Bimanual microphaco for posterior polar cataracts

Morphological variations influencing the outcomes in posterior polar cataract

Purpose

To study the intraoperative complications and postoperative clinical outcomes in different types of posterior polar cataract (PPC) following phacoemulsification, based on morphological classification.

Methods

All consecutive patients with PPC who underwent phacoemulsification during the study period from 2016 to 2019 were included and sub-grouped based on the morphological characteristics according to Daljit Singh's classification. Intraoperative complications such as posterior capsular rupture (PCR), vitreous loss, nucleus drop, and Postoperative best-corrected visual acuity (BCVA) at day 1 and day 30 were documented.

Results

A total of 388 eyes of 380 patients were included. Eighty nine (22.9%) eyes belonged to type 1, 135 (34.8%) belonged to type 2, 8 (2.1%) belonged to type 3, and 156 (40.2%) belonged to type 4. Thirty-five (9.3%) eyes had intraoperative PCR, with vitreous loss in 21 (60%) eyes, and nucleus/cortex drop in 5 (1.3%) eyes. Six (75%) eyes of type 3, 14 (10.04%) eyes of type 2, 12 (17.7%) eyes of type 4, and 3 (3.4%) eyes of type 1 PPC had PCR. PCR occurred more during the emulsification of the nucleus (18 cases, 51.4%). A significant correlation was seen between intraoperative PCR and type of PPC with a higher incidence in type 3 (P < 0.001). BCVA was found to be significantly worse on day 1 among patients with PCR compared to those who did not and improved well by day 30.

Conclusion

PPC morphology is significantly co-related with the occurrence of PCR, emphasizing the need for careful grading of posterior polar cataracts in predicting the risk of intraoperative complications.

Phacoemulsification in posterior polar cataract: Experience from a tertiary eye care Centre in North India

Purpose:

To determine the rate of posterior capsular rupture (PCR) and assess the postoperative outcomes in patients of posterior polar cataract (PPC) undergoing phacoemulsification using a combination of “V” or “λ” nucleofractis and viscodissection.

Methods:

It was a retrospective study of 80 eyes of 64 patients undergoing surgery for PPC. All surgeries were performed by a single surgeon. After completion of the continuous curvilinear capsulorrhexis (CCC), controlled hydrodelineation was used to separate the endonucleus from the epinuclear shell with limited viscodissection. Phacoemulsification was then carried out by making a “V” or lambda-shaped nucleofractis with the phaco tip followed by multiple chopping of the nucleus, ensuring the integrity of the epinuclear part of the lens. The epinuclear plate was removed after viscodissection.

Results:

The overall rate of PCR was 7.5% (6 out of 80 eyes). Of the 6 eyes, 4 eyes had been documented to have a pre-existing posterior capsular defect on slit-lamp examination. The rate of “on table” PCR, that is, PCR occurring intraoperatively was only 2.6% (2 of 76 eyes). Nucleus drop was not encountered in any case. Overall 87.5% eyes achieved a final visual acuity of 20/40 or better with 68.75% being 20/20 or better. Of the eyes developing PCR, two-third achieved a visual acuity of 20/30 or better.

Conclusion:

Using a combination of surgical techniques of V groove or lambda technique for nucleofractis and removal of epinucleus by viscodissection can result in a low rate of PCR and extremely good postoperative outcomes in cases of PPC.

Managing the posterior polar cataract: An update

Posterior polar cataracts (PPC) have always been a challenge for cataract surgeons due to their inherently higher propensity for posterior capsule rupture. Over the years, several technical modifications have been suggested to enhance safety and reduce posterior capsule rupture rates in these polar cataracts. This review article tries to present the various techniques and strategies to published in literature to manage PPCs. It also discusses pearls for making surgery more reproducible and consistent, as well as the role of newer diagnostic and surgical technology based on the published literature on the subject.

INCIDENCE OF LENS TOUCH DURING PARS PLANA VITRECTOMY AND OUTCOMES FROM SUBSEQUENT CATARACT SURGERY

PURPOSE

To determine the incidence of lens touch during pars plana vitrectomy (PPV) and evaluate cataract surgery complications after lens touch.

METHODS

One thousand three hundred and ninety nine phakic patients who underwent PPV during the period from 2001 to 2013 were included in the study. Data of the PPV and lens touch (excluding lens bite) complications were reviewed from an electronic database (VITREOR). Subsequent cataract surgery data and intraoperative complications were reviewed. A control group consisted of 149 cases of phakic patients who underwent PPV with no lens touch then subsequent cataract surgery. All surgeries were performed by senior surgeons, and no cataract was present before the PPV.

