Central cortical cleanup and zonular deficiency

Comparative Study of Safety Outcomes Following Nucleus Disassembly with and without the miLOOP Lens Fragmentation Device During Cataract Surgery

Purpose

To determine the effect of a microinterventional lens prefragmentation wire loop device (miLOOP®; Carl Zeiss Meditec AG, Oberkochen, Germany), on adverse events (AEs), cumulative dispersed energy (CDE), and vision outcomes when used before phacoemulsification of high-grade mature cataracts.

Setting

Three ambulatory surgical centers in the Peoria, IL region.

Design

Retrospective comparative consecutive case series; single-surgeon.

Methods

Patient outcomes were compared before and after introduction of miLOOP-assisted lens fragmentation prior to phacoemulsification during cataract surgeries performed 2016‒2020. The primary outcome was intraoperative AE rate/type. Secondary outcomes included ultrasound cumulative dispersed energy (CDE) administered during phacoemulsification, postoperative AEs, and best-corrected visual acuity (BCVA).

Results

Data from 765 subjects (mean age 72.9 years; 1025 eyes) comprised 524 conventional lens disassembly (Control) eyes and 501 Device eyes. One hundred percent of the cataracts in both groups were advanced WHO Grade 3+ nuclei. Significantly fewer intraoperative AEs occurred in the Device group versus Controls (2.2% and 6.3% of eyes, respectively; p=0.0011). Postoperative AE rates were comparable between groups (Controls=2.9%, Device=3.5%). Mean CDE from ultrasound was significantly reduced by 21% when the microfilament loop device was used for nuclear disassembly (9.6±5.2 CDE units) versus Controls (11.6±6.4 CDE units; p<0.0001). Median postoperative BCVA was 20/25 Snellen (0.091 logMAR) in both groups. More than 70% of both Control and Device eyes had postoperative BCVA better than 20/30 Snellen.

Conclusion

Microinterventional lens fragmentation was associated with lower ultrasound energy use and improved intraoperative safety than traditional unassisted surgery of advanced high-grade cataracts, while maintaining similarly acceptable postoperative complication rates and BCVA functional outcomes.

The role of lens extraction in glaucoma management

Cataract extraction has become a much safer procedure with the development of phacoemulsification, extending its application in ocular conditions such as glaucoma for better disease control. This review aims at summarizing the effect of lens extraction with or without combined glaucoma surgeries in different types of glaucoma and describing the intraoperative techniques and changes of glaucoma care postoperatively. A comprehensive literature search was performed through Medline and PubMed, and 67 studies were selected for this review. In primary angle closure (PAC) diseases, studies have revealed significant intraocular pressure (IOP) and medication requirement reduction after lens extraction. Fewer studies described its application in primary open angle glaucoma (POAG) and ocular hypertension (OHT), but literature available suggests that it can also lead to better disease control. Likewise, lower postoperative IOP and pressure fluctuations have been shown in normal tension glaucoma (NTG). Advanced glaucoma, shallow anterior chamber and pseudoexfoliation glaucoma (PXG) are three difficult scenarios that are commonly encountered in cataract operations. Special techniques in preventing complications such as wipe out phenomenon are depicted. Goniosynechialysis, endoscopic cyclophotocoagulation and trabecular microbypass stents are a few of the popular choices of glaucoma procedures that can be performed concomitantly with phacoemulsification but evidence of their efficacy needs to be further verified. Cataract operation can improve visual field and retinal nerve fiber layer examination parameters and it is advised to set new baselines after the surgery for subsequent progression monitoring. Clearance of an optically significant cataract results in better quality of life, and with detailed and thorough explanation of the indications, expectations and risks of the surgery, cataract extraction could be considered even in cases of advanced glaucoma.

