Posterior capsule opacification after cataract surgery in patients with diabetes mellitus

Type 1 and type 2 diabetes predisposed to higher Nd:YAG capsulotomy rates following cataract surgery: analysis of 53,471 consecutive cases

OBJECTIVE

To assess the effect of diabetes type on Nd:YAG capsulotomy rates following cataract surgery.

DESIGN

A retrospective cohort study.

METHODS

All patients who underwent cataract extraction at the Department of Ophthalmology, Bristol Eye Hospital, Bristol, UK, between 2003 and 2017 were included. The Nd:YAG capsulotomy rate following cataract surgery was assessed and compared between nondiabetic, type 1 diabetes (T1D), and type 2 diabetes (T2D) patients. Multivariate Cox regression analysis controlling for age and sex was used to estimate hazard ratios for Nd:YAG laser capsulotomies.

RESULTS

Included were 53,471 consecutive cataract surgeries. Overall, 42,651 eyes (79.8%) were in nondiabetic patients, 823 eyes (1.5%) were in T1D patients, and 9,997 eyes (18.7%) were in T2D patients. The mean follow-up time was 6.8 ± 4.2 years. In univariate analysis, the eyes of T1D patients (p < 0.001) and T2D patients (p = 0.003) had significantly higher Nd:YAG laser capsulotomy rates than the eyes of nondiabetic patients. In Cox regression analysis adjusted for the patient's age and sex, DM1 (HR 1.692, 95%CI 1.390-2.059, P<0.001) and DM2 (HR 1.157, 95%CI 1.075-1.244, P<0.001) remained significantly predictive for higher Nd:YAG laser capsulotomy rates.

CONCLUSION

In our large cohort study, patients with T1D and T2D were predisposed to high risk for Nd:YAG capsulotomy following cataract surgery. This study may be beneficial and raise awareness regarding the assessment of posterior capsular opacification development in pseudophakic diabetic patients, particularly those with T1D. The significance of ophthalmology screening for diabetes individuals is further supported by this issue.

Vascular endothelial cell-derived exosomal miR-1246 facilitates posterior capsule opacification development by targeting GSK-3β in diabetes mellitus

Posterior capsule opacification (PCO) is a serious complication after cataract surgery. Diabetes could increase the occurrence of PCO, but the mechanism is still unclear. The purpose of this study is to investigate the role of small extracellular vesicles (sEVs) derived from diabetic aqueous humor in PCO process. Intraoperatively-derived aqueous humor sEVs from patients with diabetic related cataract (DRC) promoted the epithelial-mesenchymal transition (EMT) and metastasis of human lens epithelial cells (LECs). Via mouse PCO surgical model and DiI labeled fluorescence detection of sEVs, the sEVs derived from vascular endothelium were discovered directly contacting with LECs. Furthermore, we demonstrated that high-glucose-cultured human umbilical vein endothelial cells (HUVEC) -derived sEVs facilitated EMT process of HLE-B3 using co-culture model in vitro. MiRNA-seq data and GEO datasets analysis revealed that miR-1246 was essential in EMT process with diabetes. The miR-1246 was highly expressed in diabetic aqueous humor sEVs and high-glucose-treated vascular-endothelial-cell-derived sEVs. Moreover, miR-1246 promoted the metastasis and EMT process of HLE-B3 cells by directly targeting GSK-3β. Inhibiting miR-1246 could negatively regulated EMT. This finding might serve as a potential therapy for diabetic PCO.

Nd:YAG laser capsulotomy rates in the Netherlands: practice variation and association with physician practice styles

PURPOSE

To determine the practice variation in the rate of Nd:YAG laser capsulotomy within 1 year after cataract surgery and to identify possible associations with physician practice styles.

SETTING

All hospitals and private clinics in the Netherlands.

DESIGN

Retrospective observational study.

METHODS

In the national medical claims database, we identified all laser capsulotomies performed in the Netherlands within a year after cataract surgery in the years 2016 and 2017. Centers with the lowest and highest percentages of Nd:YAG laser capsulotomies were interviewed on their physician practice styles related to the development of posterior capsule opacification.

RESULTS

The incidence of Nd:YAG laser capsulotomy varied between 1.2% and 26.0% in 2016 (median 5.0%) and between 0.9% and 22.7% in 2017 (median 5.0%). The rate of capsulotomy was highly consistent over time for each center (Pearson correlation coefficient, 0.89, P < .001). In general, ophthalmology centers with a high rate of Nd:YAG laser capsulotomy more often did not (routinely) polish the posterior lens capsule, performed cortex removal with coaxial irrigation/aspiration (I/A, instead of bimanual), and more often used hydrophilic intraocular lenses (IOLs) (compared with only using hydrophobic IOLs).

