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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

PURPOSE

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

SETTING

Department of Ophthalmology, Antwerp University Hospital, Belgium.

DESIGN

Prospective cohort study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

SETTING

Monocentric, Antwerp University Hospital, Belgium.

DESIGN

Retrospective.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

SETTING

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

DESIGN

Prospective cohort study.

METHODS

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

RESULTS

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

CONCLUSION

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

FINANCIAL DISCLOSURE

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

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.

Posterior optic buttonholing prevents intraocular pressure peaks after cataract surgery with primary posterior capsulorhexis

BACKGROUND

The performance of a primary posterior capsulorhexis (PPC) with and without posterior optic buttonholing (POBH) may significantly influence the intraocular pressure (IOP) after cataract surgery in age-related cataract patients.

METHODS

The prospective randomized clinical study was performed at the department of Ophthalmology, Medical University of Vienna, Austria. Thirty consecutive cataract patients with bilateral same-day cataract surgery (60 eyes) under topical anesthesia were enrolled. In randomized order, cataract surgery with combined PPC/POBH was performed in one eye; in the other eye, cataract surgery was performed with PPC and in-the-bag implantation of the intraocular lens (IOL). Standardized IOP measurements by Goldmann applanation tonometry were performed preoperatively, 1, 2, 4, 6, 8 and 24 hours postoperatively, as well as 1 week and 1 month postoperatively.

RESULTS

During the first 24 hours after surgery, all IOP measurements were significantly lower in eyes with combined PPC/POBH when compared to eyes with solitary PPC (p < 0.001). No IOP peaks of more than 27 mmHg were observed with combined PPC/POBH. In contrast, in eyes with PPC and in-the-bag IOL implantation, seven patients had an IOP peak of more than 27 mmHg and four IOP peaks of more than 30 mmHg. One week and 1 month postoperatively, IOP measurements were statistically comparable, and no significant differences could be observed between the two groups (p > 0.05).

CONCLUSION

Postoperative IOP peaks after cataract surgery with sole PPC can be effectively prevented by the buttonholing of the IOL through the posterior capsulorhexis.

Posterior capsulorhexis combined with optic buttonholing: an alternative to standard in-the-bag implantation of sharp-edged intraocular lenses? A critical analysis of 1000 consecutive cases

Background

Current after-cataract prevention relies on optimizing the natural barrier effect of the optic rim against lens epithelial cell (LEC) migration. However, deficiencies in circumferential capsular bag closure caused by the intraocular lens (IOL) haptic or delayed secondary re-division of the fused capsules by Soemmering´s ring formation lead to primary or secondary barrier failure. Consequently, surprisingly high posterior laser capsulotomy rates have been reported long-term, even with optimal capsular surgery and the most widespread hydrophobic acrylic IOLs, considered to be the most advanced. Intraoperative removal of the central posterior capsule has been shown to be effective in further reducing LEC immigration. However, efficacy has turned out to be limited because of the propensity of LECs to use the posterior optic surface as an alternative scaffold.

Material and methods

Technique: in pediatric cataract surgery, buttoning-in of the optic into an adequately-centered posterior capsulorhexis opening has been described previously. This technique was further elaborated and applied as the standard technique in a large series of adult eyes. In general, the diameter aimed at was 5–6 mm for the anterior, and 4–5 mm for the posterior capsulorhexis. Between September 2004 and June 2007, 1000 consecutive cases have thus been performed and systematically evaluated. One hundred and fifty eyes additionally underwent extensive anterior LEC abrasion. Another sub-series investigated the option of further reducing capsular fibrosis by creating an anterior capsulorhexis larger than the optic.

Evaluation: special scrutiny was applied to detect postoperative vitreous entrapment. Regeneratory and fibrotic after-cataract formation were both meticulously followed-up. Postoperative pressure course, anterior segment inflammation, macular thickness and morphology, as well as axial optic stability and optic centration, were evaluated in intraindividual comparison studies.

Results

A low rate of vitreous complications was found, which can be avoided by appropriate surgery. Vitreous entanglement occurred in six eyes, and vitreous herniation after PPCCC over-sizing in two. In three, anterior vitrectomy was performed. There was only one single case of retinal detachment—supposedly unrelated to the technique itself—and no case of cystoid macular edema. Retro-optical regenerate formation was completely abolished, while fibrosis was drastically reduced by the posterior capsule sandwiched in between the anterior LEC layer on the backside of the anterior capsule and the anterior optic surface, thereby blocking contact-mediated myofibroblastic LEC transdifferentiation. Additional capsular polishing further reduced residual fibrosis emerging from the anterior capsule contacting the optic adjacent to the haptic junction, as well as regeneratory LEC re-proliferation on the posterior capsule overlying the optic. Postoperative pressure course was almost identical to that found after standard in-the-bag implantation of the IOL, as was flare, and macular thickness and morphology. As opposed to bag-fixated IOLs, no axial movement of the optic was detected. IOL optics always perfectly centered even when the capsular opening was not optimally centered. Due to the exquisite stretchability and elasticity of the posterior capsule, the 6-mm IOL optic could safely be buttoned-in in a posterior capsulorhexis of 4 mm and smaller.

