Management of large traumatic zonular dialysis with phacoemulsification and IOL implantation using the capsular tension ring

Capsular tension ring as protective measure against in-the-bag dislocations after cataract surgery

PURPOSE

To assess the influence of capsular tension ring (CTR) implantation on the development of in-the-bag (ITB) dislocations after cataract surgery.

SETTING

Department of Ophthalmology Graz, Graz, Austria.

DESIGN

Single-center, retrospective cohort study.

METHODS

The medical records of patients who underwent cataract operation between 1996 and 2017 were analyzed. Cox proportional hazards regression analysis was used to assess the influence of CTR implantation and other predisposing factors (pseudoexfoliation [PEX], age, retinitis pigmentosa, sex, zonular weakness, uveitis, high myopia, and intraocular lens design and material) on ITB dislocations.

RESULTS

ITB dislocations were found in 111 (0.16%) of 68199 eyes (46 632 patients). In the multivariate analysis adjusted for other predisposing risk factors, a CTR implantation was associated with a lower risk of an ITB dislocation (hazard ratio [HR], 0.29; 95% CI, 0.11-0.80; P = .017). In eyes with PEX, a CTR implantation was associated with an HR of 0.16 (95% CI, 0.04-0.70; P = .015), whereas eyes without PEX had an HR of 0.80 (95% CI, 0.14-4.41; P = .793). A CTR implantation in eyes with zonular weakness resulted in a potentially lower risk (HR, 0.37; 95% CI, 0.12-1.12; P = .078).

CONCLUSIONS

According to the dataset, implantation of a CTR was a protective measure against an ITB dislocation. Especially in patients with zonular weakness and PEX, the CTR implantation was association with a lower risk of ITB dislocations. In patients without PEX, no association was established.

Intrascleral fixation of capsular bag and intraocular lens in cases with large zonular dialysis

PURPOSE

To evaluate the clinical outcomes of sutureless capsular bag and intraocular lens (IOL) fixation with flattened, flanged intrascleral fixation technique in patients with large zonular dialysis.

METHODS

Fifty-five eyes of 51 patients who underwent flattened flanged intrascleral capsular bag and IOL fixation and optic capture for traumatic cataract, subluxated cataract, and pseudoexfoliation syndrome (PEX) with zonular dialysis greater than 180° were included in the study. The main difference of this technique from the Yamane technique is that it has a flattened flange with sharp borders at the haptic tip. Uncorrected visual acuity, corrected distance visual acuity (CDVA), astigmatism, endothelial cell loss, IOL tilt, and intraoperative and postoperative complications were evaluated.

RESULTS

The mean age of the patients was 57.4 ± 15.1 years (range 18-83). Of the patients, 28 (55%) were male and 23 (45%) were female. The mean duration of follow-up after surgery was 19.3 ± 6.5 months (range 12-36). The mean preoperative and postoperative CDVA were 0.71 ± 0.16 logMAR and 0.13 ± 0.20 logMAR, respectively (p < 0.001). The mean preoperative and postoperative astigmatism were 2.0 ± 1.4 D and 1.0 ± 0.7 D, respectively (p < 0.001). The mean IOL tilt was 5.7° ± 5.2°. The mean endothelial cell loss was 9% (range 0.9-19.5). Anterior capsular phimosis was developed in 2 eyes (4%).

CONCLUSION

The flattened flanged intrascleral technique of the capsular bag combined with optic capture provides good visual outcomes, robust capsular bag-IOL fixation, and minimal adverse events. However, further studies with more patients are needed for long-term results.

Femtosecond laser-assisted cataract surgery in management of posterior capsule tear following blunt trauma: Case report and review of literature

Purpose

To describe the diagnosis and management of a patient with rupture of the posterior capsule (PC) following blunt trauma to the left eye.