CONCLUSIONS

We found a significant practice variation in performing Nd:YAG laser capsulotomy within 1 year after cataract surgery in the Netherlands. Routinely polishing the posterior capsule, using bimanual I/A, and the use of hydrophobic IOLs are associated with a lower incidence in Nd:YAG laser capsulotomy. Incorporating these practice styles may lower the practice variation and thus prevent added medical burden for the patient and decrease costs.

Cataract Surgery Considerations for Diabetic Patients

PURPOSE OF REVIEW

Given the epidemiology and demographic trends of diabetes mellitus and cataracts, ophthalmologists are likely to encounter patients with both comorbidities at an increasing frequency. Patients with diabetes represent a higher risk population than healthy patients for cataract surgery. In this review, we discuss key risks and risk-mitigation practices when performing cataract surgery on these patients.

RECENT FINDINGS

Patients with diabetes continue to represent a high-risk surgical population: Nagar et al. suggest a dose-dependent relationship may exist between number of intravitreal injections and likelihood of posterior capsular rupture. However, novel treatments are improving outcomes for patients with diabetes. Several studies have reported intracameral phenylephrine/ketorolac may reduce the incidence of post-operative cystoid macular edema while others have discussed the efficacy of pre-treatment and post-treatment with intravitreal bevacizumab on improving cataract surgery outcomes in patients with diabetic retinopathy. Pre-operatively, ophthalmologists should perform an enhanced evaluation, consider timing and lens selection decisions, and complete any appropriate pre-operative treatment. Peri-operatively, surgeons should be aware of pupillary dilation adjustments, combination surgery options, and potential complications. Post-operatively, clinicians should address pseudophakic cystoid macular edema, diabetic macular edema, diabetic retinopathy, and posterior capsular opacification.

Posterior Capsule Opacification: A Review of Experimental Studies

Posterior capsule opacification (PCO) is the most common complication of cataract surgery. It causes a gradual deterioration of visual acuity, which would otherwise improve after a successful procedure. Despite recent advances in ophthalmology, this complication has not been eradicated, and the incidence of PCO can be as high as 10%. This article reviews the literature concerning the pathomechanism of PCO and examines the biochemical pathways involved in its formation and methods to prevent this complication. We also review the reported tests performed in cell cultures under laboratory conditions and in experimental animal models and in ex vivo human lens capsules. Finally, we describe research involving human eyes in the clinical setting and pharmacological methods that may reduce the frequency of PCO. Due to the multifactorial etiology of PCO, in vitro studies make it possible to assess the factors contributing to its complications and search for new therapeutic targets. Not all pathways involved in cell proliferation, migration, and contraction of the lens capsule are reproducible in laboratory conditions; moreover, PCO in humans and laboratory animals may be additionally stimulated by various degrees of postoperative reactions depending on the course of surgery. Therefore, further studies are necessary.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

Anti-inflammatory Medication After Cataract Surgery and Posterior Capsular Opacification

PURPOSE

To assess the role of anti-inflammatory medication following cataract surgery on the formation of posterior capsular opacification.

DESIGN

Cohort study.

METHODS

A retrospective registry analysis of 25,818 consecutive patients who underwent cataract surgery between the years 2014 and 2018 at Helsinki University Hospital in Finland. Nd:YAG laser capsulotomy rates were compared between patients treated postoperatively with topical steroids, nonsteroidal anti-inflammatory medications (NSAIDs), or their combination. Kaplan-Meier and Cox regression analyses were used. A single eye of each patient was included. Main outcomes were confirmed against a second independent dataset.

RESULTS

A total of 13,368 patients were included in the analysis, with a mean age of 73.2 ± 9.7 years; 61.7% were female. Pseudoexfoliation was noted in 10.1% of cases. The mean follow-up time was 22.8 ± 15.7 months. Patients were treated with steroid monotherapy (28.9% of cases), NSAID monotherapy (62.2%), or a combination of both (8.9%). Treatment with steroids resulted in significantly lower Nd:YAG capsulotomy rates compared to NSAIDs (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.62-0.93, P = .009). Treatment with combination therapy of steroids and NSAIDs showed no added benefit over steroid monotherapy (HR 1.11, 95% CI 0.68-1.80, P = .674). Cox regression analysis adjusted for patients' age, sex, pseudoexfoliation, and risk stratification remained significantly predictive for lower capsulotomy rates with steroid treatment over NSAIDs (HR 0.70, 95% CI 0.52-0.88, P = .001).

CONCLUSIONS

Postoperative treatment with steroids among patients undergoing uncomplicated cataract surgery was associated with lower rates of clinically significant posterior capsule opacification compared to treatment with NSAIDs alone. Combination therapy of steroids and NSAIDs had no added benefit over steroids alone.

Efficacy of long-term topical flurbiprofen in limiting lens capsule opacities following phacoemulsification in dogs

OBJECTIVE

To assess lens capsule opacity (LCO) following phacoemulsification in dogs receiving long-term topical ophthalmic flurbiprofen sodium 0.03%.

