Lens Capsule Research Articles

Применение интраоперационной ОКТ в хирургическом лечении перезрелых катаракт с фемтолазерным сопровождением

Purpose. To evaluate the capabilities of intraoperative OCT in optimizing the femtocapsulotomy technique during the surgical treatment of overripe cataracts with femtolaser support. Material and methods. The study included 20 patients (20 eyes) with overripe cataracts who underwent femtolaser-assisted cataract surgery (FACS). The patients were divided into 2 groups (10 eyes in each group). For the 1st group, femtocapsulorexis was performed taking into account the morphological changes in the anterior lens capsule and the state of the lens according to intraoperative OCT. Dosing of the laser energy depended on the condition of the anterior capsule and the underlying altered cortical masses. For prophylactic purposes, to reduce the tension of the anterior capsule and equalize the intralenticular pressure (ICP) gradient, cohesive-dispersed viscoelastics were preliminarily introduced. The anterior capsule was stained with trypan blue to improve visualization. For the 2nd group, the femtocapsulorexis technique was standard. Results. There were no cases of radialization of the anterior lens capsule in the 1st group. In all cases, a perfectly round, centrally located capsulorhexis with a diameter of 5-5.2 mm was achieved. The IOL was implanted into the capsule bag, without intra- and postoperative complications. An incomplete capsulotomy was performed with a femtolaser in 3 cases in the 2nd group. Out of these 3 cases, in two cases, radialization of the anterior capsulorhexis occurred without transition to the posterior capsule. The IOL was implanted in the capsule bag in all cases. Conclusion. The use of intraoperative OCT makes it possible to evaluate morphological changes in the lens capsule and to plan the individual parameters and femtocapsulorexis algorithm, which reduces the risk of complications of overripe cataract surgery with femtolaser support. Key words: intraoperative OCT, overripe cataract, femtolaser support.

Изучение особенностей интра- и послеоперационного состояния интерфейса «интраокулярная линза – задняя капсула хрусталика» при факоэмульсификации возрастной катаракты

Presence of full contact of interface «intraocular lens (IOL) – posterior capsule (PC)» ensures the transparency of the latter in the early period after phacoemulsification (PE) of senile cataract (SC). The main reasons for absence of full contact of IOL with PC are: the presence of residuals of viscoelastic (VE) in the capsular bag, uneven tension of the capsule by the haptic elements of the IOL, and the incommensurability of the size of the IOL with the capsule. Purpose. To study the features of the intra- and postoperative state of interface «IOL – PC» during PE SC. Material and methods. Dynamic observation of 42 patients (42 eyes), who operated on immature senile cataracts, was carried out. All operations were performed using OPMI LUMERA 700 surgical microscope (Carl Zeiss Meditec AG, Jena, Germany) with integrated intra-operative OCT, state of interface «IOL – PC» was examined. 2 hours after and on the 1st day after the operation state of interface «IOL – PC» was studied in all eyes by OCT on Optovue RTVue-100 (Optovue, Inc., US) with module for anterior segment examining to protocols «Cornea Line» and «Cornea Cross Line». Results. During the operation, the presence of contact between IOL and PC was observed only in 9 eyes (21.4%). 2 hours after surgery, 40 eyes (95.2%) had absence of contact between lens and capsule. On the 1st day after surgery, the optimal interface between IOL and PC was observed in 32 eyes (76.2%). Conclusion. Studies have shown that state of interface «IOL – PC» on the 1st day does not depend on its characteristics revealed intraoperative and 2 hours after the operation. The main reason for absence of contact between IOL and PC is residues of VE, and the using «impulse-irrigation» technique allows completely removing VE from the central zone of the capsule in all cases. Key words: cataract, phacoemulsification, intraocular lens, lens capsule, viscoelastic, interface «IOL – PC».

