Intraoperative Posterior Capsule Rupture Research Articles

Simulation-based training for intraoperative posterior capsule rupture management: an analysis of nontechnical skills development and the relationship between technical and nontechnical skills.

To analyse development of individual nontechnical skills (NTS) domains after undertaking a previously developed simulation-based training model and analyse the relationship between technical skills (TS) and NTS in ophthalmic surgery. The simulation-based training model involved a cataract surgery case complicated by intraoperative posterior capsule rupture. Cataract surgeons underwent the simulation twice, separated by a training intervention. Two blinded independent experts assessed participants' NTS using HUFOES, NOn-Technical Skills for Surgeons (NOTSS), and the OSATS global rating scale for TS. Paired t-tests assessed differences in individual NTS domains, with p < 0.05 indicating significance. The Pearson Product Moment Correlation Coefficient was used to assess the correlation between scores from each scoring system. All NTS domains within HUFOES and NOTSS demonstrated statistically significant improvements secondary to the training intervention. Positive correlations were demonstrated between HUFOES and OSATS scores in the pre- and post-training simulations, r = 0.870 (p < 0.001) and r = 0.861 (p < 0.001), respectively. Positive correlations were also demonstrated between NOTSS and OSATS scores in pre- and post-training simulations, r = 0.849 (p < 0.001) and r = 0.757 (p = 0.001), respectively. Positive correlations were demonstrated between HUFOES and NOTSS scores; r = 0.979 (p < 0.001) (n = 17) and r = 0.959 (p < 0.001) for pre- and post-training simulations, respectively. All NTS domains contained within HUFOES and NOTSS demonstrated significant increases following the completion of the simulation-based training model. Positive correlations exist between an ophthalmic surgeon's TS and NTS. This is the first study to report these findings within ophthalmic surgery.

CHALLENGES IN THE SURGICAL MANAGEMENT OF BILATERAL POSTERIOR LENTIGLOBUS

Introduction : Lentiglobus is a lens deformation characterized by spherical bulging of the lens surface. The weakness of the posterior capsule in the lentiglobus makes the surgery challenging. We present a case of bilateral posterior lentiglobus and its management.&#x0D; Case Illustration : A 5-year-old boy was presented with the chief complaint of gradually blurred vision since 1 year ago. Visual acuity were 0.1 and closed face finger counting in the right and left eyes, respectively. An ophthalmology examination revealed lens opacities with partially reabsorbed lens material and protrusion of the lens surface posteriorly in both eyes (figure 1). The patient was diagnosed with developmental cataracts of the membranous type and posterior lentiglobus in both eyes. The patient underwent a surgical intervention for cataract extraction with aspiration technique. A spontaneous posterior capsule rupture was found with a shape like a lentiglobus. An anterior vitrectomy was performed. An intraocular lens was implanted. At one month after surgery, the best corrected visual acuities were 0.5 in both eyes (figure 2).&#x0D; Discussion : Several difficulties can be encountered during pediatric cataract surgery with the posterior lentiglobus morphology because of the thin or ruptured capsule. Previous studies have found preoperative and intraoperative posterior capsule rupture in 25% and 3.13% of lentiglobus cases, respectively. Hydrodissection should be avoided due to the weakness of the posterior capsule.&#x0D; ConclusionAppropriate surgical techniques to anticipate posterior capsule defects in the lentiglobus are required to produce a favorable outcome.

Vascular occlusion in a patient with posteriorly dislocated double IOL

Age and uncontrolled hypertension are well established risk factors for retinal vascular occlusion. IOL (intraocular lens) implantation following intraoperative posterior capsule rupture has an increased risk of IOL dislocation in the posterior segment. We came across a case of infero-temporal branched retinal vein occlusion followed by a direct injury by a mobile IOL which was posteriorly dislocated. The patient also had one another posteriorly dislocated IOL which was stuck in the anterior vitreous. This case highlights the need for the urgent removal of a posteriorly dislocated mobile IOL, which should precede the placement of a secondary IOL to avoid ocular complications.

