Anterior capsule contraction and flare intensity in the early stages after cataract surgery in eyes with diabetic retinopathy

Exploring anterion capsular contraction syndrome in cataract surgery: insights into pathogenesis, clinical course, influencing factors, and intervention approaches

Anterior capsular contraction syndrome (ACCS) is a challenging complication that can occur following phacoemulsification cataract surgery. Characterized by capsular bag wrinkling, intraocular lens (IOL) decentration and tilt, ACCS can have negative effects on visual outcomes and patient satisfaction. This review aims to investigate the pathogenesis, clinical course, influencing factors, and intervention approaches for ACCS after cataract surgery. By understanding the underlying mechanisms and identifying factors that contribute to ACCS, surgeons can enhance their ability to predict and manage this complication. Various intervention strategies are discussed, highlighting their importance in reducing complications and improving surgical outcomes. However, further research is needed to determine optimal prevention and management strategies through long-term follow-up and comparative analyses. Advancements in this field will ultimately lead to improved visual outcomes and optimized cataract surgery for patients.

Surgical approach for management of complete anterior capsular contraction syndrome

Anterior capsular contraction syndrome is an uncommon but well-known complication associated with continuous curvilinear capsulorhexis performed during cataract surgery. It remains asymptomatic unless the constriction progresses to involve the visual axis or causes late intraocular lens-related complications. A male patient in his 50s presented with severely decreased vision in his right eye 2 years after uneventful cataract surgery. Slit-lamp biomicroscopy revealed capsular phimosis and a dense, central, fibrous plaque with total occlusion of the anterior capsulorhexis opening. Neodymium-doped yttrium aluminium garnet laser anterior capsulotomy and vitrectorhexis were attempted, but proved ineffective. Surgical excision with manual cutting of the fibrotic membrane was performed, successfully clearing the visual axis and restoring vision.

Laboratory Evaluation of Optical Performance of Aspheric Monofocal Intraocular Lenses With Various Anti-misalignment Designs Under the Influence of Decentration and Tilt

PURPOSE

To assess the effectiveness and characteristics of aspheric monofocal intraocular lenses (IOLs) with different anti-misalignment designs.

METHODS

Three types of anti-misalignment IOLs (with aspheric balance curve design, ZO optic design, and high-order optical aspheric surface design) and no anti-misalignment IOLs were involved. From each type of these IOLs, +8.00, +17.00, and +26.00 diopter (D) lenses were used for detection at the 3- and 4.5-mm apertures. The modulation transfer function (MTF) and 50% of the maximum value of the MTF (MTF50) were measured while IOLs were centered, decentered by 0.3, 0.5, and 0.7 mm, and tilted by 3, 5, and 7 degrees.

RESULTS

Within the average clinical range of IOL malpositions (0.3-mm decentration or 3.00-D tilt), the anti-misalignment design slightly reduced the negative effect of decentration and tilt (P = .1845 and .6495, t test) on the optical performance of IOLs. Beyond the average range, the anti-misalignment design narrowed the reductions of MTF50 from 23.18% to 8.60% for decentration and from 40.31% to 27.96% for tilt (P = .0010, two-factor analysis of variance). The optical performance varied in anti-misalignment IOLs with different diopters, types, and degrees of malpositions at different aperture sizes. In both photopic and mesopic conditions and all probable misalignments, from the perspective of MTF50, better sharpness generally may be achieved with the 8.00-D ZO optic designed lens and 17.00-D high-order optical aspheric surface designed lens. For 26.00-D IOLs with different misalignments, the ABC design was more resistant to decentrations, whereas the high-order optical aspheric surface design was more resistant to tilts.

CONCLUSIONS

Aspheric monofocal IOLs with an anti-misalignment design can effectively resist decentration and tilt. Anti-misalignment IOLs for complicated cataract could be selected according to diopter of IOL and types and degrees of probable IOL malpositions. [J Refract Surg. 2023;39(7):446-455.].

Factors influencing aqueous flare after cataract surgery and its evaluation with laser flare photometry

Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended.

