Late in-the-bag intraocular lens dislocation: Incidence, prevention, and management

Characteristics of patients with spontaneous dislocation of in-the-bag intraocular lens after pars plana vitrectomy

PURPOSE

To determine the characteristics of eyes with late in-the-bag dislocation of an intraocular lens (IOL) after pars plana vitrectomy (PPV).

METHODS

Fourteen eyes of 14 patients with a dislocated IOL after PPV were studied retrospectively. The data collected from the medical charts included the age, sex, history of eye diseases, axial length, and interval from PPV to time of IOL dislocation. The surgical procedures used during the PPV were also recorded.

RESULTS

Seven eyes had undergone PPV for rhegmatogenous retinal detachment; 6 eyes, for proliferative diabetic retinopathy; and 1 eye, for retinal vein occlusion. The average interval between the PPV and the diagnosis of the dislocated IOL was 6.2 years (range 2.3-10.1 years). In all eyes, the peripheral vitreous was thoroughly removed with scleral depression during the PPV.

CONCLUSIONS

The IOL dislocation was most likely caused by damage to the zonular fibers by the peripheral vitrectomy with scleral depression.

Intermittent pupillary capture of intraocular lens after transscleral fixation in congenital ectopia lentis patient triggered by dark environment: A case report

RATIONALE

Although transscleral-fixated intraocular lens (IOL) implantation has been the most frequently chosen treatment for patients with inadequate capsule support, the ghost pupillary capture phenomenon did not cause enough attention.

PATIENT CONCERNS

We present an unusual case withintermittent pupillary capture of intraocular lens.

DIAGNOSIS

After 5 minutes staying in the dark environment, the pentacam examination revealed a mild nasal pupillary capture of the IOL.

INTERVENTIONS

A clear observation using the slit-lamp was attempted, and the light shining on the pupil sped up the sliding of the captured IOL.

OUTCOMES

The captured portion of the IOL recovered rapidly accompanied with pupil retraction when the patient was exposed in the light.

CONCLUSIONS

Pupillary capture of an IOL is an uncommon but potentially serious postoperative complication of transscleral fixation. Many pupillary capture cases may have been overlooked in the past. Physicians should be aware of its potential side effect, recognize its clinical manifestation, and knowledgeable of effective management.

Late In-the-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial Comparing Lens Repositioning and Lens Exchange

PURPOSE

To compare the efficacy and safety of 2 operation methods for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel-group surgical trial.

PARTICIPANTS

Patients referred to Oslo University Hospital (tertiary referral center).

METHODS

We randomly assigned 104 patients (104 eyes) either to IOL repositioning by scleral suturing (n = 54) or to IOL exchange with retropupillary fixation of an iris-claw IOL (n = 50). One surgeon performed all operations. Patients were evaluated comprehensively before surgery, and most patients (82%) attended an examination 6 months after surgery.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) 6 months after surgery.

RESULTS

The mean postoperative BCVA was 0.24±0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.16 logMAR) in the repositioning group and 0.35±0.54 logMAR (range, -0.20 to 3.0 logMAR) in the exchange group (P = 0.23). A BCVA of 20/40 or better (Snellen) was reached by 61% and 62% of the patients, respectively (P = 0.99). The mean postoperative corneal cylinder was 1.2±1.0 and 1.2±0.8 diopters, respectively (P = 0.84), and the postoperative endothelial cell density changes were -3±10% (P = 0.07) and -10±14% (P = 0.001), respectively (group difference, P = 0.04). Repositioning had a longer mean surgical time than exchange (P < 0.001). There were 2 (4%) and 0 cases of perioperative fluid misdirection syndrome, respectively. Postoperative complications were intraocular pressure (IOP) increase (n = 12), cystoid macular edema (CME; n = 3), and nonarteritic anterior ischemic optic neuropathy (n = 1) in the repositioning group, and IOP increase (n = 9), pupillary block (n = 1), choroidal effusion (n = 2), CME (n = 4), and redislocation (n = 1) in the exchange group.

CONCLUSIONS

We found satisfactory and not significantly different outcomes for BCVA 6 months after surgery in the 2 groups. Both operation methods seemed safe, with low frequencies of serious perioperative and postoperative complications. However, some of the observed differences in complications should be taken into consideration when selecting the most suitable method in clinical practice.

Surgical management of spontaneous in-the-bag intraocular lens and capsular tension ring complex dislocation

We describe a technique to manage late spontaneous intraocular lens (IOL) and capsular tension ring (CTR) dislocation within the intact capsular bag. The subluxated IOL and CTR complex can be positioned in a closed chamber and fixed to the pars plana at both 3 and 9 o’clock quadrants with the presented ab externo direct scleral suturation technique which provides an easy, safe and effective surgical option for such cases.

