Anterior Hyaloid Face Research Articles

Anterior hyaloid face opacification after pediatric Nd:YAG laser capsulotomy

Purpose: The purpose of this study was to examine the clarity of the visual axis after Nd:YAG laser capsulotomy following cataract extraction and primary intraocular lens implantation in a pediatric population. Methods: A retrospective review was performed of all cases of cataract extraction and primary intraocular lens implantation over a period of 5 years. A group of children who had been treated by primary surgical posterior capsulotomy and anterior vitrectomy (Group 1) was used as the “gold standard,” with whom the children treated with Nd:YAG laser capsulotomy (Group 2) were compared. The groups were studied for the incidence of opacification of the visual axis after the primary procedure. Results: Data on 78 eyes were reviewed, and 56 eyes met inclusion criteria. Of these, 33 eyes were treated with primary posterior capsulotomy and anterior vitrectomy (Group 1) and 23 eyes were treated with Nd:YAG laser capsulotomy (Group 2). One eye (3%) of Group 1 experienced postoperative visual axis reopacification. Thirteen (57%) of 23 eyes in Group 2 experienced reopacification, requiring retreatment. Four eyes (17%) treated with Nd:YAG laser required a third treatment. Conclusions: In our series, 57% of patients treated with Nd:YAG laser capsulotomy experienced reopacification across the anterior hyaloid face. With the removal of the anterior vitreous at the time of cataract extraction, the scaffolding for cell migration is removed and reopacification of the visual axis is rarely seen. For patients in whom slit-lamp capsulotomy is not possible, especially if there is no Nd:YAG laser available for use in the operating room or when loss to follow-up may be an issue, primary posterior capsulotomy and anterior vitrectomy should be strongly considered. (J AAPOS 1999;3:303-7)

Recalcitrant Malignant Glaucoma Following Pars Plana Vitrectomy, Scleral Buckle, and Extracapsular Cataract Extraction With Posterior Chamber Intraocular Lens Implantation

Pars plana vitrectomy is employed to treat cases of aqueous misdirection that are refractory to medical and laser treatment. The authors describe a 65-year-old man without previous aqueous misdirection in whom this condition developed after a procedure that included pars plana vitrectomy. The aqueous misdirection recurred despite multiple interventions, including medical treatment, transiently successful Nd:YAG laser capsulo-hyaloidotomy, and surgical disruption of the anterior hyaloid face. It finally resolved after repeated pars plana vitrectomy with hyaloido-capsulo-iridectomy. There has been no recurrence 7 months after this procedure. The authors conclude that the surgical treatment of aqueous misdirection refractory to more conservative measures should include adequate disruption of the anterior hyaloid to prevent recurrence.

Ultrasound Biomicroscopy in Pseudophakic Malignant Glaucoma

Malignant glaucoma (ciliary block glaucoma; aqueous misdirection glaucoma) is an incompletely understood, rare and serious complication of intraocular surgery. A woman with pseudophakic malignant glaucoma underwent successful neodymium: YAG (Nd:YAG) laser photodisruption of the anterior hyaloid face with resolution of the glaucoma. High-resolution ultrasound biomicroscopy was used to image the anterior segment and anterior chamber angle before and after laser surgery. Ultrasound biomicroscopy provided cross-sectional images of the iris, posterior chamber intraocular lens (IOL), and ciliary body and their relative positions before and after resolution of the malignant glaucoma. Anterior rotation of the ciliary body and anterior chamber shallowing normalized after rupture of the anterior hyaloid face. High-resolution ultrasound biomicroscopy provided images consistent with accepted concepts of the pathophysiology of this disease and offers great promise for the future elucidation of the anatomic mechanisms underlying various forms of glaucoma.

Brown-McLean Syndrome

Brown-McLean syndrome has been reported as a late complication, usually occurring 6 to 16 years after intracapsular and extracapsular cataract extractions. 1-3 To our knowledge, our patient's onset of symptoms 34 years after cataract extraction represents the longest interval between cataract surgery and development of symptoms due to Brown-McLean syndrome. Report of a Case. —A 52-year-old man presented complaining of a foreign body sensation in his right eye. He had undergone an intracapsular lens extraction 34 years previously for a traumatic cataract of the right eye. Best corrected visual acuity was 20/25 OU. Slit-lamp examination of the right eye revealed peripheral epithelial and stromal corneal edema with a central clear zone (4 mm horizontally and 6 mm vertically) (Fig 1) and orange pigmentation along the endothelial surface of the involved areas (Fig 2). There was a large superior sector iridectomy; the anterior hyaloid face was intact. The left eye was

Ciliary Sulcus Suturing of a Posterior Chamber Intraocular Lens

We describe a method for ciliary sulcus fixation of a posterior chamber intraocular lens (PC-IOL) in the absence of an intact posterior capsule. This method, which combines a lens fixation procedure with trans pars plana vitrectomy techniques to ensure safe manipulation of the lens implant in the absence of an intact anterior hyaloid face, is ideally suited for retrieval and repositioning of PC-IOLs dislocated into the vitreous. It also permits closed system repositioning and fixation of the implant, thereby avoiding the complications of vitreous loss and the need for reopening the limbal incision.

