Cumulative neodymium:YAG laser rates after bag-in-the-lens and lens-in-the-bag intraocular lens implantation

Recurrent Posterior Capsular Opacification in Adults: A Case Report and an Overview of Literature

Posterior capsular opacification (PCO), also known as "secondary cataract", is a common complication following cataract surgery that can significantly impair visual acuity. The incidence of PCO varies widely in the literature, influenced by intraocular lens (IOL) type and patient risk factors. Neodymium-doped yttrium-aluminum-garnet (YAG) laser posterior capsulotomy is the standard treatment for PCO-related visual impairment. Recurrence of PCO after initial treatment with YAG capsulotomy, though more common in children, is rare in adults. Its underlying pathophysiological mechanisms are similar to that of primary PCO, which includes proliferation, migration, and/or clustering of lens epithelial cells (LECs), with subsequent reclosure of the posterior aperture. Potential risk factors for PCO recurrence that have been speculated through a comprehensive search of the current literature include younger age, female sex, high myopia, diabetes, vitrectomized status, uveitis, low-diopter IOLs, and certain IOL types with higher water content. We present a case of recurrent PCO in a highly myopic 48-year-old male following cataract surgery and implantable collamer lens (ICL) explantation who received a hydrophobic acrylic lens with 4% water content. Surgical techniques that may reduce recurrent PCO occurrence and appropriate postoperative care are emphasized to assist surgeons in their approach to patients at high-risk for this complication.

Cataract surgery in patients with retinitis pigmentosa: systematic review

Retinitis pigmentosa (RP) is an inherited bilateral retinal degenerative disease with an incidence of 1 in 4000 people. RP affects more than 1 million individuals worldwide. Although night blindness and restricted visual field are the most typical symptoms of these individuals, generalized vision loss due to cataracts can be expected in the latter stages of the disease. It has been demonstrated that posterior subcapsular cataract is the most prevalent cataract in younger individuals with RP, as opposed to age-related cataracts. Although most ophthalmologists may have a negative view of cataract surgery in patients with RP, it appears that it can play an important role in the visual restoration of patients with RP. However, there are concerns about performing cataract surgery for patients with RP. Herein, a systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses on databases of MEDLINE and Scopus.

Safety of the bag-in-the-lens implantation regarding the development of clinically significant pseudophakic cystoid macular edema: A retrospective case series study

PURPOSE

To determine the incidence of clinically significant pseudophakic cystoid macular edema (CSPME) after phacoemulsification using the 'bag-in-the-lens' lens (BIL) implantation technique and to examine the influence of associated risk factors for clinically significant pseudophakic macular edema (CSPME), both ocular and systemic.

METHODS

This retrospective study included 2419 first-operated eyes of 2419 adults who underwent phacoemulsification cataract surgery using the BIL implantation technique between January 2013 and December 2018 in the Antwerp University Hospital, Belgium. The significance of several risk factors (age, gender, previous history, intra- and postoperative complications) was examined by extraction of electronic medical files.

RESULTS

The 3-month incidence of CSPME in the subgroup without risk factors was 0.00% (95% CI: 0.00 -NA). The 3-month incidence of CSPME in the subgroup with risk factors was 0.57% (95% CI 0.22-1.29%). The 3-month incidence of CSPME in the total population of 2419 patients was 0.29% (95% CI: 0.11-0.65%). The risk factors most significantly associated with CSPME included renal insufficiency (hazard ration [HR]: 5.42; 95% CI: 1.69-17.44; P = .014), exudative age-related macular degeneration (HR: 74.50, 95% CI: 25.75-215.6; P < .001) and retinal vein occlusion (HR: 22.48, 95% CI: 4.55-111.02; P = .005).

CONCLUSIONS

In the absence of risk factors, the incidence of CSPME was zero. We can conclude that Primary Posterior Continuous Curvilinear Capsulorhexis (PPCCC) does not increase the risk for CSPME. Non-inferiority of the BIL implantation regarding the development of CSPME, relative to the traditional 'lens-in-the-bag' (LIB) implantation, confirms that BIL is a safe surgical technique. This study also illustrates a previously undescribed risk factor for developing CSPME, namely renal insufficiency.

