation of rigid and foldable posterior chamber intraocular lenses. Part I: Elimination of fixation-induced decentration to achieve precise optical correction and visual rehabilitation. Ophthalmology 1999; 106:883-90. [PMID: 10328385 DOI: 10.1016/s0161-6420(99)00505-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Realizing that precise posterior chamber intraocular lens (PC-IOL) centration is needed to consistently achieve good optical results and visual rehabilitation after modern cataract surgery, the authors assessed the status and success rate of lens haptic fixation and its correlation with lens optic centration-decentration in a large series of eyes with PC-IOLs obtained postmortem. DESIGN Prospective analysis of pseudophakic eyes obtained postmortem. PARTICIPANTS A total of 3493 human eyes obtained postmortem, the largest database of such specimens available to date. METHODS Miyake-Apple posterior photographic technique. MAIN OUTCOME MEASURES The amount of decentration of rigid PC-IOLs and small-incision foldable PC-IOLs was analyzed, and the results were correlated with the type of fixation that had been achieved in each case. RESULTS Determination of mean values revealed that capsular bag fixation was achieved in 52.05% of eyes, asymmetric bag-sulcus fixation in 34.21 % of eyes, and sulcus-sulcus fixation in 13.74% of eyes. Asymmetrically fixed lenses consistently showed significant decentration. During the past 5 years (1993-98), the overall rate of in-the-bag fixation increased to 59.2%; by 1998 it had increased to 64%. Most significantly, success in achieving bag-bag fixation of foldable IOLs implanted in association with modern capsular surgery with small incisions has surged to 90% over the past 4 years. CONCLUSIONS The authors found a direct correlation of decentration in eyes with asymmetric fixation, and the results underscore the need for careful in-the-bag haptic placement. Although few surgeons today would dispute the goal to implanting haptics in the capsular bag, these findings show that the overall success rate over the years has, while improving, remained surprisingly low. The overall success rate of about 60% seen with all lens designs is probably as good as can be expected with classic large-incision extracapsular techniques. However, and most important and encouraging, the success rate of haptic fixation in cases with foldable lenses has improved dramatically during the past 4 years (up to the 90% range). This coincides with the present emphasis on modern capsular surgery and small-incision techniques used to insert these lenses.
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Andreo LK, Wilson ME, Apple DJ. Elastic properties and scanning electron microscopic appearance of manual continuous curvilinear capsulorhexis and vitrectorhexis in an animal model of pediatric cataract. J Cataract Refract Surg 1999; 25:534-9. [PMID: 10198859 DOI: 10.1016/s0886-3350(99)80051-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare the tear resistance of anterior capsulotomies using manual continuous curvilinear capsulorhexis (CCC) and vitrector-cut capsulotomy (vitrectorhexis) techniques in an animal model of the pediatric eye and in 2 pairs of human infant eyes. SETTING Department of Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS Continuous curvilinear capsulorhexis and automated vitrectorhexis capsulotomy techniques were performed in 20 pig eyes, 10 with each technique. The capsules were then stretched until they ruptured. The forces required for rupture after each technique were compared. The forces required for rupture of the pig eye lens capsule were also compared with those required for the human infant eye lens capsule. Scanning electron microscopy was performed in each group following intraocular lens (IOL) insertion. RESULTS All capsules stretched adequately for IOL insertion. The percentage of stretch prior to rupture was higher in the capsulorhexis group (mean 157%, range 147% to 169%) than in the vitrectorhexis group (mean 135%, range 124% to 147%) (P < .001). The percentage of stretch in the human infant eyes was not statistically different from that in the porcine eyes (P > .05). CONCLUSIONS The manual CCC offered greater resistance to capsule tearing than the vitrectorhexis and also revealed a more smooth, regular edge. It therefore remains the gold standard. However, the vitrectorhexis displayed more than adequate resistance to unwanted anterior capsule tears when used for IOL insertion through capsulotomy sizes currently used in clinical practice.
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Assia EI, Blumenthal M, Apple DJ. Effect of expandable full-size intraocular lenses on lens centration and capsule opacification in rabbits. J Cataract Refract Surg 1999; 25:347-56. [PMID: 10079439 DOI: 10.1016/s0886-3350(99)80082-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To study the effects of expandable, hydrogel, full-size lenses (FSLs) on lens centration and posterior capsule opacification (PCO) in the rabbit model. SETTING Center for intraocular Lens Research, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS Small FSLs designed for human eyes were implanted unilaterally in 20 rabbit eyes. Lens centration and PCO in these eyes were compared with those in eyes with conventional poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) or aphakia in the fellow eyes. In a second experiment, medium-size or large FSLs designed for rabbit eyes were implanted in 20 rabbit eyes and the results compared with those in eyes with conventional PMMA IOLs. Slitlamp examination of all eyes was performed regularly, after enucleation, gross inspection and microscopic studies were performed. RESULTS Decentration of FSLs occurred in the presence of an anterior capsule tear or very large capsulorhexis. Posterior capsule opacification developed only at sites where the implanted lens was not in contact with the capsule. Aphakic eyes and looped IOLs developed Soemmering's rings peripherally. In eyes with small FSLs, PCO developed between the lens and the center of the posterior capsule, whereas in eyes with large FSLs, only small amounts of central PCO developed. Retained high-viscosity viscoelastic material had no effect on PCO development. CONCLUSIONS Complete refilling of the capsular bag by a full-size IOL was associated with excellent centration and only a small degree of PCO. Elastic lenses may thus serve as a starting point for the development of an artificial lens with accommodative function.
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