Хирургическое лечение при повреждении задней капсулы хрусталика после лазерного витреолизиса

Damage to the posterior capsule of the lens after laser vitreolysis causes the formation of traumatic cataracts and a decrease in visual acuity. The search for surgical methods of treating such complications is relevant. Purpose. To develop and improve the technique of posterior capsulorexis during phacoemulsification and implantation of IOL combined with vitrectomy in the presence of an initial injury of the posterior lens capsule. Material and methods. Clinical case - a patient came to the clinic with complaints about a decrease in visual acuity and quality after laser vitreolysis performed in another clinic. Observed the damage of the posterior capsule of the lens. The operation was performed according to the developed technique. Results. A method of primary posterior capsulorexis during phacoemulsification and implantation of IOL after vitreolysis, combined with vitrectomy, is proposed. Achieved high visual acuity after the operation, OD=1.0. Conclusions. 1) The developed technique of primary posterior capsulorexis is safe and allows partially preserving the posterior capsule of the lens, while forming a «window» in the area of damage, and implanting the IOL into a capsule bag. 2) The installation of scleral ports during primary posterior capsulorexis makes it possible to successfully combine this operation with vitrectomy and prevent the displacement of lens fragments to the fundus. Key words: сataract, posterior capsulorexis, laser vitreolysis, phacoemulsification, pseudophakia, IOL, vitrectomy, vitreous body.

An Artificial Lens Capsule with a Lens Radial Stretching System Mimicking Dynamic Eye Focusing.

Presbyopia is a common eye disorder among aged people which is attributed to the loss of accommodation of the crystalline lens due to the increasing stiffness. One of the potential techniques to correct presbyopia involves removing the lens substance inside the capsule and replacing it with an artificial lens. The development of such devices, e.g., accommodating intraocular lenses (AIOLs), relies on the understanding of the biomechanical behaviour of the lens capsule and the essential design verification ex vivo. To mimic the eye’s dynamic focusing ability (accommodation), an artificial lens capsule (ALC), from silicone rubber accompanied by a lens radial stretching system (LRSS) was developed. The ALC was manufactured to offer a dimension and deforming behaviour replicating the human lens capsule. The LRSS was calibrated to provide a radial stretch simulating the change of diameter of capsules during accommodating process. The biomechanical function of the ALC was addressed by studying its evolution behaviour and reaction force under multiaxial stretch from the LRSS. The study highlighted the convenience of this application by performing preliminary tests on prototypes of ophthalmic devices (e.g., AIOLs) to restore accommodation.

Exophiala Endophthalmitis after Cataract Surgery

Purpose: To report a case of Exophiala endophthalmitis after cataract surgery, which has not been reported previously in Korea.Case summary: A 70-year-old woman visited the hospital 7 days after cataract surgery in her right eye with unilateral vision impairment. At the time of the visit, visual acuity of the right eye was hand motion, and the fundus was not clearly observed due to numerous inflammatory cells with hypopyon in the anterior chamber. With an initial diagnosis of suspected bacterial endophthalmitis, vitrectomy was performed immediately with intravitreal injection of antibiotics and steroid. On day 14 after vitrectomy, inflammation in the anterior chamber and vitreous opacity worsened, and complete vitrectomy, including of the vitreous base, and removal of the intraocular lens and capsule was performed. Exophiala was detected in the biopsy specimen on day 6 after the second surgery, and the patient was discharged with a prescription for voriconazole eye drops. On day 23 after the second surgery, the best-corrected visual acuity in the right eye had improved to 1.0, and there was no evidence of endophthalmitis recurrence and no observed additional abnormal findings of the fundus until 6 months after second surgery.Conclusions: In a case of fungal endophthalmitis that occurred after cataract surgery, good results were obtained by vitrectomy involving complete removal of the peripheral vitreous body, including the intraocular lens and lens capsule, which was the basis for growth of the fungus in the early stage of endophthalmitis.

In-the-Bag Versus Ciliary Sulcus Secondary Intraocular Lens Implantation for Pediatric Aphakia: A Prospective Comparative Study