ANIMAL STUDIED

Twenty-five client owned dogs undergoing phacoemulsification surgery for either diabetic or nondiabetic cataracts.

METHODS

Prospective, randomized, masked clinical study assessing two groups of dogs for twelve months following phacoemulsification. All dogs underwent a complete eye examination and were photographed at each visit, beginning three weeks post-surgery, and repeated at 2, 3, 6, and 12 months post-surgery. Post-operative treatment protocols were similar for both groups, except that Group F received topical flurbiprofen once daily for 12 months and Group A received artificial tears once daily for 12 months. Digital photographs were analyzed for LCO using a subjective grading scale (0-4). The change in capsular opacities from 3 weeks to 12 months post-surgery was evaluated for each dog, and the groups were compared.

RESULTS

There were 25 dogs evaluated post-phacoemulsification at each designated time point of the study. There were 12 dogs in Group A and 13 dogs in Group F. There was no significant statistical difference in LCO score between Groups A and F at baseline (3 weeks post-surgery), 6 months post-surgery, or 12 months post-surgery. Scores did not change significantly from baseline to 12 months within or between groups.

CONCLUSIONS

Topical ophthalmic flurbiprofen sodium 0.03% solution applied once daily for 12 months following phacoemulsification does not appear to lead to a decrease in LCO formation as compared to artificial tears control.

A HGF‑derived peptide suppresses EMT in human lens epithelial cells via the TGF‑β/Smad and Akt/mTOR signaling pathways

Posterior capsule opacification (PCO) as a result of proliferation and fibrogenesis of lens epithelial cells (LECs) is the most frequent long‑term complication of modern cataract surgery. LECs may undergo epithelial‑mesenchymal transition (EMT) that resembles the morphological and molecular characteristics of PCO. A pre‑identified novel, hepatocyte growth factor (HGF)‑derived peptide H‑RN, was reported to exhibit anti‑angiogenic activity and anti‑inflammatory effects in ocular cells both in vitro and in vivo. However, the role of H‑RN in the promotion of the development of EMT in LECs is unknown. In the present study, the effects of H‑RN on the development of EMT induced by transforming growth factor (TGF)‑β in human LECs, and the possible signaling pathways participating in this process were investigated. The results showed that H‑RN promoted the expression of the EMT‑associated markers, α‑smooth muscle actin and fibronectin, whereas the expression of E‑cadherin and connexin 43 were reduced. The morphological changes typically associated with EMT seen in LECs induced by TGF‑β2 were inhibited by H‑RN, which was consistent with the effects of a TGF‑β2 inhibitor, SB431542. Smad2 and Smad3 phosphorylation induced by TGF‑β2 were reduced by H‑RN, and phosphorylation of Akt, mTOR and P70S6K induced by TGF‑β2 were also notably reduced by H‑RN in LECs. Therefore, the results of the present study showed that H‑RN treatment significantly suppressed the development of EMT induced by TGF‑β2, at least partially through the TGF‑β/Smad and Akt/mTOR signaling pathways in human LECs. The present study highlights that H‑RN, a novel HGF‑derived peptide, may be a novel therapeutic agent for prevention and treatment of PCO.

The effects of c-Src kinase on EMT signaling pathway in human lens epithelial cells associated with lens diseases

Background

The signaling pathway of epithelial to mesenchymal transition (EMT) is regulated by c-Src kinase in many cells. The purpose of this study was to investigate the effects of c-Src kinase on EMT of human lens epithelial cells in vivo stimulated by different factors.

Methods

Human lens epithelial cells, HLE-B3, were exposed to either an inflammatory factor, specifically IL-1α, IL-6, TNF-α or IL-1β, at 10 ng/mL or high glucose (35.5 mM) for 30 mins. Activity of c-Src kinase was evaluated by the expression of p-Src⁴¹⁸ with western blot assay. To investigate the effects of activation of c-Src on EMT, HLE-B3 cells were transfected with pCDNA3.1-Src^Y530F to upregulate activity of c-Src kinase, and pSlience4.1-ShSrc to knock it down. The expressions of c-Src kinase and molecular markers of EMT such as E-cadherin, ZO-1, α-SMA, and Vimentin were examined at 48 h by RT-PCR and western blot. At 48 h and 72 h of transfection, cell proliferation was detected by MTT, and cell mobility and migration were determined by scratch and transwell assays.

