Secondary closure of posterior continuous curvilinear capsulorhexis

Efficacy and safety of primary posterior capsulotomy during phaco-vitrectomy for epiretinal membrane

Purpose

To evaluate the necessity and safety of primary posterior capsulotomy during phaco-vitrectomy for idiopathic epiretinal membrane (ERM).

Setting

Seoul National University Bundang Hospital, Seongnam, Korea.

Design

Retrospective consecutive cohort analysis.

Methods

This study enrolled 219 patients (228 eyes) who underwent combined 25-gauge phaco-vitrectomy for idiopathic ERM and cataract, divided into capsulotomy (−) group (152 eyes, 144 patients) and capsulotomy (+) group (76 eyes, 75 patients). The main outcomes were rate of posterior capsular opacity (PCO) occurrence and postoperative complications. Ophthalmic examinations were performed at baseline, 1, 3, 6, and 12 months postoperatively.

Results

PCO only occurred in capsulotomy (−) group (20 eyes, 13.2%), with mean onset of 10.59 months. Visually-significant PCO that needed Nd:YAG posterior capsulotomy was present in 9 eyes (45.0% of PCO eyes). The rate of cystoid macular edema (CME) was higher in capsulotomy (+) group (6.6% vs. 15.8%, p = 0.026) with longer duration (1.50 vs. 3.36 months, p = 0.019). Female sex and posterior capsulotomy were significant risk factors for CME occurrence (p < 0.05).

Conclusion

Primary posterior capsulotomy during phaco-vitrectomy for idiopathic ERM obviated the need for Nd:YAG posterior capsulotomy, but visually-significant PCO that needed Nd:YAG laser was not common. Considering the low rate of visually-significant PCO and high rate of postoperative CME, routine posterior capsulotomy during phaco-vitrectomy may not be necessary for preventing PCO in ERM.

[Future perspectives of the femtosecond laser in anterior segment surgery]

Around 12 years after its introduction laser cataract surgery (LCS) has enabled remarkable progress, such as extremely precise capsulotomy and lens fragmentation with reduced or no ultrasound energy at all (zero phako); however, another innovation push is necessary to bring this technology to its full potential. Among the many benefits that have not yet been fully explored are primary posterior laser capsulotomy (PPLC) and the use of the femtosecond laser in pediatric cataract patients. In the present collective of patients in whom a PPLC was carried out at the end of the operation, a clearly reduced prevalence of secondary cataract could be observed, whereas the short additional intervention was not associated with notable complications. The LCS in infants is best carried out as an off-label procedure, which has been rendered more precise by the Bochum formula. In the near future, postoperative laser fine tuning will enable the target refraction to be achieved in most patients. Laser-induced refractive index change (LIRIC) will enable very exact refraction alterations on an already implanted intraocular lens (IOL), on a contact lens and on a treatment native cornea. A new version of the Scheimpflug camera will be used just prior to surgery to analyze the morphology and kernel density of the lens opacity and to carry out a real-time grading of lens hardness. Based on this categorization, where the system classifies the results into five different density grades, the surgeon is automatically provided with an individualized fragmentation pattern defined preoperatively by the operator. A further innovation of the same system involves microcorneal incisions for fine tuning of residual refractive deficits.

Analysis and management of intraoperative and early postoperative complications of bag-in-the-lens intraocular lens implantation in different age groups of paediatric cataract patients: report of the Giessen Paediatric Cataract Study Group

PURPOSE

To report the rate and management of intra- and early postoperative complications of bag-in-the-lens intraocular lens (IOL) implantation technique for cataract treatment in paediatric patients of different age groups.

SETTINGS

Department of Ophthalmology, Justus-Liebig-University Giessen, University Hospital Giessen and Marburg GmbH, Campus Giessen, Giessen, Germany.

DESIGN

Retrospective non-randomized consecutive case series.

METHODS

Ninety eyes of 60 paediatric cataract patients were enrolled to this retrospective non-randomized observational consecutive case series single-centre study. All patients underwent cataract surgery with bag-in-the-lens IOL implantation between January 2008 and December 2018, performed by two experienced surgeons. The entire cohort was divided into four age groups: first - 0-<3 months, second - 3-<12 months, third - 12-<36 and fourth - >36 months-17 years of age. The intra- and postoperative complications were based on the clinical records. The description of management of complications related specifically to bag-in-the-lens IOL technique was based on the 39 consecutive cases operated since 1 Jan 2016 by one single surgeon that were all video documented. The early postoperative period was defined as 12 months after surgery.

RESULTS

Overall, there were 27 unilateral and 33 bilateral surgical cases of 24 female and 36 male children. The mean age at surgery was 45.25 months (range 1-200 months). The most common intraoperative events were vitreous prolapse and anterior capsule rupture with 28.9% and 13.3%, respectively. Within 12 months of follow-up, five eyes (5.6%) were re-operated because of visual axis reo-pacification (VAR). Intraocular hypertension was diagnosed in seven eyes (7.8%), including two cases that required surgical treatment. In all cases with intra- and early postoperative complications related specifically to bag-in-the-lens technique, it was possible to manage them and successfully implant bag-in-the-lens IOL.

CONCLUSIONS

Implementation of bag-in-the-lens technique in the treatment of paediatric cataract was associated with a relatively low rate of intra- and postoperative complications, including rare cases of VAR. The correct management of complications related specifically to bag-in-the-lens IOL implantation technique shall to be considered during the learning curve.

