Intraocular lens stability and refractive outcomes after cataract surgery using primary posterior continuous curvilinear capsulorrhexis

Repeatability of Pentacam-derived intraocular lens decentration measurements and the level of agreement with OPD-Scan III: A prospective observational case series

PURPOSE

This study aimed to assess the repeatability of intraocular lens (IOL) decentration measurements obtained through Pentacam, based on corneal topographic axis (CTA) and pupillary axis (PA), and to evaluate the level of agreement between Pentacam and OPD-Scan III devices in measuring IOL decentration.

METHODS

In this prospective observational case series, three measurements were performed with Pentacam to evaluate the repeatability of the measurements. The analysis included the calculation of the mean and standard deviations (SD), conducting a repeated measures analysis of variance (rANOVA), and determining an intraclass correlation coefficient (ICC) to assess the repeatability of the measurements. Moreover, Bland-Altman analysis was employed to assess the agreement between Pentacam and OPD-Scan III devices in measuring IOL decentration. IOL decentration measurements were obtained with respect to both CTA and PA.

RESULTS

A total of 40 eyes from 40 patients were analyzed. The rANOVA revealed no significant difference among three consecutive measurements of IOL decentration obtained with Pentacam. The mean SD of all parameters ranged from 0.04 mm to 0.07 mm. With CTA as the reference axis, the ICC values for Pentacam measurements of IOL decentration were 0.82 mm for the X-axis, 0.76 mm for the Y-axis, and 0.82 mm for spatial distance. When using PA as the reference axis, the corresponding ICC values were 0.87, 0.89, and 0.77, respectively. The 95% limits of agreement for all IOL decentration measurements were wide when comparing Pentacam and OPD-Scan III.

CONCLUSIONS

Pentacam demonstrated high repeatability in measuring IOL decentration with respect to both CTA and PA. However, due to poor agreement between Pentacam and OPD-Scan III measurements, caution should be exercised when using data interchangeably between the two devices.

Postoperative intraocular lens stability following cataract surgery with or without primary posterior continuous curvilinear capsulorrhexis: an intra-individual randomized controlled trial

PURPOSE

To evaluate the effect of primary posterior continuous curvilinear capsulorrhexis (PPCCC) on the positional stability of IOLs.

METHODS

This study is a prospective intra-individual comparative randomized controlled trial including 31 patients (62 eyes). Eyes of the same patient were randomly assigned to the PPCCC group (18 right eyes and 13 left eyes) or group without PPCCC (NPCCC group). Eyes in both groups were implanted with a one-piece foldable hydrophobic acrylic IOL via routine cataract surgery. Patients in the PPCCC group underwent additional manual PPCCC before IOL implantation. Examinations were performed 1 day, 1 week, 1 month and 3 months postoperatively. IOL tilt (x, y), decentration (x, y), anterior chamber depth (z) and refractive prediction error data were collected and analyzed with Pentacam.

RESULTS

Postoperatively, the range of IOL position change over 3 months in PPCCC group was comparable to NPCCC group, which indicated smaller value in every tilt and decentration index. PPCCC eyes showed comparable tilt and decentration with NPCCC eyes in this study endpoint: mean tilt (x, y), decentration (x, y) and anterior chamber depth (ACD) were 1.04 ± 0.56°, 0.90 ± 0.64°, 0.239 ± 0.140 mm, 0.233 ± 0.133 mm and 4.01 ± 0.32 mm, respectively, in the PPCCC group vs. 1.09 ± 0.76°, 1.10 ± 0.82°, 0.252 ± 0.153 mm, 0.244 ± 0.155 mm and 4.01 ± 0.38 mm, respectively, in the NPCCC group. Refractive prediction error in the PPCCC group demonstrated a mild hyperopic shift vs. the NPCCC group (0.13 ± 0.50 vs. 0.05 ± 0.39; p = 0.208), and corrected distance visual acuity (CDVA) did not differ between the two groups (0.027 ± 0.014 vs. 0.059 ± 0.185; p = 0.377).

CONCLUSIONS

Comparable IOL tilt, decentration, ACD and refractive prediction error were observed in PPCCC eyes with that underwent routine cataract surgery. Little IOL position fluctuation and good visual acuity were shown in PPCCC group over time.

