Primary Posterior Capsulorhexis Research Articles

Visual outcomes and complications of posterior chamber intraocular lens implantation in the first year of life

Purpose: To document the visual outcome and postoperative complications in infants who had congenital cataract surgery with posterior chamber intraocular lens (PC IOL) implantation in the first year of life. Setting: The Children’s Hospital, Dublin, Ireland. Methods: Twenty-seven eyes of 20 infants were reviewed. Seven infants (14 eyes) had bilateral congenital cataract and 13 (13 eyes), uniocular cataract. The mean age at surgery was 4 months (range 3 weeks to 11 months). A standard surgical technique involved anterior capsulorhexis, phacoemulsification with or without posterior capsulorhexis with in-the-bag PC IOL implantation, and no anterior vitrectomy. Surgery was performed by 1 surgeon. The mean follow-up was 41 months (range 6 to 88 months). Results: The main complication was lens reproliferation into the visual axis. Of the 11 eyes that did not have a primary posterior capsulorhexis, 10 had 1 or more capsulotomies. Seven required a neodymium:YAG (Nd:YAG) laser capsulotomy a mean of 6 months postoperatively, and 2 had 2 Nd:YAG capsulotomies. Six eyes also had a surgical capsulotomy when the membrane was deemed too thick for further laser treatment. Fourteen of 25 eyes had a primary posterior capsulorhexis; 8 had no further intervention. Four eyes had persistent hyperplastic primary vitreous (PHPV), 3 required a surgical capsulotomy, 2 had an Nd:YAG laser capsulotomy, 2 had an anterior vitrectomy, and 1 developed open-angle glaucoma. There was a mean refractive shift of 6.0 diopters after a mean follow-up of 41 months, with most of the myopic shift occurring in the first 24 months. Conclusions: Visual axis reopacification was the main complication of IOL implantation in infants, with PHPV leading to more complications and repeat procedures. Anterior vitrectomy appeared to reduce the reoperation rate. Results indicate that primary posterior capsulorhexis is important and Nd:YAG capsulotomy is not satisfactory in infants. In addition, the reduction in glaucoma with IOL implantation, if borne out over the long term, is a significant advantage in cases of congenital cataract.

Optic capture of the AcrySof intraocular lens in pediatric cataract surgery

Purpose: To assess the results of acrylic intraocular lens (IOL) optic capture in children with cataract. Setting: Department of Ophthalmology, Hospital de Clı́nicas José de San Martı́n, and Instituto de la Vision, School of Medicine, University of Buenos Aires, Argentina. Methods: Eight children had cataract surgery. After lens and cortex aspiration, an AcrySof® (Alcon) IOL was implanted in the bag. A primary posterior capsulorhexis was performed. The optic edges were slipped through the posterior capsule leaflets. Clarity of the visual axis, preoperative and postoperative best corrected visual acuities (BCVAs), and refraction were evaluated. Results: The visual axis remained clear in all cases. No case required a secondary procedure. The mean preoperative BCVA was 0.06 ± 0.06 (SD). Postoperatively, the mean BCVA was 0.88 ± 0.11 and the mean spherical equivalent, +0.62 ± 1.31. The mean follow-up was 28.9 ± 5.3 months. Conclusion: Results show that the optic of an acrylic IOL may be captured through a posterior capsulorhexis in pediatric cataract surgery, combining the advantages of optic capture with a smaller incision and a decreased inflammatory response.

Management of Posterior Capsule Tears

Any breach in the continuity of the posterior capsule is defined as a posterior capsule tear. Posterior capsule tears can be preexisting (congenital or traumatic), spontaneous, or intrasurgical. Preexisting/congenital posterior capsule tears have been related to an intrauterine insult. Posterior capsule tears due to trauma may occur as a consequence of direct mechanical impact due to perforation or blunt injury. Depending on the duration of time between the posterior capsular trauma and the cataract surgery, these posterior capsule tears can have different features. Intrasurgical posterior capsule tears are the most common and can occur during any stage of cataract surgery. Also, they may be planned in the form of primary posterior capsulorhexis. The conventional management consists of prevention of mixture of cortical matter with vitreous, dry aspiration, and anterior vitrectomy, if required. In addition, during phacoemulsification low flow rate, high vacuum, and low ultrasound are advocated if a posterior capsule tear occurs. Dislocated nucleus or nuclear fragments require vitrectomy and the use of perfluorocarbon liquids. In the presence of a posterior capsule tear, the IOL can be placed in the sulcus, if the capsular rim is available, or in the bag, if the tear is small. Scleral fixated posterior chamber lenses and anterior chamber IOLs can be implanted when the posterior capsule tear is large.