Use of P1-P4 Purkinje reflections as a surrogate sign for intraoperative patient fixation

Circumferential, even anterior capsular overlap maximizes intraocular lens stability and posterior capsular opacification mitigation and provides best long-term outcomes for the cataract patient. P1 and P4 Purkinje reflections at patient fixation may provide a reliable marker for capsulotomy centration. However, patient fixation may be hindered during surgery because of anesthesia or light sensitivity. In this study, we demonstrate that the relationship between the P1 and P4 Purkinje reflections previewed prior to surgery when the patient is fixating may be recreated intraoperatively if fixation becomes difficult. The final position of P1 and P4 relative to one another at fixation is invariant in a given patient, but there are variations among patients. Knowledge of the P1 and P4 relationship can be used as a surrogate sign of patient fixation to assist in capsulotomy centration during cataract surgery.

Effect of Nd: YAG laser capsulotomy on the risk of retinal detachment after cataract surgery: A systematic review and meta-analysis

ABSTRACT

We aimed to evaluate the impact of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy on the incidence of pseudophakic retinal detachment (RD). The PubMed and Embase databases were searched for meta-analysis. Subgroup analyses were conducted according to study location, number of cases, mean follow-up time, and cataract procedure. The final analysis included 11 studies with 309 cases of RD in 65,117 eyes undergoing cataract surgery. Among them, 8,232 eyes underwent Nd:YAG capsulotomy. Our analysis demonstrated an increased risk of RD with Nd:YAG laser capsulotomy (RR=1.57; 95%CI, 1.17-2.12; P=0.003; HR=1.64; 95%CI, 1.03-2.62; P=0.04). Subgroup analysis suggested somewhat stronger associations in Asian (RR=4.54; 95%CI, 2.20-9.38; P<0.0001) than in non-Asian populations (America, P=0.12; Europe and others, P=0.21), and with extracapsular cataract extraction (RR=2.97; 95%CI, 1.83-4.83; P<0.0001) than with phacoemulsification (P=0.95). To conclude, Nd:YAG laser capsulotomy may be associated with an increased risk of pseudophakic RD.

Incidence of rhegmatogenous retinal detachment after bag-in-the-lens IOL implantation: extended follow-up in a larger cohort of patients

PURPOSE

To report the incidence of rhegmatogenous retinal detachment (RRD) and associated risk factors after cataract surgery using the bag-in-the-lens (BIL) intraocular lens (IOL) implantation technique.

SETTING

Department of Ophthalmology, Antwerp University Hospital, Belgium.

DESIGN

Prospective cohort study.

METHODS

All consecutive BIL IOL surgeries performed between January 2001 and December 2010 were included, with the exclusion of combined procedures and IOL exchanges. The incidence of RRD was reported first in the total cohort, then in a subgroup of patients with 1 year to 5 years of follow-up, and finally in the group remaining after exclusion of all risk factors, except gender. Risk factors associated with RRD were examined using multiple Cox regression analysis with a random intercept.

RESULTS

Rhegmatogenous RD was diagnosed in 36 eyes (1.06%) of 3385 BIL cases, with a mean follow-up of 48.28 ± 40.05 months (range 0 to 195 months). The 2-year cumulative RRD incidence rate was 0.66% (17 cases in 1024 eyes; 0.00% in patients without risk factors). The 5-year cumulative RRD incidence rate was 1.17% (26 cases in 931 eyes; 0.15% without risk factors). Five risk factors were confirmed: male sex, age less than 60 years at the time of surgery, axial length 25.0 mm or greater, a history of contralateral RD, and intraoperative surgical complications.

CONCLUSIONS

The incidence of RRD after BIL IOL implantation is comparable with that of lens-in-the-bag (LIB) implantation. This larger study provided a longer follow-up and suggested that RRD incidence is even lower than that previously reported. This study also confirmed intraoperative surgical complications as an additional risk factor for RRD development, as already described with LIB implantation.