The management of cataract surgery in diabetic patients

A cataract in the eye is a major cause of vision loss in diabetic patients, which occurs earlier and develops faster than non-diabetic patients, and often requires surgery for treatment. However, diabetic patients undergoing cataract surgery have a higher risk of intraoperative and postoperative complications than non-diabetic patients. For diabetic patients undergoing any surgery, careful perioperative assessment and management are required to reduce postoperative complications and improve surgical outcomes. Better understanding of their needs may guide perioperative practitioners to manage their care appropriately. This article presents recent evidence and guidance associated with the preoperative, intraoperative and postoperative management of diabetic patients undergoing cataract surgery and to inform perioperative practitioners of the challenges and potential complications to provide the best care and improve sight.

Development of an anti-oxidative intraocular irrigating solution based on reactive persulfides

Anti-oxidative intraocular irrigating solutions (IISs) based on reactive persulfides, such as oxidized glutathione disulfide (GSSG), are commonly used worldwide. However, even with GSSG-based IISs, it has been shown that oxidative stress can occur during surgery, posing a risk to intraocular tissues. This study compared two IISs: one containing GSSG and one containing an oxidized glutathione trisulfide (GSSSG). Experimental in vivo irrigation with the IISs in rabbits showed that there was less leakage into the anterior chamber of rabbit serum albumin during perfusion with a 300-μM GSSSG IIS than with a 300-μM GSSG IIS. Experimental in vivo cataract surgery in rabbits showed that aqueous flare was suppressed 3 days after surgery with a 600-μM GSSSG IIS, but not with a 300-μM GSSSG or 300-μM GSSG IIS. Furthermore, an in vitro experiment, without any live tissue, showed that reactive oxygen species were suppressed more strongly with a 600-μM GSSSG IIS than with a 300-μM GSSG IIS. Thus, this study found that novel IISs based on GSSSG had anti-inflammatory and anti-oxidative effects during and after intraocular surgery and may decrease the rate of complications after surgery.

Implementing a Diabetic Algorithm for Ophthalmology Surgery Patients: A Quality Improvement Initiative

Introduction

The objective of this quality improvement, interventional study regarding patients with diabetes undergoing diabetic ophthalmology outpatient surgery aimed to develop, implement, and evaluate a new diabetic algorithm to improve safety, operating room efficiency, and decrease supply cost.

Methods

A multidisciplinary study team was assembled, including ophthalmologists, endocrinologists, anesthesiologists, management, and nurses to review the current diabetic protocol. From August 2016 to July 2017, 13 patient safety concerns or incident reports were reviewed that identified two serious cases of hypoglycemia. Using the concerns data, frontline perspectives, and reviewing best practice guidelines, a new diabetic algorithm was developed and trialed for 24 months. The new algorithm limited the use of an existing preoperative insulin protocol and reduced the number of nurses required. The number of adverse events, nursing setup process steps, setup time, and preoperative insulin infusion protocols used were collected. An evaluation of the supply costs was performed.

Results

After implementing the new diabetic algorithm, zero safety incidents were reported, and a 97.5% reduction in the use of preoperative insulin protocol resulted. Nursing staff perceived that the new diabetic algorithm was easier to configure, 23 minutes faster to set up, and required one nursing staff member. Supply cost was reduced by $30.63 (Canadian Dollars, CAD) per patient.

Conclusion

Perioperative glucose irregularities may threaten patient safety and surgical outcomes. Healthcare professionals must improve patient safety, decrease healthcare expenditure, and prevent unnecessary delays. Multidisciplinary frontline staff experiential knowledge aided in the recognition of potential problems and comprehensive solutions to optimize patient care.

Case series: "Double arch" changes caused by capsule contraction syndrome after cataract surgery in highly myopic eyes

BACKGROUND

Capsule contraction syndrome (CCS) after cataract surgery causes intraocular lens (IOL) haptic flexion and IOL optic displacement in most former reports. However, there are few reports on CCS-induced deformation of the IOL optic. We report two cases of CCS after cataract surgery in highly myopic eyes and describe a previously unreported "double arch" complication.

CASE PRESENTATION

Two patients with history of high myopia had cataract surgery with hydrophilic acrylic plate haptic IOLs implanted in their eyes. CCS with arch shape deformation of the pupil as well as the optic of the IOL were noticed in both cases after three months, which induced refractive changes and corrected distance visual acuity (CDVA) deterioration. Visual acuity of the patients was restored by replacing the IOL from the capsular bag to the ciliary sulcus and the following neodymium: YAG (Nd:YAG) laser capsulotomy. We propose that such "double arch" change brought by CCS is related to the plate-haptic design of the IOL and the incomplete overlap between the capsular opening and the IOL optic.