Retinal detachment following neodymium YAG laser capsulotomy in aphakic and pseudo-aphakic eyes

A retrospective study of 20 eyes with retinal detachment following Nd: YAG-laser capsulotomy was performed. Time intervals between cataract extraction and capsulotomy ranged from 1 to 50 years with a median of 22 months. Time intervals between capsulotomy and diagnosis of detachment ranged from 2 days to 15 months with an average interval of 4.42 months. Fifteen eyes had one or more horseshoe tears and one had a peripapillary tear. In one eye no tear was found. No relationship could be established to the size of the capsulotomy, the total energy applied or the number of laser effects. Three characteristic features were identified: average myopia before cataract extraction was -8.37 diopters with an average axial length of 26.65 mm. Lattice degeneration in the affected eye was found in 13 eyes. In 15 eyes the anterior hyaloid face was ruptured. Eleven cases were successfully reattached with one, 7 cases with two, and two cases with three operations. The retina was ultimately reattached in all cases. The high number of reoperations indicates a higher rate of proliferative vitreoretinopathy.

Haemolytic glaucoma occurring in phakic eyes.

The occurrence of haemolytic glaucoma in phakic eyes due to ghost cells has not previously been reported. Three cases of haemolytic glaucoma occurring over two years after massive vitreous haemorrhage in patients with an intact lens iris diaphragm are described. In one case there was histological confirmation of the presence of ghost cells in the anterior chamber. The mechanism proposed for the passage of ghost cells to the anterior chamber is through a defect in the anterior hyaloid face, created as the vitreous liquefies and degenerates. The reported cases were satisfactorily treated by trabeculectomy with anterior chamber washout, which management has not previously been reported in haemolytic glaucoma.

Surgical Vitrectomy for Pseudophakic Malignant Glaucoma

Four eyes that had undergone cataract extraction with intraocular lens implantation developed malignant glaucoma. Three eyes had posterior chamber lenses and one eye had an anterior chamber lens. Medical therapy was unsuccessful in each case. One eye was treated with Nd-YAG laser disruption of the anterior hyaloid face, but this did not reverse the glaucoma. In all four eyes pars plana vitrectomy reversed the glaucoma process. In the eyes with posterior chamber lenses, the vitrectomy included excision of a localized area of lens capsule and zonules. A pathway for the anterior flow of aqueous was created without dislocating the intraocular lens.

Nontraumatic Ghost Cell Glaucoma - A Case Report

Ghost cell glaucoma (GCG) has recently been described following vitrectomy, cataract extraction, and penetrating or blunt trauma. We describe the occurrence of GCG in a phakic eye with no prior ocular trauma or surgery following vitreous hemorrhage from diabetic retinopathy. We postulate the occurrence of a spontaneous rupture of the anterior hyaloid face which allowed passage of ghost cells into the anterior chamber. A therapeutic vitrectomy was complicated by intraoperative vitreous hemorrhage. Two weeks postvitrectomy, GCG recurred and was successfully controlled by irrigation through an anterior chamber approach. This is the procedure of choice in GCG following vitrectomy and may eliminate the need for a second vitrectomy.

Neodymium:YAG Lasers: An FDA Report

Analysis of data from four neodymium:YAG laser manufacturers submitted to the Food and Drug Administration (FDA) on over 17,000 cases indicate the procedure is safe and effective for cutting opaque posterior lens capsules. A successful opening in the pupillary membrane was achieved in 98% of the cases, and vision improved in 84% of the cases. Clinically significant risks include: a rise in intraocular pressure two to four hours after treatment, damage to the intraocular lens, and rupture of the anterior hyaloid face.

Neodymium-Yag Laser Therapy to the Anterior Hyaloid in Aphakic Malignant (Ciliovitreal Block) Glaucoma

In three aphakic eyes and two eyes with intraocular lens implants (five patients, four women and one man, ranging in age from 65 to 76 years) persistent shallow or flat anterior chamber was observed despite multiple patent laser or surgical iridectomies. In each case direct application of the neodymium-YAG laser (3 to 11 mJ) to the anterior hyaloid face resulted in immediate deepening of the anterior chamber. This deepening was sustained in four of the cases. These results confirm previous observations suggesting that the anterior hyaloid can be the locus of abnormality in aphakic malignant (ciliovitreal block) glaucoma. Neodymium-YAG "hyaloidotomy" may be better than penetrating surgery in such cases.