To compare outcomes of in-the-bag vs ciliary sulcus secondary intraocular lens (IOL) implantation for pediatric aphakia. Prospective interventional case series. This institutional study was conducted in 202 children (355 aphakic eyes) diagnosed as having congenital cataracts and who underwent cataract extraction before age 24 months. Pediatric aphakic eyes underwent in-the-bag or ciliary sulcus secondary IOL implantation according to the amount of residual lens capsule and were monitored for 3 years postoperatively. The main outcome measures were adverse events (AEs), IOL tilt and decentration, and best corrected visual acuity (BCVA) in the operative eye. A total of 144 eyes (40.6%, 89 children) received in-the-bag IOL implantation (capsular group), and 211 eyes (59.4%, 132 children) underwent ciliary sulcus IOL implantation (sulcus group). Kaplan-Meier curves showed that the time-dependent incidence of glaucoma-related AEs (GRAEs) (P=.005) and any AEs (P=.002) were higher in the sulcus group. In-the-bag IOL implantation was a strong protective factor against GRAE (hazard ratio, 0.08; 95% CI, 0.01-0.53; P=.009) and any AEs (hazard ratio, 0.21; 95% CI, 0.08-0.57; P=.002). Clinically significant IOL decentration (>0.4 mm) was more common in the sulcus group compared with the capsular group (vertical decentration: 29.8% vs 15.7%, P=.005; horizontal decentration: 30.3% vs 9.35%, P < .001). BCVA in the capsular group was better than that in the sulcus group (logMAR, 0.56 vs 0.67, P=.014). Compared with ciliary sulcus secondary IOL implantation, in-the-bag IOL implantation reduced AEs and yielded better IOL centration and BCVA for pediatric aphakia.

Health Care Price Transparency in Ophthalmology

Health care price transparency legislation is intended to reduce the ambiguity of hospital charges and the resultant financial stress faced by patients. To evaluate the availability, usability, and variability of standard reported prices for ophthalmologic procedures at academic hospitals. In this multicenter economic evaluation study, publicly available price transparency web pages from Association of American Medical Colleges affiliate hospitals were parsed for standard charges and usability metrics. Price transparency data were collected from hospital web pages that met the inclusion criteria. Geographic practice cost indices for work, practice expense, and malpractice were sourced from the Centers for Medicare & Medicaid Services. Data were sourced from February 1 to April 30, 2021. Multiple regression was used to study the geographic influence on standard charges and assess the correlation between standard charges. Availability and variability of standard prices for Current Procedural Terminology (CPT) codes 66984 (removal of cataract with insertion of lens) and 66821 (removal of recurring cataract in lens capsule using laser). Of 247 hospitals included, 191 (77.3%) provided consumer-friendly shoppable services, most commonly in the form of a price estimator or online tool. For CPT code 66984, 102 hospital (53.4%) provided discount cash pay estimates with a mean (SD) price of $7818.86 ($5407.91). For CPT code 66821, 71 hospital (37.2%) provided discount cash pay estimates with a mean (SD) price of $2041.72 ($2106.44). The top quartile of hospitals, prices wise, listed included prices higher than $10 400 for CPT code 66984 and $2324 for CPT code 66821. Usability issues were noted for 36 hospitals (18.8%), including requirements for personal information or web page navigability barriers. Multiple regression analysis found minimal explanatory value for geographic practice cost indices for cash discount prices for CPT codes 66984 (adjusted R2 = 0.54; 95% CI, 0.41-0.67; P < .001) and 66821 (adjusted R2 = 0.64; 95% CI, 0.51-0.77; P < .001). Despite recent legislature that codified price transparency requirements, some current standard charges remain ambiguous, with substantial interhospital variability not explained by geographic variability in costs. Given the potential for ambiguous pricing to burden vulnerable, uninsured patients, additional legislation might consider allowing hospitals to defer price estimates or rigorously define standards for actionable cash discount percentages with provisions for displaying relevant benchmark prices.

The Zonular Stripes

Long anterior zonules [LAZ] are zonules having anomalous anterior insertion on the lens capsule, thus reducing the size of zonule-free zone. This article describes a diabetic elderly female who presented to us for cataract surgery. Examination showed presence of bilateral persistent pupillary membrane [PPM] along with long anterior zonules. Association of PPM with LAZ has been established in literature but bilateral PPM-LAZ association is a unique finding. The article also illustrates different phenotypes of LAZ and their clinical associations. LAZ eyes have propensity for sight threatening diseases like glaucoma, retinal diseases etc. Hence, a thorough ocular examination is warranted.