Primary posterior capsulotomy in adults with posterior capsule opacification

PURPOSE

To evaluate the efficacy and safety of primary posterior continuous curvilinear capsulorhexis (PCCC) in adult patients with cataract.

SETTING

Zagazig University Hospital, Ash-Sharkya, Egypt.

DESIGN

Prospective nonrandomized case series.

METHODS

This study comprised patients with senile cataract who had phacoemulsification. All patients had a dense posterior capsule opacification (PCO) discovered intraoperatively. Primary PCCC was performed to remove the residual opacification after posterior capsule polishing. All patients were followed for 3 months postoperatively. The outcome measures were corrected distance visual acuity (CDVA), macular edema detected by optical coherence tomography, and the occurrence of intraoperative or postoperative complications.

RESULTS

Twenty-five eyes of 25 cataract patients had phacoemulsification. The mean age was 61.9 years ± 7.5 (SD). The mean CDVA preoperatively was 0.14 ± 0.08 and postoperatively it was 0.86 ± 0.15 at 1 week, 0.93 ± 0.08 at 1 month, and 0.94 ± 0.08 at 3 months (P = .001). The mean central macular thickness was 313.16 ± 8.39 μm preoperatively and 315.04 ± 10.6 μm, 319.88 ± 26.06 μm, and 316.4 ± 13.7 μm at 1 week, 1 month, and 3 months postoperatively, respectively (P = .35). Posterior capsule opening contracture occurred in 1 eye (4%), although it did not affect the patient's vision. Intraoperative posterior capsule extension occurred in 1 eye (4%). No serious complications, such as retinal detachment or endophthalmitis, were detected in any patient.

CONCLUSION

Cataract surgery with primary PCCC was a safe procedure to treat residual PCO in adults and had a low rate of complications.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

Capsular Outcomes After Pediatric Cataract Surgery Without Intraocular Lens Implantation: Qualitative Classification and Quantitative Measurement

The objective of this study was to investigate capsular outcomes 12 months after pediatric cataract surgery without intraocular lens implantation via qualitative classification and quantitative measurement.This study is a cross-sectional study that was approved by the institutional review board of Zhongshan Ophthalmic Center of Sun Yat-sen University in Guangzhou, China.Digital coaxial retro-illumination photographs of 329 aphakic pediatric eyes were obtained 12 months after pediatric cataract surgery without intraocular lens implantation. Capsule digital coaxial retro-illumination photographs were divided as follows: anterior capsule opening area (ACOA), posterior capsule opening area (PCOA), and posterior capsule opening opacity (PCOO). Capsular outcomes were qualitatively classified into 3 types based on the PCOO: Type I-capsule with mild opacification but no invasion into the capsule opening; Type II-capsule with moderate opacification accompanied by contraction of the ACOA and invasion to the occluding part of the PCOA; and Type III-capsule with severe opacification accompanied by total occlusion of the PCOA. Software was developed to quantitatively measure the ACOA, PCOA, and PCOO using standardized DCRPs. The relationships between the accurate intraoperative anterior and posterior capsulorhexis sizes and the qualitative capsular types were statistically analyzed.The DCRPs of 315 aphakic eyes (95.8%) of 191 children were included. Capsular outcomes were classified into 3 types: Type I-120 eyes (38.1%); Type II-157 eyes (49.8%); Type III-38 eyes (12.1%). The scores of the capsular outcomes were negatively correlated with intraoperative anterior capsulorhexis size (R = -0.572, P < 0.001), but no significant correlation with intraoperative posterior capsulorhexis size (R = -0.16, P = 0.122) was observed. The ACOA significantly decreased from Type I to Type II to Type III, the PCOA increased in size from Type I to Type II, and the PCOO increased from Type II to Type III (all P < 0.05).Capsular outcomes after pediatric cataract surgery can be qualitatively classified and quantitatively measured by acquisition, division, definition, and user-friendly software analyses of high-quality digital coaxial retro-illumination photographs.

Suction posterior capsulorhexis: an audit of 15 years' experience

AIMS

To audit the results of 15 years' experience of suction posterior capsulorhexis (SPC) during phacoemulsification and compare the outcomes with a recently published multicentre audit of cataract surgery, the Cataract National Dataset (CND).

METHODS

Prospective cohort observational study.

SETTING

Ophthalmology department of a district general hospital.

RESULTS

Data collection ran from June 1998 to November 2013, and 866 eyes of 786 patients were included. The mean (SD) age was 70.7 (12.4) years with 62% women. Low levels of perioperative and postoperative complications were noted, and the visual outcomes at 2 weeks in this audit were significantly better than those of the CND, with 75.4% achieving a best-corrected vision of ≥6/6 and 87.3% ≥6/12, improving to 95.8% and 100%, respectively, for best-case analysis (p<0.001 for all comparisons). 99% achieved the same or a better postoperative visual acuity than preoperatively compared with 95% in the CND (p<0.001) and none lost two lines of Snellen acuity (versus 1.24%; p<0.001). Patients receiving one of the two designs of square-edged hydrophobic acrylic intraocular lenses used in this audit did not require later YAG laser treatment compared with 2.72% of those who had a polymethylmethacrylate intraocular lens (p<0.02). Biometry accuracy was within ±1.0 D of the predicted refraction in 89.3%.

CONCLUSIONS

SPC, when performed by an experienced surgeon, appears to achieve better visual outcomes than the CND without causing harm to patients nor adversely affecting biometry accuracy. Use of a hydrophobic acrylic intraocular lens with SPC may avoid the need for subsequent YAG laser therapy.