Observation

68 year-old man presented with complaints of left eye pain, blurry vision and photophobia after getting hit in the left eye with a baseball. He was found to have a posterior capsule rupture, as well as mydriasis and zonular dialysis without formation of intumescent traumatic cataract. Femtosecond laser associated cataract surgery (FLACS) was performed to facilitate creation of an anterior capsulotomy and segmentation of the nucleus without additional strain on the posterior capsule, facilitating placement of a capsular tension ring segment and a 3-piece IOL in the sulcus. At three-month post-operative visit, his BCVA was 20/30 in the left eye with a well-centered IOL.

Conclusions and Importance

Isolated PC tear following high-speed blunt trauma is relatively rare and prior reports have managed these cases using standard phacoemulsification and IOL insertion. Our case highlights the advantages of using FLACS in management of traumatic PC tears and outlines modifications to this technique for such cases.

Effects of capsular tension ring on surgical outcomes of premium intraocular lens in patients with suspected zonular weakness

Purpose

To assess the influence of capsular tension ring (CTR) on surgical outcomes of toric and multifocal intraocular lenses (IOLs) in eyes at high risk of zonular instability.

Methods

Fifty-five eyes of 43 patients who had undergone phacoemulsification and IOL implantation were included in the analysis. They had some risk of zonular weakness, such as pseudoexfoliation, shallow anterior chamber, high myopia, and phacodonesis, or were judged to have unstable zonules during surgery. Toric IOL was implanted in 9 eyes with CTR and 22 eyes without CTR, while multifocal IOL was used in 9 eyes with CTR and 15 eyes without CTR. Manifest refraction, refractive astigmatism, visual acuity, and degree of IOL decentration and tilt measured using swept-source anterior segment optical coherence tomography were analyzed. Axis misalignment of toric IOLs were also evaluated.

Results

In toric IOLs, co-implantation of CTR significantly reduced decentration and axis misalignment of IOL, resulting in better uncorrected and corrected visual acuity after surgery. In multifocal IOLs, combined use of CTR significantly prevented IOL tilt, leading to better intermediate visual acuity. Spherical equivalent and residual astigmatism were not significantly affected by the use of CTR.

Conclusions

CTR reduces decentration and axis misalignment of toric IOL and tilt of multifocal IOL, achieving improvement of postoperative visual function in eyes with suspected zonular instability.

Outcome of phacoemulsification and intraocular lens implantion in eyes with pseudoexfoliation and weak zonules

PURPOSE

To evaluate the results of phacoemulsification and intraocular lens (IOL) implantation in eyes with pseudoexfoliation (PEX) and zonular weakness.

METHODS

Two hundred and ninety-five patients (295 eyes) were recruited. This study is a retrospective case review of 143 PEX eyes with preoperative (Group 1) and intraoperative (Group 2) signs of zonular weakness, 76 PEX eyes (Group 3) and 76 non-PEX eyes without zonular weakness (Group 4) undergoing phacoemulsification and IOL implantation performed by single surgeon from year 1988 to 2010. Outcome measures included frequency of postoperative pseudophakodonesis, anterior capsule contraction and IOL decentration/dislocation. Postoperative vision, intraocular pressure (IOP) and glaucoma medication requirements were also assessed. A subanalysis on identical postoperative outcomes of capsular tension ring (CTR) implantation was performed. Comparisons were made for 52 PEX eyes with zonular weakness receiving nonsutured CTR implantation (Group A), 91 PEX eyes with zonular weakness not receiving CTR implantation (Group B) and 142 PEX eyes without zonular weakness (Group C).

RESULTS

Mean follow-up was 4.08 ± 0.48 years and maximum was 8.3 years. Both Groups 1 and 2 showed higher incidence of complications than Groups 3 and 4 (p < 0.01). Vision, IOP and glaucoma medication requirements were similar postoperatively for all four groups. Groups A and B had a significantly higher proportion of postoperative complications than Group C (p < 0.01). There was no significant difference in risk of developing these complications between Groups A and B (p = 0.64).

CONCLUSION

Postoperative complication rates are higher in PEX eyes with preoperative and/or intraoperative signs of zonular weakness undergoing phacoemulsification. Nonsutured CTR implantation does not prevent IOL and capsular complications postoperatively.