Management of Posterior Capsule Rupture Complication in Cataract Patient with High Myopia and Partial Thickness Macular Hole

Introduction: To report clinical outcome after posterior capsule rupture complication in a cataract patient with partial-thickness macular hole. Case presentation: A 49-year-old woman was presented with blurred vision of the left eye two years before admission. The blurred vision increased, accompanied by eye dazzled on light exposure. There was a history of myopia on both eyes and partial-thickness macular hole in the left eye. The left eye visual acuity was 3/60 with S-7.00 correction became 5/12 no improvement with pinhole. There was a partial-thickness macular hole on the left eye in the optical coherence tomography macula. Cataract surgery was performed with intraoperative posterior capsule rupture (PCR) complication. Follow-up had been monitored from day-1 until day-60 postoperatively. Conclusions: The decision of performing cataract surgery prior to macular hole surgery is a good decision. Any intraoperative complication such as posterior capsule rupture should be followed up closely to avoid macular hole worsening. Long-term follow-up should be done to prevent the late complication after surgery.

Non-technical skills simulation-based training model for managing intraoperative posterior capsule rupture during cataract surgery.

To develop and implement a simulation-based training model for the management of posterior capsule rupture (PCR) from a non-technical skills (NTS) perspective, and analyse changes in participant's NTS and technical skills (TS). The simulation-based training model consisted of two identical PCR simulations with NTS stressors applied, separated by a predominantly NTS focussed training intervention. Participants' TS and NTS were evaluated by two blinded assessors using the Objective Structured Assessment of Technical Skill (OSATS) global rating scale and the HUman Factors in intraoperative Ophthalmic Emergencies Scoring System (HUFOES) respectively. Paired t-tests were used to establish the difference in mean HUFOES and OSATS scores between initial and repeat simulations; p < 0.05 indicated statistical significance. McGaghie's model of translational outcomes for simulation-based learning was used to establish the simulation model's educational status. Seventeen cataract surgeons of varying training grades participated in the simulation-based training model. NTS improved with statistical significance; mean HUFOES scores increased from 48.7 ± 16.6 to 59.2 ± 14.8 (p < 0.001). Mean OSATS scores increased without statistical significance from 16.0 ± 7.3 to 17.9 ± 8.3 (p = 0.07). This simulation model achieved Level 1 (internal acceptability) and Level 2 (contained effects) according to McGaghie's model. This novel simulation-based training model was designed to improve the NTS required for managing intraoperative PCR, through the provision of an interactive training session. Statistically significant improvements in participants' NTS in combination with statistically insignificant improvements in TS demonstrate that the simulation-based training model has specificity within the NTS domain.

Intraoperative posterior polar cortical disc defect: sign of intact posterior capsule

To describe the incidence and morphological characteristics of posterior polar cortical disc defect (PPCDD) sign observed during phacoemulsification in posterior polar cataract (PPC). Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Prospective case series. Sixty-seven eyes of 56 patients with PPC undergoing phacoemulsification were evaluated. Outcome measures were the incidence and characteristics of the intraoperative PPCDD sign, as well as its relation to the intraoperative surgical dynamics and posterior capsule (PC) dehiscence. Of the 67 eyes evaluated, the PPCDD sign was seen in 86.5% of eyes (58/67). Among these, 93.1% of eyes (54/58) showed a complete disc defect, whereas 6.9% of eyes (4/58) had a partial disc defect with incomplete margins. In the majority of cases (89.6%; 52/58), the PPCDD sign was seen after epinuclear plate and plaque aspiration. Among the 9 eyes that did not show the PPCDD sign, en bloc separation of the plaque and cortical matter from the PC was observed in 2 eyes, the plaque remained adherent to the PC till the end of cortical fiber aspiration in 3 eyes, and intraoperative PC rupture (PCR) was observed during the plaque separation in 4 eyes. The incidence of PCR in eyes without PPCDD sign was significantly higher (44.4% vs 0%; P < .001). The visualization of intraoperative PPCDD sign during phacoemulsification in PPC is suggestive of an intact PC and associated with a significantly lower rate of intraoperative PCR as compared with eyes without the PPCDD sign.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of cataract surgery. Report 5: Clinical outcome and risk factors for posterior capsule rupture and visual acuity loss following cataract surgery in patients aged 90 years and older.