Results

Activity of c-Src kinase, which causes the expression of p-Src⁴¹⁸, was upregulated by different inflammatory factors and high glucose in HLE-B3 cells. When HLE-B3 cells were transfected with pCDNA3.1-Src^Y530F, the expression of c-Src kinase was upregulated on both mRNA and protein levels, and activity of c-Src kinase, expression of p-Src⁴¹⁸ increased. The expressions of both E-cadherin and ZO-1 were suppressed, while the expressions of vimentin and α-SMA were elevated on both mRNA and protein levels at the same time. Cell proliferation, mobility and migration increased along with activation of c-Src kinase. Conversely, when HLE-B3 cells were transfected with pSlience4.1-ShSrc, both c-Src kinase and p-Src⁴¹⁸ expressions were knocked down. The expressions of E-cadherin and ZO-1 increased, but the expressions of Vimentin and α-SMA decreased; meanwhile, cell proliferation, mobility and migration reduced.

Conclusions

The c-Src kinase in lens epithelial cells is easily activated by external stimuli, resulting in the induction of cell proliferation, mobility, migration and EMT.

Diabetes and Phacoemulsification Cataract Surgery: Difficulties, Risks and Potential Complications

Diabetes mellitus is one of the most prevalent chronic diseases worldwide. Diabetic patients are at risk of developing cataract and present for surgery at an earlier age than non-diabetics. The aim of this study was to review the problems associated with cataract surgery in a diabetic patient. Corneal complications in diabetic patients include delayed wound healing, risk of developing epithelial defects or recurrent erosions due to the impairment of epithelial basement membranes and epithelial-stromal interactions. Diabetic patients present lower endothelial cell density and their endothelium is more susceptible to trauma associated with cataract surgery. A small pupil is common in diabetic patients making cataract surgery technically challenging. Finally diabetic patients have an increased risk for developing postoperative pseudophakic cystoid macular edema, posterior capsule opacification or endophthalmitis. In patients with pre-proliferative or proliferative diabetic retinopathy, diabetic macular edema or iris neovascularization adjunctive therapy such as an intravitreal anti-vascular endothelial growth factor injection, can inhibit exacerbation related to cataract surgery.

Cataract in diabetes mellitus

Diabetes mellitus (DM) is a chronic systemic disease that has increases in prevalence over time. DM can affect all ocular structures, with cataract being the most common ocular complication. Cataract is the leading cause of blindness worldwide. Due to several mechanisms, there is an increased incidence of cataract formation in the diabetic population. Advancements in technology have now made cataract surgery a common and safe procedure. However, the diabetic population is still at risk of vision-threatening complications, such as diabetic macular edema (ME), postoperative ME, diabetic retinopathy progression, and posterior capsular opacification.

Cataract surgery in diabetes mellitus: A systematic review

India is considered the diabetes capital of the world, and a significant proportion of patients undergoing cataract surgery are diabetic. Considering this, we reviewed the principles and guidelines of managing cataract in patients with diabetes. The preoperative, intraoperative, and postoperative factors are of paramount importance in the management of diabetic cataract patients. Particularly, the early recognition and treatment of diabetic retinopathy or maculopathy before cataract surgery influence the final visual outcome and play a major role in perioperative decision-making. Better understanding of various factors responsible for favorable outcome of cataract surgery in diabetic patients may guide us in better overalll management of these patients and optimizing the results.

Cataract Surgery in Patients with Diabetes: Management Strategies

Diabetes is a chronic systemic disease that affects nearly one in eight adults worldwide. Ocular complications, such as cataract, can lead to significant visual impairment. Among the worldwide population, cataract is the leading cause of blindness, and patients with diabetes have an increased incidence of cataracts which mature earlier compared to the rest of the population. Cataract surgery is a common and safe procedure, but can be associated with vision-threatening complications in the diabetic population, such as diabetic macular edema, postoperative macular edema, diabetic retinopathy progression, and posterior capsular opacification. This article is a brief review of diabetic cataract and complications associated with cataract extraction in this population of patients.

German claims data analysis to assess impact of different intraocular lenses on posterior capsule opacification and related healthcare costs

Aim

Cataract extraction is one of the most frequent surgeries in Germany. In most cases, the clouded natural lens is replaced by a hydrophobic or hydrophilic acrylic intraocular lens (IOL) implant. The most common long-term complication after cataract surgery is the development of a posterior capsule opacification (PCO). Although no precise real world data are available, published evidence suggests a lower risk for PCO development for hydrophobic acrylic IOLs compared to hydrophilic acrylic IOLs. Therefore, in the present study we assessed real world data on the impact of different IOL material types on the incidence of post-operative PCO treatment.

Subject and methods

In this retrospective study, we included 3,025 patients who underwent cataract extraction and implantation of either an acrylic hydrophobic or hydrophilic IOL in 2010. We assessed clinical outcomes and direct costs in a 4-year follow-up period after cataract surgery from a statutory health insurance (SHI) perspective in Germany.

Results

PCO that required capsulotomies occurred significantly (p < 0.0001) less frequent in patients who had received a hydrophobic IOL (31.57% of 2,078 patients) compared to the group with hydrophilic IOL implants (56.6% of 947 patients) and costs per patient for postoperative treatment in a 4-year follow-up were 50.03 € vs. 87.81 € (i.e. 75% higher in the latter group, p < 0.0001).