All about capsular tension rings

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Evaluation of secondary glaucoma associated with subluxated lens misdiagnosed as acute primary angle-closure glaucoma

PURPOSE

To evaluate the causes of misdiagnosis in patients with acute angle-closure glaucoma secondary to subluxated lens, and postoperative outcomes.

DESIGN

Retrospective clinical study.

METHODS

Five hundred twenty-six cases of acute angle-closure glaucoma were consecutively recruited from Zhongshan Ophthalmic Center between March 2003 and March 2009. Zonular dialysis, anterior chamber angle, and anterior chamber depth were examined by ultrasound biomicroscopy. Surgical therapy was performed according to the degree of zonular dialysis and angle closure.

RESULTS

Thirty-one eyes (5.89%) with acute angle-closure glaucoma secondary to lens subluxation were misdiagnosed as acute primary angle-closure glaucoma. In these cases, the anterior chamber depth of the affected eyes was significantly shallower than the fellow eyes (1.34±0.45 vs. 2.27±0.44, P<0.05). The best-corrected visual acuity was significantly improved 3 months after surgery, and intraocular pressure was well controlled in all eyes. Mean intraocular pressure was 12.09±4.41 mm Hg without any medication at the final visit.

CONCLUSIONS

The causes of misdiagnosis in patients with acute angle-closure glaucoma secondary to subluxated lens include neglected history and/or signs of ocular trauma. Lens extraction surgery was an effective therapy for these cases.

Management of traumatic severely subluxated cataracts

PURPOSE

To determine outcome of cataract surgery in severely subluxated traumatic cataracts.

DESIGN

Noncomparative case series.

METHODS

Retrospective review of cataract surgery in all consecutive eyes with at least 6 clock hours of zonulysis, for patient demographics, presenting best-corrected visual acuity (BCVA) and postoperative BCVA at various time points, extent of zonulysis, and type and timing of insertion of capsular tension device. Main outcome measures were retention of the capsular bag and BCVA at last visit. Secondary outcome measures included IOL stability and centration, and perioperative complications.

RESULTS

There were 41 eyes (41 patients). Mean age at time of surgery was 57 years and the mean duration of follow-up was 21.4 months. The capsular bag was preserved with aid of a Cionni modified capsular tension ring (CTR) in 36 eyes (87.8%) and a combination of a capsular tension segment (CTS) and CTR in 2 eyes. In 3 eyes with total zonulysis, the bag could not be preserved despite the use of a CTS in 2 eyes. Preoperatively only 9 of the 41 eyes (22.0%) had a BCVA of 20/40 or better, as compared to 38 eyes at the last visit (92.7%, P < .001, χ(2) test). Posterior capsule rupture occurred in 3 eyes, 2 of which occurred during fixation of the CTR.

CONCLUSIONS

The capsular bag can be successfully preserved even in severely subluxated traumatic cataracts with the aid of fixated capsular tension devices.

Combined 20-gauge and 23-gauge pars plana vitrectomy for the management of posteriorly dislocated lens: a case series

Objective:

To present a new surgical approach for the management of posteriorly dislocated lens by using a combination of 20-gauge (20G) and 23-gauge (23G) pars plana vitrectomy.

Design:

An interventional case series

Methods:

This technique was performed on six patients (five men, one woman; mean age, 66.67 years; range, 66–72 years). Two 23G trans-conjunctival sclerotomy ports were created for infusion and illumination along with a 20G sclerotomy port for introducing the vitrectomy probe or fragmatome.

Results:

This procedure was successfully performed on six eyes. On postoperative day one, the media were clear and the retina could be seen by indirect ophthalmoscopy. Hyphema developed in one eye and resolved within a week. There were no observed cases of retinal tear, wound leakage, hypotony, or endophthalmitis. The post-operative follow-up period ranged from three to twelve months (mean, 8.1 months). By the final visit, two patients had achieved a visual acuity of 20/40 or better, three patients, 20/70, and one patient, 20/200.

Conclusion:

The combination of 20G and 23G pars plana vitrectomy is an efficacious and safe procedure for management of posteriorly dislocated lens.

