Posterior Polar Cataract Research Articles

Manual-delineation and dissection technique for posterior polar cataract

In posterior polar cataract (PPC), the posterior capsule is weak or dehiscent. This can lead to posterior capsular rent at any time during cataract surgery, leading to complications. Various techniques have been used to manage such cataracts, and modifications are advised at each and every step of cataract surgery. We describe a new technique in which a blunt chopper is used to manually delineate the epinucleus from the nucleus at 360 degrees, and the nucleus is chopped and removed by phacoemulsification. Then, the chopper is inserted in the plane between the capsule and the epinucleus, and manual dissection is performed, followed by rotation and pushing it centrally. This epinucleus that is separated is aspirated simultaneously. Thus, with no pressure fluctuations and undue stress on the posterior capsule from the fluid jets, we manage to do surgery in tricky cases of PPCs successfully using manual delineation and dissection.

Optic capture of the intraocular lens in posterior capsular rupture

A 67-year-old female had a left eye posterior polar cataract (PPC) with a thin intact posterior capsule (PC) with nuclear sclerosis grade V (as per the lens opacities classification system III) and an intraocular lens (IOL) in the sulcus with an absent PC in the right eye. On examination, her best-corrected visual acuity (BCVA) was 6/6 (+1.00/+1.50 × 10) and 6/60 (plano) for right eye (OD) and left eye (OS), respectively. She underwent left eye phacoemulsification cataract surgery, and intraoperatively, capsular rupture occurred which was noticed before completion of the last quadrant. No vitreous leakage occurred, and a three-piece IOL was implanted in the sulcus and an optic capture was done. At one-month follow-up, her left BCVA was 6/6 (0.50 DS/+1.25 × 10) with normal IOP, and the IOL was well centered with an oval-shaped anterior capsule covering the optic anteriorly, and a ruptured PC was seen as two parallel lines. We have discussed various important steps in the management of PPC and posterior capsular rent in this paper with the illustrative image of an optic capture of the three-piece IOL in posterior capsular rupture.

Hydrodissection and femtosecond laser assisted surgery in posterior polar cataract

PurposeTo present our clinical experience using femtosecond laser-assisted cataract surgery (FLACS) and cortical cleavage hydrodissection in eyes with posterior polar cataract.MethodsMedical records of consecutive10 eyes of 6 patients with clinical diagnosis of posterior polar cataract (PPC), were retrospectively reviewed. All surgeries were done by using femtosecond laser-assisted cataract surgery. In all cases careful hydrodissection was done to separate the lens material from the posterior capsule.ResultsThere were 3 males and 3 females, ages 39–73 years (average 52.5 years), two of them were implanted with toric lenses. In all eyes hydrodissection was successfully performed and the lens material was separated from the lens capsule. The posterior capsule remained intact during nucleus removal in all cases. In one eye the posterior capsule broke during cortical cleaning and the tear was converted to posterior capsulorhexis (PCCC). No postoperative complications were recorded during follow-up in all eyes.ConclusionsHydrodissection can be safely performed in combination (but not exclusively) with FLACS, in eyes with posterior polar cataract with no evidence of a preexisting posterior capsule rent. Hydrodissection is regarded by most surgeons as contraindicated in these eyes however apparently it is more gentile to the capsule than any other surgical maneuver and allows clean and efficient separation of the lens material from the thinned posterior capsule. Femtosecond laser capsulotomy and lens fragmentation is effective and may further assist surgery by pneumo-separation of the lens material. Anterior chamber maintainer may further aid to the stability of the chamber and safety of surgery.