RESULTS

The incidence of lens touch was 3.7% (52 of 1,399 phakic patients). The Demographics and presenting complaints of the patients were not significantly associated with lens touch, but retinal detachment with proliferative vitreoretinopathy, the use of silicone oil and use of relaxing retinectomy were associated with more lens touch. Cataract developed in 49 patients of whom 45 underwent cataract surgery. Nuclear sclerosis developed in 22 patients, 16 had posterior subcapsular, 8 had mixed lens opacities, and 3 had white cataract. The median duration between PPV and cataract surgery was 4 months in the lens touch group, which was significantly shorter than the median of 8 months in the control group (P = 0.001). During the subsequent cataract surgery in the lens touch group, 5 patients (11%) had a posterior capsule rupture, whereas the control group had only 2 cases of posterior capsule rupture 1.4% (P = 0.008). Final visual acuity was 0.3 LogMar or better in 22 patients (44%).

CONCLUSION

Lens touch is a frequent complication of PPV in a phakic eye. It is more common in patients having surgery for proliferative vitreoretinopathy. Care should be taken when performing subsequent cataract surgery on an eye with lens touch as it carries a significantly increased chance of posterior capsule rupture.

Surgical approaches to posterior polar cataract: a review

The aim of this study is to provide a comprehensive overview of surgical methods used in the emulsification of posterior polar cataracts (PPCs) that have been devised to minimize the risk of posterior capsule rupture (PCR) and its consequences. A Pubmed and Medline search of relevant literature on PPC was done. Only articles relevant to the treatment of PPC were included. The posterior capsule in eyes with PPC are known to have an abnormal adhesion to the polar opacity or a pre-existing weakness of the capsule that predisposes the eye to PCR. To circumvent the consequences of cleaving the abnormal adhesion, a majority of the surgeons use the anterior approach through the limbus, whereas some advocate the posterior approach through the pars plana. Emulsifying the nucleus and cleaving the central opacity of the PPC off the posterior capsule without disrupting its integrity provides optimal surgical outcomes. To achieve this, various modifications have been applied by surgeons during different phases of surgery. The advantages, disadvantages, complications, and results of each method have been discussed. Phacoemulsification is the preferred technique for removing PPC. This review will provide methods to avoid and /or deal with intraocular surgical difficulties that can arise during emulsification. Employing these would result in least ocular morbidity and satisfactory visual outcomes for the patient. This is particularly relevant given the major advancements in technology and refinements in surgical techniques in phacoemulsification.

Corneal Optical Quality Following Sub 1.8 mm Micro-Incision Cataract Surgery vs. 2.2 mm Mini-Incision Coaxial Phacoemulsification

Purpose:

To study and compare the effects of the micro-incision cataract surgery (MICS-sub 1.8 mm) and miniincision coaxial phacoemulsification (2.2 mm) on the optical quality of the cornea characterized in terms of corneal aberrations.

Materials and Methods:

Fifty eyes underwent MICS and 50 mini-incision phacoemulsification, by the same surgeon. Both types of cataract surgery were performed using low ultrasound power and through a clear corneal incision, placed on the steepest corneal meridian ranging from 1.6 to 1.8 in MICS (Group I) and from 2.12 to 2.3 mm in mini-incision coaxial phacoemulsification (Group II). Seidel and Zernike aberration coefficients and RMS values were obtained for a 6-mm pupil preoperatively and one month after surgery.

Results:

The corneal astigmatism did not show statistically significant changes in either of the two groups: (MICS: –0.73 ± 0.63, –0.65 ± 0.53 D, P = 0.25), (mini-incision phacoemulsification; –1.21 ± 1.52, –1.00 ± 1.19 D, P = 0.12). The total RMS remained unchanged after MICS (1.77 ± 1.7, 1.65 ± 1.3 μm, P = 0.18) and mini-incision phacoemulsification (2.00 ± 1.87, 2.09 ± 1.8 μm, P = 0.41). Statistically significant changes were found for coma (P = 0.004) and higher-order aberrations (P < 0.001), showing MICS significantly less changes in cornea.

Conclusions:

Both MICS and mini-incision phacoemulsification do not degrade the optical quality of the cornea. Both surgeries do not induce a modification of the corneal astigmatism, even in the axis. It seems that 2 mm is the limit around which no optical changes are induced by cataract surgery in the human cornea.

Posterior polar cataract: A review

Posterior polar cataract is a rare form of congenital cataract. It is usually inherited as an autosomal dominant disease, yet it can be sporadic. Five genes have been attributed to the formation of this disease. It is highly associated with complications during surgery, such as posterior capsule rupture and nucleus drop. The reason for this high complication rate is the strong adherence of the opacity to the weak posterior capsule. Different surgical strategies were described for the handling of this challenging entity, most of which emphasized the need for gentle maneuvering in dealing with these cases. It has a unique clinical appearance that should not be missed in order to anticipate, avoid, and minimize the impact of the complications associated with it.

