Bag-in-the-lens Research Articles

Efficacy of intracameral mydriatics in pediatric lens surgery.

Introduction To evaluate the efficacy of intracameral administration of Mydrane® in children undergoing lens surgery. Methods We set up a single center prospective cohort trial including 40 consecutive patients between 8 weeks and 17 years old who were planned for lens surgery, including cataract, persistent fetal vasculature (PFV) or lens subluxation. We injected 0,1 ml of intracameral Mydrane at the beginning of surgery, no preoperative mydriatic eye drops were used. The aim of the study was to measure pupil size, and to monitor the evolution of the pupil size during surgery and the need for additional pupil expanding techniques. Results In 30 patients (75% (95%CI: 59 - 87%)), we did not need additional manipulations to obtain sufficient pupillary dilatation to perform the surgery and to implant an intraocular lens (IOL) following the bag-in-the-lens (BIL) technique. In the remaining 10 patients (25%), we saw an initiation of dilatation, but not to the required pupil diameter to continue the surgery without additional surgical maneuvers. The duration of surgery was significantly longer in the partial response group, reflecting the need for additional surgical steps. A significant relation between increase of pupillary diameter and age (P = 0.003), gender (P = 0.032) and horizontal corneal diameter (P < 0.001) could be shown. Even at baseline there is a larger pupil diameter in eyes with larger horizontal corneal diameters (p=0.039). No adverse events were observed during this study. Conclusion Intracameral administration of Mydrane resulted in some degree of dilatation in all eyes in this series, 75% of eyes did not need additional techniques to proceed with the surgery. Smaller pupils at baseline, younger age, male sex and small horizontal corneal diameter were related to a poorer response to Mydrane. The mydriasis persisted for the entire duration of the surgery, no ocular adverse events were observed during this study. This leads us to conclude that intracameral Mydrane is an effective and safe way to dilate the pupil in pediatric lens surgery.

Bag-in-the-lens intraocular lens implantation before 12 weeks of age in congenital cataract.

The aim of this study was to evaluate the intra- and postoperative complications, especially the risk of visual axis opacification (VAO), following the implantation of the bag-in-the-lens (BIL) intraocular lens (IOL) in infants with congenital cataract operated on before 12 weeks of age. Infants operated on before 12 weeks of age between June 2020 and June 2021 with a follow-up longer than 1year were included in the present retrospective study. This was a first-experience cohort of an experienced paediatric cataract surgeon with this type of lens. Nine infants (13 eyes) with a median age at surgery of 28 days (range, 21-49 days) were included. The median follow-up time was 21.6months (range, 12.2-23.4months). The lens was correctly implanted with the anterior and posterior capsulorhexis edges placed into the interhaptic groove of the BIL IOL in seven of 13 eyes; none of these eyes developed VAO. In the remaining six eyes, the IOL was only fixated to the anterior capsulorhexis edge, and in these cases, an anatomical anomaly of the posterior capsule and/or anterior vitreolenticular interface dysgenesis were observed. These six eyes developed VAO. One eye had a partial iris capture in the early postoperative phase. Otherwise, the IOL remained well centred and stable in all eyes. Anterior vitrectomy was necessary in seven eyes due to vitreous prolapse. One patient with unilateral cataract was diagnosed with bilateral primary congenital glaucoma at 4months of age. Implantation of the BIL IOL is safe even in the youngest age group less than 12 weeks of age. Although being a first-experience cohort, the BIL technique is shown to reduce the risk of VAO and the number of surgical procedures.

Evaluation of the vitreolenticular interface with intraoperative OCT.