Conclusion

Considering the high prevalence of cataract, the economic burden associated with adverse effects of cataract extraction is of great relevance for the German SHI. Hydrophobic lenses seem to be superior regarding both medical and economic results.

Long-term outcome of cataract surgery in patients with idiopathic hypoparathyroidism and its relationship with their calcemic status

Cataract is a cardinal manifestation of hypoparathyroidism. Although patients with hypoparathyroidism require cataract surgery at a younger age than individuals without hypoparathyroidism, there is limited information on the outcome of this surgery. We assessed long-term complications of cataract surgery in patients with idiopathic hypoparathyroidism (IH) and its relationship with their clinical and biochemical parameters. Twenty-seven patients with IH and 25 nonhypoparathyroid controls with a minimum follow-up of 2 years after cataract surgery were assessed for visual acuity, intraocular pressure, lens centricity, Nd:YAG laser capsulotomy, and the severity of posterior capsular opacification (PCO) and anterior capsular opacification. High-resolution optical slit-lamp images were analyzed by an ophthalmologist. Patients with IH had cataract surgery at a younger age than controls (34.0 ± 16.4 years vs 58.0 ± 11.2 years, P < 0.001). A higher proportion of IH patients had dense white PCO (75.0 % vs 39.4 %, P = 0.004), Nd:YAG laser capsulotomy (44.2 % vs 10.0 %, P = 0.001), anterior capsular opacification (97.7 % vs 84.2 %, P = 0.03), and a decentric lens (28.3% vs 2.6 %, P = 0.001) at a comparable time after surgery (8.6 ± 6.1 years vs 8.7 ± 6.8 years, P = 0.85). On regression analysis, the severity of PCO in IH correlated only with male sex and not with other factors, including serum total calcium and inorganic phosphorus levels at the baseline and during follow-up. To conclude, patients with IH are likelier than individuals without IH to develop PCO and to require Nd:YAG laser capsulotomy after cataract surgery. Proper precautions should be taken during surgery to minimize this complication in IH.

Long-term follow-up of posterior capsule opacification after AquaLase and NeoSoniX phacoemulsification

AIM

To compare the degree of posterior capsule opacification (PCO) after AquaLase and NeoSoniX phacoemulsification methods during an 8-year follow-up period using two types of software.

DESIGN

Prospective, randomized clinical trial.

METHODS

AquaLase was used in the right eye and NeoSoniX in the left eye of each patient with bilateral cataract.

RESULTS

Fifty patients were analyzed 1 year, 46 patients 3 years, and 37 patients 8 years after cataract surgery. Mean EPCO 2000 values were for the AquaLase group 0.324 ± 0.305 and for the NeoSoniX group 0.298 ± 0.341 (P = 0.53) 1 year after surgery, for the AquaLase group 0.582 ± 0.506 and for the NeoSoniX group 0.594 ± 0.515 (P = 0.87) 3 years after surgery, and for the AquaLase group 0.648 ± 0.567 and for the NeoSoniX group 0.673 ± 0.542 (P = 0.30) 8 years after surgery. The OSCA results were for the AquaLase group 0.7097 ± 0.3778 and for the NeoSoniX group 0.8584 ± 0.4323 (P = 0.046) 1 year after surgery, for the AquaLase group 0.9667 ± 0.736 and for the NeoSoniX group 0.9540 ± 0.5250 (P = 0.91) 3 years after surgery, and for the AquaLase group 1,035 ± 0,952 and for the NeoSoniX group 1,103 ± 0,741 (P = 0.44) 8 years after surgery.

CONCLUSION

There was minimal PCO difference between these 2 approaches, AquaLase and NeoSoniX. Neither AquaLase nor NeoSoniX technique was able to prevent a natural progression of PCO.

[Posterior capsule opacification, capsular bag distension syndrome, and anterior capsular phimosis: A retrospective cohort study]

OBJECTIVE

To determine the incidence and the risk factors involved in the development of the three main postoperative capsular complications: posterior capsule opacification (PCO), capsular bag distension syndrome (CBDS), and anterior capsular phimosis syndrome (ACP).

SUBJECTS, MATERIAL AND METHODS

A retrospective cohort study was conducted on 801 patients submitted to cataract surgery in the ophthalmology unit of Hospital del Henares (Madrid) from March 2, 2009 to February 28, 2010. Computerized clinical charts were reviewed during July 2012. PCO was studied using the Kaplan-Meier method (log rank test).

