Capsulorhexis phimosis in retinitis pigmentosa despite capsular tension ring implantation

Outcomes of vitreoretinal surgery in eyes with retinitis pigmentosa without retinal detachment

PURPOSE

Outcomes of retinal detachment (RD) have been discussed in detail in many reports of patients with retinitis pigmentosa (RP). This study tries to understand the outcomes of vitreoretinal (VR) surgery for indications other than RD in the eyes with RP.

METHODS

This is a retrospective study that includes clinical data from January 2013 to December 2021. Patients with RP who were treated with a VR surgical intervention were included in the study. The primary outcome of the study was to assess the changes in best-corrected visual acuity.

RESULTS

Forty-four eyes of 40 patients with RP were included in the study. Nearly half of the eyes (43%, 19/44) presented from 1 month to 1 year after the onset of diminished vision, with or without floaters. The mean ± standard deviation (SD) best-corrected visual acuity (BCVA) at presentation was 1.30 ± 0.79 logMAR (20/400 ± 20/125). The major surgical indications were vitreous opacities (43.2%, 19/44) and subluxated/dislocated cataractous lenses (25%, 11/44). The median follow-up duration was 8 months (interquartile range (IQR): 1.5-27). Approximately 77% (34/44) of the eyes had improvement in vision. The mean postoperative BCVA at the last follow-up was 0.95 ± 0.73 logMAR (p-value: 0.03).

CONCLUSIONS

Most eyes with RP recovered well after VR surgical interventions, with short-term improvements in visual acuity. It may be crucial to address the vitreous opacities and membranes as they hinder the residual central island of vision in RP. However, appropriate counselling is required regarding the progressive nature of retinal neuronal degeneration.

Retinitis Pigmentosa: Current Clinical Management and Emerging Therapies

Retinitis pigmentosa (RP) comprises a group of inherited retinal dystrophies characterized by the degeneration of rod photoreceptors, followed by the degeneration of cone photoreceptors. As a result of photoreceptor degeneration, affected individuals experience gradual loss of visual function, with primary symptoms of progressive nyctalopia, constricted visual fields and, ultimately, central vision loss. The onset, severity and clinical course of RP shows great variability and unpredictability, with most patients already experiencing some degree of visual disability in childhood. While RP is currently untreatable for the majority of patients, significant efforts have been made in the development of genetic therapies, which offer new hope for treatment for patients affected by inherited retinal dystrophies. In this exciting era of emerging gene therapies, it remains imperative to continue supporting patients with RP using all available options to manage their condition. Patients with RP experience a wide variety of physical, mental and social-emotional difficulties during their lifetime, of which some require timely intervention. This review aims to familiarize readers with clinical management options that are currently available for patients with RP.

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.

A Review of Complicated Cataract in Retinitis Pigmentosa: Pathogenesis and Cataract Surgery

Retinitis pigmentosa (RP) is a set of inherited retinal degenerative diseases that affect photoreceptor and retinal pigment epithelial cells (RPEs), possibly associated with some ocular complications, including cataract. The complicated cataract formation is most likely the result of RP-related inflammation response, and the most common morphology category is posterior subcapsular cataract (PSC). Despite the absence of curative pharmacologic treatment, phacoemulsification with intraocular lens implantation to deal with opacification in the lens is preferred due to the considerable visual outcomes. However, the incidence of intraocular and postoperative complications is higher in RP patients than those without, including intraoperative phototoxic retinal damage, posterior capsular opacification (PCO), capsular contraction syndrome (CCS), pseudophakic cystoid macular edema (PCME), increased postoperative intraocular pressure (IOP), and intraocular lens (IOL) dislocation. Hence, it needs much attention to surgery progress and close follow-up. In this review, we discuss the current understanding of RP patients with complicated cataracts from morphology to potential pathogenesis to cataract surgical procedure and provide a concise description and the recommended management of related surgery complications to broaden the knowledge and lower the latent risks to yield better clinical outcomes.