TRAIL REGISTRATION

The study was registered at the Chinese Clinical Trial Register Center on May 27th, 2020 (protocol code ChiCTR2000033304, 27/05/2020).

Intraocular lens tilt and decentration after cataract surgery with and without primary posterior continuous curvilinear capsulorhexis

PURPOSE

To evaluate intraocular lens (IOL) tilt and decentration and their effects on higher-order aberrations (HOAs) after cataract surgery with and without primary posterior continuous curvilinear capsulorhexis (PPCCC).

SETTING

Fujian Provincial Hospital, Fujian, China.

DESIGN

Prospective, intraindividual, randomized, comparative clinical trial.

METHODS

64 eyes of 32 patients with age-related cataract who underwent bilateral cataract surgery and IOL implantation were enrolled in this study. In randomized order, all patients had phacoemulsification cataract surgery with PPCCC in 1 eye (PPCCC group) and routine cataract surgery in the contralateral eye (NPCCC group). IOL decentration, tilt, HOAs, modulation transfer function, and point spread function were measured at 1 day, 1 week, 1 month, and 3 months after surgery using OPD-Scan III.

RESULTS

52 eyes of 26 patients were available for analysis. The mean overall decentration in the NPCCC group was significantly higher than in the PPCCC group at 3 months (0.302 ± 0.157 mm vs 0.187 ± 0.099 mm, P < .001). Under 3 mm pupil, internal spherical aberration (SA) 1 day after surgery and coma 1 week after surgery were lower in the PPCCC group compared with the NPCCC group (0.15 ± 0.10 μm vs 0.30 ± 0.21 μm, P < .001, and 0.34 ± 0.18 μm vs 0.47 ± 0.31 μm, P = .03, respectively). IOL decentration was significantly correlated with ocular and internal coma, ocular and internal SA, and internal HOAs at 5 mm pupil ( R = 0.083 and R = 0.099, R = 0.650 and R = 0.613, and R = 0.418, respectively, all P < .01).

CONCLUSIONS

Less IOL decentration was observed in the PPCCC group at 3 months after surgery, indicating that PPCCC may result in better IOL centrality.

Three-dimensional assessment of posterior capsule-intraocular lens interaction with and without primary posterior capsulorrhexis: an intraindividual randomized trial

PURPOSE

To assess the morphologic and clinical features of posterior capsule-intraocular lens (IOL) interaction following cataract surgery with and without primary posterior continuous curvilinear capsulorrhexis (PPCCC) at a three-dimensional (3-D) level using Scheimpflug imaging.

METHODS

This prospective intraindividual randomized comparative study comprised 56 patients (112 eyes) with age-related cataract who had bilateral cataract surgery and hydrophobic acrylic IOLs implantation. In randomized order, cataract surgery with PPCCC was performed in 1 eye (PPCCC group), and the posterior capsule was left intact in the fellow eye (NPCCC group). Scheimpflug imaging containing 25 images distributed in 360° was taken 1 day, 1 week, 1 month, and 3 months postoperatively.

RESULTS

46 patients completed 3 months follow-up. Posterior capsule-IOL interaction can be morphologically classified into two types including complete adhesion and floppy shape in PPCCC group, and six types including full area wave, full area flat, concentric ring wave, concentric ring flat, sector, and complete adhesion in NPCCC group. The adhesion index (AI), defined as the proportion of complete adhesion of posterior capsule-IOL in 25 cross-section tomograms, was 0.45 ± 0.45, 0.79 ± 0.37, 0.92 ± 0.26 and 1.00 ± 0.00 in PPCCC group, while 0.05 ± 0.18, 0.41 ± 0.47, 0.87 ± 0.34, and 0.96 ± 0.21 in NPCCC group at 1 day, 1 week, 1 month and 3 months postoperatively, respectively (p = 0.001, 0.001, 0.338 and 0.151).

CONCLUSIONS

3-D Scheimpflug imaging was favorable in observing of posterior capsule-IOL interaction. Faster posterior capsule adhesion to the IOL was found in PPCCC group than in NPCCC group.

Relationship Between Postoperative Intraocular Lens Shift and Postoperative Refraction Change in Cataract Surgery Using Three Different Types of Intraocular Lenses

Introduction

Understanding the relationship between postoperative intraocular lens (IOL) shift and refractive change is crucial for the accuracy of predicted postoperative refraction (PPR). We assessed the relationships between different IOL fixation methods, haptic designs, and several metrics.