Results of intraocular lens implantation with capsular tension ring in subluxated crystalline or cataractous lenses in children

Purpose:

To evaluate the outcome of intraocular lens (IOL) implantation using capsular tension ring (CTR) in subluxated crystalline or cataractous lenses in children.

Setting:

Tertiary care setting

Materials and Methods:

We prospectively studied 18 eyes of 15 children with subluxation of crystalline or cataractous lenses between 90° up to 210° after phacoemulsification, CTR and IOL implantation. Each child was examined for IOL centration, zonular dehiscence and posterior capsular opacification (PCO).

Results:

Age of the patient ranged between five to 15 years. Out of 18 eyes, seven had traumatic and 11 had spontaneous subluxation of crystalline or cataractous lens. Phacoemulsification was successfully performed with CTR implantation in the capsular bag. Intraoperative zonular dialysis occurred in two eyes. Anterior vitrectomy was performed in six eyes to manage vitreous prolapse. IOL implanted was polymethyl methacrylate (PMMA) in eight eyes, hydrophobic acrylic in seven and hydrophilic acrylic in three. Follow-up ranged from 24 months to 72 months. Sixteen eyes had a best corrected visual acuity of 20/40 or better. Nine eyes developed significant PCO and were managed with Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser posterior capsulotomy. One eye with acrylic IOL in the capsular bag had IOL dislocation after two years which was managed with vitrectomy and secondary trans-scleral fixation of IOL.

Conclusions:

Phacoaspiration with CTR implantation makes capsular bag IOL fixation possible in most of the eyes with subluxated crystalline or cataractous lenses. PCO still remains a challenge in children with successful phacoaspiration with CTR implantation

In situ nuclear disassembly: efficient phacoemulsification without nuclear rotation using lateral sweep sculpting and in situ cracking techniques

We describe an in situ nuclear disassembly technique using a simplified form of sculpting and cracking, enhanced by phacoemulsification technology with a Kelman-style tip. The technique does not require mobilization or rotation of the nucleus within the capsular bag, and hydrodissection is optional. The technique requires a Kelman-style curved tip and Kuglen hook and takes advantage of the versatility of the curved phacoemulsification needle for sculpting and cracking. Since in situ nuclear disassembly requires no rotation of the nucleus for extraction, it is useful in cases in which zonules are compromised or the surgeon suspects posterior lenticonus and the potential for loss of integrity of the posterior capsule.

Lens-induced glaucoma in the elderly

Lens-induced glaucoma comprises a number of different glaucomatous processes occurring in the elderly that share in common the role of the crystalline lens in the mechanism of increase in intraocular pressure. We will review the anatomic predisposing factors, their physiology, signs and symptoms, and therapeutic approach. We will consider two studies and discuss the visual results and risk factors associated with these pathologic conditions.

Ex vivo quantification of the time course of contractile loading of the porcine lens capsule after cataract-like surgery

Cataract surgery is an invasive procedure that replaces the quasi-spherical native lens fibers with a flat prosthetic device, which initially reduces mechanical stress within the remnant lens capsule and, ultimately, leads to contraction of the capsule about the implant. Although resultant changes in geometry have been quantified previously, little is known about the loads associated with this contraction. We present a novel experimental culture device to quantify ex vivo the time course of increases in tension within the contracting lens capsule after cataract-like surgery. Results demonstrate that contraction reaches steady state within approximately one month with a mean tension of 1.45 mN/mm and Cauchy (true) stress of 13.4 kPa. A significant increase in alpha-smooth muscle actin (alpha-SMA) was also found in post-cultured compared to fresh lens capsules, thus suggesting that transdifferentiated lens epithelial cells (LECs) modulated the contraction. Quantification of loads imparted by the contracting lens capsule is important for assessing implant/capsule interactions and implant stability in vivo. Because contraction of the capsule may be modulated in part by LECs attempting to restore their native mechanical environment, our results further suggest a possible mechanism for the long-term errant changes in capsular structure commonly observed after surgery.