Safety of Phacoemulsification with Gradual Hydro Dissection on Posterior Polar Cataract

Introduction: Phacoemulsification has been a procedure of choice for treating cataractous lenses and restoring visual function. Posterior polar cataract have been one of many cases in which phaco surgeons should be careful and aware for more to perform phacoemulsification. One hydrodissection procedure is safe to perform as an alternative to hydrodileniation during phacoemulsification for posterior cataract. It is called gradual hydrodissection. Methods: This study performed a quasi-experimental pre-post study that tested the safety of gradual hydrodissection in phacoemulsification in 50 eyes of 50 patients. The safety parameter used in this study includes the incidence of posterior capsule rupture and nucleus drop during phacoemulsification until surgery is finished. Descriptive statistics were used to summarize the characteristics of the study participants, such as age, sex, race, eye laterality, and previous intraocular surgery. A paired student’s t-test was conducted to compare preoperative and postoperative values for visual acuity and intraocular pressure. The P <0.05 was considered the level of statistical significance. Results: There was no complication of the posterior capsule during the hydrodissection procedure. There was a statistically significant difference in visual acuity and intraocular pressure before and after surgery by P value <0.001. All of the phacoemulsification studies were considered uneventful and successful. Conclusions: Gradual hydrodissection may be safe to be performed in phacoemulsification for posterior polar cataract.

Nucleus drop following phacoemulsification surgery: Incidence, risk factors and clinical outcomes.

To determine the incidence, risk factors and clinical outcomes in patients with nucleus drop (ND) following phacoemulsification surgery at a tertiary care ophthalmic institute. Medical records of patients with ND during phacoemulsification between January'2019 and December'2022 were reviewed retrospectively. Incidence of ND was calculated overall, and according to surgical expertise levels and surgical steps. Associated pre- and intra-operative risk factors were assessed. Clinical outcome parameters [best-corrected visual acuity (BCVA) and intraocular pressure (IOP)] were compared with respect to timing of PPV (immediate vs early vs delayed), location (sulcus vs scleral fixated-IOL) and timing of IOL placement (primary vs secondary). Among 93,760 phacoemulsifications, ND was noted in 130 patients (0.1%). Significant direct and associated pre-operative risk factors were advanced cataract, glaucoma, posterior polar cataract, and diabetes mellitus. Junior medical consultants had 40 ND (mostly in non-complex cases), whereas senior medical consultants had 90 ND (mostly in complex cases). ND most frequently occurred during emulsification of nuclear fragments. Sulcus placement of IOL during primary surgery yielded significantly better visual outcome compared to secondary procedures, although timing of PPV had insignificant effect. 77.1% had BCVA of 6/12 or better at final follow-up. Timing of IOL implantation, PPV, and type of IOL did not have any significant effect on IOP. Though the incidence of ND is low, it is a dreaded complication. Accurate pre-operative evaluation, risk stratification, distribution of cases among surgeons based on their surgical expertise, and immediate or early management of ND yields better anatomical and functional outcomes.

Abnormal function of EPHA2/p.R957P mutant in congenital cataract.

To identify genetic defects in a Chinese family with congenital posterior polar cataracts and assess the pathogenicity. A four-generation Chinese family affected with autosomal dominant congenital cataract was recruited. Nineteen individuals took part in this study including 5 affected and 14 unaffected individuals. Sanger sequencing targeted hot-spot regions of 27 congenital cataract-causing genes for variant discovery. The pathogenicity of the variant was evaluated by the guidelines of American College of Medical Genetics and InterVar software. Confocal microscopy was applied to detect the subcellular localization of fluorescence-labeled ephrin type-A receptor 2 (EPHA2). Co-immunoprecipitation assay was implemented to estimate the interaction between EphA2 and other lens membrane proteins. The mRNA and protein expression were analyzed by reverse transcription-polymerase chain reaction (qRT-PCR) and Western blotting assay, respectively. The cell migration was analyzed by wound healing assay. Zebrafish model was generated by ectopic expression of human EPHA2/p.R957P mutant to demonstrate whether the mutant could cause lens opacity in vivo. A novel missense and pathogenic variant c.2870G>C was identified in the sterile alpha motif (SAM) domain of EPHA2. Functional studies demonstrated the variant's impact: reduced EPHA2 protein expression, altered subcellular localization, and disrupted interactions with other lens membrane proteins. This mutant notably enhanced human lens epithelial cell migration, and induced a central cloudy region and roughness in zebrafish lenses with ectopic expression of human EPHA2/p.R957P mutant under differential interference contrast (DIC) optics. Novel pathogenic c.2870G>C variant of EPHA2 in a Chinese congenital cataract family contributes to disease pathogenesis.