Methods

Single-center, open-label study which included 69 eyes. We preoperatively measured the anterior chamber depth (ACD), lens thickness (LT), axial length (AL), and PPR. AcrySof IQ (n = 27) and FineVision (n = 24) were fixed in the bag, and FEMTIS (n = 18) was fixed in capsulorhexis. At 1 day, 1 week, and 1 month postoperatively, we checked the IOL position and refraction and compared the IOL shift, refraction change, and the margin of error of the predicted PPR (PR-PPR difference). We also analyzed the correlation between postoperative and preoperative variables.

Results

FEMTIS showed the highest stability in terms of IOL shift and refraction. The in-the-bag-fixated IOLs showed a significant forward shift between 1 day and 1 week postoperatively. There were significant differences in the PR-PPR difference between the IOLs. ACD and AL showed significant positive correlations, and LT showed a significant negative correlation with IOL shift and change in PR between 1 day and 1 week, but not between 1 week and 1 month postoperatively.

Conclusion

The relationship between postoperative IOL shift and refraction change varied according to IOLs with different haptic types. Capsulorhexis fixation may be more stable than in-the-bag fixation. Furthermore, preoperative ACD, LT, and AL may be useful factors to predict IOL shift, change in PR, and to a lesser extent the degree of the margin of error in clinical practice. Our findings may improve the accuracy of PPR and refractive outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00390-x.

[Primary posterior capsulorhexis in difficult situations]

Primary opening of the posterior capsule (primary continuous curvilinear capsulorhexis, PCCC) during cataract surgery is a safe and efficient procedure to prevent formation of an aftercataract. When combined with buttonholing of the optic in the posterior capsule opening no unintended rotation of a toric intraocular lens (IOL) can occur postoperatively. This article shows that PCCC can be safely performed even in difficult situations.

Clinical Outcomes of Primary Posterior Continuous Curvilinear Capsulorhexis in Postvitrectomy Cataract Eyes

Purpose

To evaluate the safety and outcomes of primary posterior continuous curvilinear capsulorhexis (PPCCC) combined with phacoemulsification in postvitrectomy eyes.

Design

Retrospective case series.

Methods

Twenty-one postvitrectomy eyes of 21 patients with cataract between April 2017 and December 2019 were enrolled. PPCCC through the cornea incision was performed before in-the-bag intraocular lens implantation. All patients were followed up for at least 3 months postoperatively. The outcome measures were corrected distance visual acuity (CDVA), intraocular pressure (IOP), corneal endothelium cell counts (CECC), central macular thickness (CMT), the occurrence of intraoperative or postoperative complications, and the incidence of posterior capsular opacification (PCO).

Results

The mean age was 56.14 ± 9.76 years (ranging from 31 to 68). The mean Snellen CDVA was 20/400 preoperatively and improved to 20/67 postoperatively (P < 0.001). No significant differences were found between IOP (P = 0.96) and CMT (P = 0.42) preoperatively and postoperatively. The mean CECC was 2571.8 ± 319.3 cells/mm² preoperatively and 2498.2 ± 346.3 cells/mm² postoperatively (P < 0.05). Lens epithelium cells proliferation was confined to the peripheral capsular bag during a mean follow-up of 12.9 ± 10.5 months (ranging from 3 to 28 months). Intraoperative posterior capsule extension occurred in 1 eye (4%), although it did not affect the patient's vision. No serious complications, including retinal detachment or endophthalmitis, were detected in any of the 21 cases.

Conclusion

PPCCC through cornea incision combined with phacoemulsification may be a safe and practical alternative to prevent PCO in postvitrectomy eyes with cataract.

The effects of different shapes of capsulorrhexis on postoperative refractive outcomes and the effective position of the intraocular lens in cataract surgery

BACKGROUND

To evaluate the effects of anterior capsular opening size on deviation from predicted refraction and the effective position of the intraocular lens (ELP) in cataract surgery.