Clinically significant pseudophakic cystoid macular edema after bag-in-the-lens implantation

PURPOSE

To determine the incidence of clinically significant pseudophakic cystoid macular edema (CSPME) after phacoemulsification using the bag-in-the-lens intraocular lens (BIL IOL) implantation technique and to examine the influence of associated risk factors, both ocular and systemic.

SETTING

Monocentric, Antwerp University Hospital, Belgium.

DESIGN

Retrospective.

METHODS

This study included 1 077 first-operated eyes of 1 077 adults who underwent phaco-emulsification cataract surgery using the BIL IOL implantation technique between January 2013 and December 2015.

RESULTS

The 3-month incidence of CSPME in the subgroup without risk factors was 0% (95% CI, 0.0-0.0). The 3-month incidence of CSPME in the subgroup with risk factors was 2.8% (95% CI, 1.3-4.3). The 3-month incidence of CSPME in the total group of 1077 patients was 1.4% (95% CI, 0.6-2.1). The risk factors most significantly associated with CSPME included diabetes (hazard ratio [HR]: 5.37; 95% CI, 1.5-19.3; P = .019), exudative age-related macular degeneration (HR: 121; 95% CI, 36.1-409; P < .001), and macular traction (HR: 6.47; 95% CI, 1.9-22.1; P < .009).

CONCLUSIONS

The incidence of CSPME was zero in eyes without risk factors. The incidence was consistent with previous reports in the literature regarding the lens-in-the-bag IOL implantation technique in eyes with risk factors. This indicates that the BIL IOL implantation technique is a safe procedure and does not confer a higher risk for developing cystoid macular edema after cataract surgery compared with the lens-in-the-bag IOL implantation technique, despite the requirement of a primary posterior continuous curvilinear capsulorhexis.

[Combined vitrectomy-lensectomy surgery with bag-in-the-lens or lens in the bag implantation: comparison of final visual acuity]

INTRODUCTION

Combined vitrectomy-lensectomy surgery is a safe and effective procedure. Nevertheless, it is frequently complicated by posterior capsule opacification and the formation of posterior synechiae. These complications can be avoided by placing a "bag in the lens" (BIL) implant. The objective of this study is to compare the visual acuity gain (VA) after combined vitrectomy-lensectomy surgery between a group implanted with the BIL technique and a group with implantation in the bag (LIB).

MATERIAL AND METHODS

We included in the study all vitrectomy-lensectomy procedures for epiretinal membrane and vitreomacular traction performed between May 2013 and July 2016 at the Hospital and University Center of Caen. We compared the VA gain between the BIL group and the LIB group six months after surgery.

RESULTS

A total of 33 patients were included in the study, consisting of 28 eyes in the BIL group and 8 eyes in the LIB group. The mean VA gain in the BIL group was -0.52 LogMAR (P<0.0001) and -0.56 LogMAR (P=0.0047) for the LIB group. The difference between the two groups was not significant (P=0.74).

CONCLUSION

The use of the BIL technique during vitrectomy-lensectomy allows visual recovery as good as implantation within the capsular bag. In addition, this implant has the advantage of significantly reducing the occurrence of posterior synechiae and preventing anterior and posterior capsular proliferation.

Osmotically induced removal of lens epithelial cells to prevent PCO after pediatric cataract surgery: Pilot study to assess feasibility

PURPOSE

Development of an osmotic-shock technique to remove human lens epithelial cells (LECs) as a preventive measure to address posterior capsule opacification (PCO) after pediatric cataract surgery.

SETTING

Department of Genetics, UCL Institute of Ophthalmology, London, England, and Department of Ophthalmology, Ruijin Hospital, Jiao Tong University, Shanghai, China.

DESIGN

Laboratory study.

METHODS

Various tissue preparations of human LECs (cultured on coverslips/collagen-coated membrane inserts, human lens capsule biopsies, and lens organ cultured PCO models) were subjected to a single or incremental hyperosmotic shock (NaCl, 350-4000 mOsm/L) in the presence of inhibitors of the Na+-K+-2Cl- cotransporter (NKCC) (to disable the regulatory volume increase [RVI] process). The integrity of the cell monolayer was determined by phase-contrast microscopy, viability assays, and measurement of transepithelial resistance.

