Perfluorocarbon heavy liquids in the management of posterior dislocation of the lens nucleus during phakoemulsification

Retrolental cohesive ophthalmic viscoelastic injection for severe subluxated cataracts: a prospective study

BACKGROUND

To assess anatomical and functional outcomes of retrolental cohesive ophthalmic viscoelastic injection ("Viscolift technique") in patients with severely subluxated cataracts.

METHODS

In the present prospective study, we included patients older than 18 years with severely subluxated cataracts and phacodonesis. Full medical history was obtained at the baseline ophthalmological assessment. A single 25-gauge valved trocar was inserted 4 mm from the limbus and a 27G angled cannula was introduced through the trocar into the retrolental space, while cohesive viscoelastic was progressively injected, in order to center and elevate the cataract to facilitate capsulorhexis. After complete phacoemulsification, a 3-piece intraocular lens (IOL) with a scleral fixated Cionni ring or FIL-SSF scleral fixated IOL was implanted. Patients follow-up interval was 6 months after surgery.

RESULTS

Thirteen eyes of 13 patients were enrolled in the study, mean age was 61.5 ± 9.4 years and 53.8% were females. The "Viscolift technique" resulted in centered and more stable cataracts in all cases (100%). After complete phacoemulsification, 61.5% of patients were implanted with a 3-piece IOL with Cionni ring, and 38.5% with a FIL-SSF scleral fixated IOL after complete 25G vitrectomy. Mean BCVA improved from 0.5 ± 0.1 LogMar (20/63 Snellen) to 0.1 ± 0.1 LogMar (20/25 Snellen) (p < 0.001) at the last follow-up. No major complications were noted.

CONCLUSIONS

The "Viscolift technique" proved to be a safe and effective surgical approach for recentering and elevating subluxated cataracts, thus allowing the surgeon to perform an easier and better-centered capsulorhexis.

Retrolental cohesive ophthalmic viscoelastic injection in severely subluxated cataracts: The "Viscolift technique"

INTRODUCTION

To describe a novel surgical approach in the management of subluxated cataracts.

METHODS

A 70-year-old Caucasian male with a subluxated cataract in the left eye was referred to our clinic at the Azienda Ospedaliero-Universitaria di Bologna- Ophthalmology Unit. The ophthalmic examination revealed a best-corrected visual acuity (BCVA) of 20/200 in the left eye with monocular diplopia and a severely subluxated NO6/NC6 cataract and the fundus examination did not reveal any vitreoretinal abnormalities. The right eye had 20/20 BCVA and was pseudophakic. After a 300° conjunctival peritomy, a single 25-gauge valved trocar 4 mm was inserted from the limbus in the inferotemporal quadrant, where the cataract was mainly dislocated and a corneal paracentesis to reduce the anterior chamber intraocular pressure was performed. Subsequently cohesive viscoelastic was progressively injected in the retrolental space through the trocar, to recenter and elevate the subluxated cataract. Thereafter, a complete centered capsulorhexis was performed, four capsular hooks were inserted to stabilize the bag, and complete phacoemulsification was performed with intact posterior capsular support. In the end, given the lack of capsular support elements such as the Cionni ring or Ahmed segment, a sutureless scleral fixated intraocular lens was implanted.

RESULTS

One week after surgery, the BCVA was 20/25, and the final BCVA at 6 months was 20/20, without any complications.

CONCLUSIONS

Retrolental cohesive ophthalmic viscoelastic injection could represent a novel effective surgical approach in recentering and elevating subluxated cataracts, facilitating the capsulorhexis, and reducing the risk of a pars plana approach.

Trimanual vitrectomy for severe proliferative diabetic retinopathy

PURPOSE

To describe and evaluate a novel technique of pars plana vitrectomy (PPV) under chandelier illumination which is aided with the vital dyes and perfluorocarbon liquids for the management of the complex diabetic vitrectomy cases.

METHODS

We conducted a prospective interventional comparative study on 40 eyes of 36 patients with advanced diabetic eye disease requiring PPV. The study was conducted in a single tertiary referral center. Eyes were divided on 1:1 basis by stratified randomization into two groups. Group 1 had trimanual vitrectomy done assisted with chandelier illumination, perfluorocarbon liquid (PFCL) and vital dyes. Group 2 had the conventional bimanual vitrectomy done assisted with chandelier illumination only. All patients were followed up for a minimum of 6 months after the surgery.