Long-term results of phacoemulsification combined with primary posterior curvilinear capsulorhexis in adults

Objective:

To evaluate the 2-year outcomes of phacoemulsification combined with primary posterior curvilinear capsulorhexis (PPCC) in adults.

Materials and Methods:

In this retrospective case series, 93 eyes of 91 patients with bilateral age-related cataract who underwent phacoemulsification combined with PPCC were evaluated. The study included cases due to postoperative residual posterior capsule opacification despite careful polishing. Data were evaluated on preoperative and postoperative best corrected visual acuity (CDVA) (Snellen acuity), slit-lamp biomicroscopy and intraocular pressure (IOP) measurement. Perioperative and postoperative complications were also recorded.

Results:

The mean follow-up was 24.9 ±13.5 months (range, 12-53 months). At the last visit, 87.1% of the eyes had CDVA ≥ 20/40 and 58% had ≥ 20/25. Posterior capsular opacification (PCO) occurred in 2 (2.2%) of patients. No serious complications such as retinal detachment and endophthalmitis were observed during follow-up.

Conclusions:

Cataract surgery combined with PPCC is a safe procedure with a low rate of complications over the long term. This procedure reduced the necessity of Nd:YAG laser capsulotomy in adults with postoperative residual posterior capsule opacification despite careful polishing.

Study of antiproliferative effects of synthetic substances against lens epithelial cell line (SRA 01/04)

A cataract is a clouded area of the eye, which impairs vision. Cataracts can be caused by a natural hardening of the lens in the elderly, or may be the result of eye injury. However there is a treatment by extracapsular surgery, almost 50% of operations are followed by another posterior capsule opacification. This secondary cataract is due to abnormal cellular proliferation. Pharmacologic inhibition of this cellular proliferation would be a very promising treatment. The objective of our study is to test some antiproliferative drugs, less toxic than those currently used such as 5-FU or mytomycin C. We have investigated the in vitro effects of several molecules (V0 and its derivatives) on a proliferative human lens epithelial cell line (SRA 01/04). During a first step, we have measured the IC50 of each molecule. After this first screening, we have studied the kinetic of the cell growth with or without the molecules at different concentration. Then, flow cytometry was used to determine the phase of the cell cycle at which the proliferation stopped. This study has shown that 3 molecules V19, V1, and A190 have an interesting profile in vitro and were selected to analyze their mechanism of action.

Objective assessment of intraocular flare after cataract surgery with combined primary posterior capsulorhexis and posterior optic buttonholing in adults

AIM

Combining primary posterior capsulorhexis (PPC) and posterior optic buttonholing (POBH) in cataract surgery is an innovative approach to prevent after-cataract formation effectively and to increase postoperative stability of the intraocular lens (IOL). The present study was designed to compare the postoperative intraocular flare after cataract surgery with combined PPC and POBH to conventional in-the-bag implantation of the IOL.

METHODS

Fifty consecutive age-related cataract patients with cataract surgery under topical anaesthesia in both eyes were enrolled prospectively into a prospective, randomised clinical trial. In randomised order, cataract surgery with combined PPC and POBH was performed in one eye; in the other eye cataract surgery was performed conventionally with in-the-bag IOL implantation keeping the posterior lens capsule intact. Intraocular flare was measured 1, 2, 4, 6, 12 and 24 h postoperatively, as well as 1 week and 1 month postoperatively, using a KOWA FC-1000 laser flare cell meter.

RESULTS

The peak of intraocular flare was observed in POBH eyes and eyes with in-the-bag IOL implantation 1 h postoperatively. In both groups, the response was steadily decreasing thereafter. During measurements at day 1, small though statistically significant higher flare measurements were observed in eyes with in-the-bag IOL implantation (p<0.05). At 1 week and 1 month postoperatively, intraocular flare measurements were comparable again (p>0.05).

CONCLUSION

Cataract surgery with combined PPC/POBH showed slightly lower postoperative anterior chamber reaction compared to conventional in-the-bag implantation during 4-week follow-up, indicating that POBH might trigger somewhat less inflammatory response. This could be explained by the posterior capsule sandwiching between the optic and the anterior capsule, preventing direct contact-mediated myofibroblastic trans-differentiation of anterior lens epithelial cells with consecutive cytokine depletion.

Postoperative course of intraocular pressure after cataract surgery with combined primary posterior capsulorhexis and posterior optic buttonholing

PURPOSE

To evaluate the natural course of intraocular pressure (IOP) after cataract surgery with combined primary posterior continuous curvilinear capsulorhexis (PPCCC) and posterior optic buttonholing (POBH) of the intraocular lens (IOL) in adult patients.

SETTING

Department of Ophthalmology, Medical University of Vienna, Vienna, Austria.

METHODS

Fifty consecutive patients with age-related cataract awaiting cataract surgery under topical anesthesia in both eyes were enrolled prospectively. In randomized order, cataract surgery with combined PPCCC and POBH was performed in 1 eye. In the fellow eye, cataract surgery was performed conventionally with in-the-bag IOL implantation and the posterior lens capsule kept intact. Standardized IOP measurements by Goldmann applanation tonometry were performed 1, 2, 4, 6, 8, and 24 hours postoperatively. Follow-up IOP measurements were taken at 1 week and 1 month. Twenty-five patients received 1-time IOP-lowering medication immediately after cataract surgery; the other 25 did not receive IOP-lowering drops.