RESULTS

A total of 167 patients developed PCO. No association could be demonstrated between PCO and age, sex, diabetes mellitus, phaco technique, IOL model, tamsulosin intake, glaucoma, and age-related macular degeneration. Three patients developed CBDS, all of them have received and Akreos Adapt AO(®) (Bausch & Lomb). Two of them were young men who had received surgery for posterior subcapsular cataracts. Three patients developed ACP, 2 of whom had received a MicroSlim(®) IOL (PhysIOL).

CONCLUSIONS

No association was found between PCO and any of the studied variables. Male gender, young age, subcapsular cataract and large non-angulated lens such as Akreos Adapt AO(®) could be associated with CBDS. ACP could be more frequent when microincision IOLs (like MicroSlim(®)) are implanted.

In vitro growth of lens epithelial cells from cataract patients - association with possible risk factors for posterior capsule opacification

AIM

Inter-individual differences in intrinsic proliferative capacity of lens epithelial cells may have importance for the risk of developing posterior capsule opacification (PCO) after cataract surgery. The purpose of the present study was to determine growth of human lens epithelial cells (HLEC) in culture and investigate possible associations with clinical characteristics of the donors, such as age, sex, pseudoexfoliation, uveitis and diabetes.

METHODS

Pieces of lens capsule and adhering lens epithelial cells were obtained through capsulorhexis at cataract surgery. Specimens were cultured in a humidified CO2-incubator using standard culture medium and 5% fetal calf serum for two weeks after which cultured cells were stained with carboxy-fluorescein diacetate succinimidyl ester. Image processing software was used to determine the area of the confluent epithelial cell layer in relation to the size of the original capsule specimen.

RESULTS

The increase in area of confluent HLEC showed a negative correlation with diabetes at the first week after surgery. Lower age and female sex showed border-line significant associations with a higher rate of cell proliferation. The presence of pseudoexfoliation in vivo did not significantly affect cell growth in culture postoperatively. Nor did installation of xylocain in the anterior chamber during surgery.

CONCLUSION

Diabetes is associated with lower rate of proliferation of lens epithelial cells in culture. The lack of strong correlations between in vitro growth and known risk factors for PCO in the donors suggest that other factors than the proliferative capacity of the cells per se are important for PCO formation.

Nd:YAG Capsulotomy after Phacoemulsification in Vitrectomized Eyes: Effects of Pars Plana Vitrectomy on Posterior Capsule Opacification

To compare the progression of posterior capsule opacification (PCO) in patients who required Nd:YAG laser capsulotomy following either combined cataract surgery with pars plana vitrectomy (PPV; C-CV), sequential cataract surgery after PPV (S-CV), or cataract surgery alone (CA). The medical records of 321 patients (408 eyes) who underwent Nd:YAG capsulotomy were retrospectively evaluated. The CA group had a significantly longer time interval from cataract surgery to capsulotomy than that of both the CV group (P = 0.006) and the S-CV (P = 0.013) and C-CV (P = 0.042) subgroups when age-matched comparisons were used. CV patients who implanted a hydrophobic acrylic IOL had shorter time intervals than those of CA patients (P = 0.028). CV patients had larger hazard of earlier capsulotomy than CA patients (hazard ratio (HR) = 1.337; 95% confidence interval (CI) 1.100–1.625; P = 0.004). C-CV and S-CV patients both had larger hazard than CA patients in earlier capsulotomy (HR = 1.304; 95% CI = 1.007–1.688; P = 0.044, HR = 1.361; 95%  CI = 1.084–1.709; P = 0.008, resp.). PCO progresses more rapidly in patients undergoing combined or sequential cataract surgery and PPV than in patients undergoing CA.

A prospective evaluation of posterior capsule opacification in eyes with diabetes mellitus: a case-control study

AIM

To compare the development of posterior capsule opacification (PCO) between eyes with and without diabetes mellitus after single-piece hydrophobic acrylic intraocular lens implantation 4 years postoperatively.

METHODS

In this prospective, observational case-control study carried out at Iladevi Cataract and IOL Research Centre, Ahmedabad, India, 75 consecutive eyes with diabetes mellitus (cases) were compared with 75 age-matched eyes with age-related cataract (controls). A detailed, preoperative and posterior segment evaluation was carried out in eyes with diabetes mellitus to detect the presence or absence of diabetic retinopathy (DR). The Mann-Whitney U-test was applied to compare the differences in the development of PCO between the two groups.

RESULTS

There was no difference in median PCO between cases and controls at 1 month (2.0 vs 1.50, P<0.068), but cases had a higher median PCO at 12 months (2.95 vs 1.30, P<0.001). At 4 years, there was no significant difference in median PCO between cases and controls (3.75 vs 2.25, P=0.273). The duration of diabetes increased the incidence of PCO at 4 years (P=0.02). Severity of DR had no influence on the progress of PCO at 4 years (P=0.69).

CONCLUSION

Diabetes mellitus did not increase the incidence of PCO at 4 years. The duration of diabetes increased the risk of PCO. The severity of retinopathy did not influence the development of PCO.