Older age is commonly associated with an increased risk of surgical complications and comparatively poor outcomes. To report cataract surgery outcomes and risk indicators for patients aged 90 years and older. Data collected as part of routine cataract care in 34 centres contributing to the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database (NOD) were analysed. Very elderly people undergoing cataract surgery were profiled in terms of demographics, pre- and postoperative best-measured visual acuity (VA), ocular co-morbidities, intraoperative posterior capsule rupture (PCR) or vitreous loss or both, and risk indicators for operative PCR and adverse VA outcome. 25,856 cataract operations in 19,166 people of 90 years or older between 2000 and 2014 are reported. Preoperative VA was available for 82.4% eyes, being 0.30 LogMAR or better in 21.5%. Postoperative VA was available for 61.8% eyes, being 0.30 LogMAR or better in 74.4%. For those without ocular co-morbidity, postoperative VA was 0.30 LogMAR or better in 84.7%. Various co-morbidities were present in 49% and contributed to an adverse VA outcome. PCR data were available for all operations and occurred in 2.7%. Significant risk indicators for PCR included pseudoexfoliation/phakodonesis, mature cataract, smaller pupil and worse preoperative VA. Slightly poorer cataract surgery outcome results were noted in patients of 90 years or older, more so in patients with ocular co-morbidity which was highly prevalent. However, surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation remains achievable.

Reduced posterior capsular rupture rate observed among trainee surgeons utilizing a disposable silicone-tipped irrigation and aspiration handpiece for soft lens removal

ABSTRACTBackground: To determine if there is an association between lower posterior capsule rupture (PCR) rates among trainees using silicone-tipped handpieces compared with trainees using conventional instrumentation.Methods: In a retrospective audit, anonymized data was extracted for two groups of supervised deanery trainees. Group one operated with conventional IA handpieces. Group two utilized silicone-tipped IA handpieces. Risk factors found to increase the likelihood for intraoperative PCR were included in the analysis. Statistical significance was tested using a parametric test of two proportions.Results: Group one performed 782 surgeries and had a PCR rate of 3.6% vs 1.6% from 933 surgeries in group two. Following adjustment for risk factors, the p-value was 0.057. Group two had no IA-related PCR complications vs 12% in group one. Both groups demonstrated highest rates of PCR during phacoemulsification, 48% and 57%, respectively.Conclusion: Group two had lower than expected complication rates compared to the published literature. Trainees utilizing a 45-degree silicone-tipped IA handpiece had a lower rate of PCR and vitreous loss compared to group one and experienced no complications during IA. This suggests silicone-tipped IA handpieces may be safer for soft lens extraction compared to conventional instrumentation.

INCIDENCE OF LENS TOUCH DURING PARS PLANA VITRECTOMY AND OUTCOMES FROM SUBSEQUENT CATARACT SURGERY.