Evaluation of anterior capsular contraction syndrome after cataract surgery with commonly used intraocular lenses

Purpose

The purpose of this study was to compare the incidence of anterior capsular contraction syndrome (ACCS) in cataract patients after implantation with one of two most commonly used hydrophobic acrylic lenses.

Setting

This study included patients from Loma Linda University, Loma Linda, CA, USA.

Design

This study is a retrospective chart review.

Methods

In this study, 1,047 eyes of 811 patients with and without known ACCS risk factors who underwent successful phacoemulsification and intraocular lens (IOL) implantation were included. Eyes that sustained intraoperative capsular tears and patients with a postoperative follow-up of <1 month were excluded. Each patient underwent surgery by the same surgeon receiving either the SN60WF IOL or the ZCB00 IOL. The duration of postoperative follow-up along with the presence of ACCS and the dimensions of the anterior capsule opening in these cases were recorded. The incidence of ACCS between the two lenses was compared.

Results

ACCS was significantly (P=0.045) less frequent in those patients who received the ZCB00 lens compared to those who received the SN60WF lens, despite a significantly greater (P<0.0001) number of patients with ACCS risk factors in the ZCB00 cohort.

Conclusion

In a direct comparison of the ZCB00 and SN60WF IOLs, a lower incidence of ACCS was found with ZCB00 IOL.

[Capsule contraction syndrome in pseudophakia]

This is a review of the literature on capsule contraction syndrome (CCS) in pseudophakic patients that involves severe fibrosis along the margin of the anterior capsule's opening and progressive contraction of the capsular bag. Possible causes of CCS and principles of its prevention and treatment have been analyzed.

Spontaneous Late Intraocular Lens and Capsule Tension Ring Dislocation

In this report, three cases with pseudoexfoliation (PEX) and advanced age with spontaneous intraocular lens (IOL) and capsule tension ring (CTR) dislocation were presented. All of our cases experienced progressive vision loss without an episode of strenuous physical activity, trauma, or any other ocular disease. Spontaneous dislocation was observed 2.5 to 8 years after uneventful phacosurgery. Each patient underwent complete IOL and CTR removal combined with anterior chamber IOL implantation. No complications were noticed during follow-up. As a result, capsule tension ring does not prevent late IOL dislocation after uncomplicated phacosurgery in the presence of PEX. Therefore, close follow-up is essential for patients with PEX.

Postoperative occlusion of visual axis with fibrous membrane in the presence of anterior capsular phimosis in a patient with pseudoexfoliation syndrome: a case report

Background

To report a case of postoperative fibrous membrane formation occluding the visual axis in the presence of anterior capsular phimosis in a patient with pseudoexfoliation syndrome.

Case presentation

A 79-year-old Asian woman with pseudoexfoliation syndrome underwent uneventful phacoemulsification and implantation of one-piece hydrophilic acrylic square-edged intraocular lens (Cristalens) in the right eye. Two months later, she had blurred vision in the right eye with the best-corrected visual acuity (BCVA) of 20/40. Formation of fibrous membrane occluding the capsulorhexis opening with contraction of anterior capsule was observed, which was confirmed by anterior segment optical coherence tomography. Clear visual axis was achieved by lysis of the membrane using Nd:YAG laser. The BCVA improved to 20/20.

Conclusions

Occlusion of the visual axis with fibrous membrane can develop in the presence of anterior capsular phimosis in a patient with pseudoexfoliation syndrome.

All about capsular tension rings

PURPOSE OF REVIEW

To discuss capsular tension devices and recent evidence regarding their use.

RECENT FINDINGS

The capsular tension ring, modified capsular tension ring, and capsular tension segment are well established tools for use during phacoemulsification when zonular instability is present. Recent research has provided additional evidence of their benefits in decreasing intraoperative and postoperative complications.

SUMMARY

Endocapsular support devices allow for cataract surgery success in the setting of zonular instability.