Nuclear scaffold: Three-dimensional indigenous capsular bag support combined with IOL scaffold and capsular tension ring to prevent posterior capsule rupture in zonulopathy

We describe a technique for performing phacoemulsification in eyes with zonular fiber dehiscence of less than 90 degrees using hard nuclear fragments as a scaffold. In conjunction with a capsular tension ring (CTR), hard nuclear fragments and the intraocular lens (IOL) are used as scaffolds during different steps of nuclear emulsification to prevent posterior capsule rupture and aggravation of zonulopathy. Devices such as capsular hooks, CTRs, and IOLs are used to support the capsular bag associated with zonulopathy. The mass of hard nuclear fragments provides support toward the anteroposterior and the horizontal planes, thereby providing 3-dimensional capsular bag support.

Intraoperative and postoperative complications of cataract surgery in eyes with pseudoexfoliation - An 8-year analysis

INTRODUCTION:

Pseudoexfoliation (PXM) is a fibrillar material deposited in the anterior chamber of the eye and can cause disintegration of zonules and make pupillary dilatation difficult. This can make surgery difficult and result in intraoperative and postoperative complications. The aim of this study was to learn about whether the presence of pseudoexfoliation caused significant complications during cataract surgery.

MATERIALS AND METHODS:

We did a secondary data analysis of 12,992 eyes from 2007 to 2014 using the National Eye Database of Melaka Hospital Malaysia on intraoperative and postoperative cataract surgery complications of patients with PXM.

RESULTS:

Patients with PXM were 2.68 times more likely to get intraoperative complications (P < 0.001). They had a higher incidence of lens subluxation, zonular dehiscence, and vitreous loss (P < 0.001). Although posterior capsule rupture (PCR) was the most common intraoperative complication during cataract surgery (4.8%), the presence of pseudoexfoliation was not associated with PCR (P > 0.05). We did not observe any association between patients with pseudoexfoliation and any of the postoperative complications such as corneal decompensation, raised intraocular pressure, and intraocular lens decentration (P > 0.05). Pseudoexfoliation did not cause corneal decompensation (P > 0.05) although corneal decompensation was the highest postoperative complication of cataract surgeries (0.18%).

CONCLUSIONS:

Patients with PXM had a higher rate of intraoperative complications which were mainly vitreous loss and zonular dehiscence and also lens subluxation/dislocation. We observed poorer visual outcomes in those with PXM following cataract surgery. Patients with pseudoexfoliation should be identified and precautions taken to minimize these complications to get better visual outcomes.

Monitoring and management of the patient with pseudoexfoliation syndrome: current perspectives

Pseudoexfoliation syndrome (PES) is a complex and age-related systemic disorder characterized by the progressive accumulation and granular deposition of pseudoexfoliative material in various intraocular and extraocular tissues. The diagnosis of PES is so important because it is a major risk factor for complications during cataract surgery and the most frequent cause of secondary glaucoma. In addition to ocular complications, PES is related with numerous systemic abnormalities, for which the list is growing steadily. Therefore, management and monitoring of patients with PES are crucial. The aim of this paper was to review current perspectives on monitoring patients with PES and addressing management of ocular and systemic associations of this clinically important and biologically fascinating disease.

Cataract surgery in patients with pseudoex-foliation syndrome: current updates

Pseudoexfoliation is a ubiquitous syndrome of multifactorial origin affecting elderly people by increasing the risk of cataract and secondary glaucoma development. Despite modern techniques and technologies for cataract surgery, pseudoexfoliation syndrome represents a challenge for surgeons because of the increased weakness of the zonular apparatus and limited pupil dilation. Due to the inherent difficulties during surgery, the risk of vitreous loss in these patients is several times higher than in cataract patients without pseudoexfoliation. Using currently available surgical devices (ophthalmic viscosurgical device, iris retractors and ring dilators, capsular tension ring, etc.), the risk of intraoperative complications may be much reduced, allowing the surgeon to handle difficult cases with greater confidence and safety. This review analyzes the methodologic approach to the patient with zonular laxity with the aim of providing useful advices to limit the risks of intraoperative and postoperative complications. From the preoperative planning, to the intraoperative management of the small pupil and phacodonesis, and to the postoperative correction of capsule phimosis and intraocular lens dislocation, a step approach to the surgical management of pseudoexfoliation patients is illustrated.