To determine the incidence of lens touch during pars plana vitrectomy (PPV) and evaluate cataract surgery complications after lens touch. One thousand three hundred and ninety nine phakic patients who underwent PPV during the period from 2001 to 2013 were included in the study. Data of the PPV and lens touch (excluding lens bite) complications were reviewed from an electronic database (VITREOR). Subsequent cataract surgery data and intraoperative complications were reviewed. A control group consisted of 149 cases of phakic patients who underwent PPV with no lens touch then subsequent cataract surgery. All surgeries were performed by senior surgeons, and no cataract was present before the PPV. The incidence of lens touch was 3.7% (52 of 1,399 phakic patients). The Demographics and presenting complaints of the patients were not significantly associated with lens touch, but retinal detachment with proliferative vitreoretinopathy, the use of silicone oil and use of relaxing retinectomy were associated with more lens touch. Cataract developed in 49 patients of whom 45 underwent cataract surgery. Nuclear sclerosis developed in 22 patients, 16 had posterior subcapsular, 8 had mixed lens opacities, and 3 had white cataract. The median duration between PPV and cataract surgery was 4 months in the lens touch group, which was significantly shorter than the median of 8 months in the control group (P = 0.001). During the subsequent cataract surgery in the lens touch group, 5 patients (11%) had a posterior capsule rupture, whereas the control group had only 2 cases of posterior capsule rupture 1.4% (P = 0.008). Final visual acuity was 0.3 LogMar or better in 22 patients (44%). Lens touch is a frequent complication of PPV in a phakic eye. It is more common in patients having surgery for proliferative vitreoretinopathy. Care should be taken when performing subsequent cataract surgery on an eye with lens touch as it carries a significantly increased chance of posterior capsule rupture.

Incidence of Acute Postoperative Endophthalmitis after Cataract Surgery: A Nationwide Study in France from 2005 to 2014

To report the incidence of acute postoperative endophthalmitis (POE) after cataract surgery from 2005 to 2014 in France. Cohort study. Patients undergoing operation for cataract surgery by phacoemulsification and presenting acute POE. We identified acute POE occurring within 6 weeks after phacoemulsification cataract surgery and the use of intracameral antibiotic injection during the surgical procedure by means of billing codes from a national database. Incidence of acute POE. From January 2005 to December 2014, 6 371 242 eyes in 3 983 525 patients underwent phacoemulsification cataract surgery. The incidence of acute POE after phacoemulsification decreased from 0.145% to 0.053% during this 10-year period; the unadjusted incidence rate ratio (IRR) (95% confidence interval) was 0.37 (0.32-0.42; P < 0.001). In multivariate analysis, intracameral antibiotic injection was associated with a lower risk of acute POE 0.53 (0.50-0.57; P < 0.001), whereas intraoperative posterior capsule rupture, combined surgery, and gender (male) were associated with a higher risk of acute POE: 5.24 (4.11-6.68), 1.77 (1.53-2.05), and 1.48 (1.40-1.56) (P < 0.001), respectively. Access to a national database allowed us to observe a decrease in acute POE after phacoemulsification cataract surgery from 2005 to 2014. Within the same period, the use of intracameral antibiotics during the surgical procedures increased.

Long-Term Results of Transscleral Fixation of Posterior Chamber Intraocular Lens

Purpose: To investigate the long-term results of transscleral fixation of posterior chamber intraocular lens (IOL) for unstable posterior capsular supporting structure. Methods: We performed a retrospective review of 67 patients (67 eyes) with unstable posterior capsular supporting structure who underwent transscleral fixation at Soonchunhyang University Bucheon Hospital from March 2005 to January 2013. Transscleral fixation without scleral flap was performed by a single surgeon. We analyzed the causes of transscleral fixation and compared postoperative best-corrected visual acuity (BCVA) and spherical diopter. Results: Among the 67 eyes of 67 patients, the causes of transscleral fixation included IOL subluxation (33 cases, 49.2%), IOL dislocation (11 cases, 16.4%), intraoperative posterior capsule rupture (8 cases, 11.9%), aphakia associated with previous intraocular surgery (7 cases, 10.4%), crystalline lens disorder with zonular dialysis (4 cases, 5.9%) and IOL opacity (4 cases, 5.9%). The mean BCVA before surgery was 1.26 ± 0.94 (log MAR) and the visual acuity improved to 0.59 ± 0.71, 0.60 ± 0.69, 0.58 ± 0.70, 0.55 ± 0.70, 0.60 ± 0.58 and 0.66 ± 0.70 (1 week, 1 month, 3 months, 1 year, 3 years and 5 years, respectively, after the surgery; p < 0.05). Conclusions: Posterior chamber IOL transscleral fixation in unstable posterior capsular supporting structure is effective for increasing visual acuity and spherical diopter. Specifically, the most improvement was observed at one month after surgery. Transscleral fixation is an adequate surgical procedure for fast improvement of visual acuity with long-term effects. J Korean Ophthalmol Soc 2016;57(1):43-49