Capsule contraction syndrome with a microincision foldable hydrophilic acrylic intraocular lens: two case reports and review of the literature

Here we present 2 cases of capsule contraction syndrome (CCS). In both cases, a hydrophilic acrylic Akreos MI60 (Bausch and Lomb) intraocular lens (IOL) was implanted in the capsular bag through microincision cataract surgery, and the literature on the subject is reviewed. Since CCS has been described after the implantation of every IOL type, it is unlikely that the Akreos MI60 chemical and physical properties may cause CCS. When CCS occurs with IOLs composed of increasingly flexible materials that are inserted through incisions of decreasing size, a severe dislocation and deformation of IOL optics and haptics may develop. In both cases illustrated here, Nd:YAG laser anterior capsulotomy was highly effective. Hence, also based on the literature, which reports severe complications as a result of surgical intervention, it is suggested that Nd:YAG laser anterior capsulotomy be the first line of CCS treatment when the luxation of an IOL capsular bag is absent.

Bimanual anterior segment revision surgery for anterior capsule contraction syndrome associated with anterior flexion of intraocular lens haptics

PURPOSE

To report the incidence of anterior capsule contraction syndrome (ACCS) and to present a novel minimally invasive bimanual technique for anterior segment revision surgery associated with ACCS with anterior flexion of the intraocular lens haptics.

METHODS

A consecutive cohort of 268 eyes of 161 patients undergoing phacoemulsification and implantation of the same type of hydrophilic acrylic aspheric intraocular lens cohort were analysed and a novel technique of minimally invasive bimanual technique for anterior segment revision surgery is described.

RESULTS

We identified four eyes (1.5%) of three patients with advanced ACCS. Successful restoration of a clear visual axis with minimal induction of astigmatism and rapid visual rehabilitation was achieved in all four cases.

CONCLUSION

This technique is a safe and minimally invasive alternative to laser or vitrector-cut capsulotomy to restore a clear visual axis. In cases of advanced ACCS, it offers the option for haptic reposition or amputation.

Spontaneous dislocation of posterior chamber intraocular lenses (PC IOLs) in patients with retinitis pigmentosa - Case series

PURPOSE

To report the outcomes of intraocular lens (IOL) dislocation management in 6 cases with Retinitis Pigmentosa (RP).

SETTING

Private practice, Los Angeles, USA.

DESIGN

Retrospective interventional case series.

METHODS

The medical reports of six eyes of four RP patients with capsule bag fixated posterior chamber IOL dislocation were retrospectively reviewed. Pre-operative data included demographics, systemic or ocular disorders, history of trauma, previous intraocular surgery and pre-operative visual acuity. Outcome measures included the type of surgery, surgical complications, elevation of intraocular pressure (IOP), ocular inflammation, cystoid macular edema (CME) and IOL dislocation at 3 months or greater post-operatively.

RESULTS

The medical records of six eyes of four patients operated on between December 2009 and May 2011 were evaluated. In four cases, dislocated PC IOL implants were sutured to the sclera. In two eyes of one patient anterior chamber IOLs (AC IOLs) were implanted after PC IOLs were explanted. One eye developed CME during the follow-up period. Despite modest tilt in one case and modest decentration in another, stability and centration of the IOLs was excellent during the follow-up period. No eyes had intraocular inflammation requiring long term medical treatment, new onset glaucoma or retinal detachment. Mean follow-up time was 6.9 months (range 3-20).

CONCLUSIONS

Cataract surgeons should be aware of the increased risk for decentration and malposition of PC IOLs in patients with RP. Satisfactory results can be achieved by fixation of the PC IOL or AC IOL implantation.

Cataract extraction outcomes and the prevalence of zonular insufficiency in retinitis pigmentosa

PURPOSE

To examine surgical outcomes in patients with retinitis pigmentosa (RP) undergoing phacoemulsification cataract extraction.

DESIGN

Retrospective observational case series.