Comparison between two-hole-assisted phaco-chop and stop-and-chop techniques for nuclear disassembly in residents’ cataract surgery

Abstract PURPOSE: The purpose of this study was to evaluate the safety of the novel two-hole-assisted phaco-chop technique as a transition between stop-and-chop and direct-chop techniques and to compare its phacoemulsification parameters with the stop-and-chop technique. METHODS: A prospective quasi-experimental study was conducted at Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan. One hundred and three patients (103 eyes), aged 18 years and above, with nuclear sclerosis (NS)+2, NS +3, +4, cortical, and posterior subcapsular cataracts (WHO Cataract Grading Group) were included, whereas patients with uveitis, glaucoma, traumatic cataracts, small pupils, zonular weakness, lens subluxation, small palpebral fissures, soft cataracts (NS + 1), and posterior polar cataracts were excluded from the study. The stop-and-chop technique was performed in 58 (56.3%) patients, whereas the two-hole-assisted chop technique in the rest. Ultrasound time (UST), total surgical time, and volume of balanced salt solution (BSS) delivered were recorded. RESULTS: The mean age of the participants was 65.12 ± 8.85 years. The comparison of the two techniques revealed no statistically significant difference in the UST (P = 0.723), volume of BSS used (P = 0.102), and total surgery time (P = 0.517). However, a significant positive correlation between cataract grade and UST (Spearman’s r = 0.888, P < 0.001), BSS volume delivered (Spearman’s r = 0.831, P < 0.001), and surgery time (Spearman’s r = 0.846, P < 0.001) was observed. Moreover, the UST comparison between cataract grades revealed a significant difference between the three groups (F = 185.09 P < 0.001). P < 0.05 was considered statistically significant. CONCLUSION: The two-hole-assisted phaco chop is a safe and efficient transitional technique between stop-and-chop and direct-chop techniques for nuclear disassembly in cataract surgery performed by resident surgeons. In addition, the phacoemulsification parameters of the two-hole-assisted chop technique are comparable with the stop-and-chop technique.

Innovative utilization of ultra-wide field fundus images and deep learning algorithms for screening high-risk posterior polar cataract.

To test a cataract shadow projection theory and validate it by developing a deep learning algorithm that enables automatic and stable posterior polar cataract (PPC) screening using fundus images. Department of Ophthalmology, Far Eastern Memorial Hospital, New Taipei, Taiwan. Retrospective chart review. A deep learning algorithm to automatically detect PPC was developed based on the cataract shadow projection theory. Retrospective data (n = 546) with ultra-wide field fundus images were collected, and various model architectures and fields of view were tested for optimization. The final model achieved 80% overall accuracy, with 88.2% sensitivity and 93.4% specificity in PPC screening on a clinical validation dataset (n = 103). This study established a significant relationship between PPC and the projected shadow, which may help surgeons to identify potential PPC risks preoperatively and reduce the incidence of posterior capsular rupture during cataract surgery.

Dr. Sohel Khan's prechopper and prechopping technique.

The quest of every dedicated phaco surgeon is to develop skills to emulsify all forms of hard nuclei efficiently with minimal damage to the endothelium and reducing the risk of wound burn. Obtaining a pristine cornea the very next day in a hard cataract is a dream far from reality. Prechop means nuclear division without the use of phaco energy. In this article, we describe a prechopping technique using a new sickle-shaped (saber tooth curvature and tip) novel prechopper that has a slender, sleek, and elegant design well suited for nuclear disassembly. The novel prechopper has proved to be a wonder device for hard, soft, white, posterior polar, and exfoliation cataracts. All maneuvers of prechop are performed in the bag away from the endothelium to be easily emulsified, subsequently making phacoemulsification easier, faster, and safer.

Slow swirl phaco.

This article reports a novel surgical technique in the management of soft posterior polar cataracts. This technique avoids hydro procedures, trenching, and chopping. Viscodissection is avoided or minimal, and polar opacity is removed last. These modifications minimize the risk of intraoperative complications.