To determine the prevalence of anterior vitreous detachment (AVD) in routine bag-in-the-lens (BIL) cataract cases and possibly to identify risk factors for its presence. University Hospital of Antwerp, Belgium. Prospective cross-sectional study. Patients having routine BIL cataract surgery were included. Patients with traumatic cataract, previous intraocular surgeries, YAG laser treatment, intravitreal injection, or medical conditions that might affect normal ophthalmologic anatomy were excluded. Several parameters were collected from the patients' records, and their surgical videos/photographs/optical coherence tomography were evaluated. 99 eyes of 99 patients were included. Detectable AVD was observed in 62 eyes (63%). AVD was not present in 37 eyes (37%). The difference in prevalence of AVD between men and women was not statistically significant ( P = .55, Pearson χ 2 test). The Mann-Whitney U test for axial length was not statistically significant ( P = .38). However, it was statistically significant for age ( P < .005). A logistic regression model to ascertain the effect of age on the likelihood that patients had AVD did reach statistical significance (χ 2 (1) = 8.246, P < .005). The prevalence of AVD in a routine cataract population was 63%. Age was identified as a risk factor. This study model determined that the odds for AVD increase 5.3% with each year of patient age. These data allowed for better preoperative and postoperative assessment of complications. The BIL, by its mandatory primary posterior continuous curvilinear capsulorhexis, did not increase the risk for postoperative ocular complications in the posterior segment of the eye.

Intraocular bag-in-the-lens exchange: indications, outcomes, and complications

To report the indications, outcomes, and complications regarding bag-in-the-lens (BIL) intraocular lens (IOL) exchange over a period of 13 years in a tertiary ophthalmologic center. Department of Ophthalmology of the University Hospital of Antwerp, Belgium. Observational retrospective study. Between 2003 and 2020, 12 176 patients were operated using the BIL technique. Adult patients who underwent an intraocular BIL exchange were included, and the demographics, indications, outcomes, and complications were recorded. 59 eyes (0.48%) of 59 patients who underwent a BIL exchange between 2007 and 2020 were included. The mean age was 61.15 ± 13.53 years. The mean time between primary surgery and IOL exchange was 25.73 ± 41.88 months. The main indication for explantation was refractive surprise mostly related to patient risk factors, for example, preoperative corneal and refractive surgery. The mean preoperative uncorrected (UDVA) and corrected (CDVA) distance visual acuity were 0.36 ± 0.24 and 0.79 ± 0.24, respectively. The postoperative 1-month UDVA and CDVA were 0.66 ± 0.28 and 0.86 ± 0.19, respectively. The improvement in UDVA was statistically significant (<0.0001). The most common intraoperative complication was damage to the anterior hyaloid in 9 eyes (15%), which did not prohibit reimplantation of a secondary BIL. BIL to BIL exchange was a viable and successful technique that provides good refractive results with few, manageable complications. Because of the tertiary profile of the study center with referral of complex cases, BIL was the preferred IOL in patients at risk for postoperative refractive surprise.

The importance of the epithelial fibre cell interface to lens regeneration in an in vivo rat model and in a human bag-in-the-lens (BiL) sample

Human lens regeneration and the Bag-in-the-Lens (BIL) surgical treatment for cataract both depend upon lens capsule closure for their success. Our studies suggest that the first three days after surgery are critical to their long-term outcomes. Using a rat model of lens regeneration, we evidenced lens epithelial cell (LEC) proliferation increased some 50 fold in the first day before rapidly declining to rates observed in the germinative zone of the contra-lateral, un-operated lens. Cell multi-layering at the lens equator occurred on days 1 and 2, but then reorganised into two discrete layers by day 3. E- and N-cadherin expression preceded cell polarity being re-established during the first week. Aquaporin 0 (AQP0) was first detected in the elongated cells at the lens equator at day 7. Cells at the capsulotomy site, however, behaved very differently expressing the epithelial mesenchymal transition (EMT) markers fibronectin and alpha-smooth muscle actin (SMA) from day 3 onwards. The physical interaction between the apical surfaces of the anterior and posterior LECs from day 3 after surgery preceded cell elongation. In the human BIL sample fibre cell formation was confirmed by both histological and proteome analyses, but the cellular response is less ordered and variable culminating in Soemmerring's ring (SR) formation and sometimes Elschnig's pearls. This we evidence for lenses from a single patient. No bow region or recognisable epithelial-fibre cell interface (EFI) was evident and consequently the fibre cells were disorganised. We conclude that lens cells require spatial and cellular cues to initiate, sustain and produce an optically functional tissue in addition to capsule integrity and the EFI.

Adapted Bag-in-the-Lens Implantation Technique in Children with Congenital Ectopia Lentis.