PATIENTS AND METHODS

In this single-institution study of consecutive RP patients who underwent phacoemulsification cataract extraction and intraocular lens implantation by a single surgeon between 2002 and 2012, preoperative, intraoperative, and postoperative records were analyzed with attention to best-corrected visual acuity (BCVA), lens and zonular status, capsular tension ring use, incidence of posterior capsular opacification and neodymium-doped yttrium-aluminum-garnet (YAG) laser capsulotomy, and surgical complications.

RESULTS

Eighty eyes of 47 RP patients (21 male) underwent cataract surgery during the study period at an average age of 48.9 years (range, 31-78 years). Mean follow-up time was 23.3 months (range, 1 day - 95 months). Posterior subcapsular cataracts were present in 97.5% of patients. Mean BCVA improved from 20/340 (logarithm of the minimal angle of resolution [logMAR] 1.23) to 20/129 (0.81) within 3 months of surgery, P < .0001. Eyes with a preoperative vision of 20/40 to 20/200 (47 eyes) improved from a mean of 20/81 (logMAR 0.61) preoperatively to 20/43 (0.33), P < .0001, postoperatively. Posterior capsule opacification occurred in 66 eyes (82.5%), and 42 eyes (52.5%) underwent a YAG laser capsulotomy at a mean of 10.8 months after surgery. Fifteen eyes (18.8%) of 10 patients (21.3%) had signs of phacodonesis (3 eyes noted preoperatively, 8 intraoperatively, and 4 postoperatively). One patient had bilateral dislocated in-the-bag intraocular lenses at 5.5 years and 6 years after surgery.

CONCLUSION

Cataract surgery yields significantly improved Snellen visual acuity in a majority of RP patients with a preoperative vision of 20/200 or better. Conversely, patients with a preoperative visual acuity of 20/400 or worse generally have more limited objective improvements, likely because of macular involvement, but usually report noticeable subjective improvement. A high prevalence of zonular instability is seen in RP patients undergoing cataract extraction. It is therefore important to conduct a careful preoperative assessment of lens stability with preparation for adjunctive methods that augment intraoperative and postoperative lens stabilization.

Rapid anterior capsular contraction after phacoemulsification surgery in a patient with retinitis pigmentosa

A decrease in the anterior capsule opening after cataract surgery has been observed in eyes with weakened lens zonules. It commonly occurs in diabetes mellitus, uveitis, pseudoexfoliation syndrome, high myopia, and elderly patients. Herein, we report the case of a middle-aged man with advanced retinitis pigmentosa who developed a rapid contraction of the anterior capsule after an uneventful phacoemulsification surgery that resulted in severe visual loss during the early postoperative period.

Long-term clinical results after cataract surgery with and without capsular tension ring in patients with retinitis pigmentosa: a retrospective study

OBJECTIVES

To describe the long-term clinical outcomes after cataract surgery with and without capsular tension ring (CTR) in a group of patients with retinitis pigmentosa (RP).

DESIGN

A retrospective study.

SETTING

Tertiary referral centre.

PARTICIPANTS

52 eyes (46 patients) with RP.

INTERVENTIONS

Cataract surgery was undertaken between October 2002 and May 2010.

PRIMARY AND SECONDARY OUTCOME MEASURES

Visual acuity, secondary cataract, capsular contraction syndrome (CCS), intraocular pressure, cystoid macular edema (CME), intraocular lens dislocation and endophthalmitis.

RESULTS

The mean age at surgery was about 53 years and the overall mean follow-up was 26 months (range 3-60 months). The mean preoperative logarithm of the minimal angle of resolution of the best corrected visual acuity (LogMAR BCVA) in the entire group was 1.45±0.85 (95% CI 1.21 to 1.69) and had increased to 1.32±0.95 (95% CI 1.06 to 1.58, p=0.02). The mean preoperative and the mean postoperative LogMAR BCVA in the non-CTR group (group 1) improved from 1.16±0.8 (95% CI 0.83 to 1.48) to 0.98±0.88 (95% CI 0.62 to 1.33, p=0.02) and in the CTR group (group 2) from 1.74±0.81 (95% CI 1.42 to 2.07) to 1.66±0.90 (95% CI 1.3 to 2.03, p=0.31), respectively. Secondary cataract was observed in a total of 23 eyes (44%), of which 13 (50%) were belonged to group 1 and 10 (38%) to group 2. CCS was seen in a total of two eyes (4%) all under group 1. CME was noted in two eyes (4%), of which one belonged to group 1 and a second one to group 2. Endophthalmitis was not observed in any group.