AYURVEDIC MANAGEMENT OF POSTERIOR POLAR CATARACT: A CASE STUDY

Posterior Polar Cataract is the rare subset of congenital cataracts resulting in defective vision. It follows an autosomal dominant inheritance pattern and is occasionally sporadic due to the high incidence of intraoperative complications, which include posterior capsular rent, nucleus drop, etc. Posterior Polar Cataract is a surgical challenge for ophthalmologists. Ayurveda cataracts can be described in the context of Timira, Kacha and Linganasha. Timira is a disease of the Drishti Mandala, which presents with blurred vision initially, and if left untreated, it will progress to Kacha, which, if neglected, will lead to Linganasha. Linganasha is the last stage, where there is complete vision loss. A 37-year-old female patient complaining of blurred vision for distance and glare at night for two years is presented here. She was diagnosed with Posterior polar cataract one year back. The patient underwent Ayurveda treatment of shodhana and shamana chikitsa after properly assessing Rogi and Roga bala, which includes- Kayavirchana, Shirovirechana, Kriyakalpas (Akshitarpana, Anjana) and Rasayana prayogas. Assessment after the above treatment has shown improvement in the patient's visual acuity. From this study, it can be concluded that Ayurvedic treatment can preserve and give a better quality of vision to the patient of Posterior Polar Cataract, as surgery includes a high risk of capsular rupture and vitreous loss that can lead to worse visual outcomes.

Ultrasound biomicroscopy in the management of complex cataract and intraocular lens: A review.

Ultrasound biomicroscopy (UBM) is an invaluable investigation for imaging anterior segment structures. Although it is operator-dependent and time consuming, unlike optical-based imaging techniques, it is able to image structures posterior to the iris, such as the zonules, ciliary body and part of the pars plana. It is especially useful in advanced cataracts, traumatic cataracts, subluxed lenses, posterior polar cataracts, and congenital and developmental anomalies affecting the anterior segment. It provides diagnostic information in eyes with complex cataracts or intraocular lens (IOL)-related pathology, and aids in surgical planning in order to minimise complications. In this review, we describe the UBM features of various lenticular pathologies and demonstrate its application in the diagnosis and surgical management of lens and IOL-related pathologies.

Trident technique of safe nuclear emulsification in posterior polar cataracts.

The common complications associated with a posterior polar cataract (PPC) with deficient or weak posterior capsules (PCs) are posterior capsular rupture (PCR), vitreous loss, and luxation of lens material into the vitreous. Often the commonly used technique of hydrodelineation in such cataracts can lead to accidental hydrodissection, and even the slightest nucleus rotation during phacoemulsification can cause the PC to give way. We describe a modified relatively safe technique (Trident technique) for managing the nucleus in PPCs which does not involve any hydroprocedure or nucleus rotation.

Prevalence, Complications and Visual Outcome of Posterior Polar Cataract(PPC) among Patients Undergoing Surgery at A Tertiary Care Center

Prevalence, Complications and Visual Outcome of Posterior Polar Cataract(PPC) among Patients Undergoing Surgery at A Tertiary Care Center

Chop and tumble nucleotomy - A technique for safe nuclear emulsification in posterior polar cataract.

A modified phaco chop technique for nuclear emulsification in posterior polar cataracts with nuclear sclerosis that avoids hydrodissection or nuclear rotation has been described. After performing a vertical chop maneuver to divide the nucleus, two pie-shaped nuclear fragments are removed from either side of the initial chop. The remaining nuclear fragments are then sequentially tumbled toward the center using the second instrument and emulsified while maintaining an intact epinuclear shell, which safeguards the fragile posterior capsule. The technique was successfully performed in 62 eyes of 54 patients with posterior polar cataract and grade II-IV nuclear sclerosis. The Chop and Tumble nucleotomy is a safe and effective technique for phacoemulsification in posterior polar cataracts with nuclear sclerosis, where hydrodissection and nuclear rotation are typically avoided.

Biomarkers of Pediatric Cataracts: A Proteomics Analysis of Aqueous Fluid.