METHODS

Nonrandomized clinical trial. Eighty patients (80 eyes) with simple age-related cataracts were treated from May 2018 to September 2018 at the Fourth Affiliated Hospital of China Medical University. All patients undergoing phacoemulsification received intraocular lens based on the voluntary principle. Forty eyes were implanted with the C-loop haptic intraocular lens (AMO Tecnis ZCB00) while the other 40 eyes were implanted with the plate haptic intraocular lens (CT ASPHINA 509 M). Follow-up visits were conducted postoperatively at 1 week, 1 month, and 3 months during which patients underwent refraction and data collection after pupil dilation, which included anterior segment photography and Scheimpflug imaging by Pentacam. The area, horizontal and vertical diameter of the capsulorrhexis, circularity, decentration, and package were analysed using the image analysis software Image-Pro-Plus 6.0,then evaluated the relationship between the different shapes of capsulorrhexis with deviation from predicted refraction and ELP in cataract surgery.

RESULTS

Deviation from predicted refraction and all of the parameters of capsulorrhexis were not correlative in the 509 M IOL group, however, in the Tecnis IOL group, while the deviation from predicted refraction and all of the capsulorrhexis parameters were not correlative at 1 week, the deviation from predicted refraction did correlate with capsulorrhexis area, horizontal diameter at 1 month (P = 0.029, P = 0.048), and with capsulorrhexis area, vertical diameter at 3 months (P = 0.03, P = 0.017). The ELP correlated with package in both groups postoperatively (r > 0, P < 0.05), but there is no other capsulorrhexis parameters correlated with ELP in the 509 M IOL group (all P > 0.05). For the Tecnis IOL group, the ELP and capsulorrhexis area were correlated at 1 week and 1 month, while the ELP and horizontal diameter, the ELP and vertical diameter were correlated at 1 week, but did not correlate with the other capsulorrhexis parameters in the Tecnis IOL group (all P > 0.05).

CONCLUSIONS

The shape of the capsulorrhexis has an effect on postoperative refractive outcomes and the effective position of the intraocular lens in cataract surgery, and plate haptic intraocular lenses have better refractive stability than C-loop haptic intraocular lenses.

TRIAL REGISTRATION

ChiCTR1800015638 ,2018-04-12.

Primary posterior capsulotomy in femtosecond laser-assisted cataract surgery: In vivo spectral-domain optical coherence tomography study

PURPOSE

To evaluate whether the size of Berger space is safely predictable in patients having cataract surgery using 3-dimensional spectral-domain optical coherence tomographic (3-D SD-OCT) image analysis.

SETTING

Ruhr University Eye Hospital, Bochum, Germany.

DESIGN

Prospective interventional case series.

METHODS

Eyes having routine femtosecond laser-assisted cataract surgery were included. After wound closure, the anterior eye segment was visualized using the incorporated 3-D SD-OCT. Visualization of Berger space was performed in the axial and sagittal planes.

RESULTS

The study comprised 165 consecutive eyes. In 155 eyes, 3-D SD-OCT visualized Berger space and its dimensions were analyzed. In 72% of the cases, Berger space was large enough to perform a femtosecond laser-assisted primary posterior capsulotomy. In 24 eyes (15.5%) with a minimum axial length of 25.0 mm, Berger space was 500 μm or larger.

CONCLUSION

Femtosecond laser systems incorporating real-time SD-OCT allowed direct visualization of Berger space intraoperatively, providing surgeons with the information needed to safely create posterior capsulotomies after intraocular lens implantation.

FINANCIAL DISCLOSURE

Dr. Dick is a consultant to Abbott Medical Optics, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

In vivo evaluation of a new hydrophobic acrylic intraocular lens in the rabbit model

PURPOSE

To evaluate the uveal and capsular biocompatibility as well as positioning stability of a new hydrophobic acrylic intraocular lens (IOL) in vivo in the rabbit model and compare it with a commercially available IOL.

SETTING

John A Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

DESIGN

Experimental study.

METHODS

Fifteen New Zealand rabbits had the new test IOL (Clareon CNA0T0) implanted in one eye and a control IOL (Acrysof SN60WF) implanted in the contralateral eye. The test IOL is manufactured from a new hydrophobic acrylic material incorporating ultraviolet blocker and blue light filter. Its design is based on the control IOL's platform. The rabbits were followed up with weekly slitlamp evaluations, which assessed inflammatory reactions as well as capsular bag opacification. Anterior chamber depth was measured at 1 and 4 weeks post-implantation (high-frequency ultrasound). After 4 weeks, the rabbits were killed humanely and the eyes were enucleated. The anterior segment was evaluated from the posterior or Miyake-Apple view, and was then processed for complete histopathology.