Conclusions

Posterior optic buttonholing (POBH) is a safe and effective technique which not only excludes retro-optical opacification, but also withholds capsular fibrosis by obviating direct contact between the anterior capsular leaf and the optic surface. Anterior LEC abrasion significantly reduced both the residual fibrosis and regeneratory LEC proliferation. Apart from pediatric cataract, POBH is currently recommended for eyes with pseudoexfoliation syndrome, high axial myopia, peripheral retinal disease, and multifocal IOL implantation. Toric IOLs and magnet-driven accommodative IOL systems are other potential applications. Generally, POBH holds promise for becoming a routine alternative to standard in-the-bag IOL implantation in the future.

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.

[After-cataract following intraocular lens implantation. Part II: prevention with alternative implants and techniques]

The introduction of sharp-edged optics has drastically reduced, but not fully eradicated, retro-optical after-cataract formation. The effectiveness of capsular bending rings or primary posterior capsulorhexis is also limited, and these have not become widespread because of the demanding surgical technique and the costs associated with an additional implant. Anterior capsule polishing has been found to even increase the need for laser capsulotomy, and rinsing the sealed capsular bag with cell-toxic agents has not yet gained clinical application. Routine posterior optic buttonholing through a well-centered posterior capsulorhexis opening is a promising alternative because it precludes access of lens epithelial cells behind the optic while at the same time counteracting fibrosis of the anterior capsule. Because this effect is independent of optic rim design and lens material, future efforts in lens refinement may concentrate on reducing the reflectivity of the optic rim and optimizing the biocompatibility of the lens material.

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 #1: repeat Nd:YAG laser posterior capsulotomy

A descriptive case series of five patients identified either opportunistically or from a retrospective review of the laser register is presented. All underwent cataract surgery between 1995 and 1999 and required initial Nd:YAG laser posterior capsulotomy 15-30 months after surgery. They subsequently developed reclosure of the capsulotomy, necessitating repeat laser capsulotomy 11-82 months later. One patient, who received a hydrogel intraocular lens, required a third capsulotomy after a further 12 months. The rate of repeat Nd:YAG laser capsulotomy in our unit was 0.31%.

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.

Visual axis opacification after AcrySof intraocular lens implantation in children

PURPOSE

To evaluate visual axis opacification after AcrySof intraocular lens (IOL) (Alcon) implantation in pediatric eyes.

SETTING

Iladevi Cataract and IOL Research Centre, Ahmedabad, India.

METHODS

This prospective study evaluated 103 consecutive eyes of 72 children with congenital cataract. Two groups were formed based on age at surgery: Group 1, younger than 2 years, and Group 2, older than 2 years. All eyes in Group 1 (n = 37) had primary posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy. In Group 2 (n = 66), management of the posterior capsule was assigned randomly to no PCCC (Group 2A, n = 37) or PCCC (Group 2B, n = 29). The PCCC group was further randomized into 2 subgroups: no vitrectomy (Group 2BN, n = 14) or vitrectomy (Group 2BV, n = 15). The primary outcome measures were visual axis opacification and the resulting need for a secondary procedure. Statistical analysis was performed using SPSS for Windows (version 11.0.1).

RESULTS

The mean age of the patients was 5.2 years +/- 5.0 (SD) (range 0.2 to 16.0 years) and the mean follow-up, 2.3 +/- 0.9 years (range 1.0 to 4.0 years). Overall, 41 eyes (39.8%) developed visual axis opacification and 14 (13.6%) required secondary intervention. In Group 1, 4 eyes (10.8%) developed visual axis opacification and 3 (8.1%) had a secondary pars plana vitrectomy. In Group 2A, 31 eyes (83.8%) developed posterior capsule opacification (PCO) and 10 eyes (27.7%) had secondary intervention. Children 8 years or younger at the time of surgery developed significantly greater PCO than older children (P =.01). Five eyes (37.5%) in Group 2BN had opacification of the anterior vitreous face, 1 of which required a secondary procedure. One eye (6.7%) in Group 2BV had visual axis opacification that did not require a secondary procedure.

CONCLUSIONS

AcrySof IOL implantation with appropriate management of the posterior capsule maintained a clear visual axis in 60.2% of eyes. Of the 39.8% of eyes with visual axis opacification, 13.6% had visually significant opacification and required a secondary procedure.

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.