Cataracts are among the most common causes of childhood vision loss worldwide. This study seeks to identify differentially expressed proteins in the aqueous humor of pediatric cataract patients. Samples of aqueous humor were collected from pediatric and adult cataract patients and subjected to mass spectrometry-based proteomic analysis. Samples of pediatric cataracts were grouped by subtype and compared to adult samples. Differentially expressed proteins in each subtype were identified. Gene ontology analysis was performed using WikiPaths for each cataract subtype. Seven pediatric patients and ten adult patients were included in the study. Of the pediatric samples, all seven (100%) were male, three (43%) had traumatic cataracts, two (29%) had congenital cataracts, and two (29%) had posterior polar cataracts. Of the adult patients, seven (70%) were female and seven (70%) had predominantly nuclear sclerotic cataracts. A total of 128 proteins were upregulated in the pediatric samples, and 127 proteins were upregulated in the adult samples, with 75 proteins shared by both groups. Gene ontology analysis identified inflammatory and oxidative stress pathways as upregulated in pediatric cataracts. Inflammatory and oxidative stress mechanisms may be involved in pediatric cataract formation and warrant further investigation.

Retrospective analysis of the role of anterior segment optical coherence tomography and outcomes of cataract surgery in posterior polar cataract.

To evaluate the visual and surgical outcomes of cataract surgery in patients with posterior polar cataract (PPC) and to evaluate the benefits of preoperative anterior segment optical coherence tomography (AS-OCT). This was a retrospective, single-center study. Case records of patients diagnosed with PPC who underwent cataract surgery either by phacoemulsification or manual small-incision cataract surgery (MSICS) from January to December 2019 were analyzed. Data collected include demographic details, preoperative best corrected visual acuity (BCVA), AS-OCT, type of cataract surgery, intraoperative and postoperative complications, and visual outcome at 1-month follow-up. One hundred patients were included in the study. Preoperative posterior capsular defect was noted on AS-OCT in 14 patients (14%). Seventy-eight underwent phacoemulsification and 22 underwent MSICS. Intraoperatively, posterior capsular rupture (PCR) was seen in 13 patients (13%) and cortex drop was noted in one among them (1%). Out of 13 PCRs, 12 were found to have posterior capsular dehiscence preoperatively in AS-OCT. The sensitivity of AS-OCT for detecting posterior capsule dehiscence was 92.3% and specificity was 97.7%. The positive predictive value and negative predictive value were 85.7% and 98.8%, respectively. There was no significant difference in the incidence of PCR between phacoemulsification and MSICS (P = 0.475). The mean BCVA at 1 month was found to be better with phacoemulsification than MSICS (P = 0.004). Preoperative AS-OCT has excellent specificity and negative predictive value in identifying posterior capsular dehiscence. It thus helps to plan the surgery and counsel patients appropriately. Both phacoemulsification and MSICS provide good visual outcome with similar complication rates.

Outcomes of "Complex" Cataract Surgeries Performed by Long-Term Glaucoma Fellows in a Tertiary Eye Centre from Eastern India.

To evaluate the outcomes of operating on "complex cataracts" by the glaucoma fellows. This was a retrospective study done at a tertiary referral eye care centre in eastern India. After obtaining IRB approval, a retrospective chart review of all patients who underwent "complex" cataract surgery by one of four long-term (2 years) glaucoma fellows between January 2016 and November 2020 was conducted. 'Complex' was defined as cataracts complicated with pseudoexfoliation syndrome, phacodonesis with or without blunt ocular trauma, posterior polar cataract, small pupil, co-existent corneal opacity or uveal coloboma, post-glaucoma filtering surgery, post-vitreoretinal surgery, co-existent glaucoma or post-laser iridotomy and monocular patients. Out of a total of 677 eyes done by the glaucoma fellows during the study period, 83 eyes had complex cataract surgery and completed the six-week post-operative follow-up. Intraoperative surgical complications like posterior capsular rent or vitreous loss were noted in 36 of the cases. Thirty of the eyes were left aphakic. Despite a high rate of complications, the LogMAR best-corrected visual acuity (mean ± standard deviation) improved from the preoperative level of 1.7 (±0.5) to 1.0 (± 0.8) at post-operative six weeks, significant at p < 0.001. As far as the surgeon's experience was concerned-less than or more than a year since joining the fellowship-there was statistically no difference in the final visual acuity. The group with greater experience had shorter surgical time and lesser complications though this difference was not statistically significant. This is the first study in the literature reporting the outcomes of "complex" cataract surgery performed by glaucoma fellows. Though high rates of postoperative complications were noted in this study, the mean best-corrected visual acuity improved significantly in all eyes after the surgery.