Fluid-Shifting Technique for Preventing Argentinian Flag Sign

PURPOSE: To present a novel technique to prevent Argentinian flag sign in intumescent white cataracts. METHODS: Surgical technique. RESULTS: After puncturing the anterior lens capsule, the liquefied cortical material is easily shifted from the retronuclear space to the anterior chamber by gently injecting viscoelastic above the mid periphery of the anterior capsule (not inside the bag). After depressurizing the intracapsular forces, capsulorhexis can be safely completed. CONCLUSIONS: This is a convenient strategy when at risk of observing Argentinian flag sign during the removal of mature cataracts. [ Journal of Refractive Surgery Case Reports. 2021;1(3):e45–e46.]

Siderotic cataract without an intralenticular foreign body

Among foreign bodies involved in ocular trauma, three-fourths are accounted by iron, causing ocular siderosis. We report a case of total white cataract with golden-brown deposits over the anterior lens capsule. Clinical examination made us suspicious about a foreign body which was detected on a computerized tomography (CT) scan in the ciliary body. The patient underwent cataract surgery, and the anterior capsule was histopathologically proven to have siderotic changes. Caution is advised in cases when there may be a long time interval for the development of ocular siderosis. Siderotic changes in the lens may occur even when there is no intralenticular foreign body.

Photo-responsive intraocular lens with on demand drug release for posterior capsule opacification prevention and improved biosafety

Posterior capsular opacification (PCO) is the most common complication after cataract surgery, which is caused by the adhesion, proliferation, migration and epithelial-mesenchymal transformation of the residual lens epithelial cells (LECs) in lens capsule. The drug eluting coating modification provides a powerful way to inhibit PCO incidence after IOL implantation. However, the uncontrolled proliferative drug brings intraocular biosafety issues when application. Therefore, developing new strategies with controlled drug release for PCO prevention is of great significance. In this investigation, a hydrophilic photo-responsive drug release coating was successfully constructed on IOL surface, which was verified through 1H•NMR, UV–Vis, FTIR and XPS. In vitro assay indicated that the IOL coating exhibited excellent anti-adhesion and anti-proliferation effects on LECs under irradiation. The photo-controlled drug release in vitro can be achieved by simply adjusting the intensity and time of irradiation. Finally, the surface-modified IOL was implanted in rabbit eyes and in vivo evaluation was carried out. In vivo assay demonstrated that the implantation of the modified IOL into eyes can significantly reduce the occurrence of PCO. Moreover, the modified IOL exhibited good biocompatibility and biosafety. We believe that this work will provide a synergistic strategy for effective prevention of PCO through a photo-controllable drug release coating on IOL surface.

Glaucoma secondary to congenital fibrovascular pupillary membrane: a single tertiary center experience

We report the clinical features, treatments, and outcomes of 9 infants with glaucoma secondary to congenital fibrovascular pupillary membrane. The clinical features included unilateral low vision, high intraocular pressure (IOP), enlarged and cloudy cornea, loss of anterior chamber, and pupillary membrane. All patients underwent membranectomy, peripheral iridectomy, pupilloplasty, and goniosynechialysis as primary treatment. The membranes were posterior to the iris in all 9 eyes. In 5 eyes, the membrane covered the ciliary processes, and in 1 eye the membrane reached the posterior lens capsule. Following primary surgery, 3 patients developed membrane recurrence, 4 had refractory elevated IOP, and 2 developed lens opacities. All 4 eyes with poor postoperative IOP control had iris root insertion anterior to the scleral spur. Five patients received additional surgeries including membranectomy, pupilloplasty, goniosynechialysis, cyclocryotherapy, ciliary photocoagulation, Amhed valve implantation, and lensectomy. One patient had refractory elevated IOP at last follow-up. IOP in the other 8 eyes was well controlled. None of the affected eyes was able to fix and follow at last follow-up.

Spontaneous absorption of congenital cataract in trisomy 21

We report a case of spontaneous cataract absorption over a period of 19weeks in a 5-week-old boy with trisomy 21. Ultrasound biomicroscopy images at 5 and 24weeks of age showed that 71% of the initial lens thickness was absorbed during this period. At surgery, the lens thickness was 0.92mm in the right eye and 0.91mm in the left eye. Uncomplicated cataract extraction was performed. Trypan blue staining revealed an area of possible lens leakagethrough the anterior lens capsule in the left eye, suggesting a mechanism for cataract absorption.