RESULTS

Forty eyes of 36 patients with the mean age of 51.42 years (range 28-69) were evaluated. The anatomical success at 6 months could be achieved in all the eyes in both groups. The complete removal of the pre-retinal proliferations could be accomplished in all the eyes in the trimanual PPV group, and only in 85% of the eyes in the bimanual PPV group. Operative time was significantly shorter in the trimanual PPV group (p < 0.001). More eyes in the trimanual PPV group (55.0%) could achieve better vision (> 6/60) 6 months after the operation compared to the bimanual PPV group (50.0%), but this difference was not statistically significant.

CONCLUSION

Trimanual PPV is a novel, safe and effective technique that can improve the results of the complex diabetic PPV.

Comparision of surgical outcomes of intraocular lens refixation and intraocular lens exchange with perfluorocarbon liquid and fibrin glue-assisted sutureless scleral fixation

AIM

The purpose of this study was to compare the surgical outcomes of intraocular lens (IOL) refixation with intraocular lens exchange using perfluorocarbon liquid (PFCL) and fibrin glue-assisted sutureless scleral fixation surgery in patients with dislocation of the IOL.

METHODS

Twenty-five eyes of 25 patients who underwent surgery for dislocated IOLs with PFCL and fibrin glue-assisted scleral fixation were studied; 13 eyes experienced IOL refixation (in-the-bag and out-of-the-bag), and 12 eyes experienced IOL exchange. Preoperative and postoperative clinical features from patient charts and 25 eyes with >6 months' follow-up information were reviewed and analyzed.

RESULTS

At postoperative 6 months, best-corrected visual acuity (BCVA) and spherical equivalent of IOL refixation and exchange were significantly improved (P=0.042, P=0.001), and endothelial cell density was significantly decreased in the two groups with no significant difference between them. Surgically induced astigmatism of IOL refixation improved from 0.90±0.47 to 0.61±0.37 (P=0.012), and IOL exchange improved from 1.17±0.64 to 0.73±0.37 (P=0.037) at postoperative 6 months, with no significant difference between the two groups. Complications occurred in four eyes in the IOL refixation group and in three eyes in the IOL exchange group.

CONCLUSION

PFCL and fibrin glue-assisted IOL sutureless scleral refixation or exchanged fixation was an effective surgical treatment for IOL dislocation. Also, because postoperative BCVA, surgical outcomes, and complications did not differ significantly between IOL refixation and exchange surgery, if IOL exchange surgery is not indicated, IOL refixation surgical techniques should be considered.

Clinical outcomes of intraocular lens scaffold surgery: a one-year study

PURPOSE

To evaluate the safety and 1-year outcome of the intraocular lens (IOL) scaffold technique in eyes with soft to moderate nuclear remnants after intraoperative posterior capsule rupture (PCR).

DESIGN

Single-center, retrospective, interventional, noncomparative, consecutive case series.

PARTICIPANTS

A total of 20 eyes of 20 patients who had intraoperative PCR underwent IOL scaffold surgery in a tertiary clinic.

METHODS

A retrospective analysis of medical records of a consecutive series of patients who underwent IOL scaffold surgery from August 2011 to February 2013 was reviewed. All surgeries were performed by a single surgeon, and a 3-piece, 6.0-mm optic, acrylic, foldable IOL with a modified C-loop haptic configuration was implanted in all eyes.

MAIN OUTCOME MEASURES

The preoperative and postoperative parameters evaluated were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), specular microscopy, gonioscopy, ultrasound biomicroscopy, central macular thickness, intraocular pressure (IOP), and anterior and posterior segment inflammation. The final visual outcome at 1 year was evaluated.

RESULTS

At 1-year follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.58 ± 0.15 and 0.90 ± 0.17, respectively. The IOL was placed in the sulcus for 14 eyes and in the capsular bag for 3 eyes, and glued intrascleral fixation of IOL was performed in 3 eyes. The mean postoperative refractive error at the final examination was -0.4 ± 0.05 diopter (standard error of mean). Postoperative CDVA of 20/20 and 20/30 was achieved in 75% (15 eyes) and 25% (5 eyes), respectively. There was no correlation between preoperative specular count and percentage loss of cells (P = 0.602; r(2)=0.015). The mean central macular thickness at 1 year was 182.5 ± 11.79 μm. Clinical macular edema was observed in 1 of 20 eyes (5%).

CONCLUSIONS

The IOL scaffold provided an effective, relatively noninvasive means of emulsifying moderate to soft nuclear remnants in eyes with intraoperative PCR, with a good visual outcome and a favorable complication rate.

Phacoemulsification with perfluorocarbon liquid using a 23-gauge transconjunctival sutureless vitrectomy for the management of dislocated crystalline lenses

BACKGROUND

We describe the modified technique of phacoemulsification in dislocated crystalline lenses.