Anterior vitreous face behavior with AcrySof in pediatric cataract surgery

PURPOSE

To describe anterior vitreous face behavior when AcrySof (Alcon, Fort Worth, TX) intraocular lenses come in contact with the anterior vitreous face after posterior continuous curvilinear capsulorhexis without anterior vitrectomy in pediatric patients undergoing cataract surgery.

METHODS

This study comprised 14 eyes of 12 children whose mean age was 9.6 years (range, 2.3 to 16.0). All eyes underwent primary posterior continuous curvilinear capsulorhexis without anterior vitrectomy and had AcrySof IOLs implanted in the bag. Changes on the anterior vitreous face were documented, and visual acuity was recorded. Statistical analysis was performed using Student group t and Mann Whitney tests.

RESULTS

Mean length of follow-up was 21.1 +/- 7.4 months (range, 15.0 to 36 months). Nine eyes (64.3%) had a clear visual axis, whereas 5 eyes (35.7%) developed anterior vitreous face changes. Of those with anterior vitreous face changes, 60% (3 of 5) eyes showed a fine meshwork-like reticular response termed "anterior vitreous reticular response" (AVR); 20% (1 of 5) eyes showed a scaffold response; and 20% (1 of 5) eyes showed a mixed response at the last follow-up examination. The difference in visual acuity before and after the development of the AVR response was not significant (P =.712). The mean age of patients with eyes having a clear visual axis was 12.1 +/- 2.3 years (median = 11.0; range, 9.1 to 16.0), and the mean age of patients with eyes having anterior vitreous face changes was 5.1 +/- 3.4 years (median = 3.6; range, 2.3 to 11.6) (P =.0098).

CONCLUSION

The results suggest that when the AcrySof intraocular lenses come in contact with the anterior vitreous face, they produce the AVR response during the early postoperative period in younger eyes. This does not seem to have any significant impact on visual acuity.

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.

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.

Posterior continuous curvilinear capsulorhexis with hydrogel and silicone intraocular lens implantation: development of capsulorhexis size and capsule opacification

PURPOSE

To evaluate the influence of primary posterior continuous curvilinear capsulorhexis (PCCC) on capsule opacification development and capsular bag changes within the first year after cataract surgery with 2 intraocular lenses (IOLs) of comparable design but different material.

SETTING

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

METHODS

Thirty-seven patients with age-related cataract had bilateral small incision cataract surgery with a PCCC performed after capsular tension ring insertion. One eye was randomly assigned to receive a hydrogel IOL and the other eye, a silicone IOL. Standardized digital retroillumination photographs were taken 1 day, 1 week, and 1, 3, 6, and 12 months after surgery to evaluate changes in the dimensions of the anterior and posterior capsulorhexis opening area and the presence of anterior and posterior capsule opacification.

RESULTS

The area of the anterior continuous curvilinear capsulorhexis (ACCC) opening was significantly reduced during the first 6 postoperative months. The shrinkage was more pronounced (-25%) in the silicone IOL group than in the hydrogel IOL group. Ten percent of eyes with a silicone IOL had marked shrinkage of the ACCC. The area of the PCCC did not change in eyes with a hydrogel IOL but was larger (+20%) in eyes with a silicone IOL. Anterior ongrowth was observed in 60% in the hydrogel group and in no eye in the silicone group. Anterior capsule fibrosis was observed in 90% in the silicone group and in 20% in the hydrogel group. Total closure of the PCCC was not observed within the first year, but posterior ongrowth was observed in 40% in the hydrogel group and 10% in the silicone group.

CONCLUSIONS

Anterior capsulorhexis shrinkage with concomitant posterior capsulorhexis enlargement was observed in eyes with a silicone IOL. The hydrogel IOL induced more ongrowth on the anterior and posterior IOL surfaces, whereas the silicone IOL induced more anterior capsule fibrosis. Total closure of the PCCC was not observed within the first year after surgery.

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.

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 capsular opacification after cataract surgery

This is a review of the current status of clinical research on the prevention of posterior capsular opacification (PCO), which is now the commonest complication of cataract surgery occurring in up to 50% of patients by 2 to 3 years after the operation. PCO is caused by lens epithelial cells retained in the capsular bag following surgery which then proliferate, migrate and transform to myofibroblasts. Interest in the prevention of PCO has centred around surgical technique, pharmacological methods to remove or destroy lens epithelial cells and changes in intraocular lens material and design. Changes in surgical technique have little effect in prevention of PCO although a capsulorhexis size which lies on the optic diameter appears to be beneficial. Many different cytotoxic drugs and pharmacological agents have been used experimentally to prevent PCO but the problem has limited damage only to lens epithelial cells. So far, no method has been shown to be safe for clinical use. Current interest is centred once again on the intraocular lens itself, particularly the material that it is made from and changes in its edge profile.