CONCLUSIONS

We recommend careful IOL selection and proper capsulorhexis in patients with high myopia or with other risk factors of CCS. Early diagnosis and timely treatment of CCS are critical to prevent visual symptoms and further ocular complications.

Evaluation of the etiology of persistent iritis after cataract surgery

Background

The purpose of this study was to evaluate patients with persistent iritis after cataract surgery to determine its incidence and risk factors. Adjusting the management of patients at risk could allow for a more predictable post-operative course and outcome. A retrospective chart review was performed of patients who had post-operative iritis longer than 1 month after cataract surgery during a 2-year period at Storm Eye Institute at the Medical University of South Carolina (MUSC) in Charleston, South Carolina. Patient demographics and various pre-operative, intra-operative, and post-operative factors were analyzed for trends.

Results

Thirty-nine patients (49 eyes) met the inclusion criteria, and this group was compared to a control cohort of 40 patients (66 eyes) who did not have persistent iritis after cataract surgery. The overall incidence of post-operative iritis was 1.75%. In all patients with post-operative iritis lasting greater than 1 month, African American race and pupil expansion device use were statistically significant factors. After excluding patients with a history of ocular inflammation or known inflammatory or autoimmune diagnosis (1.20% incidence), there were still a significantly higher proportion of African Americans compared to the control group. When patients with post-operative iritis of less than 6 months in duration were additionally excluded, the incidence was 0.32%, and history of diabetes was statistically significant in addition to race.

Conclusions

Risk factors for persistent iritis after cataract surgery include being diabetic, of African American racial background, and pupil expansion device use. These patients can be better informed of the higher risk of prolonged inflammation in their post-operative course, and peri-operative management can be tailored accordingly.

Effect of Local Anesthesia and General Anesthesia Using I-gel Laryngeal Mask Airway in Diabetic Patients Undergoing Cataract Surgery: Comparative Study

Background

Cataract surgery is one of the most commonly performed ophthalmic procedures. On choosing the appropriate method of anesthesia for diabetic patients with cataract whether regional or general, one should consider a technique that is associated with less stress response, minimal effect on hemodynamic and essentially associated with a good intraoperative glycemic control. This is yet to be determined.

Aims

The aim of this study is to evaluate the use of I-gel as an alternative to local anesthesia (LA) in diabetic patients undergoing cataract surgery.

Patients and Methods

This study was conducted on 60 controlled insulin-dependent diabetic patients undergoing cataract surgery. They were randomized to receive either LA by sub-Tenon's block (LA group n = 30) or general anesthesia (GA) using I-gel (GA group n = 30). Mean arterial blood pressure (MBP) and heart rate were monitored. Furthermore, blood glucose level and plasma cortisol level were measured at basal level, after induction of anesthesia or local block, after nuclear extraction, at the end of surgery, and 30, 60, 120, and 240 min postoperative.

Results

There was no significant difference in either blood glucose or cortisol levels in both groups. Blood glucose level increased with induction of anesthesia in both groups. The use of I-gel was not associated with increase heart rate or MBP compared to the LA group.

Conclusion

Both local and GA using I-gel are relatively safe without marked changes in hemodynamics, blood glucose, or cortisol level in insulin-dependent diabetic patients.

Biomaterial Influence on Intraocular Lens Performance: An Overview

There is strong evidence that the IOL material is the factor having the greatest impact on posterior capsule opacification (PCO), anterior capsule opacification (ACO) development, and glistening formation after cataract surgery, even though there are other IOL features—such as haptic material and design and edge and optic design—that also have some influence. We reviewed the published literature describing the adverse events that are mainly related to the intraocular lens (IOL) material, such as PCO, ACO, and the subsequent capsule contraction, as well as glistening formation. The adverse events presented in this overview are the most common ones in clinical practice, and therefore, they are generally included in the clinical protocols for IOL evaluation.

Comparison of Anterior Capsule Stability Following Implantation of Three Single Piece Acrylic Intraocular Lenses with Different Haptic Design

Purpose

To compare the anterior capsule contraction and intraocular lens (IOL) decentration among three types of IOL to determine the influence of haptic design on anterior capsule stability.

