Secondary in-the-bag intraocular lens implantation in children who have been aphakic since early infancy

Complications, Visual Acuity, and Refractive Error 3 Years after Secondary Intraocular Lens Implantation for Pediatric Aphakia

PURPOSE

To report the cumulative incidence of complications and to describe refractive error and visual acuity (VA) outcomes in children undergoing secondary intraocular lens (IOL) implantation after previous surgery for nontraumatic cataract.

DESIGN

Pediatric cataract registry.

PARTICIPANTS

Eighty children (108 eyes: 60 bilateral, 48 unilateral) undergoing lensectomy at younger than 13 years of age.

METHODS

Annual data collection from medical record review through 5 years after lensectomy.

MAIN OUTCOME MEASURES

Cumulative incidence of newly emergent complications after secondary IOL implantation; refractive error and VA by 5 years after lensectomy.

RESULTS

Median follow-up after secondary IOL implantation was 2.7 years (interquartile range [IQR], 0.8-3.3 years; range, 0.6-5.0 years) for bilateral and 2.1 years (range, 0.5-6.4 years) for unilateral cases. A common complication after secondary IOL implantation was a glaucoma-related adverse event (GRAE; glaucoma or glaucoma suspect); the cumulative incidence was 17% (95% confidence interval [CI], 3%-29%) in bilateral cases and 12% (95% CI, 0%-23%) in unilateral cases. The cumulative incidence of surgery for visual axis opacification was 2% (95% CI, 0%-7%) for bilateral cases and 4% (95% CI, 0%-10%) for unilateral cases. The median prediction error within 90 days of implantation was 0.88 diopter (D; IQR, -0.50 to +3.00 D) less hyperopic than intended among 21 eyes for bilateral cases and 1.50 D (IQR, -0.25 to +2.38 D) less among 19 unilateral cases. The median spherical equivalent refractive error at 5 years (at a median of 5.1 years of age) in eyes receiving a secondary IOL was +0.50 D (IQR, -2.38 to +2.94 D) for 48 bilateral cases and +0.06 D (IQR, -2.25 to +0.75 D) for 22 unilateral cases. Median monocular VA at 5 years was 20/63 (IQR, 20/50-20/100) for bilateral cases (n = 42) and 20/400 (IQR, 20/160-20/800) for unilateral cases (n = 33).

CONCLUSIONS

Eyes with secondary IOL implantation have a risk of developing new GRAEs. Five years after lensectomy (approximately 2.5 years after secondary IOL implantation), the average refractive error was less hyperopic than desired given the anticipated further myopic shift before refraction stabilizes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Reopening the capsular bag by removing the capsular proliferative membrane to enable secondary in-the-bag intraocular lens implantation in pediatric aphakic eyes

PURPOSE

To present a surgical technique for reopening the capsular bag in pediatric aphakia.

SETTING

Zhongshan Ophthalmic Center, Guangzhou, China.

DESIGN

Case series study.

METHODS

Consecutive pediatric patients with bilateral aphakia requiring secondary intraocular lens (IOL) implantation between July 2021 and June 2022 were included. The diameter of the capsular proliferative membranous ring (PMR) and position of IOL implantation were documented. Various parameters of capsular bag opening during primary cataract removal and secondary surgery were also analyzed.

RESULTS

48 eyes were included with a mean follow-up of 8.1 ± 4.4 months. Using the surgical technique developed in this study, the capsular bag was successfully reopened with in-the-bag (ITB) implantation in 43 eyes (89.6%). ITB implantation was accomplished in all eyes with an outer diameter of PMR ≤5.5 mm and in 3 of 8 eyes (37.5%) with an outer diameter of PMR >5.5 mm. A positive correlation was observed between the primary and secondary anterior capsular opening diameters (ACODs) ( r = 0.422, P = .007) and the primary and secondary posterior capsular opening diameters (PCODs) ( r = 0.619, P < .001). The inner diameter of PMR was found to be positively correlated with secondary PCOD ( r = 0.728, P < .001) and the outer diameter with secondary ACOD ( r = 0.669, P < .001).

CONCLUSIONS

This was a safe and effective surgical technique for pediatric secondary IOL implantation with maximum preservation of the peripheral capsule. Aphakic eyes with an outer diameter of PMR ≤5.5 mm are preferred for secondary ITB implantation.