Visual outcomes in patients with zonular dialysis following cataract surgery

PurposeTo evaluate the visual outcomes of patients with zonular dialysis following cataract surgery.Patients and methodsMedical records of all patients with documented zonular dialysis, either pre- or peri-operatively, undergoing cataract surgery between 2004-2010 at Queen Alexandra Hospital, Portsmouth, were retrospectively reviewed. Baseline demographics and biometry were analysed, and ocular co-morbidities documented. Intraoperative complications and the use of a capsular tension ring (CTR) were identified. Early and late best-corrected visual acuity (BCVA) post surgery were determined using LogMar values. Univariate and multivariate linear regression analysis was performed to determine associations with BCVA post surgery, and further subgroup analysis performed in groups determined by CTR use.ResultsThe records of 22 312 consecutive eyes undergoing cataract surgery were reviewed. The incidence of zonular dialysis was 0.50% (111 eyes). A CTR was inserted in 46 eyes. Using a multivariate linear regression model, better initial pre-operative BCVA (P=0.019), the use of a CTR (P=0.014), and the absence of vitreous loss during surgery (P=0.008, β 0.45) were associated with improved early postoperative BCVA (mean follow-up 6.6 weeks). Better medium-term postoperative BCVA was significantly associated with preoperative BCVA (P=0.002) and the use of a CTR during surgery (P=0.004, β -0.41).ConclusionsThe overall incidence of zonular dialysis is low. CTR use intra-operatively suggests improved early and medium-term BCVA and should be considered in all cases of zonular dialysis.

Axial Length of the Eyeball Is Important in Secondary Dislocation of the Intraocular Lens, Capsular Bag, and Capsular Tension Ring Complex

Purpose. To analyze the patients with secondary dislocation of CTR and IOL within 5 years from cataract surgery, to determine predisposing factors. Methods. 16 eyes of 15 patients aged 66.2 ± 6.7 (from 49 to 82) with CTR/IOL complex dislocation within 5 years from cataract surgery were compared with 26 patients aged 67.1 ± 7.2 (from 53 to 85), implanted with CTR during cataract surgery to manage zonule dehiscence and did not dislocate for at least 5 years, in respect of cause, axial length and IOL power, refraction, coexistent pathology, and trauma. Results. Axial length of the eyeball was 23.8 ± 1.3 (from 21 to 29) in the group of patients with CTR/IOL dislocation and 20.7 ± 1.2 (from 19 to 24) in patients with no dislocation present (p = 0.008). Crystalline lens dislocation was diagnosed before surgery in 13 of 16 patients with CTR/IOL complex dislocation as opposed to 7 of 26 eyes in the control group (p = 0.01). Pseudoexfoliation was present in 50% and 58% in both groups, respectively. Traumatic dislocation was present in 8 patients, none of them with CTR/IOL dislocation (p = 0.04). Conclusion. Longer axial length may contribute to the failure of the CTR to prevent in-the-bag IOL dislocation. Traumatic dislocation appears to be well fixed with the CTR.

Repositioning a decentered intraocular lens with 4 haptics

We describe a technique to reposition a decentered 4-haptic intraocular lens (IOL). Using an ophthalmic viscosurgical device, the haptic with the worst distortion is dissected from the capsular bag and pulled outside the bag. The opposite haptic (180 degrees away) is also dissected and placed in front of the anterior capsule. The remaining 2 haptics are left in the capsular bag. With this repositioning, the 2 haptics in the bag limit the IOL movement, the 2 haptics outside the bag are no longer distorted, and the IOL is centered. We present 2 cases in which this technique was used to reposition decentered 4-haptic IOLs.

[Technique for surgical repositioning of in-the-bag dislocated intraocular lenses]

AIM

to develop and test a new technique for surgical repositioning of in-the-bag dislocated intraocular lenses (IOLs).

MATERIAL AND METHODS

Surgical outcomes of 21 patients with in-the-bag IOL dislocation were analyzed (follow-up period 1-12 years).

RESULTS

The proposed method of IOL-capsular bag complex fixation with two double sutures provides a reliable anatomic and functional result.

CONCLUSION

The new technique enables surgical repositioning of in-the-bag dislocated IOLs following trauma in patients who have not had an intracapsular ring implanted before.

Epidemiology, Etiology, and Prevention of Late IOL-Capsular Bag Complex Dislocation: Review of the Literature

Posterior chamber intraocular lens (PC-IOL) subluxation is uncommon but represents one of the most serious complications following phacoemulsification. Late spontaneous IOL-capsular bag complex dislocation is defined as occurring three months or later following cataract surgery. Unlike early IOL dislocation, late spontaneous IOL dislocation is due to a progressive zonular dehiscence and contraction of the capsular bag many years what seemed to be uneventful surgery. In recent years, late in-the-bag IOL subluxation or dislocation has been reported with increasing frequency, having a cumulative risk of IOL dislocation following cataract extraction of 0.1% after 10 years and 1.7% after 25 years. A predisposition to zonular insufficiency and capsular contraction is identified in 90% of reviewed cases. Multiple conditions likely play a role in contributing to this zonular weakness and capsular contraction. Pseudoexfoliation is the most common risk factor, accounting for more than 50% of cases. Other associated conditions predisposing to zonular dehiscence are aging, high myopia, uveitis, trauma, previous vitreoretinal surgery, retinitis pigmentosa, diabetes mellitus, atopic dermatitis, previous acute angle-closure glaucoma attack, and connective tissue disorders. The recognition of these predisposing factors suggests a modified approach in cases at risk. We review certain measures to prevent IOL-bag complex luxation that have been proposed.