Modified technique for epinucleus removal in posterior polar cataract

The authors describe a novel technique for the removal of the sub-incisional epinucleus in cases of posterior polar cataracts. After the removal of the nucleus, the epinucleus is removed from the quadrant opposite to the section by aspiration using the phaco probe. Then hydrodissection is performed to dislodge the sub-incisional epinucleus, which is aspirated out. The rate of posterior capsular rupture decreased considerably with this technique because it reduced the manipulations required.

Inverse horse-shoe technique for the phacoemulsification of posterior polar cataract

OBJECTIVE

To study a new technique of controlled hydrodelineation followed by viscodelineation and viscodissection during phacoemulsification in eyes with posterior polar cataracts and to report its effectiveness in preserving the posterior capsule.

DESIGN

Prospective interventional study.

PARTICIPANTS

Twenty-eight eyes of 22 patients with posterior polar cataracts.

METHODS

All patients underwent phacoemulsification under topical anaesthesia with controlled hydrodelineation, viscodelineation, and viscodissection with minimal stress on the posterior capsule. Hydrodissection was not done. The preoperative complications and visual outcome were recorded.

RESULTS

The mean follow-up time was 8 months (range 2-24 months). Posterior capsule rupture occurred only in 2 eyes (7.1%); neither of the 2 had any vitreous prolapse, so anterior vitrectomy was not required. Mean visual acuity improved significantly after surgery (p = 0.0001, paired t test). The causes of the low postoperative visual acuity were amblyopia in 3 eyes (10.7%) and age-related macular degeneration in 1 (3.6%).

CONCLUSIONS

This inverse horse-shoe technique of controlled viscodelineation and viscodissection markedly reduced the risk of posterior capsule rupture. Moreover, if it occurred, the anterior vitreous face remained intact, so the IOL could be implanted in the sulcus without resorting to anterior vitrectomy.

Modified epinucleus pre-chop for the dense posterior polar cataract

A novel technique for the surgical management of dense posterior polar cataracts is described. In instances where hydrodelineation may be difficult to achieve due to the density of the nucleus, the anterior epinucleus is first pre-chopped in a piecemeal in situ maneuver before mobilizing, segmenting, and emulsifying the dense endonucleus. This is followed by the removal of the posterior epinucleus and the posterior polar plaque. Because the chopper is repositioned at different meridians in the mid-periphery of the anterior epinucleus, it stops short of the central posterior epinucleus, thus avoiding extension of the crack toward the posterior polar plaque and the posterior capsule.

Preoperative considerations and outcomes of primary intraocular lens implantation in children with posterior polar and posterior lentiglobus cataract

PURPOSE

To report outcomes for pediatric posterior polar and posterior lentiglobus (lenticonus) cataracts.

METHODS

All posterior polar and posterior lentiglobus cataracts operated by the senior author were identified by retrospective database review. Excluding one eye in bilateral cases, preoperative and intraoperative details were collected. All eyes were analyzed for preoperative biometry and surgical details; however, a minimum of 4 weeks of follow-up was required for analysis of visual function.

RESULTS

Of 415 nontraumatic cataract cases with primary intraocular lens (IOL) implantation, 62 (15.0%) were identified with posterior polar (30/415, 7.3%) or posterior lentiglobus cataract (32/415, 7.7%). Twenty-eight (93%) posterior polar and all 32 posterior lentiglobus cases were monocular. Statistical comparison between the posterior polar and posterior lentiglobus groups for each of the following: age at time of surgery, preoperative axial length, lens thickness, and keratometry, showed no significant differences. IOL implantation was primarily in the capsular bag in both groups, 27/28 (96%) posterior polar and 25/32 (78%) posterior lentiglobus. Operative complications were rare. Twenty-five eyes in each group have follow-up greater than 4 weeks and were analyzed for visual function. A robust majority of patients in both groups, 21/25 (84%) posterior polar and 17/25 (68%) posterior lentiglobus cases, demonstrated postoperative visual acuity of 20/40 or better (or none to only a slight contralateral eye preference). Strabismus was infrequent in both groups pre- and postoperatively.

CONCLUSIONS

Posterior polar and posterior lentiglobus cataracts represent a large subset of nontraumatic cataracts in a pediatric cataract specialty practice. Visual outcomes are generally good. Complications are rare.