The capsular tension ring: designs, applications, and techniques

Originally, the open poly(methyl methacrylate) (PMMA) capsular tension ring (CTR) was designed to compensate for zonular defects or to stretch the posterior capsule in highly myopic eyes not receiving an intraocular lens (IOL). We address the variety of subsequent designs, applications, and techniques that have evolved. With pre-existing or intraoperative zonular defects, a standard CTR may be inserted before or at any time during cataract removal to maintain or re-establish an extended capsular diaphragm. For profound zonular dialysis or weakness, a CTR was designed for scleral fixation. Capsular tension rings with integrated tinted sector shields have been developed to compensate for sector iris colobomas or aniridia. The CTR has also been used as a measuring gauge for in vivo quantification of capsule dimensions and postoperative capsular shrinkage. The CTR has improved control during primary posterior capsulorhexis and prevented oval distortion along the lens axis postoperatively. During combined cataract and vitreous surgery, a CTR prevents capsule damage and provides undisturbed peripheral visualization before IOL implantation. Capsular tension rings may also influence capsule opacification formation. A special band-shaped CTR with sharp edges was developed to inhibit lens epithelial cell migration and avoid capsulorhexis–optic contact.

Primary posterior capsulorhexis without anterior vitrectomy in pediatric cataract surgery: Longer term outcome

Purpose To assess the effectiveness of primary posterior capsulorhexis without anterior vitrectomy in preventing posterior capsule opacification (PCO) in pediatric cataract surgery. Setting Children’s Hospital, Dublin, Republic of Ireland. Methods The study comprised 32 eyes of 22 pediatric patients who had cataract extraction between 1994 and 1998. Extracapsular cataract extraction was performed using radiofrequency diathermy capsulorhexis to the anterior and posterior capsules without an anterior vitrectomy. Posterior chamber intraocular lens implantation was performed in 20 eyes. There were 23 congenital, 6 developmental, and 3 traumatic cataracts. Results Patient age ranged from 1 month to 12 years. Mean follow-up was 19 months (range 6 to 50 months). Twenty-seven of 32 eyes (84.4%) had a clear visual axis at last follow-up. Five eyes required a neodymium:YAG capsulotomy, which was performed a mean of 5 months postoperatively (range 1 to 9 months). The incidence of PCO requiring capsulotomy was 15.6%. Conclusion Primary posterior capsulorhexis without anterior vitrectomy was safe and effective, with a low reopacification rate. Long-term follow-up of this patient cohort is necessary.

Phacoemulsification, primary posterior capsulorhexis, and capsular intraocular lens implantation for uveitic cataract

Purpose: To evaluate the safety and efficacy of phacoemulsification, primary posterior capsulorhexis (PCCC), and primary intraocular lens (IOL) implantation for uveitic cataracts.Setting: Institutional practice.Methods: Fifteen consecutive eyes of 13 patients with various causes of uveitis received anterior capsulorhexis, phacoemulsification, PCCC, and in-the-bag implantation of a heparin-surface-modified IOL for visually disabling cataract. The safety and efficacy of the combined operation were studied prospectively.Results: At a mean follow-up of 16.9 months (range 8 to 30 months), all eyes had a clear central visual area. Fourteen of 15 eyes (93.3%) had good visual improvement after surgery. Eight eyes (53%) achieved a best corrected visual acuity (BCVA) of 20/30 or better and 6 (40%), 20/20 or better. Seventy-three percent of eyes attained a BCVA of 20/80 or better. The mean improvement in visual acuity was 5.2 Snellen lines (range 0 to 11 lines). No cases of uveitis flare-up or other major complications related to the cataract surgery occurred.Conclusions: The study's preliminary results are encouraging and indicate that phacoemulsification, PCCC, and IOL implantation can be considered in patients with visually disabling uveitic cataract.

Primary posterior capsulorhexis with and without anterior vitrectomy in congenital cataracts

Purpose: To determine whether anterior vitrectomy is necessary along with primary posterior capsulorhexis in children less than 5 years of age with congenital cataracts.Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India.Method: This prospective study comprised 18 eyes of 16 children whose mean age was 2.3 years (range 3 months to 5 years). Primary posterior continuous curvilinear capsulorhexis (PCCC) and posterior chamber intraocular lens (IOL) implantation were performed in all eyes. No vitrectomy was done in 8 eyes (Group 1); an anterior vitrectomy was performed in 10 eyes (Group 2). Optic capture through the posterior capsule was achieved in 3 eyes in Group 1 and in 5 eyes in Group 2. Average follow-up was 13.3 months.Results: Five eyes (62.5%) in Group 1 needed secondary pars plana vitrectomy because the visual axis was obscured; no eye in Group 2 needed a secondary procedure. Four Group 1 eyes developed significant complications (updrawn pupil, decentration, occlusio pupillae, transient glaucoma). While no Group 2 eye developed a serious complication, some degree of pigment dispersion was noted in all the eyes.Conclusion: The results suggest that anterior vitrectomy is desirable along with primary PCCC in children younger than 5 years with congenital cataracts.