SURGICAL OUTCOME OF SIMULTANEOUS INTRAOCULAR LENS RESCUE AND SUTURELESS INTRASCLERAL TUNNEL FIXATION OF DISLOCATED INTRAOCULAR LENSES

PURPOSE

To report short-term surgical outcomes of single-stage simultaneous rescue and sutureless intrascleral fixation of dislocated intraocular lens (IOLs).

METHODS

Sixteen eyes of 16 patients who underwent simultaneous rescue and intrascleral fixation of dislocated 3-piece IOLs were retrospectively evaluated. Partial thickness limbal-based scleral flaps (2.0 × 2.0 mm) were created, and a 22-gauge round needle was used to create a sclerotomy at 1.5 mm from the limbus under the previously created scleral flap, and a 23-gauge trans pars plana vitrectomy was performed. Bimanual maneuvers using two 23-gauge end-grasping forceps under chandelier illumination and a wide-angle viewing system enabled 1 step rescue of IOLs from the posterior vitreous cavity with 1 hand and simultaneous haptic externalization through sclerotomy with the other hand. An externalized haptic was placed into the 3-mm intrascleral tunnel created using a bent 26-gauge needle. Fibrin glue was used to fixate haptics and close the scleral flaps.

RESULTS

Intraocular lenses were successfully rescued and sclera-fixated through intrascleral tunnels in all 16 eyes (mean age, 56.56 ± 19.89 years). The mean preoperative logarithm of the minimum angle of resolution best-corrected visual acuity was 0.92 ± 0.68, and this significantly improved at 6 months to 0.289 ± 0.36 (P = 0.003). During the follow-up period (10.1 ± 3.21 months), no significant change of endothelial cell count or central foveal thickness was noted postoperatively (P = 0.203 and P = 0.979, respectively). There were no significant postoperative complications such as IOL dislocation, IOL decentration, retinal detachment, endophthalmitis, or postoperative hypotony.

CONCLUSION

Simultaneous rescue and sutureless intrascleral haptic fixation of dislocated 3-piece IOLs using bimanual maneuvers is an effective, safe, and minimally invasive surgical method to rescue and fixate the dislocated IOL without further explant.

Pseudoexfoliation Syndrome and Pseudoexfoliation Glaucoma: A Review of the Literature with Updates on Surgical Management

Pseudoexfoliation syndrome (PES) is a systemic disorder caused by progressive accumulation of extracellular material over various tissues. PES usually determines increased intraocular pressure, changes in the anatomical aspects of the optic nerve, and visual field alterations leading to the diagnosis of pseudoexfoliation glaucoma (PEG). Use of topical medical treatment usually leads to poor results in terms of long-term follow-up but many surgical techniques, such as Argon Laser or Selective Laser Trabeculoplasty, have been proposed for the management of PEG affected patients. The present paper is a review on the pseudoexfoliation syndrome and pseudoexfoliation glaucoma with an update on surgical management.

Incidence and risk factors of late in-the-bag intraocular lens dislocation: evaluation of 140 eyes between 1992 and 2012

PURPOSE

To identify risk factors for late in-the-bag intraocular lens (IOL) dislocation and estimate the incidence of this condition over a 21-year period.

SETTING

Department of Ophthalmology, County Hospital of Värmland, Karlstad, Sweden.

DESIGN

Retrospective cohort study and nested case-control study.

METHODS

The medical records of eyes operated on for late in-the-bag IOL dislocation between 1992 and 2012 were reviewed. The annual incidence and cumulative risk were calculated.

RESULTS

Of 140 eyes whose records were reviewed, 123 qualified for comparison (24 variables) with an equal number in a control group. The annual incidence varied between 0.00% and 0.08%. An increasing trend was found (P < .001). The cumulative risk 5, 10, 15, and 20 years after cataract extraction was 0.09%, 0.55%, 1.00%, and 1.00%, respectively, and was significantly higher (P < .001) in eyes that had cataract surgery between 2002 and 2012 than in those operated on between 1992 and 2001 (0.89% versus 0.39% at 10 years postoperatively) (P < .001). Calendar time (date) of dislocation was positively correlated with the duration of preceding pseudophakia (P = .005). Phacoemulsification time was longer in eyes with dislocation than in control eyes (P < .001). Other identified risk factors were pseudoexfoliation, zonular dehiscence, pseudophacodonesis, and increased axial length.