RESULTS

Hyperosmotic shock (400 mOsm/L) caused rapid cell shrinkage (<5 minutes) in all the LEC models studied. In the absence of the NKCC inhibitor, the shrunk cells gradually returned to their original cell volume and architecture over time, while still exposed to the hyperosmotic shock. However, inhibition of the RVI process disabled the ability for restoration of cell volume leading to persistent cell shrinkage, subsequently resulting in cell detachment from the underlying support medium.

CONCLUSION

Hyperosmotic shock in the presence of inhibitors of the RVI process was effective in rapidly detaching LECs from their basement membranes. This technique could potentially facilitate removal of residual LECs left on the lens capsule after cataract surgery, thus decreasing or eliminating the risk for aggressive cell proliferation and the development of PCO.

Bag-in-the-lens implantation helps avoid posterior synechiae of the iris after phacovitrectomy

PURPOSE

To compare the rate of posterior synechiae of the iris (PSI) occurrence after phacovitrectomy between a group with lens-in-the-bag (LIB) implantation, that is, implantation in the capsular bag, and a group with bag-in-the-lens (BIL) implantation.

SETTING

CHU de Caen, Department of Ophthalmology, Caen, France.

DESIGN

Comparative retrospective study.

METHODS

One hundred consecutive cases of phacovitrectomies conducted between May 2013 and July 2016 were included. A retrospective analysis of the occurrence rate of PSI in the LIB group and in the BIL group was performed, using multivariate analysis including multiple risk factors such as preoperative synechiae, proliferative diabetic retinopathy, use of 20-gauge vitrectomy, use of gas or silicone tamponade, and use of endophotocoagulation.

RESULTS

One hundred eyes of 92 patients were included in this study (55 eyes in the LIB group and 45 in the BIL group). The occurrence of PSI was significantly lower in the BIL group with 1 case (2%) versus 22 cases (40%) in the LIB group (P < .001). Among the risk factors studied, preoperative synechiae and the use of retinal endophotocoagulation were almost significantly associated with the occurrence of PSI (P = .068 and P = .087, respectively). In the LIB group, these PSI led to 1 case of acute elevation of intraocular pressure by pupillary seclusion and the use of laser iridotomy in 8 cases.

CONCLUSION

The use of BIL rather than LIB implantation in phacovitrectomy practically eliminates PSI.

Phacoemulsification and primary implantation with bag-in-the-lens intraocular lens in children with unilateral and bilateral cataract

PURPOSE

To report outcome in a paediatric cohort with cataract extraction and implantation of bag-in-the-lens intraocular lens (BIL-IOL).

METHODS

Children younger than 16 years of age subjected to phacoemulsification with primary implantation of BIL-IOL during 2009 through 2013 were analysed retrospectively. Exclusion criteria were uveitis or ≤6 months of follow-up.

RESULTS

In total, 109 eyes of 84 children were included; 40 unilateral and 44 bilateral cataracts. For all eyes, median age at surgery was 2.5 years (range 2 weeks to 14.1 years) and 16 children (24 eyes) were ≤6 weeks. Coexisting systemic disease was more common in children with bilateral cataract (24 patients, 54.5%) compared to unilateral cataract (6 patients, 15.0%, p < 0.0001). Ocular comorbidity was more common in unilateral cataracts; n = 14 eyes (35.0%) compared to bilateral cataracts; n = 10 eyes (14.5%; p = 0.017). Median follow-up was 2.8 years (range 7 months to 5.8 years). During the follow-up period, 15 (13.8%) eyes developed glaucoma and five (4.6%) eyes required treatment for visual axis opacification (VAO). Corrected distance visual acuity (CDVA) for bilateral cataracts at last follow-up was 0.42 ± 0.45 (logMAR; mean±SD) with 35 (55.6%) eyes attaining a CDVA of ≥0.5 (dec). For unilateral cataracts mean CDVA was significantly poorer; 0.67 ± 0.51 (p = 0.010) with 15 (37.5%) eyes attaining a CDVA of ≥0.5.