Methods

One hundred fifty patients were enrolled in this prospective, randomized study and 260 eyes underwent implantation of one of the following IOLs: modified L-haptic IOL (n = 74), modified C-haptic IOL (n = 97), or a plate-haptic IOL (n = 89). The area of the anterior capsule opening, IOL decentration, and capsule overlap were measured using retroillumination photospot 1 day and 2 months after cataract surgery.

Results

The area of capsule opening at postoperative day 1 was significantly different between the three IOLs (p < 0.01). All IOLs showed reduction of the anterior capsule opening from 1 day to 2 months after surgery, and greater reduction was shown in the modified C-haptic IOL (p < 0.001). At postoperative month 2, IOL decentration was significantly different between the IOLs and showed a positive correlation with the mean area reduction during month 2.

Conclusions

The degree of anterior capsule contraction and IOL decentration in modified L-haptic IOLs were less than those in modified C-haptic IOLs and comparable to those in plate-haptic IOLs.

Perioperative glycaemic control in diabetic patients undergoing cataract surgery under local anaesthesia: a survey of practices of Singapore ophthalmologists and anaesthesiologists

INTRODUCTION

Perioperative glycaemic control is an important aspect of clinical management in diabetic patients undergoing cataract surgery under local anaesthesia. While poor long-term glycaemic control has significant implications for surgery, perioperative hypoglycaemia or hyperglycaemia may also compromise patient safety and surgical outcomes. We aimed to survey ophthalmologists and anaesthesiologists on their approach and to identify the prevalent practice patterns in Singapore.

METHODS

This was a cross-sectional questionnaire-based survey conducted in four public hospitals in Singapore with established ophthalmology and anaesthesia units. Respondents were approached individually, and the self-administered questionnaires comprised questions related to practice patterns, clinical scenarios and awareness of pre-existing guidelines.

RESULTS

A total of 129 doctors responded to the questionnaire survey. 76 (58.9%) were from ophthalmology departments and 53 (41.1%) were from anaesthesia departments. The majority chose to withhold oral hypoglycaemic agents (82.9%) and/or insulin (69.8%), and keep the patient fasted preoperatively. A blood glucose level ≥ 17 mmol/L prompted 86.0%-93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%-96.9% of respondents to cancel the cataract surgery. The respondents were consistently more concerned about perioperative hyperglycaemia (n = 99, 76.7%) than intraoperative hypoglycaemia (n = 83, 64.3%).

CONCLUSION

The current study presented the prevalent practice patterns of ophthalmologists and anaesthesiologists in the perioperative management of diabetic patients undergoing cataract surgery in four public hospitals in Singapore. Further research in this field is required, and may be useful for the future formulation of formal guidelines and protocols.

Proinflammatory status in the aqueous humor of high myopic cataract eyes

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

Large capsulorhexis with implantation of a 7.0 mm optic intraocular lens during cataract surgery in patients with diabetes mellitus

PURPOSE

To evaluate the efficacy of a large capsulorhexis and intraocular lens (IOL) in obtaining a larger anterior capsule opening after cataract surgery in patients with diabetes mellitus (DM).

SETTING

Department of Ophthalmology, University of Fukui, Fukui, Japan.

DESIGN

Prospective clinical trial.

METHODS

Patients with DM had bilateral cataract surgery with a 2.8 or 3.0 mm scleral incision, a capsulorhexis with a diameter of approximately 5.0 or 6.0 mm, and implantation of a 6.0 mm optic (Eternity X-60) or 7.0 mm optic (Eternity X-70) IOL. The anterior capsule opening area, aqueous flare intensity, surgically induced astigmatism (SIA), corneal endothelial cell density (ECD), and central corneal thickness (CCT) were measured 1 day, 1 week, and 1, 3, and 6 months after surgery.

RESULTS

Thirty-one patients (62 eyes) with DM were enrolled. At all postoperative timepoints, the anterior capsule opening was significantly larger in eyes with the 7.0 mm optic IOL than in eyes with the 6.0 mm optic IOL (P<.05, Mann-Whitney U test). There were no significant differences in postoperative aqueous flare intensity, SIA, ECD, or CCT based on the size of the capsulorhexis and IOL.

CONCLUSION

A larger capsulorhexis and implantation of a 7.0 mm IOL resulted in a larger anterior capsule opening after cataract surgery in patients with DM.

FINANCIAL DISCLOSURE

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