CONCLUSIONS

The increasing number of late in-the-bag IOL dislocations cannot be explained by the growing pseudophakic population only. The increase in the incidence was due primarily to the longer duration of pseudophakia in the population and to a greater dislocation risk with recent cataract surgery. The increase in life expectancy played a minor role. Long phacoemulsification time was a risk factor for dislocation.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Intraocular lens dislocation and tube shunt in the posterior chamber: a case report

Background

To describe management of a case of intraocular lens (IOL) and capsular bag (CB) dislocation in an eye with an Ahmed glaucoma valve in the posterior chamber.

Case presentation

A 75-year-old pseudophakic man with open-angle glaucoma and diabetic retinopathy developed neovascular glaucoma. After two intravitreous injections of bevacizumab and panretinal photocoagulation were administered, the new vessels regressed. However, goniosynechiae were observed over 360° of the angle. An Ahmed glaucoma valve model FP7 was implanted with the tube in the posterior chamber with adequate intraocular pressure control. Nineteen years after cataract surgery, when the IOL-CB complex became dislocated, they were sutured transclerally to the sulcus without Ahmed glaucoma valve modification. After a coughing episode, the vitreous pushed the IOL-CB complex forward and the tube was behind the IOL-CB complex. A 25-gauge posterior vitrectomy was performed, and the tube was returned to in front of the optic of the IOL using a forceps tip through a sclerotomy.

Conclusion

This case suggested that management of IOL-CB dislocation can modify glaucoma shunt function. A complete pars plana vitrectomy may be required in order to reposition the dislocated IOL-CB complex in the presence of a posterior chamber drainage tube implant.

Cataract surgery in pseudoexfoliation syndrome

Pseudoexfoliation (PXF) syndrome is characterized by the deposition of distinctive fibrillar material in the anterior segment of the eye. It is an age-related process that is associated with open and narrow angle glaucomas and the formation of cataracts. Not only is PXF associated with the formation of dense nuclear cataracts, it is also well known that those presenting with PXF are at a higher risk of developing complications during, and even after, cataract surgery. Complications associated with cataract surgery in PXF can occur from poor pupillary dilation, zonular weakness leading to intraoperative or postoperative lens dislocation and vitreous loss, postoperative intraocular pressure (IOP) spikes potentiating glaucomatous damage, capsular phimosis, prolonged inflammation, and postoperative corneal decompensation. The surgeon should be prepared to encounter the various potential intraoperative and postoperative complications in eyes with pseudoexfoliation syndrome during cataract surgery. In this way, the surgeon can plan his/her surgical technique to help avoid surprises during cataract surgery and be prepared to manage the potential postoperative complications that can occur in pseudoexfoliation eyes.

Transscleral suture fixation following recurrent toric intraocular lens rotation

We describe a surgical technique of transscleral suture fixation for recurrent rotation of a double-loop hydrophilic acrylic toric intraocular lens (IOL) in the capsular bag. Two 9-0 polypropylene sutures are placed in the proximal and distal angulations of 1 of the IOL haptics through the capsular bag. The clockwise and counterclockwise traction provided by these sutures prevents rotation of the IOL in either direction. This technique can be used in cases of spontaneous postoperative IOL rotation to achieve stabilization. In the case we describe, the IOL remained stable 11 months following transscleral suture fixation at the desired axis.

In-bag dislocation of intraocular lens in patients with uveitis: a case series

Background

Improvement in surgical devices and intraocular lenses has made modern cataract surgery a safe procedure with decreasing complication rates. Intraocular lens dislocation is a serious complication after cataract surgery. Although most dislocations occur during the first week postoperative period, late intraocular lens dislocation occurring 3 months or later post-surgery has been reported with increasing frequency in recent years as a result of progressive zonular dehiscence. We report the clinical features, management and outcomes of five cases of late in-bag dislocation of intraocular lens in patients with underlying uveitis. This is a retrospective case series and literature review.

Results

We identified five eyes in five patients with uveitis and late in-bag intraocular lens dislocation. Two patients had multifocal choroiditis, two herpetic uveitis and retinitis and two Fuchs’ heterochromic iridocyclitis in five patients. Mean age at the time of cataract surgery was 50. Best vision ranged from counting fingers to 6/18 preoperatively and ranged from 6/36 to 6/6 postoperatively. All had right eye dislocation with mean time from initial cataract surgery to intraocular lens dislocation of 81 months. Explantation of dislocated intraocular lens and vitrectomy were performed in four cases; three had anterior chamber intraocular lens placement. One case was managed conservatively. Best vision ranged from light perception to 6/7.5 at time of dislocation and ranged from 6/36 to 6/6⁻² at follow-up.