Safety and efficacy in pediatric secondary intraocular lens implantation, in-the-bag versus sulcus implantation: a multicenter, single-blinded randomized controlled trial

BACKGROUND

Treatment of pediatric cataract remains challenging because of the extremely high incidence of postoperative adverse events (AEs), especially the AEs related to the locations of secondary implanted intraocular lens (IOL). There are two common locations for secondary IOL implantation in pediatric aphakic eyes: ciliary sulcus or in-the-bag implantation. However, there are currently no large, prospective studies comparing complication rates and visual prognosis of in-the-bag versus ciliarysulcus secondary IOL implantation in pediatric patients. Whether or how much secondary in-the-bag IOL implantation benefits the pediatric patients more than sulcus implantation and deserves to be performed routinely by surgeons remains to be elucidated. Here, we describe the protocol of a randomized controlled trial (RCT) designed to evaluate the safety and efficacy of two approaches of IOL implantation in pediatric aphakia.

METHODS

The study is a multicenter, single-blinded RCT with 10 years of follow-up. Overall, a minimum of 286 eyes (approximately 228 participants assuming 75% have two study eyes) will be recruited. This study will be carried out in four eye clinics across China. Consecutive eligible patients are randomized to undergo either secondary in-the-bag IOL implantation or secondary sulcus IOL implantation. Participants with two eyes eligible will receive the same treatment. The primary outcomes are IOL decentration and the incidence of glaucoma-related AEs. The secondary outcomes include the incidence of other AEs, IOL tilt, visual acuity, and ocular refractive power. Analysis of the primary and secondary outcomes is to be based on the intention-to-treat and per-protocol analysis. Statistical analyses will include the χ² test or Fisher's exact test for the primary outcome, mixed model and generalized estimated equation (GEE) model for the secondary outcome, Kaplan-Meier survival curves for the cumulative probability of glaucoma-related AEs over time in each group.

DISCUSSION

To the best of our knowledge, this study is the first RCT to evaluate the safety and efficacy of secondary IOL implantation in pediatric aphakia. The results will provide high-quality evidence for the clinical guidelines for the treatment of pediatric aphakia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136950. Registered on 1 November 2021.

Primary versus secondary intraocular lens implantation following removal of congenital/de al of congenital/developmental catar elopmental cataracts: outcomes after acts: outcomes after at least 4 years

BACKGROUND

The aim of this study is to evaluate the long-term outcomes of primary and secondary intraocular lens (IOL) implantation following removal of congenital/developmental cataracts.

METHODS

One hundred and forty-four patients aged under 16 years who were followed up between 2003 and 2021 were analyzed retrospectively. The long-term results of children who underwent surgery before 2 years of age for congenital or developmental cataracts and underwent secondary IOL implantation after 2 years of age and those who underwent cataract surgery with primary IOL implantation after 2 years of age were compared. Patients with traumatic, secondary cataracts and cataracts due to ocular anomalies were not included in the study.

RESULTS

We evaluated 64 patients (mean age 9.5 ± 4.5 years) with secondary IOL implantation and 80 patients (mean age 12.8 ± 4.1 years) with primary IOL implantation in the study. Distance and near best-corrected visual acuities were significantly better in the primary IOL group than the secondary IOL group (p < 0.001). Incidence of strabismus after primary IOL surgery was significantly lower and presence of binocular vision was more often than the secondary IOL group (p = 0.002). There was no significant difference between the two groups in terms of refraction and myopic shift (p = 0.242, p = 0.172, respectively). Mean refractive changes were significant in unilateral cases of secondary IOL group and primary IOL group (p = 0.013, p = 0.049, respectively) and myopic shift was also greater in both groups of unilateral cases than the fellow eyes (p = 0.023, p = 0.012, respectively).

DISCUSSION

Visual outcomes and binocular vision were better, and the incidence of strabismus was also much less in the primary IOL group.

Accuracy of Intraocular Lens Power Calculation in Pediatric Secondary Implantation: In-the-Bag Versus Sulcus Placement

PURPOSE

To compare the effects of secondary in-the-bag vs ciliary sulcus intraocular lens (IOL) implantation on the accuracy of IOL power calculation in pediatric eyes.

DESIGN

Prospective nonrandomized interventional study.

METHODS

Pediatric aphakic eyes that underwent either in-the-bag or ciliary sulcus secondary IOL implantation were included. The mean prediction error (PE), mean absolute error (MAE), median absolute error, and percentages of eyes with PE within ±0.25 diopter (D), ±0.50 D, ±0.75 D, and ±1.00 D were calculated and compared using SRK/T formula.