Subluxation of the crystalline lens in childhood confronts the surgeon with a dilemma: to operate or to wait and see. Surgery is usually not performed when the subluxation is still limited. However, postponing the surgery increases the surgical difficulty as the capsular bag becomes more difficult to use as a means of support for the intraocular lens (IOL). A large number of children already present a pronounced subluxation at first presentation. In this paper, we describe a technique to optimise centration and fixation of the bag-in-the-lens (BIL) IOL in children younger than 7 years of age with congenital ectopia lentis. Between October 2019 and December 2020, we performed lens extraction using a combination of bean-shaped segments to support the BIL IOL and a 6 - 0 polypropylene loop fixated at the sclera, following the Yamane technique, for the purpose of centration. We used this technique for seven eyes of four patients. The patients were between 2 and 6 years old; 3 boys and 1 girl. A definite diagnosis of Marfan syndrome was made for two children; for the other two, there was no proven underlying pathology. The luxation was upwards in all cases. The degree of luxation was severe in all eyes. The preoperative refraction values showed high astigmatism values for all eyes, ranging from 6.5 to 11.25 dioptres. Three out of the four patients were myopic, ranging from - 1.5 to - 9 dioptres. The surgery could be performed without major complications in all eyes. Good centration was obtained, which remained stable in the postoperative period. Refraction improved with greatly diminished degrees of astigmatism (ranging from 0.25 to 3 dioptres) and myopia (spheres ranging from - 2 to + 1.75 dioptres). Our novel technique incorporated the BIL technique with the addition of bean-shaped segments and a polypropylene 6/0 suture fixated at the sclera. In this way, we were able to obtain good centration and stability of the implanted IOL, as well as a good refractive outcome in all cases.

Bag‐in‐the‐lens intraocular lens in paediatric cataract surgery: intraoperative and postoperative outcomes

To report intra- and postoperative surgical outcome using the bag-in-the-lens (BIL) technique in paediatric cataract surgery. In a retrospective case series, we studied the outcomes of children aged <12 years operated for cataract with the bag-in-the-lens intraocular lens (IOL), with a minimum of 6 months of follow-up. Since 2013, 50 eyes in 30 patients <12 years (20 bilateral and 10 unilateral) have been operated at our department with the BIL technique, with a median follow-up time of 33.5 months (range 6-77). Median age at surgery was 49.5 months (4-139). In one case, the IOL luxated through the capsulorhexes to the vitreous, but could be secured and repositioned as planned without further difficulties. Anterior vitrectomy was necessary in one case due to prolapse of vitreous to the anterior chamber during surgery. No other intraoperative complications occurred. Visual axis opacification (VAO) developed in four eyes (8%). So far, only one of these has needed a reoperation with clearing of the secondary cataract. A complete absence of VAO was thus seen throughout the study period in 92%. In two eyes, postoperative iris capture occurred. In both cases, surgical repositioning of the iris was needed. No eyes developed secondary glaucoma during the study period. The BIL technique seems to be a safe surgical procedure in paediatric cataract, with significantly less complications and need for additional surgery compared with the conventional lens-in-the-bag technique.

Clinical and Surgical Outcome of a Supplementary Multifocal Intraocular Lens Implanted with a Bag-In-the-Lens Intraocular Lens: 5-Year Follow-Up

Introduction: To assess the postoperative outcome and patient-reported satisfaction, spectacle independence, and dysphotopsia after implantation with the mutifocal Rayner Sulcoflex supplementary intraocular lens (sIOL). Materials and Methods: We analyzed the outcome of all patients implanted with a multifocal sIOL between 2009 and 2011. In all cases, the sIOL was the Rayner Sulcoflex IOL (type 653F) and the primary IOL was a bag-in-the-lens (BIL) IOL. The data were obtained through a retrospective analysis of the patient records and by means of a questionnaire, 5 years after sIOL implantation. Results: This study included 31 eyes of 20 patients. In 13 eyes, the sIOL needed explantation (n = 13, 41.94%). Dysphotopsia is a frequent complaint (12/15 patients: 80.0%) after sIOL implantation. In 13 out of 31 eyes (41.94%), pigment deposits were found on the sIOL with variable clinical complaints. Five eyes required additional surgery because of clinically significant deposits. Discussion/Conclusion: Patients with a multifocal sIOL in combination with a BIL implantation have a higher incidence of dysphotopsia compared to previously published studies. Dysphotopsia was the main complaint and reason for explantation. We encountered a high incidence of pigmented IOL deposits. The sIOLs can be safely removed even years after implantation.

