Posterior continuous curvilinear capsulorhexis and postoperative inflammation

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.

Effect of primary posterior continuous curvilinear capsulorhexis with and without posterior optic buttonholing on postoperative anterior chamber flare

PURPOSE

To evaluate the effect of primary posterior continuous curvilinear capsulorhexis (PCCC) with and without posterior optic buttonholing (POBH) on the anterior chamber reaction after small-incision cataract surgery.

SETTING

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

METHODS

Consecutive patients with age-related cataract having cataract surgery in both eyes under topical anesthesia were prospectively enrolled in a randomized clinical trial. In randomized order, cataract surgery with combined primary PCCC and POBH was performed in 1 eye; in the other eye, cataract surgery was performed with primary PCCC and in-the-bag implantation of an intraocular lens. Intraocular flare was measured with an FC-1000 laser flare-cell meter preoperatively and postoperatively at 1, 4 to 6, and 24 hours, 1 week, and 1 month.

RESULTS

Thirty patients (60 eyes) were evaluated. The peak of intraocular flare was 1 hour postoperatively in all study eyes. In both groups, the response steadily decreased thereafter. Anterior chamber flare was statistically significantly higher in eyes with primary PCCC without POBH than in eyes with combined primary PCCC-POBH at all postoperative testing points (P<.001), including at 1 month (P = .01).

CONCLUSIONS

Cataract surgery with combined primary PCCC-POBH led to significantly lower postoperative anterior chamber reaction than conventional in-the-bag implantation during a 4-week follow-up. The tight capsule-optic diaphragm effectively prevented the ophthalmic viscosurgical device captured behind the optic from entering the anterior chamber postoperatively.

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 Morganella morganii endophthalmitis associated with subclinical urinary tract infection

We report a case of Morganella morganii acute endophthalmitis following clear corneal phacoemulsification cataract surgery in which a coincident asymptomatic chronic urinary tract infection was detected postoperatively. Morganella morganii is a gram-negative bacillus that inhabits the gastrointestinal tract and is part of the normal fecal flora. It is an opportunistic pathogen usually encountered in postoperative and nosocomial settings, causing urinary tract and wound infections. Chronic urinary tract infection may be a risk factor for postoperative endophthalmitis. A dipstick urinalysis before elective cataract surgery in elderly patients with a history of recurrent urinary tract infections may be considered.

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.

Cystoid macular edema following cataract surgery

Cystoid macular edema (CME) remains a troublesome problem after cataract surgery and other types of ocular surgical procedures. It is recognized as the most frequent cause of decreased vision in patients following cataract surgery. Although the disease was first described more than 40 years ago, its cause is unclear, and all available therapeutic interventions, mainly based on theories regarding the pathogenesis of the condition, are of doubtful effectiveness and are still far from being satisfactory. Most published literature on the incidence and treatment of CME consists of small, retrospective case series and cannot provide reliable answers as to whether a given factor or intervention is associated with the occurrence or outcome of the disease.

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.