CONCLUSION

For children having cataract surgery with primary implantation of BIL-IOL, VAO is rare and visual outcome overall good. Unilateral cataracts are associated with a higher proportion of ocular comorbidity and poorer visual outcome.

Nd:YAG Capsulotomy Rates With Two Trifocal Intraocular Lenses

PURPOSE

To compare Nd:YAG capsulotomy rates following implantation of two diffractive trifocal intraocular lenses (IOLs).

METHODS

This multi-center retrospective analysis included patients who underwent uncomplicated lens phacoemulsification and were implanted with a diffractive trifocal IOL: FineVision MicroF (PhysIOL, Liège, Belgium) or AT Lisa tri 839MP (Carl Zeiss Meditec, Jena, Germany). All surgeries were performed during the same period. The postoperative follow-up period was at least 1 year. Chi-square and Kaplan-Meier tests analyzed non-parametric estimates for survival/failure functions. The Wilcoxon (Breslow) test compared Nd:YAG capsulotomy rates between the two groups.

RESULTS

Of 5,130 eyes included, 3,387 were implanted with the FineVision MicroF IOL and 1,743 with the AT Lisa tri 839MP IOL. There were no statistical differences in age, axial length, or IOL power between groups. Nd:YAG capsulotomies were necessary in 330 eyes (9%) in the FineVision group and 408 eyes (23%) in the AT Lisa tri group (P < .001). The probability of having Nd:YAG capsulotomy up to 9 months postoperatively was equal for both lenses. Beyond 9 months, the Nd:YAG capsulotomy rate increased significantly more in the AT Lisa tri group, reaching a probability of 35% for eyes with a follow-up of 34 to 44 months, whereas in the FineVision group the probability was 14% after a follow-up of 37 to 47 months. The differences in survival (without Nd:YAG capsulotomy)/failure (with Nd:YAG capsulotomy) functions were significant (P < .001).

CONCLUSIONS

Eyes implanted with the FineVision MicroF IOL required significantly fewer Nd:YAG laser capsulotomies than those with the AT Lisa tri 839MP IOL during the first years after implantation. The design of the IOL platforms could account for these differences. [J Refract Surg. 2016;32(11):748-752.].

Incidence of rhegmatogenous retinal detachment after bag-in-the-lens intraocular lens implantation

PURPOSE

To determine the incidence of rhegmatogenous retinal detachment (RRD) and associated risk factors after phacoemulsification and bag-in-the-lens intraocular lens (IOL) implantation.

SETTING

Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium.

DESIGN

Prospective cohort study.

METHODS

All consecutive bag-in-the-lens IOL implantations performed between January 2001 and December 2007 were included, with the exception of combined procedures and IOL exchanges. The retinal detachment (RD) incidence was studied in the total cohort, in a subgroup of patients with 1 to 5 years of follow-up, and finally in the group remaining after exclusion of all risk factors except gender.

RESULTS

RD after bag-in-the-lens IOL implantation in 1323 eyes with an average follow-up of 44.75 months (range 0 to 152 months) was found in 19 eyes (1.44%). The 1-year RD incidence was 0.49% (5 RD cases in 1024 eyes) (0.00% in patients without risk factors). The 2-year cumulative RD incidence was 0.84% (9 RD cases in 931 eyes; 0.15% without risk factors). Four clinically significant risk factors were confirmed: male gender, young age at time of surgery (<60 years), axial myopia (axial length ≥25 mm), and history of contralateral RD in the total cohort.

CONCLUSION

The RRD incidence following bag-in-the-lens IOL implantation was comparable to that seen after lens-in-the-bag (LIB) implantation. The wide variation in study design in the literature precludes direct comparison, so there is a need for standardization in evaluating RRD incidence after cataract surgery. Future prospective studies should consider patients with and without risk factors (except gender) separately.