Incidence of rhegmatogenous retinal detachment after bag-in-the-lens IOL implantation: extended follow-up in a larger cohort of patients.

To report the incidence of rhegmatogenous retinal detachment (RRD) and associated risk factors after cataract surgery using the bag-in-the-lens (BIL) intraocular lens (IOL) implantation technique. Department of Ophthalmology, Antwerp University Hospital, Belgium. Prospective cohort study. All consecutive BIL IOL surgeries performed between January 2001 and December 2010 were included, with the exclusion of combined procedures and IOL exchanges. The incidence of RRD was reported first in the total cohort, then in a subgroup of patients with 1 year to 5 years of follow-up, and finally in the group remaining after exclusion of all risk factors, except gender. Risk factors associated with RRD were examined using multiple Cox regression analysis with a random intercept. Rhegmatogenous RD was diagnosed in 36 eyes (1.06%) of 3385 BIL cases, with a mean follow-up of 48.28 ± 40.05 months (range 0 to 195 months). The 2-year cumulative RRD incidence rate was 0.66% (17 cases in 1024 eyes; 0.00% in patients without risk factors). The 5-year cumulative RRD incidence rate was 1.17% (26 cases in 931 eyes; 0.15% without risk factors). Five risk factors were confirmed: male sex, age less than 60 years at the time of surgery, axial length 25.0 mm or greater, a history of contralateral RD, and intraoperative surgical complications. The incidence of RRD after BIL IOL implantation is comparable with that of lens-in-the-bag (LIB) implantation. This larger study provided a longer follow-up and suggested that RRD incidence is even lower than that previously reported. This study also confirmed intraoperative surgical complications as an additional risk factor for RRD development, as already described with LIB implantation.

Chirurgie combinée vitrectomie et phakoéxérèse avec implantation bag-in-the-lens (BIL) ou de sac : comparaison de l’acuité visuelle finale

Combined vitrectomy-lensectomy surgery is a safe and effective procedure. Nevertheless, it is frequently complicated by posterior capsule opacification and the formation of posterior synechiae. These complications can be avoided by placing a "bag in the lens" (BIL) implant. The objective of this study is to compare the visual acuity gain (VA) after combined vitrectomy-lensectomy surgery between a group implanted with the BIL technique and a group with implantation in the bag (LIB). We included in the study all vitrectomy-lensectomy procedures for epiretinal membrane and vitreomacular traction performed between May 2013 and July 2016 at the Hospital and University Center of Caen. We compared the VA gain between the BIL group and the LIB group six months after surgery. A total of 33 patients were included in the study, consisting of 28 eyes in the BIL group and 8 eyes in the LIB group. The mean VA gain in the BIL group was -0.52 LogMAR (P<0.0001) and -0.56 LogMAR (P=0.0047) for the LIB group. The difference between the two groups was not significant (P=0.74). The use of the BIL technique during vitrectomy-lensectomy allows visual recovery as good as implantation within the capsular bag. In addition, this implant has the advantage of significantly reducing the occurrence of posterior synechiae and preventing anterior and posterior capsular proliferation.

Bag-in-the-lens implantation helps avoid posterior synechiae of the iris after phacovitrectomy

To compare the rate of posterior synechiae of the iris(PSI) occurrence after phacovitrectomy between a group with lens-in-the-bag (LIB) implantation, that is, implantation inthe capsular bag, and a group with bag-in-the-lens (BIL) implantation. CHU de Caen, Department of Ophthalmology, Caen, France. Comparative retrospective study. One hundred consecutive cases of phacovitrectomies conducted between May 2013 and July 2016 were included. A retrospective analysis of the occurrence rate of PSI in the LIB group and in the BIL group was performed, using multivariate analysis including multiple risk factors such as preoperative synechiae, proliferative diabetic retinopathy, use of 20-gauge vitrectomy, use of gas or silicone tamponade, and use of endophotocoagulation. One hundred eyes of 92 patients were included in this study (55 eyes in the LIB group and 45 in the BIL group). The occurrence of PSI was significantly lower in the BIL group with 1 case (2%) versus 22 cases (40%) in the LIB group (P<.001). Among the risk factors studied, preoperative synechiae and the use of retinal endophotocoagulation were almost significantly associated with the occurrence of PSI (P=.068 and P=.087, respectively). In the LIB group, these PSI led to 1 case of acute elevation of intraocular pressure by pupillary seclusion and the use of laser iridotomy in 8 cases. The use of BIL rather than LIB implantation in phacovitrectomy practically eliminates PSI.