CONCLUSIONS

Both surgical approaches were beneficial to the RP patients. Eyes under group 2 showed less long-term postoperative complications. This includes secondary cataract and CCS. Eyes under group 1 performed significantly better in respect of visual acuity. Further research would include insights into the genetic subsets.

The impact of capsulorhexis diameter, localization and shape on posterior capsule opacification

BACKGROUND

The aim of this study was to evaluate the impact of capsulorhexis diameter, localization and shape on posterior capsule opacification (PCO) development after cataract extraction with phacoemulsification.

MATERIAL/METHODS

We retrospectively analyzed of 297 patients who underwent phacoemulsification and AcrySof SA60AT implantation. In a first group of 97 patients, 53 received small capsulorhexis (3.9 to 4.9 mm in diameter) and 44 patients received large capsulorhexis (5.0 to 5.9 mm in diameter). Another group of 99 patients was split into subgroups--66 patients whose capsulorhexis were centrally located and 33 patients whose capsulorhexis were paracentral. A third group of 101 patients was split into subgroups--a subgroup of 59 patients were classified as having a regularly rimmed capsulorhexis and a subgroup of 42 patients as having an irregularly rimmed capsulorhexis. At 6 months follow-up, PCO was classified as none, mild, moderate, or severe, depending on the number of quadrants involved.

RESULTS

86.79% of the patients with a small capsulorhexis had no or mild PCO (p<0.001), whereas, 68.18% of the patients with a large capsulorhexis experienced moderate or severe PCO; 89.4% of the patients with a central capsulorhexis had no or mild PCO (p<0.001), whereas, 75.75% of the patients with a paracentral capsulorhexis had moderate or severe PCO; 86.44% of the patients with a regularly rimmed anterior capsulorhexis had no or mild PCO (p<0.001); and 69.04% of the patients with an irregular capsulorhexis rim had moderate or severe PCO.

CONCLUSIONS

A small capsulorhexis diameter, its central localization and regular shape result in less PCO following phacoemulsification.

Rapid capsular phimosis in retinitis pigmentosa

This case report retrospectively reviews the outcome of a 43-year-old man with retinitis pigmentosa who suffered rapid anterior capsular phimosis in each eye within 3 weeks following uncomplicated phacoemulsification with continuous curvilinear capsulorrhexis and single-piece acrylic intraocular lens (IOL) implantation. Anterior YAG capsulotomy was successfully performed in both eyes. It has been previously documented in the literature that capsular phimosis is more common in patients with retinitis pigmentosa. However, in the cases that were reviewed, capsular contracture progressed much less rapidly than in this patient. It is proposed that zonular dehiscence or increased lens epithelial cell fibrosis accompanying retinitis pigmentosa may be responsible for phimosis following phacoemulsification; in this case, the single-piece IOL may have offered less resistance to capsular contraction. Using a three-piece IOL, capsular tension ring, or making radial relaxing incisions in the anterior lens capsule may be useful approaches to minimize the aforementioned complications in patients with retinitis pigmentosa and cataracts.

Capsule contraction syndrome in Behcet's disease

We reported the case of a 39-year-old patient with inactive Behcet's syndrome developed capsule contraction syndrome after uneventful phacoemulsification and a foldable intraocular lens implantation. Two weeks after the operation, the patient was accepted to hospital with severe decrease of visual acuity (VA) on the operated eye. Capsule opening area had been reduced considerably by fibrotic tissue, which evaluated with full dilated pupil. Since capsule contraction syndrome (CCS) had been diagnosed in very early stage and which structure was not severely thick, the fibrotic band was treated successfully, 360 degree circular shape, by neodymium YAG (Nd:YAG) laser. Capsule opening area was remained stable during follow up period of one month. But a significant reocclusion was developed that need surgical reopening 3 months after initial operation. Continuous curvilinier capsulorhexis (CCC) may be recurred again after a successful treatment in patient with uveitis like Behcet's disease.