Neodymium:yttrium-aluminum garnet capsulotomy rates after combined cataract surgery with implantation of a 4% water content hydrophobic acrylic intraocular lens and vitrectomy

BACKGROUND

The purpose of this study was to examine neodymium:yttrium-aluminum garnet (Nd:YAG) capsulotomy rates after combined cataract surgery with implantation of a three-piece 4% water content hydrophobic acrylic intraocular lens (X-70, Eternity®) and vitrectomy, and compare diabetic retinopathy with nondiabetic retinopathy.

METHODS

Nd:YAG capsulotomy rates were evaluated for 72 eyes of 72 patients with diabetic retinopathy and 81 eyes of 81 patients with nondiabetic retinopathy (50 eyes with retinal detachment, 13 eyes with macular hole, nine eyes with epiretinal membrane, seven eyes with branch retinal vein occlusion, and two eyes with uveitis) who underwent combined cataract surgery and vitrectomy and implantation of X-70.

RESULTS

Two years after combination surgery, four of 72 eyes (5.6%) in the diabetic retinopathy group and four of 81 eyes (5.0%) in the nondiabetic retinopathy group required Nd:YAG capsulotomies. Kaplan-Meier survival analysis showed no statistically significant differences between the two groups (P=0.30, Mantel-Cox log-rank test).

CONCLUSION

The rate of Nd:YAG capsulotomy did not significantly differ between diabetic retinopathy and nondiabetic retinopathy after combined cataract surgery with implantation of the X-70 and vitrectomy. X-70 is an acceptable intraocular lens for patients undergoing combined cataract surgery and vitrectomy.

Assessment of the bag-in-the-lens implantation technique in diabetic patients

Cataract is a common condition observed in patients with diabetes mellitus frequently requiring surgical intervention. The bag-in-the-lens (BIL) intraocular implant is an alternative approach to standard lens-in-the-bag cataract surgery. The lens is supported by anterior and posterior capsulorhexes, which confers a number of advantages in terms of lens centration, rotational stability and prevention of posterior capsular opacity. The purpose of this report is to describe the results of BIL cataract surgery in a retrospective cohort of diabetic patients. Fifty-four cases of BIL surgery are included with a follow-up period of 1 year. Visual acuity outcomes were comparable to previously published standard lens-in-the-bag procedures. There were no reports of posterior capsular opacification and the grade of diabetic retinopathy remained stable. Three cases of clinically significant macular edema were detected over the follow-up period. We conclude that the BIL implantation technique is an advantageous approach to treating cataract in the diabetic population.

Posterior capsule opacification and neovascularization treated with intravitreal bevacizumab and Nd:YAG capsulotomy

We reported a 75-year-old diabetic man, who developed opacification and neovascularization of the posterior capsule after extracapsular cataract extraction and posterior chamber intraocular lens implantation. The patient was treated with two injections of 2.5 mg of intravitreal bevacizumab. The treatment produced an important regression of the posterior capsular new vessels, allowing us to perform a successful Nd:YAG capsulotomy, clearing the visual axis and improving the visualization of the posterior pole. Even though, best corrected visual acuity was 20/200 due to diabetic macular edema.

Factors contributing to posterior capsule opacification following 23-gauge transconjunctival phacovitrectomy

BACKGROUND AND OBJECTIVE

To determine posterior capsule opacification (PCO) rate and identify contributory factors in a series of patients undergoing combined 23-gauge transconjunctival phacovitrectomy.

PATIENTS AND METHODS

Retrospective data on 221 consecutive patients operated on by a single senior surgeon using a standard technique were collected and subjected to univariate analysis with chi-square tests and multivariate analysis with logistic regression.

RESULTS

PCO developed in 46 of 221 cases (20.8%). Major risk factors were: rhegmatogenous retinal detachment (relative risk = 3.3, P = .002), axial length greater than 24.5 mm (relative risk = 2.0, P = .093), intraoperative/postoperative complications (relative risk = 3.3, P = .04), C2F6 tamponade (versus SF6/air) (relative risk = 2.8, P = .01), and postoperative posturing (relative risk = 4.1, P < .001). Multiple logistic regression analysis showed the latter two to be most important.

CONCLUSION

PCO rate following 23-gauge phacovitrectomy is lower than most rates reported for 20-gauge phacovitrectomy. Using shorter-acting gas tamponade and avoiding postoperative posturing may help lower PCO rates.

Three-year follow-up of posterior capsule opacification after AquaLase and NeoSoniX phacoemulsification

PURPOSE

To prospectively compare the degree of posterior capsule opacification (PCO) after AquaLase and NeoSoniX phacoemulsification methods during the 3-year follow-up period.

DESIGN

Prospective, randomized clinical trial.