Conclusions

Late in-bag dislocation intraocular lens can complicate cataract surgery in patients with underlying uveitis. This case series identified that the mean time to in-bag intraocular lens dislocation in five uveitis patients was 81 months after uncomplicated cataract surgery, comparable with the time reported in the available literature of patients with pseudoexfoliation syndrome. This series also found that lens explantation and replacement with anterior chamber intraocular lens achieved good outcomes. Further investigation is warranted to ascertain the strategies to identify patients at risk and to prevent and better manage intraocular lens dislocation in patients with uveitis.

Proinflammatory status in the aqueous humor of high myopic cataract eyes

High myopia has long been recognized as an inflammation-related disease, and high myopic eyes are thought to have a proinflammatory internal microenvironment, which might predispose to the occurrence of certain inflammation-related complications such as fibrotic capsular contraction syndrome after cataract surgery. Therefore, the purpose of this study was to detect inflammatory cytokines expressed in the aqueous humor (AH) of high myopic cataract (HMC) patients. The cytokines were screened using a RayBio Human Cytokine Antibody Array in AH samples from 15 age-related cataract (ARC) patients and 15 HMC patients. Those detected by the screening assays were verified using a Bio-Plex Suspension Array System in AH samples from 35 ARC patients and 45 HMC patients. The cytokine antibody array showed that the expression level of interleukin-1 receptor antagonist (IL-1ra) in the AH was higher in ARC than in HMC, whereas opposite trends were found for monocyte chemoattractant protein-1 (MCP-1), regulated on activation, normal T-cell expressed and presumably secreted (RANTES), IL-8, platelet-derived growth factor-BB, and IL-6 (all P < 0.05). In the verification assay using the suspension cytokine array, only the expression levels of IL-1ra and MCP-1 were significantly different between the ARC and HMC groups (P = 0.014 and 0.038, respectively); these results were confirmed by western blot assays. Our results demonstrated that the expression of IL-1ra was significantly lower and the expression of MCP-1 was significantly higher in the AH of HMC than in ARC, suggestive of a proinflammatory status in the anterior chamber of HMC eyes.

Comparision of surgical outcomes of intraocular lens refixation and intraocular lens exchange with perfluorocarbon liquid and fibrin glue-assisted sutureless scleral fixation

AIM

The purpose of this study was to compare the surgical outcomes of intraocular lens (IOL) refixation with intraocular lens exchange using perfluorocarbon liquid (PFCL) and fibrin glue-assisted sutureless scleral fixation surgery in patients with dislocation of the IOL.

METHODS

Twenty-five eyes of 25 patients who underwent surgery for dislocated IOLs with PFCL and fibrin glue-assisted scleral fixation were studied; 13 eyes experienced IOL refixation (in-the-bag and out-of-the-bag), and 12 eyes experienced IOL exchange. Preoperative and postoperative clinical features from patient charts and 25 eyes with >6 months' follow-up information were reviewed and analyzed.

RESULTS

At postoperative 6 months, best-corrected visual acuity (BCVA) and spherical equivalent of IOL refixation and exchange were significantly improved (P=0.042, P=0.001), and endothelial cell density was significantly decreased in the two groups with no significant difference between them. Surgically induced astigmatism of IOL refixation improved from 0.90±0.47 to 0.61±0.37 (P=0.012), and IOL exchange improved from 1.17±0.64 to 0.73±0.37 (P=0.037) at postoperative 6 months, with no significant difference between the two groups. Complications occurred in four eyes in the IOL refixation group and in three eyes in the IOL exchange group.

CONCLUSION

PFCL and fibrin glue-assisted IOL sutureless scleral refixation or exchanged fixation was an effective surgical treatment for IOL dislocation. Also, because postoperative BCVA, surgical outcomes, and complications did not differ significantly between IOL refixation and exchange surgery, if IOL exchange surgery is not indicated, IOL refixation surgical techniques should be considered.

Prevalence and Prognosis of Pseudoexfoliation Glaucoma in Western India

PURPOSE

To investigate the prevalence and reconnoiter treatment modalities for Pseudoexfoliation Glaucoma (PXG) in subjects with Pseudoexfoliation Syndrome (PXF) in a rural scenario of western India.

DESIGN

A prospective prevalence study.

METHODS

Occurrence of PXG in 250 subjects with PXF was studied in the Department of Glaucoma, Shri Ganapati Netralaya, Jalna, India, from 2009 to 2011. The subject pool presented with PXF, having intraocular pressure (IOP) ≥ 20 mm of Hg, and evidencing optic nerve damage and abnormal visual fields were judiciously selected as PXG cohorts. A decision table is formulated to assist the physician in rendering medical or surgical treatment options.