FINANCIAL DISCLOSURE

Prof. dr. M.J. Tassignon has intellectual property rights to the bag-in-the-lens intraocular lens (U.S. patent 6 027 531; EU patent 009406794; PCT/120268), which is licensed to Morcher GmbH, Stuttgart, Germany.

Femtosecond laser-assisted cataract surgery--current status and future directions

Femtosecond laser-assisted cataract surgery (FLACS) putatively offers several advantages over conventional phacoemulsification. We review the current status of FLACS and discuss the evolution of femtosecond lasers in cataract surgery and the currently available femtosecond laser platforms. We summarize the outcomes of FLACS for corneal wound creation, limbal relaxing incisions, capsulotomy, and lens fragmentation. We discuss surgical planning, preoperative considerations, clinical experiences including the learning curve and postoperative outcomes with FLACS, and also the cost effectiveness of FLACS. We present the intraoperative complications and management of challenging cases where FLACS offers an advantage and also speculate on the future directions with FLACS. Further advancements in laser technology to refine its efficacy, advancement in intraocular lens design to harness the potential benefits of FLACS, and a reduction in cost are needed to establish a clear superiority over conventional phacoemulsification.

Combined phacoemulsification, primary intraocular lens implantation, and pars plana vitrectomy in children with uveitis

PURPOSE

To evaluate the outcome of combined cataract surgery with primary intraocular lens (IOL) implantation and pars plana vitrectomy (PPV) in children with uveitis.

METHODS

Data regarding visual acuity (VA), inflammatory status, medical therapy, and complications was collected from the medical charts of 17 children (21 eyes) with chronic uveitis who underwent combined cataract surgery and PPV at the Eye Clinic, Sahlgrenska/Mölndal, between 2002 and 2011.

RESULTS

Seventy-six percent of the children had juvenile idiopathic arthritis. Median preoperative VA was 1.70 logMAR and median VA after 12 months was 0.17 logMAR. Postoperatively, glaucoma developed in 7 eyes, cystoid macular edema in 3 eyes, and visual axis opacification requiring treatment in 5 eyes.

CONCLUSIONS

Although combined phacoemulsification, primary IOL implantation, and PPV in children with uveitis resulted in favorable visual outcome and stable inflammation in a majority of children, the technique should so far be reserved for uveitic cases with vitreous pathology.

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.

Clinical outcomes of cataract surgery after bag-in-the-lens intraocular lens implantation following ISO standard 11979-7:2006

PURPOSE

To assess the clinical outcomes of bag-in-the-lens intraocular lens (BIL IOL) implantation following the International Organization for Standardization (ISO) 11979-7:2006 in pediatric eyes and eyes with ocular comorbidities.

SETTING

Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium.

DESIGN

Cohort study.

METHODS

This cohort included the first series of patients having IOL implantation using the bag-in-the-lens technique. Surgeries were performed between December 1999 and September 2006. In addition to IOL implantation, the technique comprised creation of a primary posterior continuous curvilinear capsulorhexis (PCCC) equal in size to the anterior capsulorhexis.

RESULTS

The study enrolled 807 eyes of 547 patients; 326 of the eyes (40.40%) had ocular comorbidity. In the 481 eyes without ocular comorbidity, the mean decimal corrected distance visual acuity was 0.52 ± 0.24 (SD) (0.276 ± 0.206 logMAR) preoperatively and 0.94 ± 0.18 (-0.012 ± 0.053 logMAR) postoperatively. The mean postoperative achieved spherical equivalent was 0.48 ± 0.83 diopter (D) and the mean targeted refraction, -0.24 ± 0.71 D. The A-constant was modified from 118.4 to 118.04. Posterior capsule opacification (PCO) did not occur in any adult eye during the follow-up. Retinal detachment after IOL implantation occurred in 10 eyes (1.24%). In 19 eyes, the iris was captured by the IOL haptics postoperatively. Hypopyon occurred in 3 patients and toxic anterior segment syndrome in 1 patient.

CONCLUSION

The BIL IOL met the ISO criteria; that is, primary PCCC was safe in healthy eyes and in eyes with ocular comorbidities and no eye developed PCO over a mean follow-up of 26.1 ± 21.3 months.