METHODS

After the vitreous and posterior hyaloid membrane were removed using a 23-gauge three-port vitrectomy, perfluorocarbon liquid (PFCL) was injected at the posterior pole in order to fill the vitreous cavity. The dislocated lens floated on the PFCL, and the injection was ceased once the lens had risen to the iris plane. The lens was then removed from the anterior chamber using standard phacoemulsification procedures. During the phacoemulsification, the PFCL provides a support underneath the nucleus, like a trampoline, and even small fragments can be completely removed.

RESULTS

The final best-corrected visual outcome was more than 20/40 in 11 eyes. Although two eyes showed LP(-) due to optic neuropathy, those eyes showed a remission in inflammation and an increase in IOP.

CONCLUSION

This modified use of PFCL in the removal of dislocated lenses fragments may overcome the limitation of earlier management of dislocated lenses.

Vitreous loss during cataract surgery: prevention and optimal management

Vitreous loss during cataract surgery is associated with a poor visual outcome. Experienced surgeons and those performing a high volume of cataract operations have lower rates of vitreous loss. Risk stratification systems, which allow prediction of intraoperative complications from preoperative criteria exist, so that less experienced surgeons can avoid higher risk cases. The management of vitreous loss includes counselling patients before surgery of the potential risks and complications. When vitreous loss occurs, it is important for the surgeon to avoid actions [corrected] which increase the chance of disaster for the eye. These include phacoemulsification in the presence of vitreous and attempts to recover dropped lens fragments from the posterior segment without vitrectomy. There are advantages in performing an anterior vitrectomy by the pars plana route rather than through the anterior chamber and this approach is facilitated by sutureless 23-gauge instruments. Dislocation of lens nuclear fragments into the vitreous is associated with a high incidence of retinal detachment as well as secondary glaucoma and cystoid macular oedema. Early involvement of a retinal surgeon in the management of these eyes is recommended.

The effect of specific gravity of perfluorocarbon liquid on the retina after experimental vitreous substitution

PURPOSE

To evaluate the histological changes in the retina after experimental vitreous substitution with various amounts of perfluorophenanthrene (PFPH).

METHODS

Thirty-two rabbit eyes were mechanically vitrectomized and filled up with 0.8 cc or 0.2 cc highly purified PFPH. The substance remained for 1 week (4 eyes), 2 weeks (8 eyes), 4 weeks (10 eyes) or 8 weeks (10 eyes). Eight eyes underwent the same surgical procedure without PFPH exchange to serve as a control group. A histological comparison of corresponding areas in the center and in the periphery of the inferior retina ensued.

RESULTS

After 2 weeks, nuclear drop-downs and irregularities of the outer plexiform layer and of both nuclear layers were observed centrally in the eyes with a 0.8 cc substitution. The changes proceeded to irregularities and cell loss of all retinal layers with focal areas of complete destruction of the retinal architecture after 8 weeks. In contrast, single nuclear drop-downs, wrinkling of the outer nuclear layer and cell loss in the photoreceptor layer were observed in the peripheral retina at the end of the observation period. In those eyes where 0.2 cc PFPH was exchanged nuclear drop-downs were found after 2 weeks, leading to focal thinning of the outer plexiform layer and irregularities of the outer nuclear layer after 4 weeks with an insignificant increase after 8 weeks. At this time these histological alterations were comparable with those that we observed after 2 weeks in the eyes with a 0.8 cc tamponade in a corresponding area.

CONCLUSIONS

Even high purification of PFPH does not prevent retinal damage. The different results in different areas after vitreous substitution with 0.2 cc and with 0.8 cc demonstrate that the high specific gravity of the substance may also play a role in the development of histological changes after extended tamponade.

Use of perfluorocarbon liquid during vitrectomy for severe proliferative diabetic retinopathy

AIM

To evaluate the value of using perfluorocarbon liquid (PFCL) during vitrectomy in eyes with proliferative diabetic retinopathy (PDR).

METHODS

The surgical records of eyes with PDR (291 eyes of 228 patients) that underwent vitrectomy in the vitreoretinal service of Osaka Medical College (April 1999 to October 2001) were reviewed. From these, 18 eyes of 15 patients had PFCL used during vitrectomy, and the preoperative and postoperative findings of these eyes were analysed.

RESULTS

All of the 18 eyes had advanced PDR with tractional and/or rhegmatogenous retinal detachment. PFCL enabled easier flattening of the retinal folds and effective endophotocoagulation. In two cases, PFCL was used to flatten a bullous retinal detachment that developed when a tight vitreoretinal adhesion was loosened. In two other cases with combined traction/rhegmatogenous retinal detachment, PFCL was used to tamponade the detached retina which then allowed successful membrane dissection. Anatomical success was obtained in 16 of the 18 cases (mean follow up time 13.3 months) with visual acuity of 20/200 or better in nine eyes (50%).