RESULTS

There were no statistically significant differences between test and control eyes in terms of postoperative inflammation and capsular biocompatibility, including posterior capsule opacification (P = .34, paired t test), and anterior capsule opacification (P = .53, paired t test), as observed during clinical and pathological evaluation. In vivo axial positioning for the test IOL was comparable to the control IOL and stable over time (P = .531 versus P = .788).

CONCLUSIONS

The new IOL showed biocompatibility and stability comparable to the control IOL.

Adhesion of the posterior capsule to different intraocular lenses following cataract surgery

PURPOSE

To investigate the prevalence and morphologic and clinical features of posterior capsule-optic inadhesion following cataract surgery.

METHODS

In this prospective cohort study, we examined 518 consecutive patients who had undergone uneventful phacoemulsification and posterior chamber intraocular lens (IOL) implantation. They were assigned into five groups based on the type of IOL used: MC X11 ASP, Rayner 920H A, ZCB00, SN60WF and KS-3Ai. Routine ophthalmic examinations were performed. Patients were followed up at 1 day, 1 week, and 1 and 2 months postsurgery. Anterior segment photography, Scheimpflug imaging and KR-1W aberrometry were conducted after the patients' pupils were dilated.

RESULTS

The overall rate of posterior capsule-optic inadhesion on the first day after surgery was 215/518 (41.5%), and it decreased to 37/518 (7.1%) at 2 months postsurgery. Posterior capsule-optic inadhesion can be morphologically classified into five types with three outcomes, of which gradual absorption of the accumulated fluid predominated for all IOLs. The clinical characteristics of patients with inadhesion varied with IOL type. Notably, visual quality data (Strehl ratios and modulation transfer function) were poorer in patients with posterior capsule-optic inadhesion, especially in those with irregular forms of suspension. Four cases of capsular contraction syndrome were identified among the patients with inadhesion.

CONCLUSIONS

Posterior capsule-optic inadhesion is a prevalent capsule-IOL interaction following cataract surgery. Although the accumulated fluid is absorbed in the majority of patients, its adverse effects on visual outcomes, especially visual quality in the operated eye(s), must not be underestimated in patients with persistent inadhesion.

In-the-bag intraocular lens placement via secondary capsulorhexis with radiofrequency diathermy in pediatric aphakic eyes

Pediatric ophthalmologists increasingly recognize that the ideal site for intraocular lens (IOL) implantation is in the bag for aphakic eyes, but it is always very difficult via conventional technique. We conducted a prospective case series study to investigate the success rate and clinical outcomes of capsular bag reestablishment and in-the-bag IOL implantation via secondary capsulorhexis with radiofrequency diathermy (RFD) in pediatric aphakic eyes, in which twenty-two consecutive aphakic pediatric patients (43 aphakic eyes) enrolled in the Childhood Cataract Program of the Chinese Ministry of Health were included. The included children underwent either our novel technique for secondary IOL implantation (with RFD) or the conventional technique (with a bent needle or forceps), depending on the type of preoperative proliferative capsular bag present. In total, secondary capsulorhexis with RFD was successfully applied in 32 eyes (32/43, 74.4%, age 5.6±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved in 30 eyes (30/43, 70.0%), but in the remaining 2 eyes (2/32, 6.2%) the IOLs were implanted in the sulcus with a capsular bag that was too small. Secondary capsulorhexis with conventional technique was applied in the other 11 eyes (11/43, 25.6%, age 6.9±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved only in 3 eyes(3/43, 7.0%), and the IOLs were implanted in the sulcus in the remaining 8 eyes. A doughnut-like proliferative capsular bag with an extensive Soemmering ring (32/43, 74.4%) was the main success factor for secondary capsulorhexis with RFD, and a sufficient capsular bag size (33/43, 76.7%) was an additional factor in successful in-the-bag IOL implantation. In conclusion, RFD secondary capsulorhexis technique has 70% success rate in the capsular bag reestablishment and in-the-bag IOL implantation in pediatric aphakic eyes, particularly effective in cases with a doughnut-like, extensively proliferative Soemmering ring.