RESULTS

The prevalence of PXG increased with increasing age at 30% (95% CI: 28.56-33.72) in the 60-year-old and older population. It was predominantly higher in cohorts involved in outdoor physical activities at 46% (95% CI: 41.24-52.38). The eminence and prevalence of nuclear cataract in subjects with PXG was 72 % (95% CI: 65.72-76.34). Visual impairment was highly prevalent in 75% (95% CI: 73.43-78.29) and 10% (95% CI: 6.87-13.21) cohorts with PXG and PXF respectively. In general, linear modelling IOP was 26.37±1.64 in subjects with PXG, which was managed to 16.50±1.32 after rendering our adapted treatment protocols.

CONCLUSIONS

Increased IOP, occludable angles, and glaucomatous optic neuropathy occur more frequently in the population with PXF. It is inferred that that treatment protocol of combined cataract and glaucoma surgery gives maximum reduction in IOP.

Investigation of phacoemulsification on exfoliation syndrome combined cataract with different nuclear hardness

PURPOSE

We investigated the clinical staging and management of cataracts to decrease the incidence of complications of phacoemulsification and improve the postoperative visual function of patients with exfoliation syndrome (XFS) with cataract.

METHODS

Cataracts with XFS were divided into early, middle, and late stages using the Emery-Little lens opacities classification system. Phacoemulsification and intraocular lens (IOL) implantation were performed in all eyes. The incidences of intraoperative and early postoperative complications of phacoemulsification were compared, and differences in the outcomes of phacoemulsification were evaluated.

RESULTS

There were 23, 31, and 34 eyes with early-, middle- and late-stage XFS, respectively. The mean ultrasound time, cumulative dissipated energy, and incidence of moderate to severe corneal edema and wound burn in the late-stage group were significantly higher than in the early- and middle-stage groups (p&lt;0.05). The incidence of zonular dehiscence, capsular rupture, vitreous loss, and iritis were not significant among the 3 groups (p&gt;0.05). Intraocular pressure rise in the early postoperative period and the level of optic atrophy in the late-stage group were significantly higher than in the other 2 groups (p&lt;0.05). The gain in visual acuity in the early- and middle-stage groups after surgery was better than in the late-stage group of XFS, and the difference was statistically significant (p&lt;0.05).

CONCLUSIONS

The clinical staging of cataract with XFS contributed to the choice of operation time and its management. Phacoemulsification and IOL implantation in early- and middle-stage XFS induced fewer complications and led to better recovery of visual function after surgery.

All about capsular tension rings

PURPOSE OF REVIEW

To discuss capsular tension devices and recent evidence regarding their use.

RECENT FINDINGS

The capsular tension ring, modified capsular tension ring, and capsular tension segment are well established tools for use during phacoemulsification when zonular instability is present. Recent research has provided additional evidence of their benefits in decreasing intraoperative and postoperative complications.

SUMMARY

Endocapsular support devices allow for cataract surgery success in the setting of zonular instability.

Spontaneous dislocation of lens bag with acrylic lens after uneventful cataract surgery - unusual complication of cataract surgery

Introduction: Spontaneous dislocation of intraocular lens with bag is rare.

Methods: We report a case of a 56-year-old male who presented with spontaneous anterior dislocation of an in-the-bag intraocular lens 3 years after manual small incision cataract surgery. He had undergone manual small incision cataract surgery with foldable acrylic intraocular lens implantation, and 18 months after cataract surgery ND: YAG capsulotomy with uneventful post capsulotomy follow-up. 17 months after capsulotomy, the patient presented with sudden decrease of vision. On anterior segment examination, the intraocular lens with bag was dislocated into the anterior chamber.

Result: It was managed with intraocular lens explantation with bag, anterior vitrectomy and sclera fixated intraocular lens.

Conclusion: Spontaneous intraocular lens dislocation with bag is possible after 1.5 years of uneventful surgery which may be managed using different techniques.

[Iris suture fixation of posterior chamber lenses. New perspectives for an old technique]

BACKGROUND

Intraocular approaches to correct aphakia in cases of inadequate capsular support include an anterior chamber intraocular lens, fixation of a posterior chamber lens to the sclera or iris by suturing or iris claw, respectively.

OBJECTIVES

This article reviews the indications and contraindications for iris fixation with sutures and gives an overview of surgical techniques, potential complications and outcomes.

METHODS

Based on a selective search of pertinent literature in PubMed the information from original articles and reviews are analyzed, summarized and discussed.

RESULTS

New surgical techniques have imparted an impetus to iris suture fixation with encouraging functional and morphological results offering a new promising alternative to the established options. Improved aspects arise for repositioning of a decentered intraocular lens and for a minimally invasive method for repair of late in-the-bag lens dislocation as seen more frequently by cataract surgeons.

CONCLUSION

A final evaluation of the proposed techniques is not possible because none has clearly emerged as the optimal method. Precise determination of small differences in visual outcome or complication rates requires a large prospective, randomized clinical trial.