Clinical effect of peripheral capsule preservation in eyes with silicone oil tamponade.

BACKGROUNDAt present, silicone oil has been widely used in vitrectomy to deal with complex fundus diseases. Usually, cataract extraction is combined with vitrectomy. However, reducing the complications of silicone oil tamponade and facilitating the secondary implantation of intraocular lens (IOL) are still an urgent problem.AIMTo evaluate the clinical effect of vitrectomy combined with peripheral capsule preservation (PCP) in eyes with silicone oil tamponade.METHODSThis single-center retrospective analysis included 70 patients (73 eyes) who underwent vitrectomy and silicone oil tamponade combined with cataract surgery (stage I) between January 2015 and July 2019. All patients underwent selective reoperation for silicone oil extraction and IOL implantation (stage II) more than 3 mo after stage I. These patients were divided into three groups according to the different lens capsule preservation methods: 28 patients (31 eyes) in a whole capsule preserved (WCP) group, 17 (17 eyes) in a capsule absent (CA) group, and 25 (25 eyes) in a peripheral capsule preserved (PCP) group. Intraocular pressure (IOP), best-corrected visual acuity, surgery time, and other complications were recorded at each time point (1 d, 1 wk, and 1 mo after stages I and II).RESULTSThe IOP values were 14.9 ± 8.2 mmHg in the WCP group, 20.3 ± 13.0 mmHg in the CA group, and 14.2 ± 9.7 mmHg in the PCP group (P < 0.05) at 1 mo after stage I operation. Five eyes had IOP higher than 30 mmHg, and one eye in the WCP group appeared to have silicone oil entering the anterior chamber. There was no significant difference in IOP among the three groups at any other time point (P > 0.05). With IOL implantation, visual acuity improved significantly compared to stage I. The incidence rate of posterior capsule opacity was higher in the WCP group than in the other groups (P < 0.001). In the CA group, IOL deviation due to suture relaxation occurred in one case. There was no significant difference in the surgery time among the three groups in stage I (P = 0.618). In stage II, the surgery time of the PCP group and WCP group was significantly shorter than that of the AC group (P = 0.031).CONCLUSIONPreservation of the peripheral capsule in vitrectomy combined with lens removal is a better option. This method has significant advantages in reducing intraoperative and postoperative complications.

Surgical Management of Recurrent and Persistent Macular Holes: A Practical Approach.

Primary surgery for macular hole (MH) closure has a high success rate with current methods of pars plana vitrectomy and internal limiting membrane (ILM) peeling. When primary surgery fails, there are several options available for secondary repair, including extension of the ILM peel, creation of an ILM flap, pedunculated ILM flap, lens capsule flap transplantation, autologous retinal transplantation, use of a human amniotic membrane plug, adjuvant autologous platelet concentrate, induction of macular detachments with subretinal blebs, and creation of retinal incisions. In this review, we discuss the practical approach to each of these surgical techniques for the management of recurrent or persistent MHs.

Behavior of Generated Gas during Femtosecond Laser Lens Irradiation in Porcine Cadaver Eyes

(1) Background: We investigated the behavior of gas inside a lens and its influence on the lens capsule, which may cause complications by lens irradiation with a femtosecond laser cataract surgery device. (2) Methods: The crystalline lenses of 6-month-old porcine cadaver eyes were observed during laser irradiation. An intraocular endoscope in the vitreous cavity was used to measure the posterior capsule position. Optical coherence tomography measurements of the anterior chamber depth before and after the laser irradiation, as well as measurements of the equatorial perimeter of the extracted lens, were compared with those of the controls. (3) Results: Femtosecond laser-generated gas in the porcine lens was dependent on laser irradiation energy. Increases in the amount of laser irradiation energy caused the generated gas to coalesce, move backwards beyond the laser irradiation site, and expand the lens capsule and posterior capsule. (4) Conclusions: The present results suggest that laser irradiation-induced gas moves in the direction of the posterior capsule beyond the lens irradiation site and expands the lens capsule, which may be involved in the development of capsular block syndrome.

Real-time intraoperative OCT imaging of the vitreolenticular interface during pediatric cataract surgery.