RESULTS

During the first 24 hours postoperatively, no significant differences in IOP were observed between the PPCCC-POBH group and the conventional surgery group (P>.05). No IOP peaks greater than 27 mm Hg were observed in any eye. One week and 1 month postoperatively, no significant differences in IOP were found between groups (P>.05). The use of IOP-lowering drops significantly reduced postoperative IOP. However, no IOP spikes >27 mm Hg were found with and without the use of IOP-lowering drops.

CONCLUSION

The course of IOP after cataract surgery with combined PPCCC and POBH showed the technique to be as safe as conventional cataract surgery with in-the-bag IOL implantation.

Effect of primary posterior continuous curvilinear capsulorhexis on clinical performance of ACR6D SE single-piece hydrophilic acrylic intraocular lenses

PURPOSE

To evaluate the effects of a primary posterior continuous curvilinear capsulorhexis (PCCC) on the clinical performance of a single-piece hydrophilic acrylic intraocular lens (IOL) with haptic angulation.

SETTING

Department of Ophthalmology, Medical University of Vienna, Vienna, Austria.

METHODS

A prospective study of 52 patients with bilateral age-related cataract was conducted. Patients had standard cataract surgery with implantation of the same IOL in both eyes. Randomly, a PCCC was created in 1 eye and the posterior capsule was left intact in the fellow eye. Assessed parameters were visual axis opacification (VAO) in eyes with a PCCC or regeneratory posterior capsule opacification (PCO) in eyes without PCCC (scale 0 to 10) in the central (3.0 mm eccentricity), intermediate (3.0 to 4.5 mm eccentricity), and peripheral (>4.5 mm eccentricity [capsulorhexis edge]) areas; neodymium:YAG (Nd:YAG) laser capsulotomy or laser polishing of ongrowing lens epithelium; anterior capsule opacification (ACO); best corrected visual acuity (BCVA); and contrast sensitivity.

RESULTS

Thirty patients completed the 2(1/2)-year follow-up. Visual axis opacification was significantly lower in the central region in the PCCC group (mean 0.5 +/- 0.7 [SD]) than PCO in the central region of the non-PCCC group (mean 1.1 +/- 1.1) (P = .02). Forty percent in the non-PCCC group had an Nd:YAG laser capsulotomy during the follow-up period; none in the PCCC group had laser polishing. There were no significant differences in ACO, SE, BCVA, or contrast sensitivity. There was no additional gain in BCVA or contrast sensitivity in eyes with a PCCC compared with eyes without a PCCC when VAO and PCO were low.

CONCLUSION

A PCCC significantly reduced PCO formation within the central 3.0 mm eccentricity as well as the need for Nd:YAG laser capsulotomy in eyes with a single-piece hydrophilic acrylic IOL with angulated haptics.

Clinical effects of primary posterior continuous curvilinear capsulorhexis in eyes with single-piece hydrophilic acrylic intraocular lenses with and without haptic angulation

PURPOSE

To evaluate the clinical effects of a primary posterior continuous curvilinear capsulorhexis (PCCC) on the intraocular performance of hydrophilic acrylic single-piece intraocular lenses (IOLs) with and without haptic angulation.

SETTING

Department of Ophthalmology, Medical University of Vienna, Vienna, Austria.

METHODS

A prospective study comprised 52 patients with bilateral age-related cataract who had standard cataract surgery including a PCCC. One eye of each patient was randomized to receive a hydrophilic acrylic IOL with haptic angulation (ACR6D SE, Laboratoires Cornéal) and the contralateral eye, a hydrophilic acrylic IOL without haptic angulation (C-flex 570C, Rayner). The following parameters were assessed: regeneratory posterior opacification (RPO) in the central, intermediate, and peripheral areas (scale 0 to 10); anterior capsule opacification (ACO); best corrected visual acuity (BCVA); and contrast sensitivity (CSF).

RESULTS

Thirty-one patients completed the 1(1/2)-year follow-up. In both IOL groups, RPO within the PCCC was slight in the central area, with a mean score of 0.33 +/- 0.84 (SD) in the angulated IOL group and 0.16 +/- 0.57 in the nonangulated IOL group (P = .29). The mean RPO score in the peripheral area was 2.07 +/- 1.37 and 2.35 +/- 1.45, respectively (P = .12). The difference between the central and peripheral areas was 1.74 in the angulated IOL group (P<.00001) and 2.19 in the nonangulated IOL group (P<.00001). Haptic deformation occurred in 9 eyes (29%) with an angulated IOL and no eye with a nonangulated IOL. There was significantly more ACO in the nonangulated IOL group (P = .012). There were no significant differences in BCVA or CSF between the 2 groups.

CONCLUSIONS

Creating a PCCC led to significantly lower RPO intensity within the PCCC area than in the peripheral area in eyes with hydrophilic acrylic IOLs with and without haptic angulation. Haptic angulation had no apparent significant influence on the intensity of RPO or on BCVA and CSF. Haptic deformation may occur in hydrophilic IOLs with angulated haptics.

One-year follow-up of bag-in-the-lens intraocular lens implantation in 60 eyes

PURPOSE

To report the feasibility and clinical results of implanting a bag-in-the-lens intraocular lens (IOL) designed to prevent posterior capsule opacification after cataract surgery.

SETTING

Departments of Ophthalmology, University of Antwerp, Antwerp, Belgium, and University of Munich, Munich, Germany.