Late in-the-bag intraocular lens dislocation in eyes with pseudoexfoliation syndrome

PURPOSE

To assess preoperative features, frequency, surgical approaches and outcomes of late in-the-bag dislocation of posterior chamber intraocular lenses (IOLs) in eyes with pseudoexfoliation syndrome.

METHODS

Seventy-seven patients (81 eyes) were enrolled. Inclusion criteria were patients with pre-existing pseudoexfoliation syndrome who underwent surgery for late in-the-bag IOL dislocation between March 2004 and April 2010. Medical records were reviewed. Data from before and after secondary surgery were analysed.

RESULTS

Mean time between cataract extraction and secondary surgery for late in-the-bag dislocation of posterior chamber IOLs was 8.5 years. The increase in frequency within the reviewed period was statistically significant, ranging from six patients in the first year to 25 patients in the final year (p = 0.004). When surgical correction was performed within 1 month of referral, deterioration of the dislocation occurred in only one of 23 patients (4.3%). Complications, especially vitreous loss, occurred significantly more frequently during exchange surgery (n = 23) when compared with scleral suturing (n = 50) (p < 0.0001). After surgery, however, no differences in complications (p = 0.98) or best-corrected visual acuity (p = 0.74) was found. In general, following secondary surgery, there was a statistically significant improvement in best-corrected visual acuity (p < 0.0001).

CONCLUSION

The frequency of late in-the-bag dislocation of posterior chamber IOLs in eyes with pseudoexfoliation syndrome increased during the observation period. Our study suggests that surgical repair should not be delayed beyond 1 month and that scleral suturing is preferable to exchange surgery, because of less intraoperative complications.

In vitro optical performance of a new aberration-free intraocular lens

PURPOSE

To assess the optical performance of the new EnVista intraocular lens (IOL).

MATERIALS AND METHODS

Four aspheric IOLs were evaluated; the new EnVista is one amoung them. This IOL, similarly to the Z-Flex HB and the Bi-Flex 1.8 667AB ones, has a neutral aspheric design, whereas the fourth IOL under test (AcrySof IQ IOL SN60WF) presents a negative spherical aberration (SA). The IOL's aberration patterns were measured in vitro, by setting them up on an optical bench. From these aberration-pattern data, the modulation transfer function (MTF), the average modulation values, and the points spread function (PSF) were calculated. Furthermore, in order to assess the potential optical quality that these IOLs would yield once they are implanted, an average corneal-aberration pattern was juxtaposed to the in-vitro profiles and the same parameters were calculated again.

RESULTS

For the IOL-only scenario (ie, without including the corneal factor), it was the EnVista IOL, which is aberration-free that showed the higher MTF, PSF values. This was followed by the other two aberration-free IOL models. However, when the effect of an average corneal pattern was also taken into consideration, the AcrySof IQ IOL SN60WF always outperformed the other neutral-asphericity IOLs.

CONCLUSIONS

The in-vitro optical performance of the EnVista IOL was good, but it decreases substantially in a whole-eye scenario, when the wavefront profile of an average cornea is added. Other designs with different degrees of SA should be considered for this IOL in order to surpass these results.

Indications and outcomes of intraocular lens exchange during a recent 5-year period

PURPOSE

To analyze and classify the indications, clinical presentations, and surgical outcomes of intraocular lens (IOL) exchange performed in a recent 5-year period.

DESIGN

Retrospective, interventional case series.

METHODS

setting: Private clinical practice. study population: Chart records of 57 eyes of 53 consecutive patients who had undergone IOL exchange between May 2007 and December 2011 were reviewed. observation procedures and main outcome measures: The preoperative clinical characteristics, treatment parameters, intraoperative and postoperative complications, and pre- and postoperative logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) were recorded and analyzed.

RESULTS

IOL dislocation (46%), incorrect IOL power (23%), patient dissatisfaction (21%), and optic opacification (7%) were the most common indications for IOL exchange. In the IOL dislocation group, posterior capsule opening presented in 57% of eyes (8/14) with in-the-bag dislocation. Of the dissatisfaction patients, 42% (5/11) had undesired visual acuity without symptoms of glare/optical aberrations. Surface calcification of silicone lenses associated with asteroid hyalosis accounted for the most cases (3/4) of optic opacification. Overall, the mean logMAR BCVA improved significantly (P < .001) and 88% of all eyes were 20/40 or better, including 73% in the IOL dislocation group and 100% in all other groups. No vision-threatening complications occurred in this series.

CONCLUSIONS

The request for IOL exchange owing to patient dissatisfaction is increasing, especially for those with undesired visual acuity in the absence of photic symptoms. Surface calcification of silicone lenses suggests that this type of lens is not appropriate in the presence of asteroid hyalosis. Optimal visual results with a low rate of complications can be achieved in each category of indication. The findings of the study may stimulate discussion of a question: Does in-the-bag IOL dislocation occur only in eyes with an intact posterior capsule?