CONCLUSIONS

PFCL is considered to be a useful adjunct during vitrectomy for the treatment of severe PDR.

Phacofragmentation without perfluorocarbon liquid for dislocated crystalline lenses or lens fragments after phacoemulsification

PURPOSE

To evaluate the clinical outcome of vitrectomy with phacofragmentation without perfluorocarbon liquid (PFCL) in the management of dislocation of the crystalline lens, caused by trauma, hereditary disorders, or hypermature cataracts, and lens fragments due to phacoemulsification.

METHODS

A prospective study was conducted to evaluate 30 eyes of 29 patients who had undergone standard pars plana vitrectomy with phacofragmentation without PFCL in the vitreous cavity, for the removal of dislocated crystalline lenses or lens fragments, from January 1998 to July 2000. All cases were followed for more than six months.

RESULTS

Final best corrected visual acuity of 0.5 or better increased from 0% preoperatively to 36.7% postoperatively, and 0.2 or better rose to 76.7%. The mean IOP was significant reduced, from 26.35 mmHg to 12.75 mmHg. No intraoperative complications occurred. Although two eyes (6.7%) developed retinal detachment, one (3.3%) had cystoid macular edema (CME) and one (3.3%) had a transient intraocular pressure increase (to 25 mmHg) postoperatively, all others had a favorable outcome.

CONCLUSIONS

Standard pars plana vitrectomy with phacofragmentation without PFCL in the vitreous cavity is a safe, simple, and effective method for removing a dislocated crystalline lens or lens fragments, with good visual outcome.

Management of posterior capsule tears

Any breach in the continuity of the posterior capsule is defined as a posterior capsule tear. Posterior capsule tears can be preexisting (congenital or traumatic), spontaneous, or intrasurgical. Preexisting/congenital posterior capsule tears have been related to an intrauterine insult. Posterior capsule tears due to trauma may occur as a consequence of direct mechanical impact due to perforation or blunt injury. Depending on the duration of time between the posterior capsular trauma and the cataract surgery, these posterior capsule tears can have different features. Intrasurgical posterior capsule tears are the most common and can occur during any stage of cataract surgery. Also, they may be planned in the form of primary posterior capsulorhexis. The conventional management consists of prevention of mixture of cortical matter with vitreous, dry aspiration, and anterior vitrectomy, if required. In addition, during phacoemulsification low flow rate, high vacuum, and low ultrasound are advocated if a posterior capsule tear occurs. Dislocated nucleus or nuclear fragments require vitrectomy and the use of perfluorocarbon liquids. In the presence of a posterior capsule tear, the IOL can be placed in the sulcus, if the capsular rim is available, or in the bag, if the tear is small. Scleral fixated posterior chamber lenses and anterior chamber IOLs can be implanted when the posterior capsule tear is large.

Visual outcome after management of a posteriorly dislocated lens nucleus during phacoemulsification

PURPOSE

To evaluate the characteristics of eyes with a posteriorly dislocated lens nucleus during phacoemulsification and to assess the results of the management.

SETTING

Department of Ophthalmology, Nagoya University School of Medicine, Nagoya, Japan.

METHODS

Fifteen eyes (15 patients) with posteriorly dislocated lens nuclei during phacoemulsification were evaluated retrospectively. Patients ranged in age from 56 to 86 years old (mean 73.9 years +/- 9.6 [SD]). Thirteen of the 15 eyes had advanced cataract with hard nucleus before surgery Three patients developed secondary glaucoma resulting from the lens particle after nuclear dislocation.

RESULTS

One dislocated lens nucleus was not removed surgically and only observed. In three patients, an attempt had been made to remove the dislocated lens nucleus at the time of cataract surgery. This caused massive choroidal hemorrhage with giant retinal tear, posterior retinal tear, and ora tear, respectively. Finally, the displaced nucleus was removed in 14 patients who had a pars plana vitrectomy at the time of cataract surgery (4 eyes) or a secondary procedure (10 eyes). In 5 eyes, liquid perfluorocarbon was used for the procedure. An intraocular lens (IOL) was successfully implanted in all eyes that were expected to have IOL implantation before surgery except in 1 eye with choroidal hemorrhage.

CONCLUSION

Although the results of secondary management of displaced lens nucleus were fairly good, surgeons should take great care to avoid serious secondary complications such as retinal detachment and massive choroidal hemorrhage.