Secondary glaucoma and visual outcome after paediatric cataract surgery with primary bag-in-the-lens intraocular lens.

To determine predictors of secondary glaucoma and poor visual outcome in children undergoing cataract surgery with bag-in-the-lens (BIL)-IOL implantation. Medical records were retrospectively analysed for children with primary implantation with BIL-IOL during 2009-2013. The study included 109 eyes. Median age at surgery was 2.5years (range 2weeks-14.1years), 26.6% being ≤12weeks of age (=early group). Median follow-up time was 2.8years (7months-5.8years). 15 eyes (13.8%) developed glaucoma, 14 (48.3%) in the early group and 1 (1.3%) in the late group (p<0.001). Within the early group, mean time for surgery differed significantly. Patients developing glaucoma had cataract surgery at 3.5±1.1weeks (mean±SD) and the non-glaucoma patients at 5.7±3.3weeks (p=0.024). In the entire cohort, 21 eyes (19.3%) had conditions associated with glaucoma; 57.1% of these developed glaucoma compared to 3.4% without these conditions (p<0.001). Corrected distance visual acuity (CDVA) (decimal) of ≥0.5 was seen in 50 eyes (48.5%), median 0.63 in the late group and 0.15 in the early group. Glaucoma eyes in the early group (surgery at 3.5weeks) achieved 0.56 median (range, 0.4-1.0) logMAR, (0.28 decimal) CDVA, whereas non-glaucoma eyes (surgery at 5.7weeks) achieved 0.89 median (range 0.7-1.6) logMAR (0.13 decimal) CDVA; p=0.016. Glaucoma development in infants between 5weeks and 2years of age was 6.7% (n=2/30). Comorbidity strongly increases the risk of secondary glaucoma. Surgery during the first month is correlated with better CDVA outcome and glaucoma. After 5weeks of age, glaucoma rate is low with the BIL-IOL.

Bean-shaped Ring Segments as a Capsule Enhancement Tool in Complex Bag-in-the-Lens Intraocular Lens Implantation.

To describe the outcome of a novel capsular or sulcular device to support the bag-in-the-lens (BIL) implant in cases of capsular or zonular instability. Bean-shaped ring segments or 'beans' (Morcher GmbH, Stuttgart, Germany) are designed to fit the groove of the BIL and may be placed in either the capsule or the ciliary sulcus in cataract cases with loose zonules or unstable capsule. This was a retrospective single center observational study of all consecutive cases of bean implantation between May 2011 and April 2015. Sixty-four eyes of 57 patients were included in this study. Beans were used to support the BIL implant in all cases. Surgical technique, positioning, visual outcomes, refractive outcomes, and complications were evaluated in all cases. The beans were implanted in 23 eyes after IOL exchange, 14 eyes with crystalline lens dislocation, 12 eyes presenting with traumatic cataract, 8 eyes presenting with unstable capsules, and 7 eyes with postoperative visual complaints due to an unstable BIL implant. The mean increase in visual acuity was 0.35 decimal Snellen for the total cohort. Visual gain was highest in the crystalline lens dislocation (0.43 decimal Snellen) and traumatic cataract (0.41 decimal Snellen) groups. Best refractive outcomes were achieved in the traumatic cataract and intraocular lens exchange groups (0.73 and 0.80 diopters mean deviation from target refraction, respectively). Bean-shaped ring segments are a useful tool to augment the stability of the capsule/zonular complex, expanding the indications of patients who can be treated with the BIL implant. [J Refract Surg. 2017;33(7):454-459.].