[Implantation of intraocular lenses in the ciliary sulcus]

Implantation of an intraocular lens (IOL) into the ciliary sulcus is the second most common implantation site after the regular capsular bag (in the bag) placement of an IOL. Although mainly not primarily intended, it is very often used in both complicated cataract surgery and secondary implantation due to IOL dislocation or aphakia. In most cases stable positioning is possible, especially when using optic capture techniques. A variety of difficulties can occur with sulcus implantation depending on the anatomical and surgical conditions present at the time of implantation. The most anterior position of the sulcus lense has to be considered for calculation of the refractive power of the IOL.

Spontaneous dislocation of posterior chamber intraocular lenses (PC IOLs) in patients with retinitis pigmentosa - Case series

PURPOSE

To report the outcomes of intraocular lens (IOL) dislocation management in 6 cases with Retinitis Pigmentosa (RP).

SETTING

Private practice, Los Angeles, USA.

DESIGN

Retrospective interventional case series.

METHODS

The medical reports of six eyes of four RP patients with capsule bag fixated posterior chamber IOL dislocation were retrospectively reviewed. Pre-operative data included demographics, systemic or ocular disorders, history of trauma, previous intraocular surgery and pre-operative visual acuity. Outcome measures included the type of surgery, surgical complications, elevation of intraocular pressure (IOP), ocular inflammation, cystoid macular edema (CME) and IOL dislocation at 3 months or greater post-operatively.

RESULTS

The medical records of six eyes of four patients operated on between December 2009 and May 2011 were evaluated. In four cases, dislocated PC IOL implants were sutured to the sclera. In two eyes of one patient anterior chamber IOLs (AC IOLs) were implanted after PC IOLs were explanted. One eye developed CME during the follow-up period. Despite modest tilt in one case and modest decentration in another, stability and centration of the IOLs was excellent during the follow-up period. No eyes had intraocular inflammation requiring long term medical treatment, new onset glaucoma or retinal detachment. Mean follow-up time was 6.9 months (range 3-20).

CONCLUSIONS

Cataract surgeons should be aware of the increased risk for decentration and malposition of PC IOLs in patients with RP. Satisfactory results can be achieved by fixation of the PC IOL or AC IOL implantation.

Management of posteriorly dislocated crystalline lens with perfluorocarbon liquid and fibrin glue-assisted scleral-fixated intraocular lens implantation

We describe a technique that uses a 23-gauge transconjunctival sutureless vitrectomy with perfluorocarbon liquid (PFCL) and phacoemulsification to manage a dropped nucleus. The PFCL is injected into the vitreous space until the dislocated lens reaches the iris plane and is then removed using phacoemulsification in the anterior chamber. After intraocular lens (IOL) implantation, a 23-gauge forceps is passed through the sclerotomy to grasp the IOL haptic, which is pulled onto the ocular surface. Tunnels are made at the edge of the flap with a 26-gauge needle into which the 2 haptics are tucked for additional stability. The scleral flaps and conjunctiva are then glued using biological glue. Perfluorocarbon liquid reduces lens repulsion and blocks the transmission of the ultrasound stream to the retina. The fibrin glue-assisted sutureless IOL implantation technique could reduce complications and suture-related problems.

Late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes

PURPOSE

To study the predisposing factors for late in-the-bag intraocular lens (IOL) dislocation and to analyze the outcomes after explantation surgery.

METHODS

In this retrospective multicentre study, 61 eyes were enrolled. The main inclusion criterion was in-the-bag spontaneous IOL dislocation after uneventful phacoemulsification cataract extraction. Only eyes with serious dislocation that required IOL explantation were eligible. Follow-up after explantation surgery of at least 3 months was required. Exclusion criteria were complicated cataract surgery, out-of-the-bag IOL dislocation, and dislocations that occurred in the first year after the cataract surgery. The main outcome measures were predisposing factors for dislocation, interval between cataract surgery and dislocation, surgical treatment at the time of explantation, preoperative and postoperative corrected distance visual acuity (CDVA), and postoperative complications.

RESULTS

High myopia was detected in 12 cases (19.7%) and it was the main predisposing factor. Mean time interval from cataract surgery to dislocation was 7.5 (SD 5.2) years. The dislocated in-the-bag IOL was replaced with a scleral fixated IOL (36.1%), angle-supported anterior chamber IOL (31.1%), sulcus repositioning (18%), or posterior chamber iris sutured IOL (4.9%). Finally, 9.8% of the patients were left aphakic. Mean CDVA improved significantly after surgery (P=0.005). Final CDVA of 20/40 or better was achieved in 29 cases (47.5%).

CONCLUSIONS

High myopia was the main risk factor for late in-the-bag IOL dislocation. Surgical treatment significantly improved the CDVA in our sample and was associated with a low complication rate.