Neodymium-Yag Laser for Posterior Capsulotomy

We used the neodymium-YAG laser to perform discission of the posterior capsule in 49 eyes of 47 patients who had undergone previous extracapsular cataract extraction. The visual results were encouraging, with an improvement in visual acuity of one or more Snellen lines in 45 eyes and an improvement of three or more Snellen lines in 33 eyes. The complications included increases in intraocular pressure in 28 eyes. Intraocular pressures between 21 and 40 mm Hg were detected in 21 eyes and exceeded 41 mm Hg in another seven. In 14 of the 16 eyes in which intraocular pressure increased to more than 30 mm Hg, the maximum intraocular pressure was detectable within three hours after treatment. Other complications included damage to the intraocular lens in 12 of 30 eyes with implants and rupture of the anterior hyaloid face with forward displacement of vitreous into the anterior chamber in six of 19 eyes without implants. One of these eyes later developed a rhegmatogenous retinal detachment. A transient laser-induced hemorrhage occurred in one eye.

Ghost Cell Glaucoma Following Trauma

Ghost cell glaucoma was described in 1975. The details of this glaucoma as it occurred following vitrectomy and following cataract extraction have been reported. This glaucoma occurred following trauma as well, and this report describes the clinical and pathologic characteristics. Fourteen patients, five with positive anterior chamber aspirate examinations, were studied. All had in common: (1) severe trauma to the eye, either blunt or penetrating, with hyphema and vitreous hemorrhage; (2) gradual clearing of the anterior chamber hemorrhage and conversion of fresh red blood cells to ghost cells in the vitreous cavity; (3) forward passage of ghost cells into the anterior chamber through a traumatic opening in the anterior hyaloid face; and (4) elevation of intraocular pressure caused by these cells approximately two weeks to three months following the trauma. The glaucoma required medical and often surgical therapy. The surgical procedure of choice was anterior chamber irrigation, which was often effective and is advised before proceeding to vitrectomy. The vitreous findings of an enucleated eye with ghost cell glaucoma are presented.

Hemolytic ghost cell glaucoma. Further studies.

Three variations of ghost cell glaucoma that occur following cataract extraction are presented. The most common variant occurred when a large, anterior chamber and vitreous hemorrhage complicated the immediate postoperative course. Weeks later, as the anterior chamber hemorrhage cleared, ghost cells that had formed within the vitreous cavity passed forward into the anterior chamber and obstructed the aqueous outflow channels. Ultramicroscopy of aqueous specimens confirmed that RBC ghost were the major aqueous component and were therefore the cause of the glaucoma, distinguishing this glaucoma from glaucoma due to macrophages and RBC debris. Scanning and transmission electron microscopy of hemorrhagic vitreous showed that RBCs disintegrated into ghosts and denatured extracellular hemoglobin aggregates. The latter, common in the vitreous, were bound within vitreous strands, accounting for their absence in the anterior chambers of patients with ghost cell glaucoma. In correlation with clinical findings, perfusion studies showed that neither fresh RBCs nor ghosts could pass through an intact anterior hyaloid face.

Acute aphakic pupil block glaucoma: an alternative surgical approach.

In a series of 7 cases of acute aphakic pupil block glaucoma a surgical approach designed to break adhesions between the iris and the anterior hyaloid face was uniformly successful. Reasons for the success of the method are discussed and comparisons made with other surgical approaches.

Ghost Cells as a Cause of Glaucoma

Clinical and investigative evidence indicated a glaucoma caused mainly by degenerated red blood cells, or ghost cells. These ghost cells, with altered shape, color, and pliability, accumulated in the vitreous cavity after hemorrhage. Following disruption of the anterior hyaloid face, they passed into the anterior chamber and caused severe glaucoma. In the anterior chamber, the tiny, khakicolored cells, circulating slowly, were frequently mistaken for white blood cells. They covered the trabecular meshwork or filled the inferior angle with a pathognomonic khaki-colored layer. They were identified by phase-contrast microscopic examination of anterior chamber aspirates. The decreased pliability of these degenerated cells seemed to account for their inability to pass easily through the human trabecular meshwork and, therefore, to cause severe glaucoma.

Lens aspiration using a side-opening needle.

ASPIRATION of a cataract through a needle, a technique which probably dates back into antiquity, was reintroduced and modified by Scheie in 1960.1It has provided the clinician with a relatively simple and safe means of extracapsular cataract removal in infants and young adults. The principal technical hazard of the operation is inadvertent rupture of the posterior capsule and anterior hyaloid face with the aspirating needle. The purpose of this report is to describe the use of a new side-opening aspirating needle which reduces the possibility of this complication. This needle is the end result of several modifications which I have used since beginning lens aspiration in 1960. Early, it was apparent that the 22-gauge needle was of adequate caliber to aspirate even immature cataracts. Figure 1 depicts the aspirating needle which I began using initially. The length of the needle shaft was kept to a minimum (10 to