Clinical outcomes of the glued intraocular lens scaffold

To report the visual outcomes and complications of the glued intraocular lens (IOL) scaffold procedure in patients with intraoperative posterior capsule rupture and retained nuclear fragments, subluxated cataract, and Soemmerring ring associated with aphakia and deficient posterior capsule. Dr. Agarwal's Eye Hospital, Chennai, India. Retrospective noncomparative interventional case series. Medical records of patients who had a glued IOL scaffold procedure performed were reviewed. The main outcome measures were visual acuity at final follow-up and intraoperative and postoperative complications during the entire follow-up. The mean preoperative and mean final postoperative corrected distance visual acuity (CDVA) (Snellen decimal equivalent) in 19 eyes of 17 patients were 0.39 ± 0.13 (SD) and 0.73 ± 0.27, respectively (P = .002, Wilcoxon test). No eye lost CDVA. The CDVA was stable in 7 eyes, improved 1 line in 2 eyes, and improved 2 lines or more in 10 eyes. Postoperatively, 20/20 visual acuity was attained in 9 eyes. Intraoperatively, Soemmerring ring drop into the vitreous cavity in 1 eye and hyphema in 2 eyes were observed. Postoperative complications included corneal edema (2 eyes), choroidal detachment (1 eye), mild vitritis (1 eye), ocular hypertension (1 eye), and fibrin reaction in the anterior chamber that resolved with medical management (2 eyes). The glued IOL scaffold enabled a closed-chamber approach with proper placement of an IOL in cases with inadequate sulcus or iris support and allowed safe emulsification of the retained nuclear fragments with good visual outcomes. No author has a financial or proprietary interest in any material or method mentioned.

Clinical Outcomes of Intraocular Lens Scaffold Surgery: A One-Year Study

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). Single-center, retrospective, interventional, noncomparative, consecutive case series. A total of 20 eyes of 20 patients who had intraoperative PCR underwent IOL scaffold surgery in a tertiary clinic. 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. 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. 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%). 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.

Posicionamento das alças de lentes intraoculares implantadas intencionalmente no sulco ciliar através da biomicroscopia ultrassônica

To evaluate the position of haptics of intraocular lens intentionally implanted in the ciliary sulcus in eyes undergoing cataract surgery complication associated with intraoperative posterior capsule rupture, as well as to correlate the findings with clinical changes observed in ophthalmic examination, utilizing ultrasound biomicroscopy. Eleven eyes (11 patients) who had posterior capsule rupture during cataract surgery with intentional implantation of the haptics in the ciliary sulcus, underwent complete ophthalmic examination and ultrasound biomicroscopy. Ultrasound biomicroscopy evaluated the parameters: positioning of the distal portion of the haptics, tilt and decentration of the intraocular lens. Ophthalmic examination was aimed to evaluate the presence of flare and cells in the anterior chamber, deposits on the lens and iris transillumination defects. Intraocular pressure was measured, pigmentation of the trabecular meshwork was determined, and a fundoscopic evaluation was needed to rule out peripheral retinal rupture and macular edema. Mean postoperative time for the examinations: 103.09 ± 32.93 days. Asymmetry of the haptics positioning was observed in 3 eyes (27.2%) that had one haptic in the ciliary sulcus, the second haptic was placed in the pars plana in 2 eyes, associated to intraocular lens tilt and decentration; or in the ciliary body (1 eye). Ophthalmic examination observed: 5 (45.5%) eyes with iris transillumination defects, 2 (18.1%) with intraocular lens decentration; 1 eye (9%) presented ocular hypertension. In all cases trabecular hyperpigmentation was observed at gonioscopy. No cases of peripheral retinal rupture and/or macular edema were reported. Ultrasound biomicroscopy was able to locate the intraocular lens haptics intentionally implanted in the ciliary sulcus during complicated cataract surgery, and could demonstrate the relation of intraocular lens decentration to assymetric haptic implantation.