RESULTS

One hundred fourteen eyes (38.26%) received in-the-bag IOL implantation and 184 (61.74%) underwent ciliary sulcus IOL implantation. Compared with the sulcus group, the capsular group displayed significantly lower MAE and higher percentage of eyes within ±0.50 D of PE (MAE: 0.90 vs 1.56 D; ±0.50 D: 40.40% vs 14.29%, both P < .001). The eyes receiving in-the-bag IOL implantation (sulcus IOL implantation β: -1.060, 95% CI: -1.415 to -0.705; P < .001), unilateral (β: 0.647, 95% CI: 0.144-1.150; P = .012), or with deeper anterior chamber depth (β: 0.362, 95% CI: 0.068-0.656; P = .016) were prone to maintain hyperopia (PE > 0). To reduce PE, when the predicted capsular IOL power was between 11.50 and 30.00 D, the power of a sulcus-implanted IOL should be reduced by 0.50 to 2.50 D accordingly (the exact amount of reduction is positively related to the predicted power).

CONCLUSIONS

In-the-bag implantation yielded smaller PE in pediatric eyes undergoing secondary IOL implantation. Adjustment of IOL power for ciliary sulcus implantation is required to reduce PE, and the amount of adjustment is positively correlated with the IOL power predicted by SRK/T formula.

In-the-Bag Versus Ciliary Sulcus Secondary Intraocular Lens Implantation for Pediatric Aphakia: A Prospective Comparative Study

PURPOSE

To compare outcomes of in-the-bag vs ciliary sulcus secondary intraocular lens (IOL) implantation for pediatric aphakia.

DESIGN

Prospective interventional case series.

METHODS

This institutional study was conducted in 202 children (355 aphakic eyes) diagnosed as having congenital cataracts and who underwent cataract extraction before age 24 months. Pediatric aphakic eyes underwent in-the-bag or ciliary sulcus secondary IOL implantation according to the amount of residual lens capsule and were monitored for 3 years postoperatively. The main outcome measures were adverse events (AEs), IOL tilt and decentration, and best corrected visual acuity (BCVA) in the operative eye.

RESULTS

A total of 144 eyes (40.6%, 89 children) received in-the-bag IOL implantation (capsular group), and 211 eyes (59.4%, 132 children) underwent ciliary sulcus IOL implantation (sulcus group). Kaplan-Meier curves showed that the time-dependent incidence of glaucoma-related AEs (GRAEs) (P = .005) and any AEs (P = .002) were higher in the sulcus group. In-the-bag IOL implantation was a strong protective factor against GRAE (hazard ratio, 0.08; 95% CI, 0.01-0.53; P = .009) and any AEs (hazard ratio, 0.21; 95% CI, 0.08-0.57; P = .002). Clinically significant IOL decentration (>0.4 mm) was more common in the sulcus group compared with the capsular group (vertical decentration: 29.8% vs 15.7%, P = .005; horizontal decentration: 30.3% vs 9.35%, P < .001). BCVA in the capsular group was better than that in the sulcus group (logMAR, 0.56 vs 0.67, P = .014).

CONCLUSIONS

Compared with ciliary sulcus secondary IOL implantation, in-the-bag IOL implantation reduced AEs and yielded better IOL centration and BCVA for pediatric aphakia.

Comparison of Aphakic Refraction and Biometry-Based Formulae for Secondary In-The-Bag and Sulcus-Implanted Intraocular Lens Power Estimation in Children

PURPOSE

The aim of the study was to compare the accuracy of refractive outcomes in children undergoing secondary in-the-bag or cilliary sulcus intraocular lens (IOL) implantation, using aphakic refraction (AR)-based formulae (Hug and Khan) and biometry-based formulae (Holladay 1, Hoffer Q, SRK/T, and SRK II).

METHODS

In this retrospective study, a total of 65 eyes of 44 patients who underwent secondary in-the-bag or cilliary sulcus IOL implantation were included and divided into 2 groups: 39 eyes of the in-the-bag IOL group and the other 26 eyes of the sulcus-implanted IOL group. Holladay 1, Hoffer Q, SRK/T, and SRK II formulae were employed depending on the biometric data, while Hug and Khan formulae were used based on preoperative AR. The prediction error (PE) and the absolute value of predicted error (APE) were compared between the 2 groups and formulae.