METHODS

This prospective study comprised 63 eyes (55 patients; 7 children, 48 adults) scheduled for cataract surgery and bag-in-the-lens IOL implantation. A posterior curvilinear capsulorhexis the same size as the anterior capsulorhexis was created for IOL insertion. After surgery, lens epithelial cell (LEC) proliferation was documented every 6 months with a minimum follow-up of 12 months.

RESULTS

Sixty of 63 eyes (95%) had implantation of the bag-in-the-lens IOL. Conversion to a conventional IOL was necessary in 2 cases. In 1 eye, postoperative luxation of the IOL into the vitreous occurred as a result of an oversized anterior and posterior capsulorhexis. Three eyes had early postoperative iris incarceration in the lens groove that required surgery. No LEC proliferation on the optic occurred during a mean follow-up of 22.7 months (range 12 to 64 months); LEC proliferation was confined to the peripheral capsular bag.

CONCLUSION

Lens epithelial cell proliferation was mild and confined to the periphery of the capsular bag during follow-up, and the bag-in-the-lens IOL optic remained clear.

Routine posterior optic buttonholing for eradication of posterior capsule opacification in adults: report of 500 consecutive cases

PURPOSE

To study the efficacy of posterior optic buttonholing (POBH) through a primary posterior capsulorhexis (PPCCC) to preserve full capsular transparency, and its potential as a routine alternative to standard in-the-bag implantation of sharp-edged optic intraocular lenses (IOLs).

SETTING

Department of Ophthalmology, Medical University of Vienna, Vienna, Austria.

METHODS

After standard cataract removal, a PPCCC 4.0 to 5.0 mm in diameter was performed and the optic of a 3-piece IOL buttonholed posteriorly. One third of the eyes additionally had extensive anterior capsule polishing. All surgeries were performed under topical anesthesia.

RESULTS

The first 500 consecutive surgeries were evaluated. In 11 eyes, POBH was not performed as planned. In 4 cases, anterior capsulorhexis fixation of the optic was used as an alternative. In the early series, vitreous entanglement was seen in 5 eyes, of which 1 case prompted translimbal anterior vitrectomy. No case of cystoid macula edema was observed. One case of peripheral retinal detachment in a highly-myopic eye 4 months postoperatively appeared to be unrelated to the surgery. All lenses were well-centered without tilt, and both capsule leaves remained clear especially after additional polishing.

CONCLUSION

Posterior optic buttonholing precludes lens epithelial cells from accessing the retrolental space. The sandwiched posterior capsule blocks optic contact and thus fibrosis of the anterior capsule. Posterior optic buttonholing avoids after-cataract independent of optic edge design. Anterior capsule polishing adds to its efficacy by excluding any residual fibrosis. Surgery under topical anesthesia was well-controlled and safe. Posterior optic buttonholing may become a routine alternative to standard in-the-bag IOL implantation when supported by a longer follow-up.

YAG curios #2: Nd:YAG laser treatment following suction posterior capsulorhexis

Suction posterior capsulorhexis (SPC) is a relatively new technique for creating a posterior capsulorhexis. We present a case series of seven patients who required Nd:YAG laser treatment 27 months after SPC. No patient had pre-existing risk factors for increased postoperative inflammation and all received a one-piece polymethylmethacrylate intraocular lens placed in-the-bag. Although it reduces the need for Nd:YAG laser treatment, SPC, like the more usual forceps posterior capsulorhexis, does not completely eliminate it.

Effect of bag-in-the-lens implantation on posterior capsule opacification in human donor eyes and rabbit eyes

PURPOSE

To evaluate bag-in-the-lens implantation by studying the feasibility of implanting a new type of intraocular lens (IOL) and the occurrence of posterior capsule opacification (PCO) in human postmortem eyes and in eyes of living rabbits.

SETTING

Department of Ophthalmology, University of Antwerp, Belgium, and Netherlands Research Institute of Amsterdam, Amsterdam, The Netherlands.

METHODS

The IOL was implanted in 10 postmortem human donor eyes (in vitro study) and in 17 eyes of 10 rabbits (in vivo study). The postmortem capsular bags were cultured for 4 to 6 weeks, and the rabbits were killed 1 to 5 months after implantation. All capsular bags with the bag-in-the-lens were examined by light microscopy and scanning electron microscopy.

RESULTS

The IOL design was highly effective in restricting lens epithelial cell (LEC) proliferation in the remaining lens bag in human donor eyes and in rabbit eyes. In eyes in which the capsules were not positioned well within the groove of the IOL, LEC proliferation and PCO occurred.

CONCLUSION

Bag-in-the-lens implantation was highly effective in preventing PCO in vitro and in vivo provided the anterior and posterior capsules were secured properly in the peripheral groove of the IOL.

Lack of fluorophotometric evidence of aqueous-vitreous barrier disruption after posterior capsulorhexis

PURPOSE

To evaluate the integrity of the aqueous-vitreous barrier by assessing the flow of fluorescein from the anterior chamber to the anterior vitreous using fluorophotometry in eyes with a posterior continuous curvilinear capsulorhexis (PCCC) and in eyes without a PCCC.

SETTING

University Hospital Antwerp, Edegem, Belgium.

METHODS

Ten patients had bilateral extracapsular cataract extraction with implantation of an intraocular lens. In 1 eye, a PCCC was performed; the other eye served as a negative control. The eyes of 2 other patients who had complicated cataract surgery with posterior capsule and anterior hyaloid membrane rupture served as positive controls. All patients had fluorophotometry of both eyes 12 to 18 months after surgery to measure the flow of fluorescein from the anterior chamber to the anterior vitreous.