Pediatric bag-in-the-lens intraocular lens implantation: Long-term follow-up

To evaluate long-term follow-up results of pediatric cataract surgery using the bag-in-the-lens (BIL) intraocular lens (IOL) implantation technique. Antwerp University Hospital, Edegem, Antwerp, Belgium. Prospective case series. All pediatric cataract surgeries with BIL IOL implantation performed at the Antwerp University Hospital were evaluated. Only cases that completed a follow-up of 5 years at the hospital's Department of Ophthalmology were included in this study. Forty-six eyes of 31 children had a complete follow-up of 5 years or more after BIL IOL implantation. Sixteen cases were unilateral and 15 were bilateral. Patient age at time of surgery ranged from 2 months to 14 years. The mean refraction at the end of follow-up was -1.99 diopters (D) ± 3.70 (SD). In bilateral cases, a corrected distance visual acuity (CDVA) of better than 0.5 was attained in 86.7% and a CDVA of 1.0 was achieved in 56.7%. In unilateral cases, 31.2% achieved a CDVA of better than 0.5 but none obtained a CDVA of 1.0. A clear visual axis was maintained in 91.3% of cases during follow-up. Visual axis reopacification was detected in 4 eyes of 3 cases, all due to inadequate BIL IOL positioning. None of these eyes needed more than 1 intervention to maintain visual axis clarity. Other than 1 case of glaucoma, no severe complications were detected. Long-term follow-up results show that BIL IOL implantation is a safe, well-tolerated approach for treating pediatric cataract with a very low rate of visual axis reopacification and a low rate of secondary interventions for other postoperative complications. Dr. Tassignon has intellectual property rights to the bag-in-the-lens intraocular lens (U.S. patent 6 027 531; EU patent 009406794.PCT/120268), which is licensed to Morcher GmbH, Stuttgart, Germany. No other author has a financial or proprietary interest in any material or method mentioned.

Bean-shaped ring segments for capsule stretching and centration of bag-in-the-lens cataract surgery

The bag-in-the-lens (BIL) is a unique approach to IOL placement in cataract surgery. The BIL intraocular lens (IOL) is suspended centrally, supported by the anterior and posterior capsulorhexes. The placement confers a high degree of centration and stability; however, it is dependent on capsular and zonular integrity. In this report, we describe a patient with posttraumatic cataract featuring a sector of iris and suspensory zonule loss. The insertion of custom-designed bean-shaped segments provides capsular tension over the area of defect and a central aperture designed to support the BIL IOL.

Femtosecond laser–assisted technique for performing bag-in-the-lens intraocular lens implantation

We describe a technique for femtosecond laser-assisted bag-in-the-lens (BIL) intraocular lens (IOL) implantation. Anterior capsulotomy and lens division into small pieces are performed by the laser. A fluid-filled interface makes it possible to re-dock the laser to the eye for posterior capsulotomy after the eye has been opened for lens aspiration without complications. The integrated optical coherence tomography also visualizes the posterior capsule, allowing a centered central posterior capsulotomy for uncomplicated IOL positioning. In 31 patients, no complications were observed within a 1-month follow-up. Femtosecond laser-assisted cataract surgery facilitated the BIL technique.

Retinal straylight and the yellow Bag in the Lens IOL

AbstractPurpose To evaluate the influence of blue‐blocking Bag in the Lens (BIL) intraocular lens (IOL) on retinal straylight.Methods Twenty‐one patients scheduled for bilateral senile cataract surgery with a BIL intraocular implant (Morcher GmbH, Germany) randomly received implantation of either a UV light‐filtering and blue‐light filtering IOL (Morcher 89A yellow BIL) or a UV‐light filtering lOL (Morcher 89A, clear BIL) in both eyes. Only the left eyes were included in this study. Best corrected visual acuity and retinal straylight level were evaluated 3 months postoperatively with decimal charts at 4m and with C‐Quant (Oculus Optigeräte, Wetzlar, Germany) respectively.Results There were 11 eyes in the yellow BIL group and 10 eyes in the clear BIL group. Preoperative measurements (K1, K2, anterior chamber depth, axial length, IOL power) showed no significant differences between the yellow and the clear BIL group. No significant difference in visual acuity was found between both groups (p = 0.512). Mean retinal straylight did not differ significantly (p = 0.809) between yellow BIL (1.24 ± 0.26) and clear BIL (1.19 ± 0.21), even after correction for age and axial length with the pseudophakic model (p =0.557).Conclusion The UV and blue‐blocking bag‐in‐the‐lens had no influence on visual acuity and retinal straylight measured 3 months postoperatively, in comparison with a UV filtering bag‐in‐the‐lens.