Neodymium–Yttrium-Aluminum-Garnet Laser Lysis of Retained Cortex After Phacoemulsification Cataract Surgery

To describe the use of the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser to lyse residual cortex after phacoemulsification cataract surgery and report the complications and outcomes of treatment. Interventional, retrospective case series. Consecutive patients who underwent Nd:YAG laser treatment for residual cortex at the Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan were identified by review of laser logs from 2005 to 2011. The medical records were reviewed, and the course and complications of treatment were recorded. The main outcome measures were improvement in subjective vision and corrected distance visual acuity. Eighteen eyes of 18 patients, mean age 66 ± 11 years, were included. Eight eyes (44%) had intraoperative posterior capsule rupture. Before treatment with the Nd:YAG laser, all patients had subjective visual complaints, with 6 patients reporting counting fingers or worse visual acuity. Eleven patients (61%) were successfully treated with 1 session of cortical lysis, while 5 patients underwent 2 and 2 patients underwent 3 or more treatments. Five patients (28%) had elevated intraocular pressure (IOP) within 1 day of treatment, and 1 patient developed cystoid macular edema. All patients had resolution of subjective visual symptoms, and at final follow-up corrected distance acuity was 20/25 or better in 13 patients (72%). The Nd:YAG laser can be used to lyse residual cortex after uncomplicated cataract surgery or cases with intraoperative posterior capsular rupture, and results in an improvement in subjective and corrected distance visual acuity. Elevated IOP is a common complication.

Approaches to a posterior polar cataract

Posterior polar cataracts present special challenges to the cataract surgeon. These are often associated with weakness/dehiscence of the posterior capsule and thus have a higher rate of intraoperative posterior capsule rupture. The surgeon needs to adhere to special surgical strategies to minimize the risk of a posterior capsule rupture. These include, adhering to the principles of closed chamber technique, avoiding hydrodissection – instead performing ‘inside-out’ hydrodelineation and using modest to low phaco parameters and reducing these stepwise. This article provides important pearls on how to approach a posterior polar cataract.

The clinical observation of intraocular lens implantation in the patients of small-incision non-phacoemulsification cataract extraction with posterior capsule intraoperative rupture

Objective To study the efficacy and safety of non-phacoemulsification cataract extraction and intraocular lens implantation in the patients with intraoperative posterior capsule rupture. Methods 346 cases (381 eyes) were accepted small-incision non-phacoemulsification cataract surgery and were implanted intraocular lens. 21 cases underwent intraoperative posterior capsule rupture,of which 18 cases were accepted one-stage implantation of posterior chamber intraocular lens, 3 cases didn' t select it. The complications and postoperative visual acuity after follow-up for three months were investigated. Results Transient elevation of intraocular pressure occurred in 3 eyes ( 16. 67% ) , corneal edema in 16 eyes (88. 89% ) ,mild deviation of intraocular lens in 2 eyes ( 11. 11% ) , pupil less round and mild displacement in 5 eyes (27. 78% ). The best corrected visual acuity was more than 0. 5 in 13 eyes (72. 22% ) three months after operation. No serious complications occurred. Conclusion According to specific conditions, this technique of one-stage implantation of non-phacoemulsification intraocular lens is safe and can achieve better vision in the patients with intraoperative posterior capsule rupture during the surgery of non-phacoemulsification. Key words: non-phacoemulsification; small-incision; posterior capsular rupture; lens,intraocular