Radiofrequency diathermy capsulorhexis of the anterior and posterior capsules in pediatric cataract surgery: Preliminary results

Purpose: To assess the effectiveness of radiofrequency diathermy capsulorhexis in preventing opacification of the posterior capsule in pediatric cataract extraction.Setting: The Children's Hospital, Dublin, Ireland.Methods: Radiofrequency diathermy capsulorhexis to the anterior capsule followed by injection of sodium hyaluronate behind the posterior capsule and primary posterior capsule diathermy capsulorhexis were performed in 14 eyes of 7 children requiring cataract surgery.Results: Six patients had bilateral congenital and 1 patient bilateral developmental cataracts. Ten eyes (5 patients) received heparin-surface-modified intraocular lenses, and 4 eyes (2 patients) were left aphakic. There were no intraoperative complications, and only mild anterior segment inflammation was noted postoperatively.Conclusion: With follow-up from 7 to 16 months (mean 12.1 months), our results showed no epithelial regrowth or opacification of the posterior capsule following diathermy capsulorhexis.

Posterior capsulorhexis in adult eyes with intact and clear capsules

Purpose: To evaluate the feasibility and risks of primary posterior capsulorhexis.Setting: Department of Ophthalmology, University Hospital of Liège, Belgium.Methods: Retrospective analysis of 319 patients with cataracts who had phacoemulsification or manual extracapsular cataract extraction with a simultaneous circular posterior capsulorhexis between August 1993 and April 1994. The number of intraoperative complications and the number of postoperative complications that could be related to the posterior capsule opening were looked at. Fluorescein angiography was performed in a random sample of patients.Results: Twelve intraoperative complications consisted of 5 irregular tears, 4 vitreous prolapses into the posterior capsulorhexis, and 3 vitreous prolapses into the anterior chamber; 11 occurred in eyes with positive posterior pressure. Postoperative complications consisted of 3 vitreous prolapses into the pupil and 1 retinal detachment. Two of the 3 late vitreous prolapses occurred in eyes in which the posterior capsulorhexis was larger than the intraocular lens (IOL) optic. The retinal detachment occurred in an eye with a 25.79 mm axial length. Fluorescein angiography of 49 cases revealed 3 with cystoid macular edema.Conclusions: Based on our results, we believe that primary posterior capsulorhexis can be a routine procedure during cataract surgery and IOL implantation in adults, except in cases of positive pressure. The diameter of the posterior capsulorhexis should be smaller than the diameter of the IOL optic.

Surgical management challenges and clinical results of bimanual micro-incision phacoemulsification cataract surgery in children with congenital cataract

Small incisions in cataract surgery have shown to reduce tissue damage, postoperative inflammation and pain. To describe in detail the surgical management challenges and clinical results of bimanual micro-incision phacoemulsification cataract surgery in children with congenital cataract. In 22 eyes of 14 children aged from 11 months to 17 years with congenital cataract, micro-incision cataract surgery with lensectomy, bimanual aspiration or phacoemulsification and implantation of an intraocular lens (SN60WF, Alcon®) was performed under general anesthesia. The visual equivalent obtained with age-related methods, the slit-lamp examination, and refractive outcome were documented in the medical records and were analyzed retrospectively. The patients fulfilled at least 3 months of follow up. In all operated eyes, micro-incision cataract surgery could be performed without serious intra-operative complications. Lensectomy was safely combined with a primary posterior capsulorhexis and anterior vitrectomy in 17 of 22 eyes. Corneal incision length ranged between 2.2 mm and 2.6 mm (mean: 2.3 ± 0.2 mm). No cases of postoperative hypotony and increased inflammation were observed. One eye required surgical removal of the after-cataract 7 months after surgery. Laser capsulotomy for posterior capsular opacification had to be performed in 2 (9 %) eyes. In all other eyes (19/22), visual axis remained clear during follow-up. Micro-incision cataract surgery is a promising alternative to conventional pediatric cataract surgery, since the technique showed to be comparably safe and effective. Longer follow-up examinations will now be performed.