Capsular phimosis with complete occlusion of the anterior capsular opening after intact continuous curvilinear capsulorrhexis

Shrinkage and whitening of the anterior capsule opening - capsular contraction syndrome - is a well-known complication after continuous curvilinear capsulorrhexis. A 72-year-old women underwent continuous curvilinear capsulorrhexis, phacoemulsification, and implantation of posterior chamber intraocular lens with polymethylmethacrylate haptics. Four months postoperatively, the patient reported deterioration in visual acuity that was resulted due to complete occlusion of anterior capsular opening by fibrotic tissue. The fibrous membrane was excised surgically in capsulorrhexis fashion.

Surgical Repositioning of Dislocated Capsular Tension Rings

PURPOSE

To present techniques and results of surgical repositioning of subluxed and dislocated capsular tension rings (CTRs).

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Eleven patients with a previously implanted CTR in-the-bag for zonular weakness who presented with CTR-intraocular lens (IOL)-capsular bag decentration who underwent surgical repositioning.

METHODS

Data from 11 patients who underwent surgical repositioning were evaluated retrospectively for underlying diagnosis, interval between initial surgery and decentration, surgical technique, clinical results, and complications.

MAIN OUTCOME MEASURES

Capsular tension ring-IOL-capsular bag centration, final best-corrected visual acuity (BCVA), and surgical complications.

RESULTS

Of the 11 patients with CTR decentration, 3 had it early in the postoperative period, and 8 had it late. Mean (+/- standard deviation) durations from cataract extraction and CTR implantation to surgical repositioning were 6.1+/-7.9 months for those with decentration early and 49.6+/-15.3 months for late decentrations (overall range, 0.7-74.7). Of the 11 patients, 7 had pseudoexfoliation, and 4 of the 7 had associated glaucoma. Nine patients had subluxation of the CTR-IOL-capsular bag complex, which was managed by an anterior segment approach. A pars plana vitrectomy and levitation of the CTR was required in 2 patients due to complete dislocation of the CTR into the posterior vitreous. Surgical techniques for repositioning included single, double, or 3-point scleral suture loop fixation of the CTR through the capsular bag complex (8 eyes); use of the capsular tension segment (CTS) placed within the capsular bag for scleral suture fixation (2); or iris suture fixation of the IOL haptics (1). All patients achieved successful anatomical repositioning of the CTR-IOL-capsular bag complex. Mean preoperative BCVA improved from 20/100 to 20/40 postoperatively. After repositioning surgery, BCVA improved in 7 patients, was maintained in 2, and worsened in 2 (due to advanced glaucoma).

CONCLUSION

Postoperative CTR subluxation or dislocation is a risk for patients with severe or progressive zonulopathy. Decentrations may be effectively managed with scleral suture fixation of the CTR through the capsular bag or the use of the CTS.

Bilateral spontaneous dislocation of intraocular lenses within the capsular bag in a retinitis pigmentosa patient

A 45-year-old man with retinitis pigmentosa (RP), who had undergone uneventful extracapsular cataract extraction (ECCE) in his right eye eight years previously, and phacoemulsification in his left eye six years previously, had spontaneously dislocated intraocular lenses (IOL) within the capsular bag in both eyes one month apart. We removed the dislocated IOLs, and performed anterior vitrectomy and scleral fixation of the new IOLs. Mild contraction of the capsular bags and uneven distribution of the zonular remnants' clumps along the equator of the capsules were found by scanning electron microscopic (SEM) examination. In this study, we propose the correlation between RP and zonular weakness. To our knowledge, this is the first case report of bilateral spontaneous dislocation of IOLs within the capsular bag of an RP patient.