To report on the use of intraoperative optical coherence tomography (OCT) imaging of the vitreolenticular interface (VLI) during pediatric cataract surgery and to determine the incidence of VLI dysgenesis and surgical difficulties. Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium. Retrospective cohort study. This study included 51 pediatric patients who underwent cataract surgery between April 2016 and December 2018. Video recordings and OCT images of the VLI were analyzed and compared. VLI dysgenesis was considered present when intraoperative OCT images demonstrated partial or total adhesions between the posterior lens capsule and the anterior hyaloid membrane. Video recordings were analyzed to describe surgical difficulties, more specifically: inability to create a calibrated primary posterior continuous curvilinear capsulorhexis (PPCCC), occurrence of vitreous prolapse, need for anterior vitrectomy, and complicated IOL implantation. Of the 51 patients included, VLI dysgenesis was demonstrated in 27 patients (52.9%). The incidence of VLI dysgenesis was greater in children with unilateral cataract (72.4%), and children with a posterior capsule plaque (90%). PPCCC was challenging in 20 patients. A defect of the anterior hyaloid membrane was found in 16 patients. Anterior vitrectomy or cutting vitreous strands with scissors was necessary in 10 patients. Intraoperative OCT images were an excellent tool to evaluate the VLI and to demonstrate the presence of VLI dysgenesis during pediatric cataract surgery. Performing a calibrated PPCCC was more challenging in the presence of VLI dysgenesis. This can subsequently expose a defect in the anterior hyaloid membrane, which may result in vitreous prolapse.

A validated finite element model to reproduce Helmholtz's theory of accommodation: a powerful tool to investigate presbyopia.

To reproduce human in vivo accommodation numerically. For that purpose, a finite element model specific for a 29-year-old subject was designed. Once the proposed numerical model was validated, the decrease in accommodative amplitude with age was simulated according to data available in the literature. In contrast with previous studies, the non-accommodated eye condition was the reference configuration. Consequently, two aspects were specifically highlighted: contraction of the ciliary muscle, which was simulated by a continuum electro-mechanical model and incorporation of initial lens capsule stresses, which allowed the lens to become accommodated after releasing the resting zonular tension. The morphological changes and contraction of the ciliary muscle were calibrated accurately according to the experimental data from the literature. All dynamic optical and biometric lens measurements validated the model. With the proposed numerical model, presbyopia was successfully simulated. The most widespread theory of accommodation, proposed by Helmholtz, was simulated accurately. Assuming the same initial stresses in the lens capsule over time, stiffening of the lens nucleus is the main cause of presbyopia.

Experience in the treatment of primary malignant tumors (retinoblastoma and osteosarcoma): analysis of the clinical case

Background. Retinoblastoma is a malignant intraocular tumor developing from the retinal neuroectoderm and diagnosed primarily in young children. This type of cancer is associated with a high risk of multiple primary tumors emerging after treatment completion. Multiple primary tumors are two or more independent tumors developing in one patient. Treatment of this disease is challenging.Objective – to evaluate the impact of risk factors on the efficacy of therapy for multiple primary tumors and to analyze treatment outcomes.Materials and methods. A 2-year-old boy was diagnosed with bilateral retinoblastoma (OD – stage T3bN0M0 and OS – stage T3cN0M0). He received special treatment from September 2005 to November 2006. In 2012, the patient underwent cataract surgery: the lens was removed, then an intraocular lens was installed, and laser dissection of the posterior capsule of the lens was performed. Six years later, in August 2018, the patient was diagnosed with osteosarcoma. The boy received combination organ-sparing therapy according to the EURAMOS-1 treatment protocol for osteosarcoma. During therapy, he developed a secondary tumor, namely osteoblastic osteosarcoma. Both the boy and his father were found to have a mutation in the RB1 gene.Results. Currently, patient’s condition is satisfactory; he has no complains. The boy is in remission for 2 years.Conclusion. The development of secondary tumors depends on the genetic factors, type of treatment for primary tumor, and environmental factors. Therefore, it is extremely important to assess risk factors for multiple primary tumors at the moment of primary retinoblastoma detection. The results of such assessment will help to choose an optimal treatment strategy.

Intraocular lens optic edge design for the prevention of posterior capsule opacification after cataract surgery.

Intraocular lens optic edge design for the prevention of posterior capsule opacification after cataract surgery.