RESULTS

There were no statistically significant differences in the distribution pattern of fluorescein between eyes with PCCC and eyes without PCCC. In contrast, enhanced flow was detected in both eyes with rupture of the posterior capsule and the anterior hyaloid.

CONCLUSIONS

In this fluorophotometry study, a PCCC did not seem to disrupt the aqueous-vitreous barrier. Results indicate that an intact anterior vitreous membrane is crucial to maintain the barrier function between the anterior and the posterior segments of the eye.

After-cataract in adults with primary posterior capsulorhexis: comparison of hydrogel and silicone intraocular lenses with round edges after 2 years

PURPOSE

To evaluate the potential of primary posterior continuous curvilinear capsulorhexis (PCCC) to prevent after-cataract 2 years after surgery and perform a bilateral comparison of 2 intraocular lens (IOL) materials, silicone and hydrogel.

SETTING

Department of Ophthalmology, University of Vienna, Medical School, Vienna, Austria.

METHODS

In this randomized patient- and examiner-masked study, 37 patients (74 eyes) with age-related cataract had bilateral small-incision cataract surgery with PCCC. Randomly, 1 eye received a hydrogel IOL and the contralateral eye, a silicone IOL. Both IOLs had open-loop haptics and a round-edged optic. Standardized digital retroillumination photographs were taken 1 day and 1, 6, 12, and 24 months after surgery to evaluate development of after-cataract on the anterior and posterior capsules by subjective grading. Opacification of the PCCC area was also objectively evaluated using new software.

RESULTS

Twenty-nine patients (58 eyes) completed the 2-year follow-up. Partial closure with ongrowth at the edge of the PCCC was found in 55% in the hydrogel group and 28% in the silicone group. Total closure of the PCCC was observed in 3 eyes, 2 in the hydrogel group and 1 in the silicone group.

CONCLUSION

Ongrowth onto the PCCC area was dependent on IOL material. Because of less ongrowth and more fibrotic after-cataract with silicone IOLs, the efficacy of the PCCC was higher in this group.

Posterior continuous curvilinear capsulorhexis with and without optic capture of the posterior chamber intraocular lens in the absence of vitrectomy

PURPOSE

To evaluate the efficacy of posterior continuous curvilinear capsulorhexis (PCCC) with optic capture of the posterior chamber intraocular lens (PC IOL) in the absence of vitrectomy in preventing secondary opacification of the visual axis following pediatric cataract surgery.

PATIENTS AND METHODS

Thirty-four eyes of 28 children with congenital or developmental cataract, aged 1.5 to 12 years (mean, 6.39 years), were included in this prospective, randomized study. Anterior continuous curvilinear capsulorhexis (ACCC) with PCCC without optic capture of the PC IOL was performed in group A (18 eyes) and ACCC with PCCC with optic capture of the PC IOL was performed in group B (16 eyes). None of the eyes underwent anterior vitrectomy. Secondary opacification of the visual axis, visual acuity, and possible complications were observed and analyzed.

RESULTS

The follow-up period ranged from 8 to 28 months (mean, 17.5 months). All 16 eyes (100%) in group B had a clear visual axis at the end of follow-up. Eight eyes (44.4%) in group A had significant opacification of the visual axis. The difference between the two groups was statistically significant (P = .0011). No eye in group B required secondary intervention, whereas all 8 eyes in group A with significant secondary opacification required secondary intervention. There was no statistically significant difference in other complications such as anterior chamber reaction, fibrin formation, lenticular precipitates, and posterior synechiae. The final best-corrected visual acuity at the end of follow-up was comparable in the two groups (P > .05).

CONCLUSION

PCCC with optic capture of the PC IOL prevents secondary opacification of the visual axis even in the absence of vitrectomy.

Bag-in-the-lens implantation of intraocular lenses

PURPOSE

To report a new intraocular lens (IOL) and an IOL implantation concept, the bag-in-the-lens implantation technique, designed to prevent posterior capsule opacification (PCO).

SETTING

The University of Antwerp, Department of Ophthalmology, Edegem, Belgium, and the Netherlands Ophthalmic Research Institute, Department of Morphology, Amsterdam, The Netherlands.

METHODS

After identical curvilinear capsulorhexes are created in both the anterior and posterior capsules, the capsules are inserted in a flange of the IOL, thus the term bag-in-the-lensas opposed to the currently used lens-in-the-bagtechnique. The IOL was implanted in an in vitro human capsular bag model and in 10 eyes of 9 patients with cataract. Lens epithelial cell (LEC) outgrowth and PCO formation were observed.

RESULTS

When both capsular blades were well stretched around the IOL optic, the in vitro capsular bag model showed LEC proliferation only within the space of the remaining lens bag. The LEC proliferation was limited, and there was no tendency toward proliferation approaching the visual axis. In all 10 eyes, the optical axis remained clear during a follow-up between 4 and 15 months.

CONCLUSIONS

This new IOL prevented LEC proliferation in vitro and seems promising in vivo. Target patients are those at risk of PCO including those with congenital cataract, uveitis, diabetes, or cataract extraction combined with vitrectomy.

Intraoperative and early postoperative results of suction posterior capsulorhexis

PURPOSE

To report the intraoperative complications and early postoperative visual results of suction posterior capsulorhexis (SPC).

SETTING

Ophthalmology department of a district general hospital, Kent, United Kingdom.