RESULTS

In the in-the-bag IOL group, nonsignificant differences of APE were found among the 6 formulae, while the Holladay 1, Hoffer Q, SRK/T, and SRK II all demonstrated a significant hyperopic shift of median PE value compared to the Hug formula (p < 0.05, all), and Holladay 1 and SRK II also showed a significant hyperopic shift of PE compared to the Khan formula (p < 0.05, both). Higher percentages of eyes with PE <1 D were found using Hoffer Q and SRK/T. In the sulcus-implanted group, the Holladay 1, Hoffer Q, and SRK/T had a significantly smaller median value of APE than the Hug and Khan formulae (p < 0.05, all), and the SRK II had a significantly smaller median value of APE than the Hug formula (p < 0.05), while Holladay 1 had the lowest value of APE. Higher percentages of eyes within PE <1 D were found using Holladay 1, Hoffer Q, and SRK/T, while the highest one was SRK/T. Significantly larger hyperopic shifts of median PE value using all the 6 formulae were found in eyes with sulcus-implanted IOL than eyes with in-the-bag implanted IOL (p < 0.05, all). In the eyes of with in-the-bag implanted IOL, the Hug and Khan formulae had significantly smaller APE values when compared with the eyes with sulcus-implanted IOL (p < 0.05, both).

CONCLUSIONS

Whether IOL was in the bag or implanted in the sulcus, almost all the formulae showed hyperopic shift, SRK/T showed the best accuracy. Biometry-based formulae were superior to AR-based formulae in accuracy of IOL power calculation, especially when IOL was implanted in the sulcus. In-the-bag IOL implantation should always be with higher priorities, especially when using AR-based formulae in IOL power calculation.

Changes in intraocular pressure control in the first year after secondary intraocular lens implantation in children

PURPOSE

To compare intraocular pressure (IOP) control before and during the first year after secondary intraocular lens (IOL) implantation in children.

METHODS

This was a retrospective chart review of children who received secondary IOL implantation. We analyzed IOP and antiglaucoma medications before and after implantation. The latest exam with IOP measurement found within the 2-15 month period after IOL implantation was used for the postoperative data. Failure to maintain IOP control was defined as either the addition of antiglaucoma medication(s) or a rise in IOP > 4 mm Hg. Statistical analyses were performed to assess risk factors for failure to control IOP after surgery, namely age at IOL implantation, preoperative glaucoma status, and IOL fixation location.

RESULTS

A total of 100 eyes were included. The mean duration of follow-up was 7.74 months (SD = 3.11). Twenty-three of one hundred eyes failed to maintain IOP control according to our definition. Eyes with a history of having had a traumatic cataract (n = 3) had a more than threefold increased risk of failure (P = 0.015). Although not statistically significant, very young age at initial cataract surgery (<2 months old) had a twofold increased risk of failure compared to an older age (>12 months old) (P = 0.213). No other risk factors were found to have statistical significance.

CONCLUSION

Secondary IOL implantation carries a modest risk of worsening IOP control in the first year after implantation, for which, a history of ocular trauma or young age at initial cataract surgery seems to present the highest risk.

Outcomes of secondary sulcus intraocular lens implantation in unilateral anterior persistent fetal vasculature

AIM

To evaluate the surgical results of sulcus intraocular lens (IOL) implantation in children with unilateral anterior persistent fetal vasculature (PFV) underwent primary vitrectomy combined with lensectomy and preservation of the peripheral anterior capsule.

METHODS

Twenty-two eyes of 22 children with unilateral anterior PFV who underwent sulcus secondary IOL implantation were analyzed. Main outcome measures were preoperative and postoperative visual acuity, and complications both intraoperatively and postoperatively.

RESULTS

Review of 22 consecutive patients identified best-corrected visual acuity (BCVA) improvement from 1.37±0.84 to 0.73±0.57 logarithm of the minimal angle of resolution (logMAR) after IOL implantation (P<0.001) with a mean follow-up was 16.55±5.86mo. Average age at secondary IOL implantation was 41.05±15.41mo. Three eyes (13.64%) achieved BCVA of 0.3 logMAR at the final visit. Transient intraocular pressure rise (4 eyes; 18.18%), postoperative increased inflammation (3 eyes; 13.64%) and postoperative hypotony (2 eyes; 9.09%) were common complications.