Management of the hard posterior polar cataract

I describe a technique for managing the posterior polar cataract with a dense nucleus by initially sculpting a central trough to the depth of the polar opacity. The nucleus is partially cracked in the periphery, avoiding the polar opacity, and then chopped into quadrants without rotating. Next, the phaco tip engages the core of the nuclear quadrant while a cleavage plane is manually dissected along the lenticular lamellae using a Nagahara phaco chopper, with the tip rotated slightly so it points somewhat toward the equator of the lens, to a depth estimated to leave a nuclear shell, sparing the polar cataract. The nucleus is peeled away from the outer nucleus shell, which is kept in place by the phaco chopper. The intact nuclear plate is removed last and any capsular defect managed accordingly. This technique minimizes the risk for losing a nuclear fragment into the vitreous cavity.

Intraoperative performance and postoperative outcomes of microcoaxial phacoemulsification

PURPOSE

To evaluate the intraoperative performance and postoperative outcomes after microcoaxial phacoemulsification.

SETTING

Iladevi Cataract & IOL Research Centre, Ahmedabad, India.

METHODS

A prospective observational case series comprised 84 eyes with age-related uncomplicated cataract having microcoaxial phacoemulsification through a 2.2 mm clear corneal incision by a standard surgical technique. Phacoemulsification parameters (Infiniti Vision System, Alcon) were microburst width, 30 ms; preset power, 50%; vacuum, 650 mm Hg; aspiration flow rate, 25 cc/minute. A single-piece Alcon AcrySof intraocular lens was implanted with the C cartridge (Alcon) cartridge. The incision was measured at the end of surgery. Observations included surgical time (from commencement of sculpting to end of epinucleus removal), cumulative dissipated energy (CDE), wound burns, intraoperative complications, postoperative increase in mean central corneal thickness (CCT) at 1 day and 1 month, mean % decrease in endothelial cell density (ECD), absolute mean change in coefficient of variation (cv) 3 months, and uncorrected visual acuity (UCVA) at 1 day. Data were analyzed using a 1-sample t test with 95% confidence intervals (CIs).

RESULTS

The mean follow up was 3 months +/- 0.3 (SD). The mean incision size at the end of surgery was 2.3 +/- .09 mm; mean surgical time, 4.5 +/- 1.5 minutes; and mean CDE, 2.3 +/- 2.2 seconds. No wound burns or other intraoperative complications occurred. The postoperative CCT increased by a mean of 16 microm at 1 day (95% CI, 8-25; P = .66;) and by a mean of 3.14 microm at 1 month (95% CI, 2.26-4.05; P = .92). The ECD decreased by a mean of 5.8% (95% CI, 6.8-3.5; P = .82) and the mean coefficient of variation, by 3.3 (95% CI, 4.5-2.0; P = .65). At 1 day, the UCVA was 20/20 in 29% of cases, 20/20 to 20/40 in 58%, and 20/40 to 20/50 in 12%.

CONCLUSION

Microcoaxial phacoemulsification was safely and effectively performed, achieving consistent and satisfactory postoperative outcomes.

Posterior polar cataract surgery – a posterior segment approach

PURPOSE

To suggest a surgical approach that would pre-empt uncontrolled posterior capsular rupture and consequent posterior segment complications associated with posterior polar cataract surgery.

DESIGN

An interventional case series.

METHODS

This was a prospective, interventional study undertaken at a tertiary referral ophthalmic unit. Eleven eyes of eight patients underwent planned pars plana vitrectomy, lensectomy and posterior chamber sulcus fixated intra-ocular lens implantation. Demography, presenting features, pre- and post-operative visual acuities, complications and length of follow-up were recorded. A single surgical technique was performed in all the cases.

RESULTS

Five male and three female patients with a mean age of 49.7 years, underwent this procedure. The median-corrected pre-operative visual acuity was 6/12 and the same post-operatively was 6/6. The only major per-operative complication was one case of accidental iridectomy. Post-operatively there were transient choroidal folds in one case, mild posterior segment haemorrhage in another and retinal detachment in one patient. The mean follow-up period was 13 months.

CONCLUSIONS

This surgical technique offers a relatively controlled and predictable approach to posterior polar cataract surgery compared to others described in the literature. Although this technique is not without complications, the visual outcome is usually good.

Surgical techniques in phacoemulsification

PURPOSE OF REVIEW

Recent advances in cataract surgical techniques are described, focusing on the evolution towards less traumatic surgery.

RECENT FINDINGS

Smaller incisions, split infusion, astigmatic management, and techniques of managing floppy iris syndrome are significant changes in the cataract surgical technique within the last 12-24 months.

SUMMARY

Surgeons need to learn the new techniques and instrumentation as cataract surgery moves towards less invasive surgery, with smaller incisions, more precise refractive outcomes, and fewer complications.