Surgically induced astigmatism after intraocular lens implantation using the bag-in-the-lens technique

PURPOSE

To determine surgically induced astigmatism (SIA) after monofocal spherical intraocular lens (IOL) implantation using the bag-in-the-lens (BIL) technique.

SETTING

Department of Ophthalmology, Antwerp University Hospital, Antwerp, Belgium.

DESIGN

Case series.

METHODS

Adult patients had routine phacoemulsification followed by BIL IOL implantation, which requires a double capsulorhexis for IOL fixation. The 2.8 mm limbo-corneal self-sealing incision was temporally located. Preoperative and 3-month postoperative keratometries were measured by Scheimpflug imaging (Pentacam). The patients were divided into 2 groups based on corneal astigmatism. Group A0 consisted of eyes with physiological corneal astigmatism less than 1.00 diopter (D). Group A1 consisted of eyes with corneal astigmatism of 1.00 D or higher. Vector analysis of the corneal power was used to determine the SIA.

RESULTS

The study comprised 100 eyes (58 patients). There was no difference in SIA between Group A0 and Group A1. The mean preoperative and postoperative keratometries were highly correlated in both groups (A0: r(2) = 0.95; A1: r(2) = 0.83). The correlation between preoperative and postoperative vectorial astigmatism was low in Group A0 (J0: r(2) = 0.24; J45: r(2) = 0.10). The mean postoperative SIA was 0.06 D @ -24 degrees in Group A0 and 0.09 D @ 6 degrees in Group A1, with an uncertainty of ± 1.00 D.

CONCLUSIONS

After BIL IOL implantation, the SIA was not statistically significant. Based on these findings, the technique can be considered an option for spherocylindrical correction of corneal astigmatism of 1.00 D or more.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

A randomized intraindividual comparison of the accommodative performance of the bag-in-the-lens intraocular lens in presbyopic eyes

PURPOSE

To compare the accommodative performance of the Morcher BioComFold Type 89A bag-in-the-lens intraocular lens (IOL) with a conventional in-the-bag control IOL in presbyopic eyes.

DESIGN

Prospective, randomized clinical trial with intraindividual comparison.

METHODS

SETTING

Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom.

STUDY POPULATION

Fifty-two eyes of 26 patients with bilateral age-related cataracts.

INTERVENTION

Phacoemulsification cataract extraction with implantation of a bag-in-the-Lens and a control IOL, the Alcon AcrySof SA60AT (Alcon Laboratories, Fort Worth, Texas, USA), randomized to either eye.

MAIN OUTCOME MEASURES

Axial IOL shift stimulated by physiologic (near visual effort) and pharmacologic (pilocarpine and cyclopentolate) accommodative stimulation was measured objectively with partial coherence interferometry. Other outcome measures were objective and subjective accommodation, logarithm of the minimal angle of resolution distance-corrected near visual acuity, and defocus curves.

RESULTS

Three months after surgery, axial IOL shift stimulated by near visual effort measured -5.9 ± 10.3 μm in bag-in-the-lens eyes versus -8.4 ± 12.8 μm in control eyes (P = .37), that stimulated by pilocarpine measured 20.2 ± 165.6 μm versus 50.4 ± 164.4 μm (P = .36), and that stimulated by cyclopentolate measured -65.8 ± 64.3 μm versus -54.0 ± 37.5 μm (P = .34), respectively (n = 25). Objective accommodation measured 0.03 ± 0.18 diopters (D) in bag-in-the-lens eyes versus 0.08 ± 0.21 D in control eyes (P = .40), whereas subjective accommodation measured 2.48 ± 0.72 D versus 2.45 ± 0.80 D (P = .75), respectively. Distance-corrected near visual acuity and defocus curves showed no difference between IOLs.

CONCLUSIONS

The bag-in-the-lens IOL demonstrated negligible axial shift and objective accommodation with physiologic near visual stimulation. The IOL shift demonstrated with pilocarpine also was clinically insignificant. The bag-in-the-lens IOL showed no accommodative or near visual advantage over a conventional in-the-bag IOL, despite its unique capsular fixation method. This provides further evidence that the focus-shift principle fails to produce clinically significant IOL movement.