Removal of lens fragments from the vitreous cavity

Between March 1993 and September 1994 we treated 25 cases of lenses in the vitreous cavity. Nineteen of the 25 were the result of dislocation during phacoemulsification. During this time, we adopted a single surgical algorithm involving vitrectomy, heavy liquids and ultrasound fragmentation. The aims of this retrospective study were to test the validity of our surgical algorithm and to report on outcomes and complications. The indications for vitreous surgery were raised intraocular pressure, uveitis and poor vision. Vitreous surgery was carried out at a mean of 29 days following phacoemulsification. Six patients required heavy liquids and 5 needed ultrasound fragmentation. Vitreous surgery undertaken less than 17 days after phacoemulsification had an increased likelihood of requiring heavy liquids and/or fragmentation (p < 0.02). The greatest threat to a favourable visual outcome was retinal detachment, which was significantly associated with fragmentation and use of heavy liquids (p < 0.02). The presence of an intraocular lens (IOL) reduced the surgical options for removal of the lens fragments, and IOL should not be inserted where lens matter dislocates. The study suggests that we should avoid fragmentation and, provided the intraocular pressure and uveitis can be controlled, that vitreous surgery should be deferred for 2-3 weeks following phacoemulsification.

Outcomes of dropped nucleus during phacoemulsification

PURPOSE

To evaluate the clinical outcome of vitrectomy in the management of dropped nucleus during phacoemulsification.

METHOD

Twenty-five consecutive patients who underwent pars plana vitrectomy for the management of dropped nucleus from phacoemulsification, over a 36-month period, were studied. Twenty-two patients underwent vitrectomy within 15 days of cataract surgery. Most of the patients were followed for more than 6 months.

RESULTS

Final visual acuity was 20/40 or better in 71% (17/24) of eyes and 20/50 in 8% (2/24). Visual acuity was 20/70 or worse in 21% (5/24) of patients. Complications included persistent cystoid macular edema in three eyes, epimacular proliferation in two eyes, and a choroidal detachment in one eye.

CONCLUSION

Poor visual outcome after dropped nucleus at phacoemulsification cataract extraction can be avoided if managed by prompt pars plana vitrectomy.

Incidence of lens matter dislocation during phacoemulsification

PURPOSE

To assess the incidence and visual morbidity of lens matter dislocation during phacoemulsification and the relationship between this complication and surgical experience.

SETTING

Teaching and district general hospitals.

METHODS

A multiple-choice questionnaire was sent to members of the Northern and Midlands Ophthalmological Societies. They were asked about the incidence of lens matter dislocation, the visual outcome of the cases, and their surgical experience.

RESULTS

Forty-seven of the 177 survey respondents (26.5%) were using phacoemulsification. The incidence of lens matter dislocation was 1.1%; 49.0% of the surgeons had experienced at least one case. The incidence increased significantly when surgeons assessed their expertise with phacoemulsification toward the expert end of the scale. Final visual acuity was worse than 6/12 in 35.0% of cases.

CONCLUSIONS

The incidence of lens matter dislocation with phacoemulsification is significant and related to an incorrect assessment of expertise by the surgeons. The considerable visual morbidity associated with this complication can be minimized using the management strategy discussed.

Perfluorocarbon heavy liquids

Perfluorocarbon heavy liquids (PFCL) facilitate the transfer of intraocular fluids and other surgical manoeuvres in the posterior segment. The indications for their use have extended since first described in the management of giant retinal tears and proliferative vitreoretinopathy. We reviewed our personal experience and experimental evidence, including adverse effects, in order to identify the current role of PFCL in vitreoretinal surgery. High-density perfluorocarbon liquids represent a major advance in vitreoretinal surgery. Clinical experience and the results of experimental investigations have demonstrated their efficacy and safety as an intraoperative device.

Perfluorocarbon liquids in ophthalmology

Perfluorocarbon liquids have been used to facilitate surgery in a wide variety of conditions, including proliferative vitreoretinopathy, giant retinal tears, drainage of suprachoroidal hemorrhages, diabetic traction, retinal detachments with a rhegmatogenous component, dislocated crystalline or intraocular lenses, and retinal detachment associated with choroidal coloboma. The clarity of perfluorocarbon liquids, with a refractive index close to that of water, allows the use of a conventional contact lens for vitreous surgery while the low viscosity facilitates tissue manipulation, injection, and removal. All perfluorocarbon liquids when used as tamponading agents can compress and disorganize the retina. This "toxicity" is a physical effect rather than chemical toxicity and depends upon the amount of perfluorocarbon liquid injected. Perfluorocarbon liquids are not tolerated in the anterior chamber, causing corneal edema within 2-3 days at the site of contact.