Approach to a spontaneously ruptured posterior polar cataract

A 61-year-old man presented with gradual blurring of vision and glare in both eyes for a couple of years, with worsening of the vision in his right eye over the past 2 months. He had no medical history of note. On clinical examination, his visual acuities were 20/80 in the right eye and 20/30 in the left eye, uncorrected. The cornea was clear, and the anterior chamber (AC) was deep in both eyes. He had bilateral mild nuclear sclerosis with round central onion-ring-like posterior opacities. The opacities measured approximately 2 mm in diameter and were marginally larger in the right eye than in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202305000-00018/figure1/v/2023-04-20T184543Z/r/image-tiff). In addition, there were 2 curvilinear lines across the right posterior capsule (PC), one of which passed across the lens opacity (Figure 2JOURNAL/jcrs/04.03/02158034-202305000-00018/figure2/v/2023-04-20T184543Z/r/image-tiff). Fundus examination was normal in both eyes, and the vitreous was clear. Optical coherence tomography (OCT) of the macular and optic nerve in both eyes was normal. The endothelial cell count in both eyes exceeded 2000 cells/mm2. He had been told by a previous ophthalmologist to have bilateral cataracts and was now keen for surgery starting with the right eye. He works as a manager in a large company and is an avid golf player. He is emmetropic and wears spectacles for near work. Optical biometry using predicated posterior corneal astigmatism did not recommend a toric intraocular lens (IOL). He had done his internet research on IOL options and requested trifocal IOLs. What is your surgical plan for right cataract removal? Explain which IOL you would choose to implant.

Cataracts in Havanese: genome wide association study reveals two loci associated with posterior polar cataract

BackgroundCataract is considered an important health issue in Havanese, and studies indicate a breed predisposition. Possible consequences of cataracts include lens induced uveitis, reduced eyesight, and blindness in severe cases. Reducing the prevalence of cataracts could therefore improve health and welfare significantly. The most frequently diagnosed forms of cataract in Havanese are cortical- and anterior suture line cataract, but cases of posterior polar cataract are also regularly reported. Out of the three, posterior polar- and cortical cataracts are considered the most clinically relevant.ResultsWe performed a genome wide association study that included 57 controls and 27 + 23 + 7 cases of cortical-, anterior suture line- and posterior polar cataract, respectively. An association analysis using a mixed linear model, revealed two SNPs on CFA20 (BICF2S23632983, p = 7.2e-09) and CFA21 (BICF2G630640490, p = 3.3e-09), that were significantly associated with posterior polar cataract, both of which are linked to relevant candidate genes. The results suggest that the two variants are linked to alleles with large effects on posterior polar cataract formation, possibly in a dominant fashion, and identifies regions that should be subject to further sequencing.Promising regions on CFA4 and CF30 were also identified in the association analysis of cortical cataract. The top SNPs on each chromosome, chr4_12164500 (p = 4.3e-06) and chr30_28836339 (p = 5.6e-06), are located within, or in immediate proximity to, potential cataract candidate genes.The study shows that age at examination is strongly associated with sensitivity of cataract screening. Havanese in Norway are on average 3.4 years old when eye examinations are performed: an age where most dogs that are genetically at risk have not yet developed clinically observable changes. Increasing the average age of breeding animals could increase accuracy of selection, leading to improved health.ConclusionsThe study identified two loci, on CFA20 and CFA21, that were significantly associated with posterior polar cataract in Havanese. SNPs that showed putative association with cortical cataracts, were observed on CFA4 and CFA30. All the top SNPs are located in close proximity to cataract candidate genes. The study also show that sensitivity of cataract screening is highly dependent on age at examination.