Do we have any effective measure to minimize PCO?

AbstractIn the past, posterior capsular opacification (PCO) was considered an inevitable, albeit relatively minor complication of cataract surgery. As technology has improved, the qualities of lens implants have changed. Multifocal intraocular lenses confer visual benefits but the optics are dependent upon a clear optical medium and accurate placement. The development of PCO can distort the centration and function of these advanced optical qualities, such as diffractive rings, rendering lenses suboptimal and in some cases intolerable. Therefore long‐term quality outcomes are dependent on predictability and stability. The Bag‐in‐the‐lens (BIL) implant is currently the most effective measure to prevent PCO. The technique depends on the construction of two comparable anterior and posterior capsulorhexes. The lens is suspended centrally, supported by the integrity of the capsule and seals away lens epithelial cells preventing postoperative opacification. This placement has also been proven to be highly resistant to decentration and rotation. As the uptake of multifocal lenses and patient expectations increase, we propose that the BIL approach is currently the most stable and dependable means of ensuring quality long‐term multifocal outcomes.

Feasibility of multifocal intra‐ocular lens exchange and conversion to the bag‐in‐the‐lens implantation

Our purpose was to evaluate the surgical outcome after intra-ocular lens exchange in patients who presented impairing visual complaints after primary multifocal intra-ocular lens (MIOL) implantation. In particular, the study was undertaken to look at the number of eyes that could be equipped with the bag-in-the-lens (BIL) IOL after MIOL exchange. This series consisted of 30 eyes of 21 consecutive patients scheduled for MIOL exchange. In 15 out of the 30 eyes, IOL misalignment was measured on slit lamp anterior segment photo's after defining the mathematical centres of the IOL optic, pupil and limbus. Diffractive MIOL was more frequently explanted (25; 83%) when compared with refractive MIOL (4; 13%) and progressive optic IOL (1; 4%). In 21 out of the 30 eyes (70%) a bag-in-the-lens could be implanted. In 7 out of the 30 eyes (23%), the capsule was not considered sufficiently stable to accommodate an IOL. An iris-fixated IOL or a sulcus-fixated IOL was then implanted. In 2 out of the 30 eyes (6%) the remaining capsular bag could accommodate a traditional lens-in-the-bag only. Eyes that underwent Nd:YAG laser capsulotomy prior to the MIOL exchange needed anterior vitrectomy peroperatively (11 eyes; 37%). Visual acuity improved postoperatively in 13 out of the 30 eyes and remained stable in 17 out of the 30 eyes. Since the BIL technique requires a very well-preserved capsular bag for the purpose of the IOL implantation, the success rate of BIL implantation after MIOL is a good indicator to evaluate the degree of difficulty to exchange MIOL.

Assessment of the Bag-in-the-Lens Implantation Technique in Diabetic Patients

Cataract is a common condition observed in patients with diabetes mellitus frequently requiring surgical intervention. The bag-in-the-lens (BIL) intraocular implant is an alternative approach to standard lens-in-the-bag cataract surgery. The lens is supported by anterior and posterior capsulorhexes, which confers a number of advantages in terms of lens centration, rotational stability and prevention of posterior capsular opacity. The purpose of this report is to describe the results of BIL cataract surgery in a retrospective cohort of diabetic patients. Fifty-four cases of BIL surgery are included with a follow-up period of 1 year. Visual acuity outcomes were comparable to previously published standard lens-in-the-bag procedures. There were no reports of posterior capsular opacification and the grade of diabetic retinopathy remained stable. Three cases of clinically significant macular edema were detected over the follow-up period. We conclude that the BIL implantation technique is an advantageous approach to treating cataract in the diabetic population.