METHODS

Setting at the Department of Ophthalmology, University Hospital in Hradec Králové. Patients with bilateral cataract were included. AquaLase was used in the right eye and NeoSoniX in the left eye of each patient. The AcrySof SA60AT intraocular lens (Alcon Laboratories, Fort Worth, Texas, USA) was implanted in all eyes. The Evaluation of Posterior Capsule Opacification (EPCO) 2000 software (Developed by Tetz MR and associates, Berlin, Germany) and the Open-Access Systematic Capsule Assessment (OSCA) system (Devised by Aslam TM, Edinburgh, United Kingdom) were used for PCO assessment 1, 2, and 3 years after cataract surgery.

RESULTS

Fifty patients were analyzed 1 year, 47 patients 2 years, and 46 patients 3 years after cataract surgery. Mean EPCO 2000 values were for the AquaLase group 0.324 +/- 0.305 and for the NeoSoniX group 0.298 +/- 0.341 (P = .53) 1 year after surgery, for the AquaLase group 0.429 +/- 0.322 and for the NeoSoniX group 0.478 +/- 0.337 (P = .30) 2 years after surgery, and for the AquaLase group 0.582 +/- 0.506 and for the NeoSoniX group 0.594 +/- 0.515 (P = .87) 3 years after surgery. The OSCA results were for the AquaLase group 0.7097 +/- 0.3778 and for the NeoSoniX group 0.8584 +/- 0.4323 (P = .046) 1 year after surgery, for the AquaLase group 0.7515 +/- 0.4555 and for the NeoSoniX group 0.8103 +/- 0.4498 (P = .44) 2 years after surgery, and for the AquaLase group 0.9667 +/- 0.736 and for the NeoSoniX group 0.9540 +/- 0.5250 (P = .91) 3 years after surgery. Neodymium-yttrium-aluminun-garnet capsulotomy rate for AquaLase vs NeoSoniX was 0:1 eyes 1 year, 1:3 eyes 2 years, and 1:4 eyes 3 years after surgery. No significant difference between those 2 groups was established, except the OSCA outcomes 1 year postoperatively.

CONCLUSION

There was only minimal PCO difference between these 2 approaches, AquaLase and NeoSoniX. Neither AquaLase nor NeoSoniX technique was able to prevent a natural progression of PCO.

Diabetic vitrectomy: the influence of lens status upon surgical outcomes

PURPOSE OF REVIEW

Management of the lens in diabetic eyes undergoing vitrectomy has long been a source of controversy. Initially, the lens was removed during diabetic vitrectomy because of intraoperative changes. It was noted, however, that anterior segment neovascular complications were greater in aphakic eyes after diabetic vitrectomy, and subsequently the vitreoretinal surgeon attempted to spare the lens. Lens management in this regard continues to attract discussion. This report reviews recent trends in the management of the native lens in the diabetic eye undergoing vitrectomy.

RECENT FINDINGS

The rate of cataract formation after diabetic vitrectomy is high in eyes left phakic. The rates of anterior segment neovascularization and retinal detachment after diabetic vitrectomy are similar in phakic and nonphakic eyes. The rate of subsequent reoperation after diabetic vitrectomy may be greater in eyes left phakic.

SUMMARY

Although the management of the lens in an eye undergoing diabetic vitrectomy should be individualized, cataract extraction performed either before or in combination with vitrectomy may reduce the rate of subsequent reoperation. The vitreoretinal surgeon may consider rendering an eye nonphakic before or during diabetic vitrectomy to optimize outcomes.

Posterior capsule opacification after combined cataract surgery and vitrectomy

PURPOSE

To compare the degree of posterior capsule opacification (PCO) after combined cataract surgery and vitrectomy and after cataract surgery alone in age-matched control patients and in patients with and without diabetes mellitus (DM).

SETTING

Sugita Eye Hospital, Nagoya, Japan.

METHOD

In a prospective study, patients were divided into 2 groups: those having cataract surgery alone (cataract group) and those having combined cataract and vitrectomy surgery (combined group). The 2 groups were further divided into patients without DM (non-DM subgroup) and patients with DM (DM subgroup). The PCO rates were determined 3, 6, and 12 months after surgery using the POCO system.

RESULTS

In the cataract group, the non-DM subgroup and the DM subgroup each comprised 42 eyes of 42 patients. In the combined group, the non-DM subgroup comprised 26 eyes of 26 patients and the DM subgroup, 23 eyes of 23 patients. In the cataract group, the PCO rate in the DM subgroup was significantly higher than in the non-DM subgroup at every postoperative examination (P<.05). In the non-DM subgroup, the PCO rate was significantly higher at every postoperative examination in patients having combined surgery than in patients having cataract surgery alone (P<.05). In the combined group, the PCO rate did not differ significantly between the non-DM subgroup and the DM subgroup.

CONCLUSION

Even patients without DM must be carefully monitored for PCO development after combined surgery.