CONCLUSION

Properly preservation of the anterior lens capsule during the primary surgery facilitated secondary sulcus IOL implantation in pediatric patients with anterior PFV, with favorable postoperative visual outcomes and compatible percentage of complications.

Long-term results of secondary intraocular lens implantation in children under 30 months of age

Purpose

To report the long-term outcome of early secondary intraocular lens (IOL) implantation following congenital cataract extraction in a large number of eyes.

Methods

Data of aphakic children under 30 months of age who underwent secondary IOL implantation and had at least one year of follow-up after the surgery was reviewed. In all of the patients, a foldable three-piece acrylic IOL was implanted in the ciliary sulcus by the same surgeon using the same technique. The database studied included refractive and visual acuity (VA) outcomes and complications.

Results

Fifty patients (75 eyes) were included. The average age at the time of cataract extraction was 94.20 ± 44.94 days and 20.7 ± 6.0 months in the secondary IOL implantation. After 82.32 ± 48.91 months, the VA was 0.58 ± 0.35 LogMAR and the spherical equivalent was −2.20 ± 4.19 D. There was a negative correlation between a longer follow-up period and myopia at the SE measured (P = .001). The most frequent complications included glaucoma and corectopia. Performing the secondary IOL implantation ≤ 20 months of age was not a risk factor for glaucoma development (P = 0.095).

Conclusion

Secondary IOL implantation under 30 months of age is an option for children with unsatisfactory management of the optic treatment. A predictable IOL power calculation and satisfactory visual outcomes compared to results of later secondary IOL implantation are possible.

Secondary intraocular lens implantation following infantile cataract surgery: intraoperative indications, postoperative outcomes

PurposeThe purpose of this study was to determine the long-term complications and outcomes of secondary intraocular lens (IOL) implantation in patients with congenital cataracts.Patients and MethodsThe medical records of children operated for secondary IOL implantation surgery between 2000 and 2014 were retrospectively reviewed. Those who had undergone their initial congenital cataract surgery before 7 months of age were included and were analyzed for intra- and postoperative factors and postoperative refractive outcomes. We focused on three complications: visual axis opacification (VAO), glaucoma, and IOL exchange after at least 1 year of follow-up.ResultsA total of 49 eyes of 49 patients were analyzed for intraoperative indications. Of those, 37 eyes of 37 patients had at least 1 year of follow-up and were analyzed for postoperative outcomes. The mean age at secondary implantation was 55.2±21.6 months. At secondary implantation, 69.4% of eyes were implanted in the capsular bag, 28.6% in the sulcus, and 2.0% that were angle-supported. There was no significant correlation between the site of secondary IOL implantation and age at implantation (P=0.216). The mean follow-up after implantation was 57.6±33.6 months. The rate of VAO was 5.4%, the rate of glaucoma occurring after secondary implantation was 16.2%, and the rate of IOL exchange was 2.7%. The median visual acuity at final follow-up was 20/40. For patients with unilateral cataracts it was 20/60 and for bilateral patients it was 20/30.ConclusionsThe secondary IOL implantation in children is a relatively safe procedure associated with low rates of postoperative complications. Visual outcomes are acceptable and are better for bilateral patients than for unilateral patients.

Evaluating the evidence for and against the use of IOLs in infants and young children

Congenital cataracts account for 5-20% of childhood blindness worldwide. In the US, the prevalence of visually significant infantile cataracts is anywhere from 3-4 per 10,000 live births. Infantile cataracts need to be removed early in life in order to prevent the onset of deprivation amblyopia. As a result, cataract surgery is usually performed between age 4-8 weeks depending on the laterality and severity of the cataract. Given advances in the field, pediatric cataract surgery is now a safe and effective intervention for infants, but good visual outcomes require occlusion therapy and optical correction. This review will address current perspectives on the use of intraocular lenses to optically correct infants and young children after cataract surgery, as well as novel designs for intraocular lenses and directions for future research.

Complications and visual outcomes after secondary intraocular lens implantation in children

PURPOSE

To evaluate safety and visual outcomes in surgically aphakic children undergoing secondary intraocular lens (IOL) implantation.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

One hundred seventy-four eyes of 104 children (70 bilateral, 34 unilateral) who underwent secondary IOL implantation for aphakia after congenital cataract surgery at L. V. Prasad Eye Institute, Hyderabad, India, were analyzed. A minimum of 3 months of follow-up after surgery was required for inclusion in the study. Eyes with aphakia after surgery for traumatic cataracts and other associated ocular comorbidities were excluded. Main outcome measures were intraoperative and postoperative complications and visual outcome at the last follow-up.