Spectroscopic study of explanted opacified hydrophilic acrylic intraocular lenses

To report a detailed spectroscopic analysis of explanted hydrophilic acrylic intraocular lenses (IOLs) that were removed because of postoperative opacification of the lens optic. Thirteen Hydroview H60M (Bausch & Lomb Surgical) IOLs were explanted from 13 different patients on average 56 months after phacoemulsification and IOL implantation. All patients had decreased visual acuity because of a fine granularity of the optical surface of the IOLs. The surface was investigated by gross, microscopic, histochemical and scanning electron microscopic analysis, and the elemental composition of the opacified IOLs was determined by X-ray fluorescence spectroscopy (XRF). The spectrograms were compared to three different originally packed and never-implanted hydrophilic acrylic IOLs. Light and scanning electron microscopy of the optical surface of explanted IOLs revealed multiple fine granular deposits varying in size and shape that were positive for alizarin red. XRF confirmed that the explanted IOLs contained not only the previously reported calcium and phosphorous (calcium apatite), chlorine, silicone, sodium, aluminum and magnesium but also iron, sulfur, potassium as well as lesser amounts of iodine, zinc, strontium and yttrium. This is the first spectroscopic analysis determining the content of more than 10 elements of explanted and originally packed never-implanted hydrophilic acrylic IOLs. The possible origin of the different elements obtained from the spectrograms and their implications are discussed.

How to prevent endophthalmitis in cataract surgeries?

Postoperative endophthalmitis is a very devastating complication and every step should be taken to reduce its occurrence. Unattended air conditioning filter systems are often the culprits and regular maintenance of the filters is of paramount importance. Shedders of pathogenic organisms amongst the theater personnel should be identified by regular screening and should be promptly treated. In addition to the use of Povidone iodine 5% solution in the conjunctival sac few minutes prior to surgery, proper construction of wound, injectable intraocular lenses, use of prophylactic intracameral antibiotics or prophylactic subconjunctival antibiotic injection at the conclusion of cataract surgery, placing a patch after the surgery for at least 4 h and initiating topical antibiotics from the same day of surgery helps to lower the frequency of postoperative endophthalmitis. Intraoperative posterior capsule rupture and anterior vitrectomy are risk factors for acute endophthalmitis, and utmost care to prevent posterior capsular rent should be taken while performing cataract surgery. Also, in case of such complication, these patients should be closely monitored for early signs of endophthalmitis in the postoperative period. In the unfortunate event of endophthalmitis the diagnosis should be prompt and treatment must be initiated as early as possible.

Posterior-assisted levitation: Outcomes in the retrieval of nuclear fragments and subluxated intraocular lenses

To report the outcomes of posterior-assisted levitation (PAL) to retrieve nuclear fragments and subluxated intraocular lenses (IOLs). Singapore National Eye Centre, Singapore, Singapore. In a retrospective series, the case notes of consecutive surgeries performed by a single surgeon between 1999 and 2006 were reviewed. Posterior-assisted levitation was performed for intraoperative posterior capsule rupture with nucleus-IOL dislocation or for late subluxation of posterior chamber intraocular lenses (PC IOLs). This was accomplished by the pars plana insertion of a needle followed by levitation of the subluxated object. Ophthalmic viscosurgical device injection was not used as an adjunct for levitation. Fourteen patients with PAL were followed for a mean of 18.71 months (range 1 to 79 months). There were 3 cases of dropped nucleus/nuclear fragments, 1 case of intraoperative subluxated PC IOL, and 10 cases of late subluxated PC IOLs. Complications included 1 case of retinal detachment occurring 20 months after PAL and 1 case of cystoid macular edema in a patient with previous anterior uveitis. Best corrected visual acuity was 20/40 or better in all except 3 patients (1 retinal detachment, 1 corneal edema/scarring, 1 unspecified). Posterior-assisted levitation provided an effective, relatively noninvasive means of levitating nuclear fragments and PC IOLs with few complications.