Biocompatibility of intraocular lens materials

PURPOSE OF REVIEW

To provide an update on currently available materials used in the manufacture of intraocular lenses, as well as new materials under development, especially with regard to their uveal and capsular biocompatibility.

RECENT FINDINGS

The biocompatibility of intraocular lens materials should be assessed in terms of uveal biocompatibility, related to the inflammatory foreign-body reaction of the eye against the implant, as well as in terms of capsular biocompatibility, determined by the relationship of the intraocular lens with remaining lens epithelial cells within the capsular bag. This situation may result in different entities, e.g. anterior capsule opacification, interlenticular opacification (between piggyback intraocular lenses), posterior capsule opacification and lens epithelial cell ongrowth. Reports on intraocular lens opacification suggest that the potential to calcify should also be taken into consideration when evaluating the long-term biocompatibility of a new material.

SUMMARY

Intraocular lenses are being progressively implanted in much earlier stages of life (refractive lens exchange, pediatric implantation) and are expected to remain in the intraocular environment for many decades. Materials used in intraocular lens manufacture should, therefore, insure long-term uveal and capsular biocompatibility, as well as ultimate transparency after implantation.

Intraocular lens centration and visual outcomes after bag-in-the-lens implantation

PURPOSE

To examine the centration and visual outcomes after cataract surgery using the bag-in-the-lens (BIL) implantation technique.

SETTING

University Hospital Antwerp, Department of Ophthalmology, Edegem, Belgium.

METHODS

This study comprised 180 eyes of 125 patients who had cataract surgery with implantation of the BIL intraocular lens (IOL) between March 2002 and September 2005. Postoperative data at 5 weeks, 6 months, and 1 year were evaluated. The geometric center of the IOL, measured on a red reflex slitlamp photograph, was compared with the geometric center of the pupil and the limbus.

RESULTS

The mean decentration compared with the limbus was 0.304 mm+/-0.17 (SD) at a mean angle of -24.9+/-113.3 degrees. Compared with the dilated pupil, the mean deviation was 0.256+/-0.15 mm at a mean angle of -5.2+/-119.0 degrees. The amount of decentration was stable during the postoperative follow-up period. There was no correlation between the amount of decentration and the visual outcomes (pupil: r=-0.07, P=.494; limbus: r=0.11, P=.304).

CONCLUSIONS

Surgeon-controlled BIL centration was predictable 5 weeks and unchanged 6 months and 1 year postoperatively. It can therefore be concluded that capsular bag healing has no influence on BIL IOL centration over time.

Bag-in-the-lens intraocular lens implantation in the pediatric eye

PURPOSE

To study the efficacy, safety, and feasibility of implantation of a bag-in-the-lens intraocular lens (IOL) in children and babies.

SETTING

Departments of Ophthalmology, University Hospital, Antwerp, Belgium, and the University Hospital, Ljubljana, Slovenia, and a private ophthalmology practice, Oudenaarde, Belgium.

METHODS

Thirty-four eyes of 22 children had implantation of a bag-in-the-lens IOL. The ages ranged from 2 months to 14 years. Congenital cataract was present in 26 eyes, and persistent fetal vasculature (PFV) was concomitantly present in 4 eyes. Fifteen patients had bilateral cataract, and 6 had unilateral cataract.

RESULTS

In 3 eyes, the IOL could not be properly implanted. In these cases, secondary intervention was necessary because of early posterior capsule opacification. The mean postoperative follow-up was 17.45 months +/- 17.12 (SD) (range 4 to 68 months). None of the children except those presenting with PFV had anterior vitrectomy during surgery. The optical axis remained clear during the follow-up in all patients who had successful IOL implantation.

CONCLUSIONS

The bag-in-the-lens implantation technique in children and babies was safe and kept the visual axis clear after cataract surgery. In the near future, 4.0 or 4.5 mm IOLs will be available that may improve the success rate of IOL implantation in the small eyes of babies.