METHODS

This prospective observational study included all patients having phacoemulsification who required SPC as a planned procedure or because of posterior capsule tears (128 eyes of 122 patients). All patients were under the care of a single consultant. Intraoperative complications related to the SPC as well as postoperative complications and best corrected visual acuity (BCVA) in all cases and with best-case analysis (patients with preexisting ocular comorbidity excluded) were noted.

RESULTS

Seven cases (5.5%) of vitreous prolapse occurred; none was specifically related to the SPC. A BCVA of 0.67 (6/9) or better was achieved in 94% of cases (100% of best cases). One retinal detachment (0.8%) occurred 8 months postoperatively that was successfully treated with no loss of BCVA.

CONCLUSION

Suction posterior capsulorhexis had a low rate of intraoperative complications and did not adversely affect the early visual outcome.

Secondary closure of neodymium:YAG laser posterior capsulotomy

A 67-year-old man reported reduced vision after cataract surgery and neodymium:YAG (Nd:YAG) laser posterior capsulotomy. The diagnosis was complicated due to severe glistenings within the optic of an acrylic foldable intraocular lens (IOL), proliferation of lens epithelial remnants over the capsulotomy opening, and presumed vitreous opacity. Although IOL exchange surgery was considered, a second Nd:YAG laser intervention successfully removed the proliferated lens materials and restored the visual acuity. The glistenings were not the cause of the reduced vision.

The effect of photodynamic therapy with bacteriochlorin a on lens epithelial cells in a capsular bag model

Photodynamic therapy (PDT) with bacteriochlorin a(BCA) has proved to be a successful treatment for many cancers and to be cytocidal for different cell lines in culture. The present study aimed to investigate in vitro the potential of this treatment for killing lens epithelial cells (LECs) left in the human capsular bag after extracapsular cataract extraction (ECCE). Capsular bags were prepared from donor eyes using an ECCE procedure and incubated in various concentrations of bacteriochlorin a(1.6-50 microg ml(-1)) during various incubation periods (2-10 min). Subsequently, the capsules were illuminated during various exposure times (2-15 min) with a diode laser (wavelength 760 nm). After treatment, the capsular bags were cultured for 7 days in Eagle's minimal essential medium supplemented with 2% fetal calf serum. The specimens were fixed in glutaraldehyde/paraformaldehyde and examined with routine light microscopy, Hoechst staining for DNA and transmission electron microscopy. Proliferation of LECs on the posterior capsule was assessed in flat mounts. Capsular bags receiving BCA without illumination and capsular bags receiving illumination only served as controls.BCA alone or light alone have no effect on structure and proliferative activity of LECs. At a threshold protocol of incubation in BCA at 10 microg ml(-1)for 10 min and subsequent illumination for 15 min, proliferative activity of cells is largely arrested and nearly all LECs on the capsule exhibit severe signs of apoptosis. Photodynamic therapy with bacteriochlorin a induces cell death and suppression of proliferation inlens epithelial cells and could be a promising means of prevention of posterior capsule opacification.

Quantitative measurement of the PCCC area in the postoperative period

BACKGROUND/AIMS

The major complication of extracapsular cataract extraction (ECCE) is posterior capsule opacification (PCO). Posterior continuous circular capsulorhexis (PCCC) seems to be very promising in preventing PCO. This study was aimed at determining if the PCCC area changes as a function of time and if pearl formation could influence it.

METHODS

24 eyes of 23 patients underwent ECCE with PCCC. Retroillumination photographs were taken at 6 months and then yearly. To measure the PCCC area, the computerised program EPCO (evaluation of posterior capsule opacification) was used. The ratio of the PCCC area in relation to the IOL surface was calculated for the different time stages and the presence of pearl formation was noted. Firstly, proportional changes in diameter were compared in PCCC areas measured after 6 months and after 1 year (group I, n=13) and after 1 year and 2 years (group II, n=14). Secondly, PCCC areas were compared between two time stages in patients with (group III, n=19) and without pearl formation (group IV, n=8).

RESULTS

No statistically significant difference was found in diameter change in either group. The PCCC area remains stabile between 6 months to 1 year and 1 year to 2 years. No differences are found between eyes with or without pearl formation.

CONCLUSIONS

The PCCC area remains stable as a function of time and is not influenced by pearl formation.

Posterior capsule opacification. Part 2: Clinical findings

The incidence of posterior capsule opacification (PCO), the most common complication of modern cataract surgery with intraocular lens implantation, seems to have decreased slightly as a result of improved surgical and cortical cleanup techniques. However, the reported incidence is still significant. The diverse findings on PCO are the result in part of studies using different criteria to clinically judge and quantify the condition. In addition, the influence of intraocular and systemic factors are only now being identified. This second of a 2-part review of PCO focuses on (1) less subjective morphological and patient-dependent means to evaluate and quantify PCO; (2) the influence of ocular factors on PCO; (3) the influence of systemic factors on PCO; (4) available means and approaches to prevent or delay PCO.

Risk factors for anterior capsule contraction syndrome with polypropylene or poly(methyl methacrylate) haptics

PURPOSE

To determine the effect of haptic composition on the development of anterior capsule contraction syndrome (CCS) requiring neodymium: YAG anterior capsulotomy.

SETTING

Ophthalmology practice in Lancaster, Pennsylvania, USA.