RESULTS

Mean age at secondary IOL implantation was 6.08 ± 3.75 years. The mean follow-up was 25.7 ± 24.9 months. Mean best-corrected visual acuity improved from 1.08 ± 0.65 in aphakic children to 0.55 ± 0.51 logarithm of the minimal angle of resolution in pseudophakic children at last follow-up (P < .0001). Overall, 51 eyes (35%) attained a final best-corrected visual acuity of 20/40 (0.3 logarithm of the minimal angle of resolution) or better, whereas only 2 eyes (8.7%) attained a final best-corrected visual acuity of 20/40 (0.3 logarithm of the minimal angle of resolution) or better in children who underwent secondary IOL implantation for unilateral aphakia. The most common postoperative complications were secondary membrane formation (17 eyes; 9.77%), optic capture (15 eyes; 8.6%), IOL decentration (9 eyes; 5.17%), and secondary glaucoma (11 eyes; 5%).

CONCLUSIONS

Secondary sulcus IOL implantation in children is a relatively safe procedure and leads to favorable visual postoperative outcomes.

Refractive outcomes and prediction error following secondary intraocular lens implantation in children: a decade-long analysis

AIM

To evaluate the refractive outcomes, prediction error (PE) and factors affecting PE in children with aphakia following congenital cataract surgery undergoing secondary intraocular lens (IOL) implantation.

METHODS

We analysed the records of children less than 16 years old who underwent secondary IOL implantation for aphakia following congenital cataract surgery. PE and absolute PE for each case calculated 3 months following secondary IOL implantation were analysed. Multiple regression analysis was performed to determine the relationship between age at secondary IOL implantation, axial length, keratometry readings and PE.

RESULTS

174 eyes of 104 children were analysed. Mean age at surgery was 6.08±3.75 years. The mean PE was 1.65±2.46 dioptres (D) (range -3.25 to 7.5 D) and mean absolute PE was 2.15±1.68 D (range 0-7.5 D) at 3 months. There was a statistically significant difference in absolute PE between eyes in which IOL calculation was performed using IOL master (1.80±1.40 D) versus IOL calculation under general anaesthesia with contact method (2.43±1.83 D), p=0.01. Multiple regression analysis revealed an inverse relationship between age at secondary IOL implantation and mean absolute PE (p=0.01).

CONCLUSIONS

IOL power calculation with SRK II formula with sulcus placement of IOL gives favourable refractive outcomes. Though age-based refraction is targeted, a significant PE may be expected.

[Treatment of pediatric cataracts. Part 2: IOL implantation, postoperative complications, aphakia management and postoperative development]

There is a lot of uncertainty concerning intraocular lens (IOL) implantation for pediatric cataracts. The appropriate age which ocular abnormalities are contraindications and according to which formula IOL should be calculated are controversial. In addition to the imperative of identifying postoperative complications, such as secondary cataract formation and secondary glaucoma in a sufficiently timely manner, a modern management of aphakia with refractive compensation and occlusion is necessary. Some easy rules can help prevent pitfalls.

Modified technique for removal of Soemmerring ring and in-the-bag secondary intraocular lens placement in aphakic eyes

We describe modifications to previously described techniques for evacuation of Soemmerring ring during secondary intraocular lens (IOL) implantation in aphakic eyes following previous pediatric cataract surgery. A new anterior capsulotomy is initiated using a cystotome to incise the anterior capsule close to its attachment to the posterior capsule. A curved microscissor is used to cut circumferentially, completing the capsulotomy, and a dispersive ophthalmic viscoelastic device (OVD) is used to viscoexpress Soemmerring ring material from the capsular bag. A 2-handed maneuver is used to manually divide the Soemmerring ring. Finally, slow-motion phacoemulsification is used to emulsify and remove the pieces. Viscoexpression of fragments of Soemmerring ring is done if there is a posterior capsulotomy. The residual capsular bag is filled with OVD and a foldable 3-piece IOL injected into the bag and dialed in. This technique allows complete evacuation of Soemmerring ring and placement of a secondary IOL in the capsular bag.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.