METHODS

This retrospective study covered a 30 month period during which 1 surgeon discontinued implanting AMO SI-30NB intraocular lenses (IOLs) with polypropylene haptics (n = 216) in favor of SI-40NB IOLs with poly(methyl methacrylate) (PMMA) haptics (n = 127). The transition was motivated by the suspicion that the PMMA haptics would maintain the capsulorhexis opening better and reduce the need for an anterior capsulotomy.

RESULTS

Three eyes with SI-30NB IOLs (1.4%) required anterior capsulotomies; 2 eyes had preoperative pseudoexfoliation syndrome and required the capsulotomy within 3 months of surgery. Three eyes with SI-40NB IOLs (2.4%) required anterior capsulotomies within 4 months; 2 eyes had preoperative pseudoexfoliation syndrome and 1 had traumatic zonular weakness. The incidence of anterior capsulotomy did not differ significantly between the 2 IOL populations (P > .5), although preoperative pseudoexfoliation syndrome was a significant risk factor in both groups (P < .005).

CONCLUSIONS

The polypropylene haptics of the SI-30NB IOL and the PMMA haptics of the SI-40NB IOL did not differ significantly in their ability to prevent CCS requiring anterior capsulotomy. Regardless of IOL haptic composition, eyes with preoperative zonular weakness associated with pseudoexfoliation syndrome or ocular trauma can develop CCS within 3 months of surgery and should, therefore, be followed closely in the early postoperative weeks to minimize the sequelae of anterior capsule fibrosis.

Suction posterior capsulorhexis

A technique for creating a posterior capsulorhexis during phacoemulsification is presented. It can be used in cases with posterior capsule tears or opacities. The free edge of the capsule is grasped with suction using a 2 mL syringe and a 27 gauge Rycroft cannula introduced via the paracentesis. The edge is then manipulated to produce a continuous curvilinear opening in the posterior capsule. The combination of a closed eye plus the use of a viscoelastic agent in the anterior chamber and capsular bag minimizes the possibility of vitreous prolapse during the maneuver. Occlusion of the cannula tip by the posterior capsule reduces the risk of vitreous aspiration. In-the-bag intraocular lens implantation is readily achieved.

Posterior continuous curvilinear capsulorhexis and postoperative inflammation

PURPOSE

To evaluate the influence of posterior continuous curvilinear capsulorhexis (PCCC) on inflammation after phacoemulsification and implantation of a foldable silicone intraocular lens (IOL) in the capsular bag.

SETTING

St. Erik's Eye Hospital, Stockholm, Sweden.

METHODS

Fifty patients were enrolled in this prospective, randomized study. Eyes with diabetes mellitus, glaucoma, uveitis, exfoliation syndrome, other previous ocular diseases, or an axial length greater than 26.0 mm were excluded. One group comprised 25 eyes of 25 patients (median age 76 years) in which phacoemulsification and implantation of a silicone IOL in the capsular bag were performed. The other group consisted of 25 eyes of 25 patients (median age 77 years) who received the same surgical procedure in addition to PCCC. The aqueous protein concentration was measured using a laser flare meter (FC 500, Kowa Co.) preoperatively and 1 day, 1 week, and 1 and 3 months after surgery.

RESULTS

Surgical trauma significantly increased aqueous flare values 1 day, 1 week, and 1 month after surgery in both groups (P < .05). Three months postoperatively, flare values in both groups were not different from preoperative values. No difference between the 2 groups was found in flare intensity measurements or in best corrected visual acuity before and after uneventful surgery. The incidence of postoperative clinical cystoid macular edema was 8% (2 eyes) in the control group and 4% (1 eye) in the group with PCCC.

CONCLUSION

Postoperative flare intensity after phacoemulsification with PCCC and implantation of a foldable silicone IOL was not significantly different than postoperative flare measurements in a control group.

Secondary closure of posterior continuous curvilinear capsulorhexis in normal eyes and eyes at risk for postoperative inflammation

PURPOSE

To observe the posterior continuous curvilinear capsulorhexis (PCCC) after cataract surgery in control eyes and eyes with an increased risk for postoperative inflammation.

SETTING

Department of Ophthalmology, University Hospital Antwerp, Belgium.

METHODS

After phacoemulsification, a PCCC was performed before intraocular lens (IOL) implantation in 20 eyes of 18 patients with ocular or systemic conditions that predisposed them for increased postoperative inflammation; e.g., diabetes, uveitis, retinitis pigmentosa (inflammation group). These eyes were compared with 20 eyes of 16 patients who had the same surgical procedure but did not present a history of medical or ocular pathology (control group). The postoperative follow-up was 6 months to 3 years. Reclosure of the PCCC was evaluated by anterior segment photographs. The reclosure was classified as partial when newly formed tissue was present at the PCCC margin and total when the proliferation covered the entire PCCC area.

RESULTS

Three types of PCCC reclosure were found: fibrotic, Elschnig pearl or multilayer, and monolayer. All 3 were seen within or at the margin of the PCCC area. Reclosure (total and partial) occurred in 8 eyes (40%) in the control group and 10 (50%) in the inflammation group. Total reclosure was more frequent in the inflammation group (4 eyes [20%]) than in the control group (1 eye [5%]). Monolayered or multilayered cellular proliferation was present in 8 eyes (40%) in the control group and 4 eyes (20%) in the inflammation group; fibrotic proliferation was found in the inflammation group only (7 eyes [35%]).

CONCLUSION

Reclosure of the PCCC occurred in both groups, although the frequency of reclosure was slightly higher in the inflammation group. Although PCCC does not prevent posterior capsule opacification in all cases, it is useful in specific situations.